Hepatitis C in dialysis patients

A shield against a monster: Hepatitis C in hemodialysis patients

Hepatitis C virus (HCV) infection is highly prevalent among patients on hemodialysis (HD). The prevalence of HCV infection in HD patients varies markedly from country to country. Some factors are especially related to these high prevalence rates, such as blood transfusions and length of dialysis time. Nosocomial routes of transmission including the use of contaminated equipment and patient-to-patient exposure is considered more important. Several prophylactic measures have been suggested to avoid infection by HCV in the HD environment.

Hepatitis C virus infection in haemodialysis: the 'no-isolation' policy should not be generalized

Hepatitis C virus (HCV) infection is the most common blood-borne viral infection in haemodialysis. It causes significant morbidity and long-term mortality. Practice of universal precautions has been reported to be sufficient to prevent HCV seroconversion in dialysis units. However, the seroconversion rate remains very high in many dialysis units. A previous study from 1995 to 1998 at our own hospital without isolation showed that nosocomial transmission is the major cause of HCV seroconversion. The present study was therefore conducted with the aim to study the impact of isolation on HCV seroconversion. In this prospective cohort study, with non-probability consecutive sampling, patients with HCV infection were dialysed in an isolated room. In addition, standard universal precautions were practiced. HCV seroconversion rate was compared with the previous study. All patients with end-stage kidney disease (ESKD) admitted to our hospital for renal replacement therapy were included in the present study. At the time of admission, HCV screening was done. All anti-HCV-positive patients were dialysed in an isolated room. While on maintenance haemodialysis, all patients were monthly tested for anti-HCV, aspartate aminotransferase and alanine aminotransferase. Any patient who had HCV seroconversion was transferred to an isolated room for maintenance haemodialysis. Patients with HCV infection were managed by further testing for HCV-RNA and liver biopsy. Every patient who ultimately received renal transplantation at our hospital was also tested for HCV just prior to renal transplantation as well as 3 months after renal transplantation. HCV infection was diagnosed by detecting anti-HCV antibodies using an ELISA-based third-generation diagnostic test kit. Serum bilirubin, aspartate aminotransferase and alanine aminotransferase were assayed using standard laboratory techniques. From March 2003 to February 2006, 1,417 patients were admitted for haemodialysis in our unit. Of these 1,077 (76%) had ESKD. Mean age of patients was 42.47 +/- 16.2 (14-94) and 70.39% were males. Patients with ESKD had had more dialysis sessions (10.9 +/- 39.5 vs. 4.4 +/- 5.95, p = 0.009), more blood transfusions and more pre-existing HCV infections (4.72 vs. 1.5%, p = 0.009) than patients with acute renal failure. Of the ESKD patients, 65.7% were discharged, 9.47% died, 1.85% were shifted to chronic ambulatory peritoneal dialysis and 22.46% patients received renal transplantation. Of the patients who received renal transplantation, HCV seroconversion was detected in 2.75%. In the previous study without isolation practices, the HCV seroconversion rate in transplanted patients was 36.2%. The hazard of HCV seroconversion was 0.97 (95% CI 0.93-1.02, p = 0.2) for each additional dialysis and 1.09 (95% CI 0.88-1.36, p = 0.37) for each additional blood transfusion. The study concludes that isolation of HCV-infected patients during haemodialysis significantly decreases the HCV seroconversion rate.

Chronic viral hepatitis as a public health issue in the world

This article will focus on the impact caused by chronic viral hepatitis B and C globally and will discuss public health measures that have to be implemented in order to prevent and control these diseases. Chronic viral hepatitis is a major global public health problem, an important cause of morbidity and mortality from sequelae which include chronic hepatitis, cirrhosis and primary liver cancer. Being a 'silent' disease, the contribution of chronic hepatitis to global morbidity and mortality is generally underestimated. Hepatitis B and C prevention and control should seek to reduce both the incidence of new infections and the risk of chronic liver disease. A comprehensive public health prevention programme should include the prevention and detection of HBV and HCV infections, the diagnosis and control of viral hepatitis related chronic liver disease, conducting surveillance and monitoring the effectiveness of prevention activities, and setting up a research agenda.

HCV-RNA qualitative assay based on transcription mediated amplification improves the detection of hepatitis C virus infection in patients on hemodialysis: results from five hemodialysis units in central Greece

BACKGROUND

End-stage renal disease patients (ESRD) on maintenance hemodialysis (HD) are at increased risk of acquiring hepatitis C virus (HCV) infection. An early and accurate diagnosis of HCV infection is important for the prevention of viral transmission and the management of ESRD patients on HD but conventional ELISA and PCR have often failed to reveal active HCV infection.

OBJECTIVES

This study evaluated the prevalence of HCV infection in ESRD patients from all HD units in central Greece using a sensitive HCV-RNA transcription mediated amplification (TMA) assay and compared its sensitivity with that of anti-HCV ELISA.

STUDY DESIGN

Anti-HCV antibody (third generation ELISA), HCV-RNA (TMA) and HCV genotypes (HCV TMA-LiPA) were determined in 366 ESRD Greek patients.

RESULTS

In total, 132 (36%) ESRD patients were HCV positive by ELISA or TMA; 44 by TMA alone, 16 by ELISA alone and 72 positive by both assays. More than half of the viraemic patients had genotype 3a.

CONCLUSIONS

HCV-RNA (TMA) assay appears to increase the accuracy in the diagnosis of HCV infection in HD patients compared to the anti-HCV ELISA and could serve as an additional screening tool in these patients.

Alpha-interferon with ribavirin in the treatment of hemodialysis patients with hepatitis C

INTRODUCTION

Hepatitis C Viral (HCV) infection is the leading cause of chronic liver disease in end-stage renal disease patients (ESRD). The impact of HCV on patient and graft survival posttransplantation is controversial. The most successful approach is to eliminate the virus while the patient is on dialysis prior to transplantation. The main aim of this pilot study was to assess the efficacy of combined alpha-interferon (alpha-IFN) and ribavirin treatment of HCV hemodialysis (HDx) patients, by comparing the sustained virological response to that obtained by local historical data on treatment with alpha-IFN alone. A secondary aim was to establish the optimal therapeutic dose of ribavirin in this regimen.

METHODS

Twenty HCV-HDx patients who were histologically (liver biopsy) and virologically (HCV-PCR)-positive were selected randomly. They received combination therapy with 3 million units (MU) of alpha-IFN and 200 mg of ribavirin three times a week. Initially nine patients were treated for 24 weeks. Later, another 11 patients were randomly selected to give the combination for 48 weeks.

RESULTS

Six of the nine patients who were treated for 24 weeks (66%) became HCV-PCR-negative by the end of the treatment period. They continued to have a sustain virologic response at 6 months after the cessation of therapy. Six of the 11 patients (55%) who were treated for 48 weeks became HCV-PCR-negative at the end, and at 6 months after cessation of treatment. Of the first six responders, 4 (66%) maintained a sustained virologic response at 1 year postcessation of therapy. Nine of the 11 patients had genotype 4 and 1. No side effects were reported for a ribavirin dose of 200 mg three times a week.

CONCLUSION

This pilot study suggests that combination treatment for 24 weeks and 48 weeks with 3 MU alpha-IFN and 200 mg ribavirin three times a week, elicited a sustained virologic response in HDx patients with HCV infection better than IFN alone with minimal side effects. A prospective, double-blind, controlled study using pegylated INF plus ribavirin is currently underway.

The clinical characteristics and antiretroviral dosing patterns of HIV-infected patients receiving dialysis

BACKGROUND

Human immunodeficiency virus (HIV)-related renal disease is the third leading cause of end-stage renal disease (ESRD) among African Americans aged 24 to 60 years. This study describes the clinical characteristics and antiretroviral dosing patterns of HIV-infected patients receiving dialysis to define the clinical needs of this growing population.

METHODS

Demographic and clinical information was collected on all HIV-infected patients incident to dialysis after January 1, 1998 until January 1, 2001 at five medical centers. The cohort was described overall and by subgroups based on hepatitis status, CD4 lymphocyte count, and use of antiretroviral therapy. Continuous and categoric variables were compared using either the Wilcoxon rank sum or Student t test and Fisher's exact or chi-square tests, as appropriate.

RESULTS

A total of 89 patients were included, 55 of whom were alive at the time of data collection. The mean age was 44.6 years (range, 22.7 to 66.9 years), 74.2% were male, and 83.2% patients were African Americans. While only 45.9% of patients undergoing renal biopsy were diagnosed with HIV-associated nephropathy (HIVAN), the majority of patients who had not undergone biopsy carried the clinical diagnosis of HIVAN (69.8%, P = 0.03). Of the cohort, 19.7% tested hepatitis B surface antigen positive, and 67.1% had reactive antibody tests for hepatitis C. Patients with hepatitis C were more likely to have experienced intravenous drug use as a risk behavior for HIV acquisition (OR 8.2; 95% CI 2.39, 27.9; P = 0.001] and to be older (OR 1.1 per year of age; 95% CI 1.02, 1.2; P = 0.01). A total of 60.7% of patients were receiving antiretroviral medication at last follow-up. Among patients alive and receiving antiretroviral medications at the time of data collection, absolute CD4+ count rose (268 vs. 339 cells/mL, P = 0.03), while among patients alive, but not receiving antiretroviral medications, absolute CD4+ count did not change (389 vs. 392 cells/mL, P = 0.11) during similar periods of follow-up. No difference was seen between initial and current HIV RNA levels for either group. Among patients receiving antiretroviral medications, there were significant variations in dosing regimens. The greatest variation was seen in the prescribing patterns of lamivudine with a 12-fold difference among patients.

CONCLUSION

The projected growth of the HIV-infected ESRD population requires a better understanding of the clinical needs of this population. The high prevalence of coinfection with hepatitis C as well as the wide variations in dosing patterns for antiretroviral medications are areas that require further investigation to minimize morbidity and mortality among this group.

Low prevalence of hepatitis C virus infection in hemodialysis units: effect of isolation?

Hepatitis C virus (HCV) infection has recently become the major cause of chronic liver disease among patients on chronic hemodialysis. The use of erythropoietin for treatment of anemia has reduced the number of blood transfusions, but the frequency of HCV infection has not declined in hemodialysis units. The exact mode of transmission of HCV within dialysis units is as yet incompletely defined, but there is evidence to support nosocomial transmission by sharing dialysis machines in the hemodialysis unit. We performed a study to estimate the prevalence of HCV infection in our hemodialysis unit and to evaluate the effect of patient isolation and use of devoted dialysis machines for HCV-positive patients on the spread of HCV infection. A total of 168 patients on chronic hemodialysis (92 males and 76 females; mean age 54 +/- 12) were screened for HCV-antibodies (HCV-Ab) before their admission to the dialysis unit. Seropositive patients were isolated and confined to dedicated dialysis machines. Aminotransferases were measured monthly and HCV-Ab screening was performed second or third generation ELISA test every two months. Seropositive patients were tested by the PCR for the detection of HCV-RNA. Between March 1992 and August 2000, eight of 168 patients showed seroconversion. Seropositive patients were also found HCV-RNA positive. Four of these patients have become seropositive after they had undergone hemodialysis in other dialysis centers on holiday, two patients had received blood transfusions within the six months preceding seroconversion. The prevalence of HCV positivity in our hemodialysis unit is 4.7%. The low prevalence of HCV infection of our unit suggests that patient isolation and use of dedicated dialysis machines for seropositive patients decrease the transmission of HCV infection in hemodialysis units.

Routine serologic testing for hepatitis C virus infection should be instituted among dialysis patients

Since the cloning of hepatitis C virus (HCV), a number of serologic and virologic tests for detecting infections with this virus have been made available for clinical practice. This led to the recognition of HCV as a major health hazard in hemodialysis (HD) centers. Yet the nephrology community has not been offered explicit recommendations about routine serologic testing for HCV of dialysis patients and consequently has remained unclear and divided about the utility of this testing. This review presents evidence in support of instituting routine serologic testing for HCV among dialysis patients. It concludes that because of the peculiar features of HCV infection in HD patients, serologic testing for HCV is the only means for unequivocal diagnosis of hepatitis C and an irreplaceable instrument for monitoring the incidence and the prevalence of the infection in this population. Serologic surveillance for HCV infection is crucial for identifying the association of new cases of HCV infection with potential risk factors for HCV transmission, particularly nosocomial, that can be modified in a way to prevent further dissemination of the virus. Data collected from routine serologic testing for HCV will undoubtedly improve our understanding of the epidemiology of HCV in the dialysis population and will provide a strong foundation for developing preventive measures and infection control strategies that are highly effective in controlling HCV infection. Routine serologic testing for HCV is also of direct benefit to the individual patient since establishing the HCV serologic status of each patient is important for optimizing patient care.

Risk and management of blood-borne infections in health care workers

Exposure to blood-borne pathogens poses a serious risk to health care workers (HCWs). We review the risk and management of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in HCWs and also discuss current methods for preventing exposures and recommendations for postexposure prophylaxis. In the health care setting, blood-borne pathogen transmission occurs predominantly by percutaneous or mucosal exposure of workers to the blood or body fluids of infected patients. Prospective studies of HCWs have estimated that the average risk for HIV transmission after a percutaneous exposure is approximately 0.3%, the risk of HBV transmission is 6 to 30%, and the risk of HCV transmission is approximately 1.8%. To minimize the risk of blood-borne pathogen transmission from HCWs to patients, all HCWs should adhere to standard precautions, including the appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. Employers should have in place a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that may place a worker at risk of blood-borne pathogen infection. A sustained commitment to the occupational health of all HCWs will ensure maximum protection for HCWs and patients and the availability of optimal medical care for all who need it.

Risk and management of blood-borne infections in health care workers

Exposure to blood-borne pathogens poses a serious risk to health care workers (HCWs). We review the risk and management of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in HCWs and also discuss current methods for preventing exposures and recommendations for postexposure prophylaxis. In the health care setting, blood-borne pathogen transmission occurs predominantly by percutaneous or mucosal exposure of workers to the blood or body fluids of infected patients. Prospective studies of HCWs have estimated that the average risk for HIV transmission after a percutaneous exposure is approximately 0.3%, the risk of HBV transmission is 6 to 30%, and the risk of HCV transmission is approximately 1.8%. To minimize the risk of blood-borne pathogen transmission from HCWs to patients, all HCWs should adhere to standard precautions, including the appropriate use of hand washing, protective barriers, and care in the use and disposal of needles and other sharp instruments. Employers should have in place a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that may place a worker at risk of blood-borne pathogen infection. A sustained commitment to the occupational health of all HCWs will ensure maximum protection for HCWs and patients and the availability of optimal medical care for all who need it.

Hepatitis C infection in transplantation

This review emphasizes the role of HCV in the transplant setting. Prolonged HCV infection results in end-stage liver disease and as such represents a common indication for liver transplantation. Recurrence of infection is almost universal after transplantation in those with viremia before transplantation. Acquired disease is uncommon but nevertheless important, particularly in organ populations in whom screening for infection is not routine. The natural history of post-transplantation disease suggests that the effect on graft or patient survival is minor, at least during short-term follow-up. Long-term follow-up is needed, as well as more detailed study of the factors contributing to severity of post-transplantation disease. Kidney transplant recipients are commonly infected with HCV prior to transplantation. HCV infection after transplantation is associated with an increased risk of liver disease and infectious complications, but its effect on survival is still controversial. Similarly, observations in recipients of other solid organ transplants, such as heart and lung, and bone marrow patients suggest that HCV infection usually is not a major cause of mortality in the first 5 to 10 years of follow-up. Many issues still need to be addressed. The most important is the identification of factors that contribute to disease progression. Finally, effective therapies to eradicate infection and prevent disease progression are awaited.