Epidemiology of hepatitis C virus among long-term dialysis patients: a 9-year study in an Italian region

Global epidemiology of hepatitis C virus in dialysis patients: A systematic review and meta-analysis

Dialysis is a replacement therapy for patients with End-Stage Renal Disease (ESRD). Patients on dialysis are at high risk of acquiring hepatitis C virus (HCV), which has become a leading cause of morbidity and mortality in this population. There is a wide range of prevalence of HCV in dialysis populations around the world. It is still unknown how prevalent HCV infection is among worldwide dialysis patients (including those undergoing hemodialysis and peritoneal dialysis). A review was conducted to estimate the global epidemiology of hepatitis C in dialysis patients. We searched PubMed, Excerpta Medica Database (Embase), Global Index Medicus and Web of Science until October 2022. A manual search of references from relevant articles was also conducted. Heterogeneity was evaluated by the χ2 test on Cochrane's Q statistic, and the sources of heterogeneity were investigated using subgroup analysis. In order to assess publication bias, funnel plots and Egger tests were conducted, and pooled HCV prevalence estimates were generated using a DerSimonian and Laird meta-analysis model. The study is registered with PROSPERO under CRD42022237789. We included 634 papers involving 392160 participants. The overall HCV case fatality rate was 38.7% (95% CI = 28.9-49). The global prevalence of HCV infection in dialysis population group were 24.3% [95% CI = 22.6-25.9]. As indicated by UNSD region, country, dialysis type, and HCV diagnostic targeted; Eastern Europe had the highest prevalence of 48.6% [95% CI = 35.2-62], Indonesia had 63.6% [95% CI = 42.9-82], hemodialysis patients had 25.5% [95% CI = 23.8-27.3], and anti-HCV were detected in 24.5% [95% CI = 22.8-26.2]. Dialysis patients, particularly those on hemodialysis, have a high prevalence and case fatality rate of HCV infection. Hemodialysis units need to implement strict infection control measures.

HCV Microelimination for High-risk Special Populations

The World Health Organization has set tremendous goals to eliminate viral hepatitis by 2030. However, most countries are currently off the track for achieving these goals. Microelimination is a more effective and practical approach that breaks down national elimination targets into goals for smaller and more manageable key populations. These key populations share the characteristics of being highly prevalent for and vulnerable to hepatitis C virus (HCV) infection. Microelimination allows for identifying HCV-infected people and linking them to care more cost-effectively and efficiently. In this review, we discuss the current obstacles to and progress in HCV microelimination in special populations, including uremic patients undergoing hemodialysis, people who inject drugs, incarcerated people, people living in hyperendemic areas, men who have sex with men with or without human immunodeficiency virus (HIV) infection, transgender and gender-diverse populations, and sex workers. Scaling up testing and treatment uptake to achieve HCV microelimination may facilitate global HCV elimination by 2030.

Exposure to needle stick injuries among health care workers in hemodialysis units in the southwest of Iran: a cross-sectional study

BACKGROUND

Needle stick injury (NSI) is the most common cause of infection with blood-borne pathogens (BBP) among healthcare workers (HCWs). This study aimed to assess the prevalence of NSI and it's contributing factors among HCWs of hemodialysis (HD) units in southwest Iran.

METHODS

A cross-sectional study was performed in 13 HD centers in Shiraz, Iran. A total of 122 employees were enrolled in our study. We used self-administrated questionnaires to collect data about demographics, experiences regarding NSIs, and general health status. The statistical tests used in this study were Chi-square and Independent T-test. A P-value < 0.05 is considered significant.

RESULTS

The mean age of the study population was 36.1 ± 7.8 years (72.1%: women). Exposure to NSIs was reported by 23.0% of them at least once during the previous six months. NSI prevalence was significantly higher among those with higher age (p = 0.033), work experience > 10 years (p = 0.040), and those who graduated earlier (p = 0.031). The intravenous injection was the most common procedure leading to NSI, and being in a hurry was the most common cause. The average general health was 3.7 ± 3.2, higher among those not exposed to NSI (p = 0.042).

CONCLUSION

NSI is a prevalent hazard in HCWs of HD units. The high rate of NSI and unreported cases, besides the lack of adequate information, indicates the necessity of implementing protocols and strategies for improving the safety of this personnel. It is difficult to compare the result of this study with those performed among HCWs in other settings; hence, further studies are needed to determine whether HCWs of these units are more exposed to NSIs.

Hepatitis C Seroconversion Remains High among Patients with Regular Hemodialysis: Study of Associated Risk Factors

Methods

An analytical cross-sectional study involving patients from 2 dialysis units (1 referral hospital and 1 private dialysis unit) in Denpasar, Bali, Indonesia, from January 2020 to December 2021. We evaluated age, gender, duration of hemodialysis, vascular access, history of transfusion, history of surgery, diabetes mellitus, hepatitis B, human immunodeficiency virus (HIV) infection, and type of dialyzer as possible risk factors of hepatitis C seroconversion among hemodialysis patients.

Results

A total of 338 hemodialysis patients were enrolled in this study. We found hepatitis C seroconversion in 94 patients (27.8%), all of which occurred after regular dialysis was started. Vascular access type (OR 42.07, 95% CI 5.757-307.472) and dialyzer reuse (OR 8.324, 95% CI 4.319-16.044) were showing a statistically significant association with hepatitis C seroconversion. A separate analysis on each dialysis unit found common evidence that the duration of dialysis was significantly associated with hepatitis C infection among hemodialysis patients.

Conclusion

Hepatitis C seroconversion among dialysis patients remains high. Factors related to the dialysis procedure itself played a major role in transmitting the virus.

Establishment of an outreach, grouping healthcare system to achieve microelimination of HCV for uremic patients in haemodialysis centres (ERASE-C)

OBJECTIVE

HCV prevails in uremic haemodialysis patients. The current study aimed to achieve HCV microelimination in haemodialysis centres through a comprehensive outreach programme.

DESIGN

The ERASE-C Campaign is an outreach programme for the screening, diagnosis and group treatment of HCV encompassing 2323 uremic patients and 353 medical staff members from 18 haemodialysis centres. HCV-viremic subjects were linked to care for directly acting antiviral therapy or received on-site sofosbuvir/velpatasvir therapy. The objectives were HCV microelimination (>80% reduction of the HCV-viremic rate 24 weeks after the end of the campaign in centres with ≥90% of the HCV-viremic patients treated) and 'No-C HD' (no HCV-viremic subjects at the end of follow-up).

RESULTS

At the preinterventional screening, 178 (7.7%) uremic patients and 2 (0.6%) staff members were HCV-viremic. Among them, 146 (83.9%) uremic patients received anti-HCV therapy (41 link-to-care; 105 on-site sofosbuvir/velpatasvir). The rates of sustained virological response (SVR12, undetectable HCV RNA 12 weeks after the end of treatment) in the full analysis set and per-protocol population were 89.5% (94/105) and 100% (86/86), respectively, in the on-site treatment group, which were comparable with the rates of 92.7% (38/41) and 100% (38/38), respectively, in the link-to-care group. Eventually, the HCV-viremic rate decreased to 0.9% (18/1,953), yielding an 88.3% reduction from baseline. HCV microelimination and 'No-C HD' were achieved in 92.3% (12/13) and 38.9% (7/18) of the haemodialysis centres, respectively.

CONCLUSION

Outreach strategies with mass screenings and on-site group treatment greatly facilitated HCV microelimination in the haemodialysis population.

CLINICALTRIALSGOV IDENTIFIER

NCT03803410 and NCT03891550.

Recent advances in the treatment of hepatitis C virus infection for special populations and remaining problems

Hepatitis C virus (HCV) infection is one of the primary causes of liver cirrhosis, hepatocellular carcinoma (HCC), and liver transplantation (LT). The rate of HCV infection is high in patients on hemodialysis and in patients infected with human immunodeficiency virus (HIV). In liver transplant patients with HCV infection, recurrent HCV infection of the transplanted liver is universal and results in rapid liver fibrosis progression. In patients with HCV/HIV coinfection as well, liver fibrosis advances rapidly. Thus, there is an urgent need for prompt HCV infection treatment in these special populations (i.e. HIV/HCV coinfection, HCV infection after LT, and dialysis patients). Interferon (IFN)-based therapy for HCV infection could not achieve a high rate of sustained viral response and could cause severe adverse events in the aforementioned special populations. Direct-acting antivirals (DAAs) have recently been developed, and clinical trials have shown that IFN-free DAA-based therapies are associated with a significantly better safety and therapeutic profile than IFN-based therapies. However, the majority of the initial DAA trials excluded special populations; thus, the efficacy and safety of IFN-free DAA-based therapy in special populations remained to be clearly established. Although recent clinical trials and clinical studies have shown the high efficacy and safety of this therapy even in special populations, several unresolved problems, including emergence of resistance-associated variants after failure to respond to DAAs and HCC occurrence after DAA therapy, still exist. Hence, in this review, we discuss the recent advances in anti-HCV therapy for special populations and the remaining problems regarding this therapy.

Update on Hepatitis C Epidemiology: Unaware and Untreated Infected Population Could Be the Key to Elimination

Globally, the World Health Organization (WHO) estimates that 71 million people have chronic hepatitis C virus (HCV) infection. A significant number of these will develop cirrhosis or liver cancer. Currently, during the COVID-19 outbreak, a high mortality rate has been found in patients with COVID-19 and cirrhosis. New direct-acting antiviral agents can cure more than 90% of HCV-infected patients. The new WHO strategy has introduced global goals against viral hepatitis, including a 30% reduction in new HCV cases and a 10% reduction in mortality by 2020. HCV transmission has changed considerably, reflecting both the evolution of medicine and health and social changes. The HCV is usually spread through blood-to-blood contact. After the discovery of HCV in 1989, antibody screening has drastically decreased the incidence of post-transfusion hepatitis. Nowadays, routine blood donor screening by nucleic acid amplification testing for the presence of HCV RNA has been introduced in many countries. It is conceivable that HCV screening could be offered to people born between 1946 and 1964 in the developed world and to people at high risk for HCV infection such as those who have received blood transfusions, blood products or organ donations before the 1990s, prisoners, health care workers, drug users and infants born to HCV-infected women. To achieve HCV elimination, health programmes should include improvement to access to health care services, increased screening and new projects to identify a submerged portion of patients with HCV infection. Submerged people with HCV infection are both people who are unaware of their condition and people diagnosed with HCV but not yet treated. Based on these premises, this review will examine and discuss the epidemiological changes in contracting HCV, highlighting the ways in which to identify a submerged portion of patients with HCV infection.

Sofosbuvir-Based HCV Treatment in Maintenance Hemodialysis Patients: A Single-Center Study

There is scant data on use of sofosbuvir containing direct-acting antiviral (DAA) regimens in maintenance hemodialysis (MHD) patients infected with hepatitis C virus (HCV). Recent data have focused on possible safe use of sofosbuvir in MHD patients. The aim of this study was to study the efficacy and safety of the sofosbuvir-based combination DAA in HCV-infected naive patients on MHD. Before starting treatment HCV viral load, genotype, liver function tests, and liver ultrasound were performed in all patients. HCV RNA quantification was assessed at baseline, at end of therapy, at 12 weeks, and 24 weeks after stopping therapy. Forty-three MHD patients (67.4% male, with no cirrhosis) with HCV infection were included in the study. Fifteen patients were diabetics. Thirteen patients received multiple transfusions. None of the patients had baseline cirrhosis. Average vintage of dialysis was 6.2 years. At 24-week follow-up none of the patients relapsed. Full dose sofosbuvir was used in combination with ledipasvir (N = 40, 100% genotype 1) and valpatasvir (N = 3, 2 genotype 1, 1 genotype 3). Sustained virological response (HCV RNA < 12 IU/mL) at 12 and 24 weeks after stopping treatment was seen in 100% of the patients. Full-dose sofosbuvir-based DAA therapy is highly effective for MHD patients with HCV infection.

COMBINED NS5A & NS5B NUCLEOTIDE INHIBITOR THERAPY FOR PATIENTS WITH CHRONIC HEPATITIS C WITH STAGE 5 CHRONIC KIDNEY DISEASE ON HEMODIALYSIS

BACKGROUND

Hepatitis C virus (HCV) infection is the most common hepatotropic viral infection affecting the patients on maintenance hemodialysis. Treatment of chronic HCV infection in stage 4 and 5 CKD includes a combination of elbasvir/grazoprevir and glecaprevir/pibrentasvir, which are not available in many countries.

OBJECTIVE

Hence, we have conducted this study to look for the safety and efficacy of sofosbuvir combination therapy in this difficult to treat population.

METHODS

We conducted a single-center, prospective, open-label study in which Stage 5 CKD patients on maintenance hemodialysis with HCV infection. Total of 18 patients was included. sofosbuvir with daclatasvir or ledipasvir was used according to genotype for 12 weeks. HCV RNA, genotype, transient elastography (TE) was considered for every patient. HCV RNA was quantified at 4th week, 12th week and 12 weeks post-treatment to look for sustained virologic response (SVR 12).

RESULTS

Infection due to genotype 1 was seen in 12 (66.7%) patients followed by genotype 3 in 4 (22.3%) with each patient of genotype 2 and 5. The median value of HCV RNA was 2,35,000 IU/mL. On TE, all had liver stiffness of <9.4 KPa. All patients had HCV RNA of <15 IU/mL at 4th and 12th week of treatment and 12 weeks post-treatment. No significant change in hemoglobin, eGFR and liver stiffness was observed.

CONCLUSION

Full dose sofosbuvir i.e. 400 mg, in combination with NS5A inhibitors daclatasvir or ledipasvir is found to be safe and effective in patients with end stage renal disease, who are on maintenance hemodialysis.

Prevalence, incidence, and risk factors for hepatitis C virus infection in hemodialysis patients

Hepatitis C virus (HCV) infection is common in dialysis patients and is associated with increased morbidity and mortality. We used the Dialysis Outcomes and Practice Patterns Study (DOPPS, 1996-2015) to assess trends in the prevalence, incidence, and risk factors for HCV infection as defined by a documented diagnosis or antibody positivity. Among prevalent hemodialysis patients, HCV prevalence was nearly 10% in 2012-2015. Prevalence ranged from 4% in Belgium to as high as 20% in the Middle East, with intermediate prevalence in China, Japan, Italy, Spain, and Russia. HCV prevalence decreased over time in most countries participating in more than one phase of DOPPS, and prevalence was around 5% among patients who had recently (<4 months) initiated dialysis. The incidence of HCV infection decreased from 2.9 to 1.2 per 100 patient-years in countries participating in the initial phase of DOPPS. Although most units reported no seroconversions, 10% of units experienced 3 or more cases over a median of 1.1 years. High HCV prevalence in the hemodialysis unit was a powerful facility-level risk factor for seroconversion, but the use of isolation stations for HCV-positive patients was not associated with significantly lower seroconversion rates. Overall, despite a trend toward lower HCV prevalence among hemodialysis patients, the prevalence of HCV infection remains higher than in the general population. Combined with a high prevalence of HCV infection among patients with Stage 5 CKD, high rates of HCV seroconversion in a subset of hemodialysis units may contribute to this disparity.

Hepatitis B and C among healthcare workers and patient groups at increased risk of iatrogenic transmission in the European Union/European Economic Area

In the European Union/European Economic Area (EU/EEA) approximately 9 million people are chronically infected with hepatitis B virus (HBV) or hepatitis C virus (HCV), and many are undiagnosed. Targeted active case finding initiatives are needed. Iatrogenic transmission of HBV/HCV is relevant in Europe but people at risk of infection are often overlooked. This study aimed to identify groups at increased risk of HBV/HCV infection due to iatrogenic transmission, including healthcare workers, and to estimate incidence and prevalence. PubMed and Embase were systematically searched in February 2017 using strings combining terms for HBV/HCV, occurrence and population subgroups. All retrieved publications were screened and included articles were quality assessed. A predefined set of variables were extracted, and detailed summary tables were developed per population group of interest, virus and outcome. Thirty-eight articles were included, two reported on HBV, 22 on HCV and 16 on both, contributing 70 estimates of prevalence or incidence among: haemodialysis recipients, diabetes patients, recipients of substances of human origin, recipients of medical/dental procedures and healthcare workers. Estimates varied widely from 0.4% to 11.7% for HBV and from 0.7% to over 90% for HCV with most being higher than in the general population. Despite the limited number of studies retrieved, mostly old and focused on populations with multiple risk factors, our findings highlight the importance of considering population groups at higher risk for HBV/HCV iatrogenic transmission as target groups for active case finding in the EU/EEA. Test offers should be guided by individual risk assessment alongside local epidemiological data and local context.

Hepatitis C virus and mortality among patients on dialysis: A systematic review and meta-analysis

BACKGROUND AND RATIONALE

The role of hepatitis C virus (HCV) as an independent risk factor for death in dialysis population is unclear.

DESIGN

A systematic review of the published medical literature was performed to evaluate the impact of positive anti-HCV serologic status on all-cause and disease-specific mortality in patients on regular dialysis. The risk of all-cause, cardiovascular and liver disease-related mortality was regarded as the most reliable outcome end-point. Study-specific relative risks were weighted by the inverse of their variance to obtain fixed- and random-effects pooled estimates for mortality with HCV across the published studies.

RESULTS

Twenty-three observational studies (n = 574,081 patients on long-term dialysis) were identified. Pooling of study results demonstrated that HCV positive status was an independent and significant risk factor for death in patients on maintenance dialysis. The summary estimate for adjusted death risk (all-cause mortality) with HCV was 1.26 (95% CI: 1.18; 1.34) (P < 0.0001). Between-study heterogeneity was found (Q value 52.8, P = 0.001). The overall estimate for adjusted death risk (liver disease-related mortality) was 5.05 (95% CI: 2.53; 10.0) (P < 0.0001); heterogeneity statistics, Q value 8.2, P = 0.04. The overall estimate for adjusted death risk (cardiovascular mortality) was 1.18 (95% CI: 1.085; 1.29) (P < 0.0001) (no heterogeneity). Meta-regression showed that the effect of HCV on all-cause mortality was more evident in those studies provided with a greater size (P = 0.0001), a higher prevalence of diabetics (P = 0.0005) and HCV-infected individuals (P = 0.001).

CONCLUSIONS

An association between HCV positive serologic status and increased risk of either liver or cardiovascular disease-related mortality exists among dialysis patients.

Epidemiological, demographic and clinical data on chronic viral hepatitis C in Tuscany

BACKGROUND

Recent introduction of direct antiviral agents (DAAs) has completely changed the scenario regarding hepatitis C virus (HCV) treatment. Certain countries' economic health programs prioritize DAAs according to specific clinical features of HCV-infected patients. The aim of this study was to define epidemiological, demographic and clinical characteristics of HCV-infected patients in the Tuscany region of central Italy.

METHODS

We enrolled HCV patients with chronic viral hepatitis who were referred to the outpatient services of 16 hospitals in Tuscany from 1 January 2015 to 31 December 2015. Case report forms contained patient information including main demographic data, blood chemistry data, viral hepatitis markers, instrumental evaluations (liver biopsy or transient elastometry, liver ultrasound), eligibility for DAAs, and liver transplantation or therapy already in progress.

RESULTS

Of all patients considered, 2919 HCV patients were enrolled (mean age: 57.44 ± 15.15; 54% males, 46% females). All routes of transmission were well represented (intravenous drug use in 20.7%; nosocomial/dental care in 20.6%; and coagulation factors/blood transfusions in 13.3%). Diabetes was the highest represented comorbidity (20.8%), followed by metabolic syndrome (15.5%) and ischemic heart disease (6.2%). The most prevalent HCV genotypes were 1b (47.4%) and 2 (16.5%). In the whole cohort of patients, 32.8% were cirrhotic (40 patients were listed for liver transplantation). Signs of portal hypertension were present mostly in the group older than 45 years (92.3%). Extrahepatic HCV-related diseases were present in 13.3% of cases (cryoglobulinemic syndrome in 58.3% and B-cell non-Hodgkin's lymphoma in 10.5%).

CONCLUSIONS

Our study provides evidence of a high prevalence of epidemiological changes in HCV infection with a major prevalence of advanced liver disease, such as portal hypertension, in this elderly cohort of patients.

Health Indicators for Renal Replacement Therapy in Saudi Arabia

The renal replacement therapy in Saudi Arabia has 3 main modalities: hemodialysis, peritoneal dialysis, and renal transplantation. Hemodialysis is one of the fastest growing industries of health care providers in Saudi Arabia.

OBJECTIVE

We aimed to review the health indicators of renal replacement therapy.

MATERIALS AND METHODS

We used the Saudi Center for Organ Transplantation Annual Report 2016.

RESULTS

Patients with end-stage renal disease on hemodialysis and peritoneal dialysis totaled 17,687. Saudi Arabia increased the numbers of dialysis centers and also added 2 more sectors. The Ministry of Health hospitals have 55% of the centers, government non-Ministry of Health has 9%, private and charitable hospitals have 21%, the King Abdullah Hemodialysis Project has 2%, and the outsourcing dialysis programs have 13%. There are 243 dialysis units in Saudi Arabia. Most dialysis centers are in the central region (30%); 27% are in the western region, 19% are in the southern region, 13% are in the eastern region, and 11% are in the northern region. The average net increase of dialysis patients is 6.2% annually and is projected to reach 22,000 by 2020. Causes of renal failure are mainly diabetic nephropathy (40%) and hypertensive nephropathy (38%). Hepatitis C virus positivity is at 12% and hepatitis B surface antigen positivity is at 4%. From the year 2000 renal transplantation from deceased and living donation has tripled in number, with a total of 798 kidneys transplanted.

CONCLUSION

Renal replacement therapy is increasing and dialysis center numbers are expected to increase. Renal transplantation numbers have improved both from living and deceased donors but further actions toward the promotion of the organ donation in Saudi Arabia is essential.

Hepatitis C Infection in Hemodialysis Patients

Three centuries after the identification of hepatitis C virus (HCV), specialized literature has outlined the epidemiology, viral kinetics and clinical manifestations of this infection. A major cause of morbidity-mortality in patients with renal transplantation and in hemodialysis patients is HCV infection. In high seroprevalence countries, internal accounts are not uniform. The European trend is to decrease the incidence and prevalence of HCV in hemodialysis patients. In Europe, the prevalence of HCV infection among hemodialysis patients tends to be higher than that of the general population, but it is variable by region. Some studies indicate a decrease in incidence in parallel with prevalence in dialysis centers over the last 10 years, while others maintain a high incidence. In some countries, as is the case with Romania, both prevalence and incidence remain high, with the major route of transmission being nosocomial, probably due to limited resources for a rapidly growing dialyzed population. Some authors recommend more isolation measures to be taken in centers with high prevalence of infection.

Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN)

Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.

Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN)

Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.

Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN)

Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.

Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN)

Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.

Treatment of hepatitis C in special populations

Hepatitis C virus (HCV) infection is one of the primary causes of liver cirrhosis and hepatocellular carcinoma. In hemodialysis patients, the rate of HCV infection is high and is moreover associated with a poor prognosis. In liver transplantation patients with HCV infection, recurrent HCV infection is universal, and re-infected HCV causes rapid progression of liver fibrosis and graft loss. Additionally, in patients with HCV and human immunodeficiency virus (HIV) co-infection, liver fibrosis progresses rapidly. Thus, there is an acute need for prompt treatment of HCV infection in these special populations (i.e., hemodialysis, liver transplantation, HIV co-infection). However, until recently, the standard anti-HCV treatment involved the use of interferon-based therapy. In these special populations, interferon-based therapies could not achieve a high rate of sustained viral response and moreover were associated with a higher rate of adverse events. With the development of novel direct-acting antivirals (DAAs), the landscape of anti-HCV therapy for special populations has changed dramatically. Indeed, in special populations treated with interferon-free DAAs, the sustained viral response rate was above 90%, with a lower incidence and severity of adverse events.

Functional impairment and risk of mortality in patients on chronic hemodialysis: results of the Lazio Dialysis Registry

BACKGROUND

Functional impairment is associated with adverse outcomes in older people, as well as in patients on chronic hemodialysis. The aim of this study was to evaluate if functional impairment represents a risk factor for reduced survival in patients on chronic hemodialysis.

METHODS

All incident chronic hemodialysis patients of Lazio, a large region of central Italy, registered in the Dialysis and Transplant Lazio Region Registry (DTLRR) in the period 2008-2013 were considered eligible. Inclusion criteria were: age > 18 years, resident in Lazio, still doing dialysis after 90 days from incidence date, doing hemodialysis or hemodiafiltration treatment for > 9 h/week. Patients were stratified into three classes of functional activity: total autonomy, autonomy in some activities, and not self-sufficient. Functional activity was assessed for each patient by the referring physician for the DTLRR from the ~ 90 hemodialysis units of the Lazio region. Each patient was followed from date of first dialysis treatment to the end of the study (31/12/2015) or death or renal transplant, whichever occurred first. Cox proportional hazard models were performed to obtain mortality hazard ratios (HR), 95% confidence intervals (CI), for each class of functional activity adjusting for sex, age, country of birth, city of residence, body mass index (BMI), type of nephropathy, vascular access, previous nephrology counselling, weekly hours of hemodialysis, serum albumin, hemoglobin, and presence of comorbidities (e.g. vascular diseases, coronary disease, and diabetes).

RESULTS

A total of 3356 patients were studied. In the whole follow-up period, 1622 deaths occurred (48%). Functional impairment was associated with the risk of mortality: compared to 'total autonomy', the HR for 'autonomy in some activities' was 1.30 [95% CI: 1.14-1.49] and for 'not self-sufficient' 1.71 [1.47-1.99] (p for trend < 0.05). The number of evitable deaths attributable to reduced functional activity was 237.

CONCLUSION

Functional impairment represents a risk factor for reduced survival in chronic hemodialysis patients. There is a need for early identification of patients who might benefit from interventions aimed at preventing, reversing or delaying the functional impairment.

Ledipasvir and Sofosbuvir for untreated HCV genotype 1 infection in end stage renal disease patients: A prospective observational study

INTRODUCTION

Hepatitis C virus (HCV) infection in end stage renal disease (ESRD) is associated with increased mortality. Recently, numerous directly acting antiviral agents have been approved for the management of HCV. Ledipasvir along with Sofosbuvir has been approved for management of genotype 1 infection in patients with eGFR ≥30 mL/min. However, there is paucity of data regarding its role in the management of patients on dialysis.

MATERIAL AND METHODS

This is a single center prospective open label observational study to assess the safety and efficacy of Ledipasvir and Sofosbuvir in hemodialysis (HD) patients who were diagnosed with HCV genotype 1 infection. Eligibility criteria were treatment naive HD patients with normal liver histology. We administered Ledipasvir and Sofosbuvir combination tablet on alternate days for a period of 12 weeks. Primary efficacy end point was the assessment of sustained virological response (SVR12), and the safety end point was the discontinuation of therapy secondary to adverse drug effects.

RESULTS

A total of 21 patients were treated with this regimen. Two patients expired during the study period and are not related to the therapy. SVR12 was achieved in all the 19 patients. None of the patients in our study discontinued the therapy or had severe adverse drug effects. One patient had head ache and another patient had giddiness which were managed symptomatically.

CONCLUSION

Ledipasvir and Sofosbuvir combination therapy on alternate days, is effective even in ESRD patients, with excellent SVR12 rates, and it is as safe as in other population groups, without any major adverse reactions.

[Hepatitis C incidence in hemodialysis patients in Brazil from 2000 to 2003]

The study aimed to estimate the incidence of HCV seroconversion in hemodialysis patients in the Brazilian Unified National Health System (SUS). This was a prospective, non-concurrent study using patients' data identified by deterministic and probabilistic record linkage in the SUS information system. The study included 47,079 patients started on hemodialysis between January 1, 2000, and December 31, 2003, followed until seroconversion or conclusion of the study in 2004. Three percent of hemodialysis patients HCV-seroconverted (1.7 per 100 patient-years). Increased risk of HCV seroconversion was associated with age, glomerulonephritis, geographic region, HIV-positivity, and dialysis service. The observed HCV seroconversion rate was similar to that in developed countries, highlighting evidence of transmission among hemodialysis patients.

Hepatitis C virus infection: opportunities for an earlier detection in primary care

BACKGROUND/AIM

In the era of direct-acting antiviral medications, which can cure the hepatitis C virus (HCV) infection, the actual epidemiology of this condition in the general population is still unclear. We therefore aimed to estimate the prevalence rate of HCV and assess the determinants for incident cases of HCV in primary care in Italy.

METHODS

We identified outpatients aged at least 15 years registered in the Italian Health Search IMS Health Longitudinal Patient Database from 1 January 2002 to 30 June 2013. The annual trend of HCV prevalence was estimated. The candidate determinants for the risk of incident HCV infection included geographical area of residence, sex, age, infections by the HIV, hepatitis B virus (HBV), or other forms of hepatitis, and abuse of illicit substances or drugs.

RESULTS

The eligible cohort included 826 300 patients (53.5% women, mean age 48.1±19.1 years). The prevalence rate of HCV increased over the 11-year study period, ranging from 0.24 to 0.50%, with a small increase in men versus women. Patients aged more than 24 years had a higher risk than those aged 14-24 years, with up to a five-fold increase among patients aged 65-74 years. Being resident of Southern/Islands Italy, concurrent diagnosis HBV or HIV, and drug or illicit substance abuse were significant determinants for HCV infection.

CONCLUSION

Our study shows that the prevalence of HCV in Italy has doubled over the last decade. Patients with certain demographics and clinical characteristics are more prone to be infected by HCV. In this scenario, general practitioners may play a crucial role in screening, early identification, and therapy of high-risk patients.

Novel Treatment of Hepatitis C Virus Infection for Patients with Renal Impairment

Prevalence of hepatitis C virus (HCV) infection is high in patients with end-stage renal dysfunction, including patients undergoing hemodialysis (HD). The HCV infection itself can cause glomerulonephritis and puts individuals at increased risk of developing end-stage renal disease; fortunately, successful HCV eradication sometimes restore HCV-related renal dysfunction. Moreover, the prognosis of dialysis patients infected with HCV is significantly worse and the renal allograft survival in HCV-infected patients is also worse than in dialysis patients without HCV infection. If life prognosis is favorable, therefore, anti-HCV therapy is strongly recommended for HCV-infected patients with severe renal dysfunction. The standard therapy for HCV-infected patients with severe renal dysfunction has historically been interferon-based therapy. However, this therapy remains ineffective in achieving high, sustained viral response rates and the rate of adverse events and treatment discontinuation due to treatment-induced adverse events continues to be high in patients with severe renal dysfunction. Safe and effective anti-HCV therapies are urgently needed, and crucial, for patients with severe renal dysfunction. Recently, direct-acting antivirals (DAAs) that specifically target viral proteins have been developed, and these targets include the NS3, NS5A, and NS5B of HCV. Clinical trials have revealed high efficacy and safety of the DAA-based therapies, but patients with severe renal dysfunction were not included in the majority of these trials. However, several recent reports have shown high efficacy and safety for some regimens of DAA combination therapy for HCV-infected patients with severe renal dysfunction. In this review, we discuss novel treatments for HCV-infected patients with severe renal dysfunction and the pharmacokinetics of these drugs.

Differential Effect of Viral Hepatitis Infection on Mortality among Korean Maintenance Dialysis Patients: A Prospective Multicenter Cohort Study

The role of infection with hepatitis B virus (HBV) and hepatitis C virus (HCV) in terms of survival among dialysis patients remains incompletely understood. In the present multicenter prospective cohort study, we investigated the prevalences of HBV and HCV infection among 3,321 patients receiving maintenance dialysis in Korea, and assessed the impacts of these infections on survival. All included patients underwent hepatitis B antigen (HBsAg) and HCV antibody (Ab) testing, which revealed that 236 patients (7.1%) were HBsAg-positive, and 123 patients (3.7%) were HCV Ab-positive. HBsAg-positive and HCV Ab-positive patients were matched to hepatitis virus-negative patients using a propensity score at a ratio of 1:2. The prevalences of HBV and HCV infection did not significantly differ according to dialysis modality. Linear-by-linear association analysis revealed that hepatitis B prevalence significantly increased with increasing dialysis vintage (p = 0.001), and hepatitis C prevalence tended to be higher with increasing dialysis vintage (p = 0.074). We compared the survival of HBsAg-positive and HCV Ab-positive patients to that of hepatitis virus-negative patients. After propensity score matching, cumulative survival did not differ between HBsAg-positive and HBsAg-negative patients (p = 0.37), while HCV Ab-positive patients showed significantly lower survival than HCV Ab-negative patients (p = 0.03). The main conclusions of the present study are that HBV infection prevalence increased with longer dialysis vintage, and that both HBV and HCV infections were most prevalent among patients with the longest dialysis vintage. Additionally, HCV infection among maintenance dialysis patients is associated with an increased risk of mortality.

High Prevalence of Cardiovascular Disease in End-Stage Kidney Disease Patients Ongoing Hemodialysis in Peru: Why Should We Care About It?

Purpose. To determine clinical, biochemical, and pharmacological characteristics as well as cardiovascular disease prevalence and its associated factors among end-stage kidney disease patients receiving hemodialysis in the main hemodialysis center in Lima, Peru. Methods. This cross-sectional study included 103 patients. Clinical charts were reviewed and an echocardiogram was performed to determine prevalence of cardiovascular disease, defined as the presence of systolic/diastolic dysfunction, coronary heart disease, ventricular dysrhythmias, cerebrovascular disease, and/or peripheral vascular disease. Associations between cardiovascular disease and clinical, biochemical, and dialysis factors were sought using prevalence ratio. A robust Poisson regression model was used to quantify possible associations. Results. Cardiovascular disease prevalence was 81.6%, mainly due to diastolic dysfunction. It was significantly associated with age older than 50 years, metabolic syndrome, C-reactive protein levels, effective blood flow ≤ 300 mL/min, severe anemia, and absence of mild anemia. However, in the regression analysis only age older than 50 years, effective blood flow ≤ 300 mL/min, and absence of mild anemia were associated. Conclusions. Cardiovascular disease prevalence is high in patients receiving hemodialysis in the main center in Lima. Diastolic dysfunction, age, specific hemoglobin levels, and effective blood flow may play an important role.

Hepatitis C infection in hemodialysis patients: A review

Hepatitis C virus (HCV)-related liver disease is a significant cause of morbidity and mortality in patients with end-stage renal disease (ESRD) who is treated with dialysis or kidney transplantation (KT). The survival rate for HCV-infected renal transplant recipients is better than that for HCV-infected hemodialysis patients on transplant waiting lists. Early diagnosis and treatment HCV infection prior to KT prevents complications post-transplantation and reduces mortality. In addition to screening for anti-HCV antibodies and detecting HCV RNA, percutaneous liver biopsy is particularly valuable for assessing the stage of liver damage in HCV-infected patients, because the stage of fibrosis is important determining optimal treatment for HCV. Studies have been demonstrated that with conventional interferon (IFN) monotherapy or pegylated IFN monotherapy are similar efficacy and safety in HCV-infected hemodialysis patients. Sustained viral responses (SVRs) with these monotherapies have ranged approximately 30% to 40%. Limited reports support the use of IFN and ribavirin combination therapy as antiviral treatment for ESRD patients or patients on hemodialysis. Ribavirin can be started at low dose and careful monitoring for side effects. Patients that show SVR after treatment are strong candidates for KT. It is also generally accepted that ESRD patients with decompensated cirrhosis and portal hypertension should be referred to the liver transplant team for consideration of combined liver-KT.

Hepatitis C and kidney disease: An overview and approach to management

Hepatitis C infection and chronic kidney disease are major health burden worldwide. Hepatitis C infection is associated with a wide range of extra-hepatic manifestations in various organs including the kidneys. A strong association between hepatitis C and chronic kidney disease has come to light. Hemodialysis in supporting the end stage renal disease patients unfortunately carries a risk for hepatitis C infection. Despite much improvement in the care of this group of patients, the prevalence of hepatitis C infection in hemodialysis patients is still higher than the general population. Hepatitis C infection has a negative effect on the survival of hemodialysis and renal transplant patients. Treatment of hepatitis C in end stage renal disease patients using conventional or pegylated interferon with or without ribavirin remains a clinical challenge with low response rate, high dropout rate due to poor tolerability and many unmet needs. The approval of new direct acting antiviral agents for hepatitis C may dramatically change the treatment approach in hepatitis C infected patients with mild to moderate renal impairment. However it remains to be confirmed if the newer Hepatitis C therapies are safe in individuals with severe renal impairment. This review article discusses the relationship between hepatitis C and chronic kidney disease, describe the various types of renal diseases associated with hepatitis C and the newer as well as the existing treatments for hepatitis C in the context of this subpopulation of hepatitis C patients.

Relationships between interleukin-12B and interleukin-10 gene polymorphisms and hepatitis C in Chinese Han hemodialysis patients

BACKGROUND AND AIMS

Hepatitis C virus (HCV) commonly causes a chronic infection but portion of hemodialysis patients are able to resistant to HCV infection, even clear the virus naturally. Interleukin-10 (IL-10) and interleukin-12 (IL-12) are crucial regulators of the immune response to T-helper 1 (Th1) or T-helper 2 (Th2) categories and play a role in autoimmune and infectious diseases. This study was undertaken to investigate the possible association of genetic polymorphisms of 3' untranslated region (3'UTR) of the IL-12B (-1188) and IL-10 (-592 and -819) and hepatitis C in Chinese Han hemodialysis (HD) patients.

METHODS

The genotyping of IL-12B 3'UTR and IL-10 -592 and -819 were performed by polymerase chain reaction (PCR) restriction fragment length polymorphism (RFLP) method.

RESULTS

Compared with the IL-12B-AA genotype, CC and combined CC/AC genotypes were associated with a significant decreased risk of HCV infection in Chinese hemodialysis patients (p < 0.001). However, the IL-10-592 and -819 genotypes were not found significant difference both between the anti-HCV (+) and anti-HCV (-) patients (p > 0.05) and the persistent infection and viral clearance HD patients (p > 0.05).

CONCLUSIONS

The present study indicated that the polymorphisms of IL-12B 3'UTR might contribute to the susceptibility of HCV infection in Chinese HD population.

High hepatitis B virus surface antigen levels and favorable interleukin 28B genotype predict spontaneous hepatitis C virus clearance in uremic patients

BACKGROUND & AIMS

Host and viral factors interplay in the spontaneous clearance of hepatitis C virus (HCV) infection. We aimed to explore the roles of IL28B genotypes and hepatitis B virus (HBV) infections in spontaneous HCV seroclearance.

METHODS

IL28B rs8099917 genotypes, HCV and HBV markers were determined in 290 patients who were seropositive for HCV antibodies from 1681 total uremic patients on maintenance hemodialysis.

RESULTS

Persistent HCV viremia was observed in 74.6% (214/287) of patients. Logistic regression revealed that the strongest factors associated with spontaneous HCV seroclearance were carriage of rs8099917 TT-type (odds ratio/95% confidence intervals [OR/CI]: 6.22/1.41-27.35, p=0.016), followed by concurrent hepatitis B surface antigen (HBsAg) seropositivity (OR/CI: 2.37/1.06-5.26, p=0.035). The clearance rate was highest among patients with both positive HBsAg/rs8099917 TT-type (44.8%, OR/CI: 20.88/3.5-402.5), followed by positive HBsAg/rs8099917 non-TT-type (28.6%, OR/CI: 8.86/1.8-160.8), and negative HBsAg/rs8099917 TT-type (26.7%, OR/CI: 12.75/1.0-319.4), compared to 4% of negative HBsAg/rs8099917 non-TT-type (trend p=0.0002). HBsAg levels, but not HBV DNA levels, were significantly associated with spontaneous HCV seroclearance. Spontaneous HCV seroclearance rate was 58.3% in patients with HBsAg>200IU/ml/rs8099917 TT-type (OR/CI: 42.54/5.7-908.4), 28.0% in patients with HBsAg<200IU/ml/rs8099917 TT-type or HBsAg>200IU/ml/rs8099917 non-TT-type (OR/CI: 11.12/2.3-201.0), compared to only 3.3% in those with HBsAg<200IU/ml/rs8099917 non-TT-type (trend p=0.0004). Five of 214 (2.3%) HCV viremic patients at enrollment had spontaneous HCV seroclearance during one-year follow-up, which was associated with baseline HCV RNA and HBsAg levels.

CONCLUSIONS

High HBsAg levels and favorable IL28B genotype were additively associated with spontaneous HCV seroclearance in uremic patients.

Hepatitis C treatment in patients with kidney disease

Hepatitis C virus (HCV) remains the most common cause of liver damage in patients with kidney disease, including those on long-term dialysis. The natural history of HCV in patients on regular dialysis is not fully elucidated, but an adverse effect of HCV on survival has been noted; a novel meta-analysis of observational studies (14 studies including 145,608 unique patients) showed that the summary estimate for adjusted relative risk (all-cause mortality) was 1.35 with a 95% confidence interval of 1.25-1.47. The adjusted RR for liver disease-related death and cardiovascular mortality among maintenance dialysis patients was 3.82 (95% CI, 1.92-7.61) and 1.26 (95% CI, 1.10-1.45), respectively. It has been recommended that the decision to treat HCV in patients with chronic kidney disease be based on the potential benefits and risks of therapy, including life expectancy, candidacy for kidney transplant, and comorbidities. A pooled analysis including 494 dialysis patients on monotherapy with conventional interferon reported a summary estimate for sustained viral response and dropout rate of 39% (95% CI, 32-46) and 19% (95% CI, 13-26), respectively. All renal transplant candidates (dialysis dependent or not) with HCV should be assessed for antiviral treatment given the increased risk of progressive liver disease with immunosuppressive therapy, the increased life expectancy compared to other HCV-positive patients on dialysis, and the inability to receive interferon after transplant. Current guidelines support monotherapy with standard interferon in these patients, but modern antiviral approaches (that is, dual therapy with peg-IFN plus ribavirin) in a well-controlled setting may be an appropriate alternative.

Hepatitis C infection and chronic renal diseases

Hepatitis C virus (HCV) infection and chronic renal diseases can be linked in two different ways. Some forms of renal disease are precipitated by HCV infection, while patients with end-stage renal disease are at increased risk for acquiring HCV infection. Patients with chronic HCV infection and renal disease have a poor prognosis. Most studies on treatment of HCV and renal diseases have been uncontrolled trials with small number of subjects. So, there is a lack of evidence-based recommendations and guidelines on the management of this condition. In this review, we will attempt to provide the most recent insights on HCV infection both as a extrahepatic manifestations and as a complication of end-stage renal patients.

Hepatitis C virus infection and dialysis: 2012 update

Hepatitis C virus infection is still common among dialysis patients, but the natural history of HCV in this group is not completely understood. Recent evidence has been accumulated showing that anti-HCV positive serologic status is significantly associated with lower survival in dialysis population; an increased risk of liver and cardiovascular disease-related mortality compared with anti-HCV negative subjects has been found. According to a novel meta-analysis (fourteen studies including 145,608 unique patients), the adjusted RR for liver disease-related death and cardiovascular mortality was 3.82 (95% CI, 1.92; 7.61) and 1.26 (95% CI, 1.10; 1.45), respectively. It has been suggested that the decision to treat HCV in patients with chronic kidney disease be based on the potential benefits and risks of therapy, including life expectancy, candidacy for kidney transplant, and co-morbidities. According to recent guidelines, the antiviral treatment of choice in HCV-infected patients on dialysis is mono-therapy but fresh data suggest the use of modern antiviral approaches (i.e., pegylated interferon plus ribavirin). The summary estimate for sustained viral response and drop-out rate was 56% (95% CI, 28-84) and 25% (95% CI, 10-40) in a pooled analysis including 151 dialysis patients on combination antiviral therapy (conventional or pegylated interferon plus ribavirin).

Hepatitis C virus core antigen test in monitoring of dialysis patients

Hepatitis C virus infection is a persistent worldwide public health concern. The prevalence of HCV infection is much higher in patients on chronic haemodialysis (HD) than in the general population. HCV infection can detrimentally affect patients throughout the spectrum of chronic kidney disease. Despite the control of blood products, hepatitis C virus transmission is still being observed among patients undergoing dialysis. Detection systems for serum HCV antibodies are insensitive in the acute phase because of the long serological window. Direct detection of HCV depends on PCR test but this test is not suitable for routine screening. Recent studies have highlighted the importance of HCV core antigen detection as an alternative to PCR. Few studies exist about the efficacy of HCV core antigen test in dialysis population. We studied the utility of HCV core antigen test in routine monitoring of virological status of dialysis patients. We screened 92 patients on long-term dialysis both by PCR HCV-RNA and HCV core antigen test. The sensitivity of HCVcAg test was 90%, the specificity 100%, the positive predictive power 100%, the negative predictive power 97%, and the accuracy 97%. We think serological detection of HCV core antigen may be an alternative to NAT techniques for routine monitoring of patients on chronic dialysis.

Incidence of hepatitis C virus infection in patients on hemodialysis: a systematic review and meta-analysis

Hepatitis C virus infection is a perennial concern for hemodialysis units because the prevalence of hepatitis C is significantly higher there than in the general population. Through a systematic review and meta-analysis, we aim to assess the incidence rate of hepatitis C virus infection in hemodialysis units and explore its potential risk factors. Five electronic databases were used to search articles from 1990 to 2012, including PubMed, Embase, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang. A random-effects analysis was used to estimate the overall incidence rate of hepatitis C virus infection. A subgroup analysis and meta-regression analysis were conducted to explore factors associated with heterogeneity between studies. Twenty-two eligible articles were found, including 23 incidence rate estimates. The overall incidence rate of hepatitis C virus infection was 1.47 per 100 patient-years (95% confidence interval [CI] 1.14 to 1.80). In the subgroup analysis, the pooled incidence rate was 4.44 (CI 2.65, 6.23) per 100 patient-years in the developing world and 0.99 (CI 0.66, 1.29) per 100 patient-years in the developed world. [Correction added on 2 November 2012, after first online publication: Pooled incidence rate in the developed world has been changed.] In addition, in hemodialysis units with higher prevalence, the incidence rate of hepatitis C virus infection also tended to be higher. Meta-regression analysis showed that the country's development level and initial HCV prevalence combined could explain 67.91% of the observed heterogeneity. The incidence rate of hepatitis C virus infection among patients on hemodialysis was significantly high. Efforts should be taken to control hepatitis C virus infection in hemodialysis units, especially in developing countries.

Impact of hepatitis C on survival in dialysis patients: a link with cardiovascular mortality?

Recent evidence has been accumulated showing that anti-HCV-positive serologic status is significantly associated with lower survival in dialysis populations, but the mechanisms underlying this negative relationship are still unclear. The aim of this study was to conduct a systematic review of the published medical literature concerning the impact of hepatitis C virus (HCV) infection on all-cause and disease-specific mortality of patients on regular dialysis. The relative risk of all-cause, cardiovascular and liver disease-related mortality was regarded as the most reliable outcome end-point. Study-specific relative risks were weighted by the inverse of their variance to obtain fixed- and random effect pooled estimates for mortality with HCV across the published studies. We identified fourteen observational studies involving 145 608 unique patients on long-term dialysis. Pooling of study results demonstrated that anti-HCV antibody was an independent and significant risk factor for death in patients on maintenance dialysis. The summary estimate for adjusted relative risk (all-cause mortality) was 1.35 with a 95% confidence interval (CI) of 1.25-1.47. Stratified analysis showed that the adjusted RR for liver disease-related death was 3.82 (95% CI, 1.92; 7.61); heterogeneity statistics, R(i) = 0.58 (P-value by Q-test = 0.087). The adjusted RR for cardiovascular mortality was 1.26 (95% CI, 1.10; 1.45); no heterogeneity was found (NS). This meta-analysis of observational studies indicates that anti-HCV-positive patients on dialysis have an increased risk of either liver or cardiovascular disease-related mortality compared with anti-HCV-negative patients. Further studies are in progress to understand better the link between HCV and cardiovascular risk among patients on maintenance dialysis.

Relationships between tumour necrosis factor-α, interleukin-12B and interleukin-10 gene polymorphisms and hepatitis B in Chinese Han haemodialysis patients

AIM

To investigate the possible association of gene polymorphisms of tumour necrosis factor (TNF)-α (-238 and -308), interleukin (IL)-10 (-592 and -819) and 3' untranslated region (3'UTR) of the IL12B (-1188) and hepatitis B in Chinese Han haemodialysis (HD) patients.

METHODS

The genotyping of TNF-α -238 and -308, IL-10 -592 and -819 and 3'UTR of the IL12B were performed by polymerase chain reaction (PCR) restriction fragment length polymorphism (RFLP) method.

RESULTS

The TNF-α-238 A allele, the IL12B 3'UTR C/C, C/A genotypes were associated with decreased susceptibility to hepatitis B viral infection (P = 0.047, P = 0.003 and P = 0.001 respectively). The frequencies of IL-10-592 A/A genotype, IL-10-819 T/T genotype were lower in the HBV persistence group (P = 0.029 and P = 0.019) than those in the virus clearance group.

CONCLUSIONS

TNF-α and IL12B 3'UTR gene polymorphisms may be associated with HBV susceptibility and IL-10 gene polymorphisms may be related to the HBV persistence infection in Chinese Han HD patients.

Association of HCV core antigen seropositivity with long-term mortality in patients on regular hemodialysis

Anti-hepatitis C virus (HCV) antibody seropositivity is independently associated with poor prognosis in hemodialysis (HD) patients. However, anti-HCV antibody cannot distinguish between patients with active infection and those who have recovered from infection. We therefore aimed in this study to examine the association of HCV core antigen (HCVcAg) seropositivity with mortality in HD patients. We first measured serum HCVcAg using an immunoradiometric assay and anti-HCV antibody in 405 patients on regular HD, and followed them for 104 months. There were 82 patients (20.2%) who had been positive for anti-HCV antibodies; 57 (69.5%) of these were positive for HCVcAg. During the follow-up, 29 patients were excluded, so we tested the association of HCVcAg seropositivity with all-cause, cardiovascular (CV) and non-CV mortalities in 376 patients. A total of 209 patients (55.6%) had expired during the observational period, 92 out of them due to CV causes. After adjusting for comorbid parameters, HCVcAg was independently associated with overall mortality (HR 1.61, 95% CI 1.05–2.47, p < 0.05). HCV infection was significantly related to liver disease-related mortality. Past HCV infection also contributed to CV mortality (HR 2.63, 95% CI 1.27–5.45, p < 0.01). In contrast, anti-HCV antibody and HCVcAg seropositivities did not associate with infectious disease-related and cancer-related (expect for hepatocellular carcinoma) mortality. It follows from these findings that HCVcAg serology is associated with all-cause and CV mortality in HD patients.

Management of hepatitis C in patients with chronic kidney disease

Chronic kidney disease represents a global health problem. Chronic hepatitis C virus (HCV) infection is prevalent in patients with end stage renal disease (ESRD) on hemodialysis (HD) and in renal transplant recipients with significant impact on morbidity and mortality. Furthermore, HCV can cause various forms of glomerulopathy with the predominant type being cryglobulinemia associated membranoproliferative glomerulonephritis. Liver enzymes are traditionally used as markers of liver injury; however, there is wide variation in aminotransferase levels in patients with ESRD. Therefore, diagnosis of chronic hepatitis C (CHC) in patients with ESRD is based on HCV antibody testing and further confirmation with polymerase chain reaction testing. Current standard therapy for CHC is composed of pegylated interferon and ribavirin. However, this combination is challenging in patients with ESRD due to its tolerability. We describe in this review relevant issues in epidemiology, diagnosis and management of CHC in ESRD, HD and renal transplant recipients.

Kinetics of hepatitis C virus load and hemodialysis: is there any influence of the reuse of dialysis membrane on HCV viremia?

BACKGROUND

Patients with chronic kidney disease (CKD) on regular hemodialysis are at increased risk of acquiring hepatitis C virus (HCV). Although controversial, a distinct dynamic of the HCV load has been reported in this group - a lower HCV viremia compared to non-uremic patients. The reasons for this remain unclear, but the host immune response related to the hemodialysis procedure and the reuse of dialysis membranes are the most investigated factors.

METHODS

We analyzed the kinetics of HCV RNA viremia in 21 hemodialysis patients infected with genotype 1, through a highly sensitive quantitative method (real-time polymerase chain reaction), immediately before and at the end of the first use and the last reuse of the cellulose diacetate dialysis membrane.

RESULTS

Initial HCV load did not correlate with demographic or biochemical parameters, but higher HCV viremia was associated with a longer time on hemodialysis (r = 0.44, p = 0.04). Although not significant, HCV RNA decreased in 11/21 (52.3%) patients after the first dialysis session (median 279,000 vs 176,000 IU/ml, p = 0.91). However, a significant increase in HCV RNA viremia was observed in 17/21 (80.9%) patients after the tenth session (median 187,000 vs 342,000 IU/ml, p = 0.009).

CONCLUSIONS

Except for the first session of hemodialysis, we did not confirm a decrease in HCV viremia related to the time on hemodialysis or with the reuse of the dialysis membrane. Factors other than the reuse of the dialysis membrane might be involved in the multifaceted kinetics of HCV RNA in CKD patients on hemodialysis.

Seropositivity for anti-HCV core antigen is independently associated with increased all-cause, cardiovascular, and liver disease-related mortality in hemodialysis patients

Background

It is not known whether chronic or past hepatitis C virus (HCV) infection contributes to the high mortality rate in hemodialysis patients.

Methods

This prospective study of 1077 adult hemodialysis patients without hepatitis B virus infection used Poisson regression analysis to estimate crude and sex- and age-adjusted rates (per 1000 patient-years) of all-cause, cardiovascular, infectious disease-related and liver disease-related mortality in patients negative for HCV antibody (group A), patients positive for HCV antibody and negative for anti-HCV core antigen (group B), and patients positive for anti-HCV core antigen (group C). The relative risks (RRs) for each cause of death in group B vs group C as compared with those in group A were also estimated by Poisson regression analysis after multivariate adjustment.

Results

A total of 407 patients died during the 5-year observation period. The sex- and age-adjusted mortality rate was 71.9 in group A, 80.4 in group B, and 156 in group C. The RRs (95% CI) for death in group B vs group C were 1.23 (0.72 to 2.12) vs 1.60 (1.13 to 2.28) for all-cause death, 0.75 (0.28 to 2.02) vs 1.64 (0.98 to 2.73) for cardiovascular death, 1.64 (0.65 to 4.15) vs 1.58 (0.81 to 3.07) for infectious disease-related death, and 15.3 (1.26 to 186) vs 28.8 (3.75 to 221) for liver disease-related death, respectively.

Conclusions

Anti-HCV core antigen seropositivity independently contributes to elevated risks of all-cause and cause-specific death. Chronic HCV infection, but not past HCV infection, is a risk for death among hemodialysis patients.

Prevalence and incidence of hepatitis C virus in hemodialysis patients in British Columbia: Follow-up after a possible breach in hemodialysis machines

BACKGROUND

A possible breach of the transducer protector in specific dialysis machines was reported in June 2004 in British Columbia (BC), which led to testing of hemodialysis patients for hepatitis C virus (HCV), hepatitis B virus (HBV) and HIV. This testing provided an opportunity to examine HCV incidence, prevalence and coinfection with HBV and HIV, and to compare anti-HCV and HCV polymerase chain reaction (PCR).

METHODS

The results of hemodialysis patients who were dialyzed on the implicated machines (65% of BC dialysis patients), and tested for HCV, HBV and HIV, between June 1, 2004, and December 31, 2004, were reviewed and compared with available previous results.

RESULTS

Of 1286 hemodialysis patients with anti-HCV and/or HCV-PCR testing, 69 (5.4%) tested positive. Two HCV genotype 4 seroconversions were identified. HCV incidence rate on dialysis was 78.8 cases per 100,000 person-years. Younger age, history of renal transplant and past HBV infection were associated with HCV infection. No occult infection was identified using HCV-PCR.

INTERPRETATION

Hemodialysis patients had three times the HCV prevalence rate of the general BC population, and more than 20 times the incident rate of the general Canadian population. One of the two seroconversions occurred before the testing campaign; the patient was likely infected during hemodialysis in South Asia. The other was plausibly a late seroconversion following renal transplant in South Asia. Nosocomial transmission cannot be ruled out because both patients were dialyzed in the same centre. Baseline and annual anti-HCV testing is recommended. HCV-PCR should be considered at baseline for persons with HCV risk factors, and for returning travellers who received dialysis in HCV-endemic countries to identify HCV infection occurring outside the hemodialysis unit.

Treatment of hepatitis C virus infection in patients with end-stage renal disease

Hepatitis C virus (HCV) infection is a major health problem in patients with end-stage renal disease (ESRD). The incidence of acute HCV infection during maintenance dialysis is much higher than that in the general population because of the risk of nosocomial transmission. Following acute HCV infection, most patients develop chronic HCV infection, and a significant proportion develop chronic hepatitis, cirrhosis, and even hepatocellular carcinoma. Overall, chronic hepatitis C patients on hemodialysis bear an increased risk of liver-related morbidity and mortality, either during dialysis or after renal transplantation. Interferon (IFN) therapy is modestly effective for the treatment of HCV infection in ESRD patients. Conventional or pegylated IFN monotherapy has been used to treat acute hepatitis C in ESRD patients with excellent safety and efficacy. Regarding chronic hepatitis C, approximately one-third of patients can achieve a sustained virological response (SVR) after conventional or pegylated IFN monotherapy. The combination of low-dose ribavirin and conventional or pegylated IFN has further improved the SVR rate in treatment-naïve or retreated ESRD patients in clinical trials. Similar to the treatment of patients with normal renal function, baseline and on-treatment HCV virokinetics are useful to guide optimized therapy in ESRD patients. Of particular note, IFN-based therapy is not recommended at the post-renal transplantation stage because of the low SVR rate and risk of acute graft rejection. In conclusion, ESRD patients with HCV infection should be encouraged to receive antiviral therapy, and those who achieve an SVR usually have long-term, durable, virological, biochemical, and histological responses.

Decreased prevalence and incidence of HCV markers in haemodialysis units: a multicentric French survey

BACKGROUND

A variety of epidemiological data provide evidence for the nosocomial transmission of hepatitis C virus (HCV) infections to haemodialysis patients. We conducted a multicentric study to determine the prevalence and incidence of HCV infection in French haemodialysis units.

METHODS

Patients undergoing chronic haemodialysis in 56 French units (4718 patients) were systematically screened for anti-HCV antibodies using third-generation tests. The incidence was estimated by detecting HCV RNA in seronegative patients using a standardized real-time PCR assay on pooled samples.

RESULTS

Testing for HCV antibodies identified 361 patients with anti-HCV antibodies, giving a prevalence of 7.7%. Multivariate analysis demonstrated that anti-HCV status was linked to the time on haemodialysis, previous kidney transplantation and the presence of anti-HBc antibodies, whereas erythropoietin therapy and carrying out dialysis in dedicated spaces seem to protect against HCV infection. Only two of the 4357 patients without anti-HCV antibodies tested positive for HCV RNA, giving an estimated incidence of 0.05% new HCV infections/year. Molecular analyses indicated that the two patients probably acquired HCV outside the haemodialysis unit.

CONCLUSION

This decreased prevalence and incidence emphasizes the importance of adhering to the recommended universal infection-control precautions. Virological follow-up based on detecting anti-HCV antibodies with sensitive, specific new-generation serological tests could be adequate for dialysis units with few HCV infections. However, new infections in haemodialysis units should be identified by determining the HCV RNA status of seronegative patients. Standardized real-time PCR assays, plus pooling serum samples, make this a promising method for large-scale epidemiological studies.

Molecular epidemiology of a hepatitis C virus epidemic in a haemodialysis unit: outbreak investigation and infection outcome

Background

HCV is a leading cause of liver chronic diseases all over the world. In developed countries the highest prevalence of infection is reported among intravenous drug users and haemodialysis (HD) patients. The present report is to identify the pathway of HCV transmission during an outbreak of HCV infection in a privately run haemodialysis (HD) unit in Italy in 2005.

Methods

Dynamics of the outbreak and infection clinical outcomes were defined through an ambi-directional cohort study. Molecular epidemiology techniques were used to define the relationships between the viral variants infecting the patients and confirm the outbreak. Risk analysis and auditing procedures were carried out to define the transmission pathway(s).

Results

Of the 50 patients treated in the HD unit 5 were already anti-HCV positive and 13 became positive during the study period (AR = 28.9%). Phylogenic analysis identified that, all the molecularly characterized incident cases (10 out of 13), were infected with the same viral variant of one of the prevalent cases. The multivariate analysis and the auditing procedure disclosed a single event of multi-dose vials heparin contamination as the cause of transmission of the infection in 11 out of the 13 incident cases; 2 additional incident cases occurred possibly as a result of inappropriate risk management.

Discussion

More than 30% of all HCV infections in developed countries results from poor application of standard precautions during percutaneous procedures. Comprehensive strategy which included: educational programmes, periodical auditing on standard precaution, use of single-dose vials whenever possible, prospective surveillance for blood-borne infections (including a system of prompt notification) and risk assessment/management dedicated staff are the cornerstone to contain and prevent outbreaks in HD

Conclusions

The outbreak described should serve as a reminder to HD providers that patients undergoing dialysis are at risk for HCV infection and that HCV may be easily transmitted whenever standard precautions are not strictly applied.