A 58-Year-Old Man With a Rash and Elevated Creatinine Levels

F. Gerald Wade, MD; Elie Ghoulam, MD; Thomas Fay, MD; George Vasquez Rios, MD; Kamran Qureshi, MD


October 02, 2019

The patient in this case was initially treated with high-dose glucocorticoids and rituximab for his HCV-associated cryoglobulinemic glomerulonephritis. However, his renal function continued to deteriorate after a few days of immunosuppressive therapy; thus, he was also started on plasmapheresis. His creatinine level began to plateau shortly thereafter. As his creatinine level slowly began to improve, paperwork was submitted to his insurance for HCV therapy.

He was started on a direct-acting antiviral (DAA) regimen to treat his HCV infection, once his kidney function had stabilized. He completed 12 weeks of ombitasvir, paritaprevir, ritonavir, and dasabuvir combination therapy, with eradication of HCV infection. His liver enzymes normalized, and his creatinine level stabilized around 2 mg/dL. He was continued on immunosuppression with tacrolimus, prednisone, and mycophenolate mofetil.

The favorable efficacy and safety profiles of DAA therapy enable more liberal use among nontransplant patients compared with prior interferon therapies.[34] Patients with HCV who receive DAA therapy usually achieve sustained virologic response, which can lead to reduced morbidity, mortality, and nonhepatic HCV complications.[35,36] The decline in liver transplantations for HCV cirrhosis due to DAA therapy has freed up donor livers for other liver diseases, including nonalcoholic steatohepatitis and alcoholic liver disease.[37]

DAA therapy is also safe and effective in the posttransplant setting.[38,39] Clearance of HCV after liver transplant is associated with improved outcomes.[40] HCV infection in renal transplant recipients is associated with decreased survival, increased allograft loss, and increased risk for extrahepatic complications compared with patients without HCV infection; thus, clearance of HCV may improve outcomes in this population as well.[41,42] DAA therapy has also expanded the organ donor pool, because HCV-positive recipients can now receive some HCV-positive organs and be cured of HCV posttransplant.[43]

In conclusion, HCV infection can lead to significant morbidity and mortality from nonhepatic manifestations, such as mixed cryoglobulinemia. Cryoglobulinemia can present with a clinically aggressive course that requires immunosuppressive therapy. Interferon-free DAA regimens can cure HCV, prevent occurrence of HCV extrahepatic manifestations, and improve outcomes in patients posttransplant.


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