Glomerular Diseases Associated with Hepatitis B and C Infection, Pediatric

Abstract

The hepatitis B (HBV) and C (HCV) viruses infect billions of people worldwide causing chronic infection in hundreds of millions with high morbidity and mortality. Chronic infection with these viruses is a major cause of hepatitis, cirrhosis, and liver failure in adults throughout the world. HBV and HCV are blood-borne virus transmitted by exposure to infected blood and body fluids. Most children acquire these infections in utero or the perinatal period although the increasing use of IV drugs appears to be leading to a surge in adolescent rates of infection. In addition to liver involvement, HBV and HCV can cause extra-hepatic disease including various forms of glomerulonephritis and vasculitis resulting in proteinuria, hypertension, nephrotic syndrome, and end-stage renal disease. Children with HBV most commonly develop membranous nephropathy with clinical manifestations of proteinuria, hypoalbuminemia, and edema. HBV-associated renal disease has been reported to resolve spontaneously in some pediatric patients, but others may benefit from antiviral therapy. HCV-associated renal disease, most commonly seen as cryoglobulinemia and membranoproliferative glomerulonephritis, is rare in the pediatric population but should be considered and evaluated in high-risk patients. The prognosis, long-term sequelae, and treatment recommendations of both HBV and HCV infection are changing rapidly given recent advances in antiviral therapy. Children with chronic HBV and HCV are often not treated unless they manifest overt hepatitis or glomerulonephritis because they are unlikely to have clinically apparent disease until adulthood. Routine vaccination against HBV has decreased the rate of infection and associated disease manifestations substantially. Antiviral therapy in HBV in children is still dependent on interferon-alpha which has significant side effects and is poorly tolerated; however, new medications have been approved for use in adults and will likely change pediatric treatment recommendations in the future as well. Treatment and prognosis of HCV has changed dramatically with the approval of direct acting antiviral (DAAs) in adolescents and adults that can eradicate the virus in some patients with 3 months of treatment. DAAs are often used in combination and recommendations about optimal therapy continue to change frequently. There are ongoing trials to evaluate DAAs in children. Recommendations for when to treat children with HBV and HCV are likely to continue to evolve with the results of current and future clinical trials testing the newer more effective and tolerable antiviral medications.