Table 4.

Preventive measures to minimize HCV in renal transplant patients a

aATG, antithymocyte globulin ; ALG, antilymphocyte globulin. Other abbreviations as in Table 1.
Measures while patient is on waiting list
• avoid blood transfusions.
• isolate HCV-positive patients.
• treat with interferon-α if chronic hepatitis is documented by biopsy and if HCV-RNA is detected.
Measures in the perioperative period of renal transplantation
• avoid blood transfusions.
• do not transplant kidneys from HCV-positive donors into HCV-negative recipients.
Measures after renal transplantation
HCV-positive patients must be followed closely to detect deterioration of liver function, infectious diseases, or proteinuria.
Immunosuppression
• use “non-aggressive” immunosuppressive protocol : no routine use of ATG, ALG, or OKT3, except in immunologically high-risk patients.
• immunosuppression in the maintenance phase depending on the severity of liver disease.
Liver disease
• at each visit, liver enzymes, bilirubin, and prothrombin time should be measured ; HCV serology and HCV-RNA should be tested at least twice a year.
• liver biopsy should be considered in patients with abnormal liver function (diagnosis, prognosis, modulation of immunosuppression, possible treatment).
• antiviral therapy, except interferon, in patients with severe liver dysfunction should be considered on a case-by-case basis.
extremely important : if HCV-positive patients present severe cholestasis, liver biopsy should be performed immediately. If fibrosing cholestatic hepatitis is present, interferon therapy should be considered on a case-by-case basis.
• in patients with cirrhosis, ultrasonography and α-fetoprotein levels should be monitored frequently to detect early liver carcinoma.
• in patients with terminal hepatic failure, liver transplantation should be considered.
• avoid potentially hepatotoxic drugs and alcohol.
Infections
• be on the alert for severe and opportunistic infections.
• in case of fever, start effective antibiotic treatment early.
Proteinuria
• test for proteinuria and microhematuria at each visit.
• in case of persistent proteinuria, do immunologic tests (cryoglobulins) as part of the differential diagnosis and consider graft biopsy.
• consider antiviral treatment such as ribavirin.