Hepatitis C Virus Outbreaks in Hemodialysis Centers: A Continuing Problem

Patient Perspectives on Using Telemedicine During In-Center Hemodialysis: A Qualitative Study

Rationale & Objective

In the wake of the coronavirus disease 2019 (COVID-19) pandemic, the United States federal government expanded originating telemedicine sites to include outpatient dialysis units. For the first time, nephrology practitioners across the United States could replace face-to-face visits with telemedicine for patients receiving in-center hemodialysis. This study describes patients' perspectives on the use of telemedicine during in-center hemodialysis.

Study Design

A qualitative study.

Setting & Participants

Thirty-two patients from underserved populations (older, less educated, unemployed, persons of color) receiving in-center hemodialysis who used telemedicine with their nephrologist during the COVID-19 pandemic.

Analytical Approach

Telephone semistructured interviews were conducted in English or Spanish. Transcripts were thematically analyzed.

Results

We identified 6 themes with subthemes: adapting to telemedicine (gaining familiarity and confidence, overcoming and resolving technical difficulties, and relying on staff for communication); ensuring availability of the physician (enabling an immediate response to urgent medical needs, providing peace of mind, addressing patient needs adequately, and enhanced attention and contact from physicians); safeguarding against infection (limiting COVID-19 exposures and decreasing use); straining communication and physical interactions (loss of personalized touch, limited physical examination, and unable to reapproach physicians about forgotten issues); maintaining privacy (enhancing privacy and projecting voice enables others to hear); and supporting confidence in telemedicine (requiring established rapport with physicians, clinical stabilty of health, and ability to have in-person visits when necessary).

Limitations

Interviews were conducted later in the pandemic when some nephrology care providers were using telemedicine infrequently.

Conclusions

Patients receiving in-center hemodialysis adapted to telemedicine visits by their nephrologists in the context of the COVID-19 pandemic and observed its benefits. However, further considerations regarding communication, privacy, and physical assessments are necessary. Integrating telemedicine into future in-center hemodialysis care using a hybrid approach could potentially build trust, optimize communication, and augment care.

The influence of hemodialysis on FibroTest parameters

Chronic hepatitis C viral infection is an important cause of morbidity and mortality in patients with end-stage renal disease treated with hemodialysis. Liver fibrosis represents a main determinant of liver disease prognosis and clinical management, and its assessment by liver biopsy can decide treatment allocation. Although liver biopsy is the gold standard for staging liver fibrosis, it is an invasive procedure associated with complications that are more prevalent in patients with end-stage renal disease. FibroTest represents a surrogate marker of fibrosis which evaluates the levels of apolipoprotein A1, total bilirubin, haptoglobin, gamma-glutamyltransferase and α2-macroglobulin, generating a score that indicates the level of fibrosis. Discrepancies were observed in clinical practice between FibroTest score and histopathological findings. The aim of this study was to evaluate how hemodialysis influences the level of each FibroTest parameter and the final score. The systematic literature review conducted by us suggests that hemodialysis induces a reduction in apolipoprotein A1, haptoglobin and bilirubin levels, with an increase in gamma-glutamyltransferase and alpha-2-macroglobulin levels. In conclusion, hemodialysis modifies the levels of FibroTest parameters, suggesting that it may also have an impact on the accuracy of liver fibrosis assessment in hemodialysis patients.

A very high prevalence of hepatitis C virus infection among patients undergoing hemodialysis in Kosovo: a nationwide study

BACKGROUND

Patients on hemodialysis are at high risk for hepatitis C virus (HCV) infection if measures for effective control of HCV infection in the hemodialysis environment are not implemented. Whereas in developed countries isolated small-scale outbreaks of HCV in hemodialysis units are occasionally reported, HCV transmission in the hemodialysis environment still represents a substantial problem in low-resource countries. This study systematically assessed the prevalence of HCV infection among all patients at all hemodialysis centers in Kosovo, determined the HCV genotype distribution, and reviewed the main risk factors associated with HCV infection in this group of patients.

METHODS

From January to March 2013, blood samples from all patients undergoing hemodialysis at all seven hemodialysis centers in Kosovo were collected. The samples were screened for the presence of anti-HCV antibodies, and seropositive samples were also tested for HCV RNA. Genotyping was performed by sequencing the core region of the HCV genome. Subsequently, face-to-face interviews were conducted with consented patients attending hemodialysis in December 2015 and with the management of all hemodialysis centers in Kosovo.

RESULTS

The overall seroprevalence of HCV infection among hemodialysis patients in Kosovo was 53.0% (354/668), ranging from 22.3 to 91.1% at different centers. HCV RNA was detected in 323/354 (91.2%) seropositive patients. The most frequent HCV genotype was genotype 1a (62.2%), followed by genotypes 4d (33.1%), 1b (4.0%), and 2c (0.7%). The duration of hemodialysis and receiving dialysis at more than one center were identified as independent significant predictors of anti-HCV positivity. Shortage of staff, lack of resources, and inconsistent use of hygienic precautions and/or isolation strategies were observed.

CONCLUSIONS

The prevalence of HCV infection among hemodialysis patients in Kosovo is extremely high. The relatively low prevalence of HCV infection in the general population, predominance of two otherwise rare HCV genotypes among hemodialysis patients, and longer history of hemodialysis as a predictor of HCV infection all indicate nosocomial transmission due to inappropriate infection control practices as the main transmission route.