An epidemic of hepatitis in a chronic-hemodialysis unit. Australia antigen and differences in host response

Viral hepatitis A and B in hemodialysed patients

In 113 hemodialysed patients, 167 hospitalized patients, and 143 outpatients the frequency of HAV and HBV markers were studied by testing HBsAg, anti-HBs, anti-HBc, HBeAg, anti-HBe, and anti-HAV. The hemodialysis patients in a dialysis-center had significantly more often HBV markers (85.7%) than those maintained on home-dialysis (46.5%). 29.9% of the hospitalized patients and 32.1% of the outpatients had HBV markers. By the anti-HBc test up to 41% of additional HBV infections could be detected.--The prevalence of anti-HAV was very high in all groups. Significant differences between the hemodialysis patients and the control groups existed only in the age groups up to 39 years.--The frequencies of HAV and HBV markers were related to age, duration of dialysis treatment, transfusional frequency, and transaminases. The HBV appeared as the clinically important hepatitis agent in dialysis.

Hepatitis B surface antigen (HBSAg) in peritoneal fluid of HBSAg carriers undergoing peritoneal dialysis

Samples of ascitic fluid and outflow dialysate were collected from HBSAg carriers undergoing peritoneal dialysis and tested for HBSAg by solid-phase radioimmunoassay. The surface antigen was detected in every sample from HBSAg carriers. This finding was not dependent upon the presence of occult blood in the sample. Surface antigen particles and possibly Dane particles were also observed in HBSAg-positive samples by immunoelectron microscopy. These results identify the outflow dialysate of HBSAg carriers undergoing peritoneal dialysis as a potential source of hepatitis B virus transmission.

The complement system in uremia

Plasma C1q, C1 esterase inactivator, C4, C3 and C3 proactivator were measured in 20 chronic uremic patients on maintenance hemodialysis, in 10 conservatively treated chronic uremic patients and in 20 healthy volunteers. There was no statistical significant difference between the patient groups in any of the measured complement components. The C1q, C1 esterase inactivator and C4 concentration were found to be the same in the patient and the control groups. The C3 and C3 proactivator levels were equally and significantly lower in both patient groups compared with the healthy volunteers.

Sex differences in response to hepatitis B virus. I. History

Sex differences related to responses to hepatitis B infection are reviewed. In most human populations there is a higher prevalence of chronic carriers of hepatitis B virus (persistently HBsAg+) among males than females. Females are more likely than males to produce anti-HBs in response to infection. Diseases associated with increased frequencies of carriers are more prevalent among males. The response of parents to hepatitis B virus (HBV) infection appears to affect the sex ratio at birth of their offspring. Couples in which either parent is a carrier have higher sex ratios (higher proportion of males) compared with couples in which neither parent is HBsAg+. Couples in which the mother is anti-HBs+ have children with lower sex ratios than either carriers or uninfected couples.

Dental management for children with chronic renal failure undergoing hemodialysis therapy

Patients with chronic renal failure who are undergoing hemodialysis therapy demonstrate problems of significant importance for dental treatment. A case is presented in which secondard hyperparathyroidism, resulting from renal failure and hemodialysis, was noted in a child. Other relationships between renal failure, hemodialysis, and dental care were also presented.

"Triple infections" (fungal, bacterial and viral) in immunosuppressed renal transplant recipients

In a period of 5 years, 8 out of 77 renal transplant patients showed simultaneous fungal, bacterial and viral infections. Candida albicans was found in all cases. The most severe bacterial complications were infections with Klebsiella, Pseudomonas and Staphylococcus aureus. Cytomegalovirus, persistent HBsAg positive hepatitis, herpes zoster, and herpes simplex infections were also found. Seven patients died of bacterial superinfection and miliary tuberculosis. The data presented show that "triple infections" are associated with high mortality and that miliary tuberculosis occurred frequently in immunosuppressed renal transplant recipients.

Prevalence of hepatitis B in 27 Michigan hemodialysis centers

A large epidemiological survey of inhospital chronic hemodialysis patients was conducted in 27 (93%) of the 29 dialysis centers in Michigan. Serum was collected from 699 patients on chronic maintenance hemodialysis for periods from one month to eight years. Hepatitis B surface antigen (HBsAg) was determined in all patients by radioimmunoassay and positive samples were confirmed by specific neutralization. Antibody against HBsAg (anti-HBs) was determined by radioimmunoassay in 110 HBsAg negative patients from six dialysis units with a high prevalence of hepatitis B. HBsAg was detected in 80 (11.4%) patients distributed among 21 (78%) of 27 dialysis units and anti-HBs in 34 (31%) patients from the selected dialysis units. The prevalence of HBsAg was related to duration of dialysis, number of blood transfusions, and to a history of bilateral nephrectomy, but not to age, sex, race, nor the underlying renal disease. Twenty-one (26%) of the 80 HBsAg positive patients had not been previously identified by the clinical laboratories of their institutions. Since preventive measures were not taken in the care of these inapparent carriers of HBsAg, they represent an unrecognized risk.

A clinicopathological study of liver disease in haemophiliacs

Chronic liver disease is not often reported in patients with haemophilia. Although a high incidence of abnormal liver function tests has been reported, the clinical significance of these findings and their relation to chronic liver disease cannot be established without a liver biopsy. The results of this procedure, carried out in 11 patients with severe haemophilia A and B, in whom SGOT had been persistently raised for three years, are reported. Five patients had chronic active hepatitis, four had chronic persistent hepatitis, one had cirrhosis, and one alcoholic hepatitis. No haemorrhagic complication followed the biopsy procedure, which was carried out in patients given prophylactic clotting factor concentrates. These results suggest that duration of abnormal liver function tests is likely to represent liver disease in haemophiliacs, and that biopsy should be considered to establish the diagnosis and plan a suitable therapeutic programme.

Hepatitis B surface antigen in urine of hemodialysis patients

As part of an extensive epidemiological survey of chronic hemodialysis patients in Michigan, hepatitis B surface antigen (HBsAg) was identified in the sera of 79 of 701 (11%) patients. Of these patients, 59 were carriers of HBsAg for three or more months. Urine samples were collected from 36 of 39 HBsAg carriers having urinary output. Of these samples, 19 (52%) were positive for HBsAg by radioimmunoassay; this was confirmed by specific antibody neutralization. The HBsAg was not identified in the urine of seven hemodialysis patients who were lacking serum HBsAg or in urine samples from three HBsAg sero-carriers who had normal renal function. Patients undergoing maintenance hemodialysis appear to constitute a large reservoir of HBsAg chronic carriers. This study indicates that a minimum of 50% of persistent HBsAg carriers who are producing urine have detectable HBsAg in single, randomly timed, unconcentrated urine specimen. These data suggest that urine may represent a potential vehicle for transmission in nonparenterally acquired hepatitis B.

Liver disease in renal transplant recipients

Liver disease is a common complication in renal transplant recipients. Several types of liver disease can occur. The most common are acute and chronic hepatitis. The variety of acute hepatitis include hepatitis A, hepatitis B, cytomegalovirus hepatitis, herpes simplex hepatitis and azathioprine hepatitis. The incidence of azathioprine hepatitis may not be as high as initially suggested. Chronic hepatitis is a serious problem because the disease seems to be progressive despite prednisone therapy. The causes of this chronic hepatitis are not fully known, although hepatitis B, cytomegalovirus and herpes simplex virus have been implicated. Discontinuation of azathioprine therapy has no appreciable effect on the course of chronic hepatitis.

Humoral and cell-mediated immunity to hepatitis B virus antigen in a haemodialysis-renal transplantation unit

Hepatitis B surface antigen (HBsAg), the corresponding antibody (anti-HBs), the antibody to hepatitis B core antigen (anti-HBc), and the cellular immune response to purified HBsAg (leucocyte migration inhibition test: LMT-HBsAg) were determined in 19 staff members, 11 long-term haemodialysis patients, and 22 renal transplant patients in a haemodialysis-renal transplantation unit. Past or present infection, as expressed by the presence of circulating anti-HBs or HBsAg, was found in 30 cases (58 per cent) (11 staff members, six dialysis patients and 13 transplant patients). Anti-HBc was found in all the ten HBsAg positive cases--all patients--and in 15 out of 20 anti-HBs positive cases. Four staff members and seven patients had positive LMT-HBsAg; of these only one patient had HBsAg, whereas seven cases had anti-HBs. Neither the antibody determination nor the leucocyte migration inhibition assay disclosed any significant difference between patients and staff which could explain the different course of the hepatitis B virus infection in the two groups.

Hepatitis B antigen--a survey in a major metropolitan hospital

The prevalence of hepatitis B antigen in blood donors in the Wellington Hospital region is 0-27%. A retrospective survey of 66 persons found by the Wellington Hospital Laboratory to be hepatitis B antigen positive between September, 1971 and August, 1975, showed that over this period there has been a consistent decline in the number of new antigen positive cases found per year. This appears to be due to a decline in the numbers originating in the renal unit. A liver biopsy was taken in only one case and this showed chronic persisting hepatitis. Apart from the renal unit, high risk patients and staff are not tested regularly for hepatitis B antigen. Regular testing of laboratory staff and patients and staff of the cardiothoracic and haematology departments is recommended.

Host responses to hepatitis B infection in patients in a chronic hemodialysis unit

Host responses to hepatitis B infection were studied in 222 patients in a chronic hemodialysis unit. From 1970 to 1976, patients were monitored monthly for development of hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), and serum transaminase (SGPT) elevations. Five categories of patients were identified as: 1) chronic carriers of HBsAg; 2) transiently HBsAg(+), who developed anti-HBs; 3) HBsAg(-) on admission, who developed anti-HBs without becoming HBsAg(+); 4) anti-HBs(+) on admission; 5) uninfected who remained HBsAg(-) and anti-HBs(-). For a patient who became HBsAg(+) in this clinic, the probability of becoming a chronic carrier was 62-8% and rose to 88.5% if he or she had been HBsAg(+) for five consecutive months. Males were more likely to become chronic carriers, and females were more likely to develop anti-HBs. Neither age, race, nor type of underlying kidney disease was associated with particular host responses to hepatitis B virus. No effect of hepatitis B infection on mortality was detected. Variation in host response to hepatitis B infection among renal dialysis patients may affect the usefulness of hepatitis B hyperimmune globulin and hepatitis B vaccine and be related to the outcome of kidney transplantation.

Association of graft survival with host response to hepatitis B infection in patients with kidney transplants

We studied the relation of host response to hepatitis B infection before transplantation with survival of kidney grafts in 79 patients receiving 87 transplants. Antibody to hepatitis B surface antigen (anti-HBs) signaled early graft rejection (median survival congruent to two months), whereas hepatitis B surface antigen (HBsAg) signaled delayed rejection (greater than 22 months). Patients with neither HBsAg nor anti-HBs had graft survival times (median congruent to 16 months) similar to the HBsAg carriers but significantly longer than the anti-HBs-positive patients (p less than 0.01). Similar results were observed when patients who received HLA-identical kidneys or had anti-HLA antibodies before transplantation were excluded. The highest probability of graft rejection was in patients with anti-HBs who received kidneys from male donors. The probability that such grafts would survive for four months was less than 20 per cent. HLA-nonidentical kidneys transplanted into patients with anti-HBs have a poor prognosis, whereas such grafts in HBsAg carriers have as good a prognosis as grafts in uninfected recipients.

T-lymphocyte number and function and the course of hepatitis B in hemodialysis patients

To study the relation between general cellular immunity and the course of hepatitis B within a group of chronic hemodialysis patients, T-lymphocyte number and function were investigated in 13 persistently hepatitis B surface antigen (HBSAg)-positive patients, in 32 HBSAg-negative patients, and in 11 patients who had recovered from hepatitis B and compared with that of 21 age-matched controls. Phytohemagglutinin-induced lymphocyte stimulation in vitro and the number of circulating T-cells in the HBSAg-positive group were significantly decreased as compared with those of the recovered group and the controls. Lymphocyte stimulation by pokeweed mitogen and by an antigen cocktail showed the same tendency, but no significant differences between the HBSAg-positive and the recovered groups. Uremic sera from the three patient groups had similar depressive effects on phytohemagglutinin induced lymphocyte stimulation of controls. Serum immunoglobulin G, (IgG), IgA, and IgM were normal in the three patient groups. It is concluded that chronic hemodialysis patients, who have become persistent HBSAg-carriers, have a significantly decreased T-lymphocyte number and function as compared with hemodialysis patients who are able to eliminat hepatitis B virus (HBV). The difference could not be ascribed to the HBV infection itself. This indicates that T-cells play an important role in the elimination of HBV in hemodialysis patients.

Cytomegalovirus hepatitis in an artificial kidney unit

Serum hepatitis is a dreaded risk in connection with regular dialysis treatment (RDT). Liver damage, however, can be cuased by other diseases, such as infection with cytomegalovirus (CMV). Two cases in our artificial kidney unit revealed signs of liver damage with increased liver enzyme activity. Case 1, a woman, was on RDT after an unsuccessful renal transplantation, and Case 2, a man, belonged to the staff. Serum hepatitis was initially suspected in both cases, but repeated examinations of the sera revealed no hepatitis B antigen or antibodies (HbAg and HbAb). Later on, both showed a significant increase in antibodies in complement fixations reaction (CF) to CMV-antigen. CMV could be isolated from urine in Case 2. Case 1 had been bilaterally nephrectomized. The symptoms (tiredness, muscle pain and headache) and the course of the disease were mild in both cases and liver enzymes became normal within 1-2 weeks. Twenty out of 31 examined patients and staff had antibodies in CF to CMV-antigen, but in none was there any significant increase. The source of infection may have been transfusion of fresh blood in Case 1, but in Case 2 no particular source could be suspected. Thus, in liver damage CMV-infection may be an etiological alternative. In routine work at artficial kidney unite patients and personnel are regularly examined in respect of bilirubin, liver enzymes, HbAg and HbAb in serum. We recommend also examination of serum for antibodies in CF to CMV-antigen. Until a firm differential diagnosis has been established the patient should be isolated and the dialysis equipments used only by that patient.

Hepatitis-B: a review

The recent literature on various aspects of hepatitis-B is reviewed with emphasis on the interrelationships of viral structure, antigenic components, and host immune response in acute, chronic, and asymptomatic carrier states of the infection. The mode of replication and mechanisms of transmission are discussed. Special attention is paid to potential non-parenteral routes of spread. The role of hepatitis-B in associated immune complex diseases and in hepatoma is outlined. A guide to the interpretation of serologic tests for hepatitis-B associated antigen and antibody patterns is presented in relation to the clinical stage and prognosis of the infection. Therapy, except in conceptual terms, is not covered but a summary of the current status of active and passive immunization is given. The unresolved question of the infectivity of carrier medical staff for their patient contacts, and the reverse, is discussed.

Asymptomatic liver disease in haemophiliacs

The incidence of jaundice and of abnormal liver function tests has been assessed in 91 multitransfused patients with severe haemophilia A and B. Tests of hepatocyte function were within the normal range in the majority of patients. On the contrary, tests of biliary cell function, liver cell damage, and bromsulphthalein retention gave high rates of abnormal values, which tended to increase with age. Hepatitis B surface antigen was present in 8% and the corresponding antibody in 66% of the cases; 18% had a history of jaundice. All patients were asymptomatic and only a minority showed clinical signs of liver involvement. These data suggest that in haemophilacs repeated and prolonged contact with the agent(s) responsible for post-transfusion hepatitis may cause chronic liver damage not associated with overt illness.

Thymus-derived lymphocytes in type B acute viral hepatitis and healthy carriers of hepatitis B surface antigen (HBsAg)

To assess thymus-derived (T) lymphocyte function in hepatitis B infection, lymphocytes from patients with type B acute viral hepatitis and healthy carriers of the hepatitis B surface antigen, were compared to normal controlss using phytohemagglutinin (PHA) -induced blast cell transformation and sheep-cell rosette formation. Overall cell (T lymphocyte) -mediated immune function was similar with these in vitro assays in all three groups, except for decreases in total T cells in isolated patients with acute disease. Consequently, if a defect in cellular immunity exists in normal controls with persistent hepatitis B infection, it is probably specific for the antigens of the hepatitis B virus and not related to a generalized impairment of T-lymphocyte function.

[Immune mechanisms in uremia]

There is both clinical and experimental evidence that cellular and humoral immunity are suppressed in patients with renal insufficiency: observations in organ transplantation and in vitro stimulation of lymphocytes from uraemic patients, investigations of acute and late hypersensitivity reactions, the immune response after active immunization as well as changes of immunoglobulins and lymphatic organs in uraemia are discussed in the paper. The underlying mechanisms are complex and not yet fully understood. Lymphopenia, atrophy of the thymus gland, toxic serum factors, induction of enhancing mechanisms by certain serum fractions and metabolic defects of lymphocytes--all were shown to be involved or at least considered to be. At present, however, it is impossible to define their rank of importance and the exact place they may occupy in the genesis of this type of "natural immunosuppression".

Radioimmunoassay of hepatitis b antigen and antibody in dialysis and transplant patients

57 dialysis patients, 29 of whom had been exposed to hepatitis in 1968-69, were re-examined for hepatitis B antigen (HB-Ag) and antibody (HB-Ab) by means of radioimmunoassay (RIA) and counter immunoelectrophoresis (CIE). Infected patients were followed for five years. Compared to CIE, RIA did not detect additional HB-Ag-positive patients, but antibody could persistently be detected in seven out of fifteen patients previously supposed to have escaped infection. tnine surviving HB-Ag-positive transplant patients remained carriers for 50-72 months. None developed clinical signs of chronic hepatic failure.

Hepatitis B in a pediatric hemodialysis unit

Serial HB Ag determinations were obtained on 62 children undergoing hemodialysis during a 31/2-year period. Thirty six (58%) of the patients had atleast one positive HB Ag determination (titer larger than 1:8) either during the period of dialysis or within 2 months after transplantation. Of the children who became HB Ag positive during the period of dialysis, 89% demonstrated hepatitis B antigenemia during the initial 6 months of dialysis. Becuase of the temporal relationship between the development of HB Ag positivity and the duration of dialysis, contamination of equipment was proposed as a contributing source for transmission of HB Ag. Although 67% of the patients who were HB Ag positive during dialysis developed biochemical evidence of hepatic dysfunction, only two patients had clinical manifestations. The incidence of hepatic involvement appeared to be related to age; only one of nine children less than 12 years of age had evidence of hepatic disease. Intermittent persistence of HB Ag for periods larger than 3 years was observed. Both the incidence and persistence of HB Ag indicate the need to prevent its acquisition by pediatric patients undergoing hemodialysis.

Liver impairment during chronic hemodialysis and after renal transplantation

Liver impairment has been evaluated in a consecutive series of 79 patients with chronic renal failure of whom 23 were treated with hemodialysis alone and 37 with hemodialysis and renal transplantation alone. In half of the chronic hemodialysis patients and half of the patients receiving a renal allograft elevation of serum alanine aminotransferases was observed for a shorter or longer period during the study. In half of these cases from both groups the clinical course, laboratory data and liver histology were consistent with virus hepatitis and four patients died from fulminant hepatic failure. In the other half of the patients with elevated transaminases, this was either asymptomatic and unexplained or due to other causes such as septicaemia or urinary leakage. Liver biopsy showed unspecific changes. Renal transplantation was not performed in patients suffering from virus hepatitis, but 12 of the 37 patients who received a renal allograft had elevated aminotransferases at the time of transplantation. In seven of them a marked increase in aminotransferase was observed postoperatively, but none developed clinical sign of liver disease. It is concluded that elevated aminotransferase activity per se is no contraindication to surgical procedures, including renal transplatation, in these patients. However, a liver biopsy should be performed to detect a possible liver disease.

The relationship between hepatitis B antigen, e-antigen, and liver-pathology in patients treated with dialysis

The relationship between hepatitis B antigen (HB Ag), e-antigen and liver pathology was studied in 27 patients who had died after regular dialysis treatment. The examination of the liver histology was done without knowledge of the history of the patient. Seventeen of the patients were HB Ag positive at death and had been carriers of the antigen for between 1 and 57 months. Two had chronic aggressive hepatitis and 10 chronic persistent hepatitis, but 5 had no histological signs of chronic hepatitis. e-antigen could be found in blood samples from all these patients. The cause of kidney disease, duration of dialysis and time of carriership of HB Ag showed the same variation among the patients without as among the patients with signs of chronic hepatitis. Two patients who had been HB Ag positive but were negative at death had no signs of chronic hepatitis. HB Ag positive samples available from one of these patients were also positive for e-antigen. Eight patients who were constantly negative for HB Ag were also negative for e-antigen. One of them had autopsy findings of a chronic persistent hepatitis. There were thus very moderate or even no histological signs of chronic hepatitis among these patients in spite of prolonged carriership of HB Ag. A very close correlation between HB Ag and e-antigen was also found.

Australia antigen: persistence of immunological markers (d, y, w) in antigen carriers

It is important to establish the stability of Australia antigen subtypes in chronic carriers in order to evaluate the validity of using immunological determinants as long-term epidemiological markers. In this study sequential blood samples containing Australia antigen from 31 chronic carriers were typed for determinants d, y, and w. The subjects included asymptomatic carriers from Rongelap Atoll in the Marshall Islands, Down's syndrome patients, and renal patients receiving hemodialysis treatment. The period of time between blood samples extended from 3 months to 11 years. In no case did the subtype change within any individual. It appears from these data that the Australia antigen subtypes are good long-term markers for epidemiological studies.

Hepatitis in dialysis units in the United Kingdom

A prospective study of hepatitis in 20 dialysis units in the United Kingdom showed that the number of units with outbreaks increased from one in 1968 to three in 1969 and the overall attack rate rose from 1.7 to 5.3% in patients and from 0.5 to 1.3% in staff.In July 1969 a pilot study of patients' sera showed that all of the outbreaks were associated with Australia (Au) antigen. Au antigen was not detected in the unaffected units or in one unit in which there were several patients with abnormal liver function.In January 1970 systematic prospective testing for Au antigen was begun. Au antigen was detected in single patients in five more of the 20 units. The transfer of the affected patients to isolation for dialysis seemed to prevent the spread of infection in the units. The incidence of hepatitis in 1970 was 5.6% in patients and 0.4% in staff.

Neuropathy associated with hepatitis in patients maintained on haemodialysis

During a study of peripheral nerve function in chronic renal failure, 11 patients who were being treated by chronic intermittent haemodialysis developed serum hepatitis. Before the infection there was a trend towards improvement in nerve conduction velocities. A pronounced deterioration in the conduction velocities in motor fibres of peripheral nerves occurred in association with hepatitis. In the months after recovery from the infection there was again a trend towards improvement in conduction velocities. We suggest that this reflects the occurrence of a peripheral neuropathy which is at least in part demyelinating. The neuropathy is related to the serum hepatitis, but its pathogenesis is indeterminate.