Complex management issues: management of HCV in the atypical patient

Some patients with chronic hepatitis C virus (HCV) infection demonstrate at ypical features of presentation and clinical course. These features may be due to direct or indirect effects of the underlying HCV infection or may be part of a separate clinical syndrome. Patients that can be ;categorized as 'atypical' include immunosuppressed individuals (hypogammaglobulinaemic, c oinfected with human immunodeficiency virus, recipients of solid organ or h aematopoietic cell transplants, those with associated disease requiring chr onic immunosuppressive therapy and patients with chronic renal failure on h aemodialysis) as well as patients with various extrahepatic (HCV-associated mixed cryoglobulinaemia. membranoproliferative glomerulonephritis etc) or autoimmune manifestations. Since many of these patients have been excluded from the large trials evaluating the efficacy of interferon-alpha alone or in combination with ribavirin, data regarding management are limited. In th is chapter, the available information regarding the treatment of these pati ents is reviewed and the frequently encountered therapeutic dilemmas discus sed. Finally, some reasonable therapeutic approaches are suggested while th e need for controlled studies for these groups of patients is emphasized.