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Reversal of end-stage renal failure using direct-acting antiviral agents for chronic hepatitis C

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Clinical record

A 58-year-old Eritrean woman presented to hospital in December 2014 with a vasculitic rash, peripheral oedema, acute renal impairment and microscopic haematuria with proteinuria. She had a history of genotype 4 hepatitis C virus (HCV) infection, which was unsuccessfully treated with pegylated interferon and ribavirin in 2010. Results of laboratory investigations showed a pattern consistent with mixed cryoglobulinaemia (Box 1). After a renal biopsy to assess progressive renal impairment, a diagnosis of membranoproliferative glomerulonephritis (MPGN) was made. The patient began taking an angiotensin-converting enzyme inhibitor and diuretic therapy.

The patient’s creatinine level continued to worsen, from 202 μmol/L (reference interval [RI], 45–90 μmol/L) (estimated glomerular filtration rate [eGFR], 27 mL/min/1.73 m2 [RI, > 60 mL/min/1.73 m2]) in January 2015 to 412 μmol/L (eGFR, 10 mL/min/1.73 m2) in July 2015. The renal impairment was associated with increasing serum cryoglobulin levels, worsening proteinuria and increased requirement for ascitic drainage. The ascitic fluid was a transudate, and a transjugular liver biopsy excluded cirrhosis. Infection and malignancy were also excluded. As the eGFR was below 15 mL/min/1.73 m2 and fluid overload had become refractory to medical…