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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 3  |  Page : 132-134

Elbasvir/grazoprevir treatment in a hemodialysis patient with hepatitis C Virus Genotype 2a Infection, not responded to sofosbuvir/daclatasvir combination therapy


1 Department of Dialysis, Azzawiyah Kidney Hospital; Medical Faculty, Zawia University, Zawia, Libya
2 Medical Faculty, Zawia University, Zawia; Department of Dialysis, Sabratha Teaching Hospital, Sabratha-, Libya

Date of Submission30-Jun-2021
Date of Acceptance10-Sep-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Marwa Belgasem Elmelodi
Department of Dialysis Azzawiyah Kidney Hospital, University of Zawia,Omer Moktar Street 110, Zawia
Libya
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ljms.ljms_41_21

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  Abstract 


Since 2017, direct-acting antivirals (DAAs) are the first-line treatment for patients with chronic hepatitis C virus (HCV) infection. In hemodialysis (HD) patients, however, a small percentage of patients failed to respond, and the data for the treatment of DAAs for such patients with HCV are lacking. Herein, we report a 57-year-old Libyan female patient on regular HD therapy for 18 years who did not achieved HCV clearance 12 weeks after the treatment with sofosbuvir/daclatasvir. Later, she was treated with elbasvir/grazoprevir (EBR/GZR) for 12 weeks and achieved a sustained virological response at the end of the treatment (12 weeks) and 12 months after the end of the treatment. No obvious side effects were reported during the treatment. Thus, EBR/GZR was effective and safe in this hemodialyzed patient with HCV genotype 2b infection who was failed to respond to12 week-treatment with sofosbuvir/daclatasvir combination.

Keywords: Chronic hepatitis C, direct-acting antivirals, elbasvir/grazoprevir, hemodialysis, hepatitis C virus genotype 2a, sofosbuvir/daclatasvir


How to cite this article:
Elmelodi MB, Shaibani B, Ayad K. Elbasvir/grazoprevir treatment in a hemodialysis patient with hepatitis C Virus Genotype 2a Infection, not responded to sofosbuvir/daclatasvir combination therapy. Libyan J Med Sci 2021;5:132-4

How to cite this URL:
Elmelodi MB, Shaibani B, Ayad K. Elbasvir/grazoprevir treatment in a hemodialysis patient with hepatitis C Virus Genotype 2a Infection, not responded to sofosbuvir/daclatasvir combination therapy. Libyan J Med Sci [serial online] 2021 [cited 2021 Nov 29];5:132-4. Available from: https://www.ljmsonline.com/text.asp?2021/5/3/132/328086




  Introduction Top


Hepatitis C virus (HCV) infection is one of the main causes of chronic liver disease worldwide.[1],[2] The prevalence of HCV infection in the hemodialysis (HD) population varies worldwide from 1% to more than 70%. In Libya, the overall prevalence is 16.7%, ranging from 0% to 26.3% at different dialysis centers.[3] The duration of HD was statistically significantly longer in HCV-positive HD patients than in HCV-negative patients.[3],[4]

The treatment of patients with chronic hepatitis C (CHC) has entered a new therapy with direct-acting antivirals (DAAs) which significantly increases the sustained virological response (SVR) rates and shortens the duration of treatment.[5] However, the time and drug type of antiviral treatment for HD patients with CHC remain unclear. Some studies have shown that a satisfactory effect was achieved when chronic HCV infection has been treated with DAAs therapies. However, few patients do not respond.

Elbasvir/grazoprevir (EBR/GZR) is a fixed-dose combination treatment for HCV genotype 1 or 4 infections. The efficacy and safety of EBR/GZR in HD patients have been reported.[6],[7],[8],[9],[10] However, to our knowledge, there are no reports on EBR/GZR use in HCV-infected patients with genotype 2, with the previous failure to respond to other DDAs therapy. Herein, we report a case of successful treatment of HCV genotype 2a infection in a HD patient using EBR/GZR, who failed to respond to 12 weeks of treatment with sofosbuvir/daclatasvir combination.


  Case Report Top


A 57-year-old Libyan female polycystic patient on regular HD program three times per week at Azzawiyah Kidney Hospital-Libya, since May 2002 diagnosed with HCV infection in March 2003 and has had received interferon in 2014 for 1 year but was not cured. In 2018, her routine laboratory follow-up showed white blood cells at 6.6 × 103/dL, red blood cells at 4.3 × 106/dL, platelets at 185 × 103/dL, total bilirubin of 1.6 mg/dL, direct bilirubin of 0.8 mg/dL, alanine aminotransferase of 21U/L, aspartate aminotransferase of 13U/L, alkaline phosphatase of 128U/L, and glutamyl transpeptidase of 335 U/L. The International Standard Ratio of 1.3, and albumin of 3.6 g/dL. HBsAg was negative, anti-HCV antibody was positive, HCV-RNA viral load was 5.5 × 104 IU/mL, and HCV genotype was 2a. General and systemic examinations were unremarkable.

In mid-2017, DAAs become available in Libya, hence in November 2017; this patient (among 32 other patients) enrolled for antiviral treatment with DAAs using the combination of Sofosbuvir 400 mg tablet/daclatasvir 60 mg tablet at once-daily dose for 12 weeks. The patients were reviewed at weekly intervals during the treatment for 12 weeks, and at posttreatment months 3, 6, and 12. HCV-RNA as well as antiHCV antibodies were still positive at the end of the treatment (month 3) and remained positive 1 year later. The patient was considered nonresponder for this treatment, and in November 2018, she was given EBR/GZR in a dose of 50/100 mg single tablet/day for 12 weeks, she showed negative antiHCV antibody and finished the treatment time with no side effects. In March 2020, again tested negative for antiHCV, and no viral load was detected in her polymerase chain reaction test.


  Discussion Top


Patients undergoing dialysis treatment, and in particular HD, are at increased risk for contracting viral infections. This is due to their underlying impaired cellular immunity, which increases their susceptibility to infection. In addition, the process of HD requires blood exposure to infectious materials through the extracorporeal circulation for a prolonged period. Moreover, HD patients may require blood transfusion, frequent hospitalizations, and surgery, which increase opportunities for nosocomial infection exposure.[11] The prevalence of genotype 4 and 1a (66% and 60%, respectively) among Libyan dialysis population, with the predominance of genotype 4 at western region and genotype one predominate at eastern region.[12],[13] DAAs are recommended for patients with CHC by 15 European Association for the Study of the Liver and the American Association for the Study of Liver Diseases guidelines.[14],[15] However, the data on DAAs therapy in HD patients with CHC are limited. SOF and DCV were recommended to treat all genotypes of patients with CHC. SOF is a pan-genotypic nucleotide analog inhibitor of the HCV NS5B RNA polymerase, whereas DCV is a pan-genotypic inhibitor of the HCV NS5A protein. DCV and SOF with or without RBV achieved high SVR12 and were well tolerated by patients with CHC.[16] EBR/GZR is a combination of a NS5A replication complex inhibitor EBR and a NS3/4A protease inhibitor GZR. EBR prevents the replication of viral cells by interacting with the NS5A protein on HCV replicon cells, which are responsible for reducing human interferon antiviral activity. Basing on the clinical studies on DAAs for the treatment of patients with CHC, we presumed that they might be effective in the treatment of HCV patients on HD as well. The present patient tested positive for both HCV-RNA and anti-HCV antibody during 12 weeks after the infection with no spontaneous clearance. She was again persistently positive for HCV-RNA after 12 weeks and at 1-year posttreatment with DAAs in the form of SOF/DCV combination. After she received EBR/GZR for 12 weeks, achieved SVR-12, and have her HCV-RNA viral load undetectable, anti-HCV antibody underwent seroconversion, liver function tests returned to normal, and no adverse event occurred during treatment.


  Conclusions Top


Although DAAs proved efficient and safe in treating HCV infection, the presented case reveals that some HD patients with CHC may be resistant and are less prone to obtain spontaneous clearance with some of DAAs. Other DAA group can provide SVR. It is worth trial to treat with different DAA in case of nonresponsiveness.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors acknowledge the laboratory staff of the National Center for Disease Control for help in performing blood tests.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest



 
  References Top

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Reddy KR, Roth D, Bruchfeld A, Hwang P, Haber B, Robertson MN, et al. Elbasvir/grazoprevir does not worsen renal function in patients with hepatitis C virus infection and pre-existing renal disease. Hepatol Res 2017;47:1340-5.  Back to cited text no. 8
    
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