Hepatitis C in thalassemia, hemophilia and chronic kidney disease

Patient with transfusion- depended thalassemia are at higher risk of acquiring HCV infection, especially those who received their first transfusion in Iran before 1995. Hepatitis C seroprevalence in Iranian thalassemia patient is approximately %18. Liver failure due to HCV infection is the second cause of mortality in these patients. Before Direct-acting antiviral regimen (DAA), thalassemia patients had been treated with pegylated-intrerferon monotherapy and in some trials with low dose Ribavirin, however, these regimens had lower virologic response and followed by higher side effects. From three years ago, thalassemia patients with hepatitis C have been treated with different DAAs, such as daclatasvir and sofosbovir or ledipasvir/sofosbovir. These regimens are effective and tolerable (with virologic response more than %95). There has been reported some cardiac side effects with these regimens in the literature but it seems that DAAs are tolerable in thalassemia patients. However, cardiac consultation before DAAs should be performed in thalassemia patient. Chronic hepatitis C patients with chronic kidney disease (CKD) with eGFR≥30 ml/min, can be treated with all of the approved DAA-regimens but for those with advanced CKD (eGFR<30), there are three approved combination regimens including elbasvir and grazoprevir , combination of ritonavir-boosted paritaprevir, ombitasvir and dasabuvir and the last, comformulated glecaprevir and pibrentasvir. Sofosbuvir is eliminated by kidney, so it does not approved for eGFR<30. Although a recent meta- analysis showed that the SVR rate in patients with CKD who were treated with sofobuvir-based regimens was %89, but those with eGFR<45 have more anemia and worsening of kidney function. The prevalence of HCV infection in hemophilia patients has been estimated between %70-%95 and also they were being exposed to repeated infections with different HCV strains. Seroprevalence of HCV infection among hemophilia patients in Iran varies from %13.3 to %89.5. Before DAA regimens, hemophilic patients have been treated with pegylated interferon and ribavirin and a study had showed that SVR rate of %51 for genotype 1 and %71 for genotype non-1 infections. Daclatasvir- sofosbuvir and ledipasvir-sofosbuvir have been available in Iran from 2016 and these patients have been treated with these regimens.