Hepatitis C is associated with intrinsic renal disease, including cryoglobulinaemia and glomerulonephritis. People with renal impairment should be investigated to determine the underlying cause and managed appropriately. Those with severe acute vasculitic manifestations may require immunosuppressive therapy, including anti-CD20 antibody therapy and/or plasma exchange (note that any patient with HCV who is treated with B cell-depleting therapy must be screened for HBV infection, and patients who have been exposed to HBV will require antiviral therapy to prevent HBV reactivation). In addition, the prevalence of anti-HCV antibodies is higher in patients requiring haemodialysis compared with the general population.
Management of HCV in individuals with renal impairment is complicated by renal clearance of drugs including sofosbuvir and ribavirin, as well as the complications and treatment of the intrinsic renal disease, including drug–drug interactions. People with moderate–severe renal impairment (eGFR < 50 mL/min/1.73 m2) should be referred to specialist centres for consideration of antiviral therapy.