New recommendations in the treatment of Gram-positive bacteraemia in dialysis patients.

patients. The literature of the last few years offers convincing information that supports this opinion, both in patients with normal kidney function [1] and in haemodialysis patients [2]. So we were not surprised to learn that a second treatment course with a higher RBV dose in one of the two patients that failed a sustained viral response in our pilot study was as yet effective. At the time that the guidelines for our pilot study were settled and placed on the website of the Dutch Federation of Nephrology (NFN) only scarce information was available concerning the use of RBV in renal insufficiency. It was even considered to becontraindicated. Partly based on earlier experience [3] we were convinced that RBV could be used in a safe and possibly effective way if the dosage could be guided by plasma trough level determinations aiming at a so-called therapeutic range (1.5–2.5 μg/ml). This range was defined on the available experimental information at that moment but there was no firm proof of the clinical efficacy. To start a pilot study we had to be very careful and made a choice for a relative low dose. To prevent serious haemolytic anaemia—the most important complication of RBV—a high dose of erythropoietin (Epo) is necessary in the treatment of dialysis patients. A dose of 30 000–40 000 IU/week was permitted in the studies of Rendina [2] and Bruchfeld [4] and also in our study, but the mean dose remained limited to 19 000 IU/week in the last one. During the first 12 weeks of our study the RBV plasma level was often low despite small increases of the dose. Based on this experience we will advocate now a higher starting dose of 300 mg/day, preceded by a much more generous use of Epo. Plasma level monitoring of RBV promotes safety and helps to guide the dosing of RBV. Future results will possibly help to define an optimal therapeutic range. A higher RBV dose is necessary to achieve still better results and this needs further exploration. We believe that our pilot study has contributed to the effective treatment of hepatitis C-infected vulnerable dialysis patients.