Frequencies of hepatitis B and C infections among haemodialysis and peritoneal dialysis patients in Asia-Pacific countries: analysis of registry data

Seroprevalence and risk factors of HBV, HCV and HIV among hemodialysis patients: a multicenter cross-sectional study from Damascus Syria

OBJECTIVE

The aim of this study is to determine the prevalence rates of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections among hemodialysis (HD) patients as well as to identify associated risk factors.

METHODOLOGY

A multicenter cross-sectional study involved patients who had been on HD for at least three months. The study was conducted at five HD centers in Damascus, Syria from August 2019 to September 2021. HBsAg, HCV-Ab and HIV (antibody/antigen) seropositivity were identified using the third generation ELISA technique. Patients' information was extracted from their records and by face-to-face interview. Multiple logistic regression models were applied to identify risk factors associated with HBV or HCV seropositivity. The significance level was set at 5%.

RESULTS

A total of 637 patients were included in the study with a mean age (SD) of 50.5 (15.6) years and 56.7% of them were men. The dialytic age ranged from one to thirty years with a mean (SD) of 6.10 (5.6) years. The prevalence of positive hepatitis B surface antigen, anti-HCV, co-infection of HBV and HCV, and anti-HIV (antibody/antigen) were 3.2%, 22.1%, 0.7%, and 0%, respectively. After controlling for co-variables, hepatitis B vaccine was the only predictor of seropositivity of HBV (OR: 0.15, 95% CI: 0.057-0.393, P < 0.001), as it significantly protected against contracting HBV. On the other hand, the dialytic age (OR: 1.42, 95% CI: 1.12-1.94, P = 0.032) and the dialysis center were significant factors affecting the prevalence of HCV.

CONCLUSIONS

The prevalence of HCV and HBV infections among HD patients in Damascus, Syria has decreased remarkably compared with the results from 2001. Nevertheless, it is still considered relatively high. Thus, there is an urgent need to strengthen the prevention and control measures for viral infection transmission in HD centers in Damascus.

Peritoneal Dialysis Care for People with Diabetes, Polycystic Kidney Disease, or Advanced Liver Disease

People treated with peritoneal dialysis (PD) often have complicating conditions that require careful management. Three such conditions are reviewed in this article-diabetes mellitus, polycystic kidney disease, and chronic liver disease. Each of these conditions requires an understanding of both its effect on the delivery of the PD and the effect of the PD on the condition itself. In diabetes, glucose absorption from the dialysate complicates metabolic control and affects salt and water management and patient outcome. There is particular benefit in clinical care being delivered through a multidisciplinary team that involves both kidney and diabetes experts. In relation to polycystic kidney disease, a key issue is the potential for increased intraperitoneal pressure due to the combined effect of the enlarged polycystic organs and the presence of the dialysis solution, and therefore, the PD prescription requires to be managed with a particular focus on limiting that pressure. For patients with liver disease, key issues include nutritional support because PD can add to protein losses already consequent on the liver disease itself. Considered approaches are required to manage ascites and reduce infection risk and the potential for hernias and leaks to develop. Mortality in this group is unfortunately high-however, PD may present a better management option than hemodialysis in many patients-particularly in those where the liver disease is complicated by low BP, clotting abnormalities, or troublesome ascites. Overall, the choice to use PD in patients with these complicating conditions should be based on shared decision making with the patient and their family members informed by high-quality information in which risks, benefits, and management strategies are clearly presented.

Hepatitis C and hepatitis B virus infection in hemodialysis patients after nationwide direct antiviral agents therapy-experience of 10 Romanian HD centers

PURPOSE

End-stage kidney disease patients (ESKD) receiving hemodialysis (HD) are at a greater risk of hepatitis virus (HV) infections due to the invasive nature of the procedures, frequent hospital stays and surgeries, as well as the immune deficiency status of ESKD.

THE AIM

This study was to reassess the hepatitis virus infections prevalence in the HD population in Romania after 5 years of oral DAAs therapy and assess the impact on HD patients' outcomes in two cohorts (2015 and 2019).

METHODS

We compared ESKD patients treated with HD in 10 HD centers from the historical regions of Romania in 2015 (n = 1401, Mean age 59.7 ± 12.92 years) with patients treated in the same centers in 2019 (n = 1698, mean age 61 ± 12.93 years). All patients went through HD therapy for more than 90 days.

RESULTS

The patients from the 2019 cohort were significantly older (p = 0.005), had a longer duration of HD therapy (p < 0.0001), and had more vascular calcifications (p = 0.015); the crude one-year mortality rate did not differ from the 2015 cohort (9.9 vs. 10.7%, p = 0.46). The prevalence of HBV infection did not differ between the cohorts (4.7% vs. 4.8, p = 0.604) but the prevalence of HCV significantly decreased from 2015 to 2019 (16.9 vs. 10.5%, p < 0.0001).

CONCLUSION

After 15 years of a nationwide infection prevention program for HV infections and 5 years of DAAs treatment in Romania, the prevalence of HBV did not change but HCV infections decreased significantly, however, it still remained high.

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.

Pan-genotypic direct-acting antivirals for patients with hepatitis C virus infection and chronic kidney disease stage 4 or 5

Hepatitis C virus (HCV) infection is a major health problem with significant clinical and economic burdens in patients with chronic kidney disease (CKD) stage 4 or 5. Current guidelines recommend pan-genotypic direct-acting antivirals (DAAs) to be the first-line treatment of choice for HCV. This review summarizes the updated knowledge regarding the epidemiology, natural history, public health perspectives of HCV in patients with CKD stage 4 or 5, including those on maintenance dialysis, and the performance of pan-genotypic DAAs in these patients. The prevalence and incidence of HCV are much higher in patients with CKD stage 4 or 5 than in the general population. The prognosis is compromised if HCV patients are left untreated regardless of kidney transplantation (KT). Following treatment-induced HCV eradication, patient can improve the health-related outcomes by maintaining a long-term aviremic state. The sustained virologic response (SVR12) rates and safety profiles of pan-genotypic DAAs against HCV are excellent irrespective of KT. No dose adjustment of pan-genotypic DAAs is required across CKD stages. Assessing drug-drug interactions (DDIs) before HCV treatment is vital to secure on-treatment safety. The use of prophylactic or preemptive pan-genotypic DAAs in HCV-negative recipients who receive HCV-positive kidneys has shown promise in shortening KT waiting time, achieving excellent on-treatment efficacy and safety, and maintaining post-KT patient and graft survival. HCV elimination is highly feasible through multifaceted interventions, including mass screening, treatment scale-up, universal precautions, and post-SVR12 reinfection surveillance.

Epidemiology of peritoneal dialysis outcomes

Peritoneal dialysis (PD) is an important home-based treatment for kidney failure and accounts for 11% of all dialysis and 9% of all kidney replacement therapy globally. Although PD is available in 81% of countries, this provision ranges from 96% in high-income countries to 32% in low-income countries. Compared with haemodialysis, PD has numerous potential advantages, including a simpler technique, greater feasibility of use in remote communities, generally lower cost, lesser need for trained staff, fewer management challenges during natural disasters, possibly better survival in the first few years, greater ability to travel, fewer dietary restrictions, better preservation of residual kidney function, greater treatment satisfaction, better quality of life, better outcomes following subsequent kidney transplantation, delayed need for vascular access (especially in small children), reduced need for erythropoiesis-stimulating agents, and lower risk of blood-borne virus infections and of SARS-CoV-2 infection. PD outcomes have been improving over time but with great variability, driven by individual and system-level inequities and by centre effects; this variation is exacerbated by a lack of standardized outcome definitions. Potential strategies for outcome improvement include enhanced standardization, monitoring and reporting of PD outcomes, and the implementation of continuous quality improvement programmes and of PD-specific interventions, such as incremental PD, the use of biocompatible PD solutions and remote PD monitoring.

The use of peritoneal dialysis (PD) can be advantageous compared with haemodialysis treatment, although several barriers limit its broad implementation. This review examines the epidemiology of peritoneal dialysis (PD) outcomes, including clinical, patient-reported and surrogate PD outcomes.

Peritoneal dialysis (PD) has distinct advantages compared with haemodialysis, including the convenience of home treatment, improved quality of life, technical simplicity, lesser need for trained staff, greater cost-effectiveness in most countries, improved equity of access to dialysis in resource-limited settings, and improved survival, particularly in the first few years of initiating therapy.

Important barriers can hamper PD utilization in low-income settings, including the high costs of PD fluids (owing to the inability to manufacture them locally and the exorbitant costs of their import), limited workforce availability and a practice culture that limits optimal PD use, often leading to suboptimal outcomes.

PD outcomes are highly variable around the world owing in part to the use of variable outcome definitions, a heterogeneous practice culture, the lack of standardized monitoring and reporting of quality indicators, and kidney failure care gaps (including health care workforce shortages, inadequate health care financing, suboptimal governance and a lack of good health care information systems).

Key outcomes include not only clinical outcomes (typically defined as medical outcomes based on clinician assessment or diagnosis) — for example, PD-related infections, technique survival, mechanical complications, hospitalizations and PD-related mortality — but also patient-reported outcomes. These outcomes are directly reported by patients and focus on how they function or feel, typically in relation to quality of life or symptoms; patient-reported outcomes are used less frequently than clinical outcomes in day-to-day routine care.

Seroprevalence of Hepatitis B Virus and Hepatitis C Virus in Patients Undergoing Maintenance Hemodialysis

Background

Underdeveloped countries suffer a huge burden of infectious diseases, among which hepatitis B virus (HBV) and hepatitis C virus (HCV) are of major concern. Our study sought to determine the seroconversion rate for HBV via hepatitis B antigen (HBsAg) and HCV via anti-hepatitis C virus antibodies (anti-HCV) among patients on maintenance hemodialysis in the dialysis unit of a tertiary care hospital in Pakistan.

Methodology

This study was carried out from October 2020 to January 2022 at the hemodialysis unit and the urology department of a tertiary care hospital in Multan. A total of 172 patients of both genders were screened for HBV and HCV seropositivity. Data analysis was done through IBM SPSS Statistics for Windows, Version 25.0 (Released 2017; IBM Corp., Armonk, New York, United States). Conclusions were drawn accordingly.

Results

At the one-year follow-up, screening revealed that 20 (11.7%) patients were positive for HBsAg and 39 (23%) were positive for anti-HCV. Five patients had dual seropositivity for HBsAg and anti-HCV, while three were positive for both HBsAg and anti-HDV. Four out of 20 patients who screened positive for HBsAg and 11 out of 39 patients screened for anti-HCV had a history of one more blood transfusion. Though the correlation between the duration of hemodialysis and viral markers was significant (p<0.05) for the patients screened positive for anti-HCV, a similar correlation was not observed in the patients with seropositivity for HBsAg.

Conclusion

Our study concludes that seroconversion is statistically significant for HCV infection compared to HBV infection. Tight adherence to standard preventive measures to minimize the transmission of these pathogens can lead to a decline in the incidence of these infections. Screening should be done widely to control and optimally manage these infections.

Accessibility and quality of haemodialysis services in an urban setting in South India: a qualitative multiperspective study

OBJECTIVE

To explore the accessibility and quality of existing haemodialysis services in an urban setting.

SETTING

The study was conducted in Bangalore city, India.

PARTICIPANTS

A total of 28 stakeholders including 2 nephrologists, 7 duty doctors, 13 dialysis technicians and 6 patients on long-term haemodialysis were selected from 20 dialysis centres in Bangalore city.

DESIGN AND METHODS

Qualitative study using in-depth interviews. A thematic analysis was done using the Availability, Accessibility, Acceptability and Quality Framework of WHO and the Bruce's Quality of Care Framework.

RESULTS

The study found several gaps with regard to the access and quality of existing services for patients with end-stage kidney disease (ESKD). The charges for dialysis sessions across settings displayed a wide variance. Patients often started dialysis services in private and later shifted to government and non-governmental organisations-run centres and reduced the number of weekly dialysis sessions due to financial constraints. Most standalone dialysis centres did not have the facilities to manage any emergencies. Most centres did not admit patients with hepatitis or HIV. The quality of care in dialysis centres seemed to be variable and most centres were managed solely by dialysis technicians. There were no psychosocial interventions available to the patients irrespective of the settings. Cost-cutting practices such as employing underqualified technicians, reusing dialysis equipment and using substandard water for dialysis were common.

CONCLUSION

The study highlights the need for more financial and personnel investments in ESKD care in India to ensure optimal care for the growing patient population. The study points towards the need for comprehensive management practices, including diet counselling and psychosocial support. While there are comprehensive guidelines on the establishment and management of dialysis services, more policy attention needs to be on effective implementation of these, to ensure better accessibility and quality of existing services.

Prevalence and genotype distribution of hepatitis C virus within hemodialysis units in Thailand: role of HCV core antigen in the assessment of viremia

Background

Individuals with end-stage renal disease have a higher risk of hepatitis C virus (HCV) acquisition during long-term hemodialysis (HD). Our report was designed to investigate HCV prevalence and genotype, in addition to the clinical use of HCV core antigen (HCVcAg), within multiple HD facilities in Thailand.

Methods

This cross‐sectional report was investigated between January and June 2019. HCV infection was assessed by anti-HCV and confirmed active infection by measuring HCV RNA and HCVcAg. HCV genotype was determined by phylogenetic analysis using nucleotide sequences of NS5B region.

Results

Overall, 140 of 3,305 (4.2%) patients in 15 dialysis centers had anti-HCV positive. Among them, HCV RNA was further assessed in 93 patients and was detectable in 59 (63.4%) persons. Considering HCV viremia, HCVcAg measurement exhibited high accuracy (96.8%), sensitivity (94.9%) and specificity (100%) in comparison with HCV RNA testing. Moreover, individuals infected with HCV received a longer duration of dialysis vintage when compared to anti-HCV negative controls. The major sub-genotypes were 1a, 1b, 3a, 3b, 6f and 6n. Regarding phylogenetic analysis, there were 7 clusters of isolates with high sequence homology affecting 17 individuals, indicating possible HCV transmission within the same HD centers.

Conclusions

HCV frequency and common sub-genotypes in HD centers were different from those found in the Thai general population. HCVcAg might be an alternate testing for viremia within resource-limited countries. Enhanced preventive practices, dialyzer reuse policy and better access to antiviral therapy are crucial for HCV micro-elimination within HD facilities.

Management of hepatitis B and C in special population

Chronic viral hepatitis is one of the leading causes of cirrhosis worldwide. Chronic hepatitis B is more common in the Asia-Pacific region due to the larger population and lower screening availability. Hepatitis C predominates in the west due to injection drug abuse. The discovery of (oral) direct-acting antiviral agents (DAAs) has changed the landscape of chronic hepatitis C (CHC) management. Nucleos(t)ide analogs (NUCs) have also changed the approach to the treatment of chronic hepatitis B (CHB). Oral NUCs and DAAs have excellent efficacy and patient acceptance as well as a lower risk of resistance. However, certain populations have no robust data and safety and efficacy of such oral drugs is still evolving. In this review, we provide an overview of the management of CHB and CHC in special populations, such as those with chronic kidney disease, pregnant women, healthcare workers, and those undergoing chemo- or immunosuppressive therapy.

Acute hepatitis C treatment in advanced renal failure using 8 weeks of pan-genotypic daclatasvir and reduced-dose sofosbuvir

BACKGROUND

Sofosbuvir is not recommended in persons with estimated glomerular filtration rate (eGFR) <30 mL/min. We report the results of treatment with an off-label 8-week regimen of daclatasvir and half-dose sofosbuvir in patients with acute infection with hepatitis C virus ( HCV) and eGFR <30 mL/min.

METHODS

Clinic records were searched to identify treatment-naïve, noncirrhotic adults with acute hepatitis C (HCV viremia and a ≥10-fold elevation of serum alanine aminotransferase activity) and eGFR <30 mL/min, who had been treated with a sofosbuvir-based regimen. Treatment response was assessed using serum HCV RNA testing at 4 weeks of treatment, end of the 8-week treatment and 12 weeks after stopping treatment.

RESULTS

Of the 31 patients with acute hepatitis C, 27 [median age (range): 36 (18-74) years; 20 (74%) male] were started on treatment with 200 mg sofosbuvir and 60 mg daclatasvir daily for 8 weeks, irrespective of HCV genotype. All the 27 completed the planned 8-week treatment. One patient died 10 weeks after completing the treatment of an unrelated cause. All the 27 patients had undetectable HCV RNA after 4 weeks of and at the end of treatment. At 12 weeks after completion of treatment, only one tested HCV RNA positive and 25 were negative, with sustained virological response rate of 25/27 (92.6%) and 25/26 (96.2%) on intention-to-treat and per-protocol basis, respectively.

CONCLUSION

Eight-week course of daclatasvir and half-dose sofosbuvir is effective for acute hepatitis C in patients with eGFR <30 mL/min and could be a useful alternative to costly, kidney-safe anti-HCV oral drugs in resource-constrained settings.

Updated Evidence on the Epidemiology of Hepatitis C Virus in Hemodialysis

Prevalence rates of HCV infection are decreasing in hemodialysis units of most developed countries; however, nosocomial transmission of HCV continues to occur in the hemodialysis setting, not only in the emerging world. According to the Dialysis Outcomes and Practice Patterns Study (DOPPS, 2012–2015), the prevalence of HCV among patients on regular hemodialysis was 9.9%; in incident patients, the frequency of HCV was approximately 5%. Outbreaks of HCV have been investigated by epidemiologic and phylogenetic data obtained by sequencing of the HCV genome; no single factor was retrieved as being associated with nosocomial transmission of HCV within hemodialysis units. Transmission of HCV within HD units can be prevented successfully by full compliance with infection control practices; also, antiviral treatment and serologic screening for anti-HCV can be useful in achieving this aim. Infection control practices in hemodialysis units include barrier precautions to prevent exposure to blood-borne pathogens and other procedures specific to the hemodialysis environment. Isolating HCV-infected hemodialysis patients or using dedicated dialysis machines for HCV-infected patients are not currently recommended; reuse of dialyzers of HCV-infected patients should be made, according to recent guidelines. Randomized controlled trials regarding the impact of isolation on the risk of transmission of HCV to hemodialysis patients have not been published to date. At least two studies showed complete elimination of de novo HCV within HD units by implementation of strict infection control practices without isolation practices. De novo HCV within hemodialysis units has been independently associated with facility HCV prevalence, dialysis vintage, and low staff-to-patient ratio. Antiviral treatment of HCV-infected patients on hemodialysis should not replace the implementation of barrier precautions and other routine hemodialysis unit procedures.

Dynamics of cellular immune responses in recipients of renal allografts positive for hepatitis B surface antigen

BACKGROUND/PURPOSE

Hepatitis B surface antigen (HBsAg)-positive renal transplantation recipients must take lifelong immunosuppressants and nucleotide analogues (NAs). We investigated the cellular immune responses of HBsAg-positive renal transplantation recipients taking immunosuppressants and NAs.

METHODS

Blood samples were collected from HBsAg-positive individuals with end-stage renal disease on the transplant waiting list (Group 1) and renal transplantation recipients taking immunosuppressants and NAs (Group 2) or immunosuppressants without NAs (Group 3). Hepatitis B virus (HBV)-specific pentamers were used to quantify circulating HBV-specific CD8⁺ T cells.

RESULTS

Groups 2 and 3 had higher cellular immune responses, as indicated by significantly lower regulatory T (Treg)/CD8⁺ T cell ratios than Group 1. With undetectable viral loads under both immunosuppressant and NAs, the CD8⁺ T cell and HBV-specific CD8⁺ T cell frequencies were similar in Group 2 and Group 1. Patients in Group 3 did not use NAs and had an elevated viral load and higher HBV-specific CD8⁺ T cell and IFN-γ-producing HBV-specific CD8⁺ T cell frequencies, but lower a frequency of programmed death-1 (PD-1)⁺ HBV-specific CD8⁺ T cells than the other groups. Increased viral replication in Group 3 resulted in significantly higher CD8⁺ T cell and IFN-γ-producing CD8⁺ T cell frequencies than Group 1.

CONCLUSIONS

Immunosuppressant therapy increases viral replication in HBsAg-positive renal transplant recipients due to disabling or dysregulation of virus-specific CD8+ T cells. The higher cellular immune responses due to lower Treg/CD8+ T cell ratios in HBsAg-positive renal transplant recipients may be one of the reasons to induce liver pathology because of uncontrolled viral replication.

ALBI grade in dialysis patients with hepatocellular carcinoma: prognostic impact and staging strategy

BACKGROUND

Patients with hepatocellular carcinoma (HCC) may develop end-stage renal disease and receive dialysis, but the impact of dialysis on the prognosis is unclear. This study aimed to evaluate the outcome of dialysis HCC patients and the prognostic role of albumin-bilirubin (ALBI) grade in these patients.

METHODS

Among the consecutive 3,794 HCC patients between 2002-2017, 43 patients undergoing dialysis, and 129 age, sex-matched controls were analyzed. Multivariate Cox hazards model was used to identify independent prognostic predictors.

RESULTS

Dialysis patients had decreased overall survival when compared with non-dialysis patients (n=3,751) and matched controls (n=129; each P=0.004). Patients with ALBI grade 1 had the best survival in the pooled cohort of dialysis and matched controls (n=172). In the Cox model, total tumor volume >33 cm3 [hazard ratio (HR): 6.763, P<0.001], presence of ascites (HR: 6.168, P<0.001), dialysis duration less than 24 months (HR: 3.144, P=0.006), diabetes-related dialysis (HR: 9.366, P=0.001) and non-curative treatments (HR: 9.220, P<0.001) were poor prognosis factors associated with increase mortality among dialysis patients. Of the 9 currently-used HCC staging systems, the CLIP score was the optimal cancer staging for dialysis patients.

CONCLUSIONS

Patients receiving dialysis had decreased overall survival compared with non-dialysis patients. Longer duration of dialysis, non-diabetes related dialysis, absence of ascites, and curative treatments were associated with improved survival in these patients. The ALBI grade is a feasible prognostic model to evaluate liver functional reserve, and the CLIP model is the best staging system for dialysis patients with HCC.

Hepatitis B and C Infections in Patients With Prolonged Hemodialysis Secondary to Chronic Renal Failure

Objective

To determine the frequency of hepatitis B and C in patients with prolonged hemodialysis suffering from chronic renal failure.

Methods

A retrospective study was conducted from January to August 2017 at Tabba Kidney Institute, Karachi. A total of 255 patients on hemodialysis were included in the study by using convenient sampling technique. All the relevant data such as gender, age, duration of hemodialysis and presence of hepatitis B and C were recorded. Data were analyzed using Statistical Package for Social Sciences, version 21 (IBM Corp., Armonk, NY) while binary logistic regression was applied to develop a risk assessment model for the study outcomes.

Results

The study results showed that 134 (52.5%) patients were on hemodialysis for five years or more, 173 (67.8%) of them suffered from hepatitis B while 124 (48.6%) of them suffered from hepatitis C. The study results further revealed that after controlling for the effects of age and gender, the duration of hemodialysis was significantly associated with both hepatitis B (AOR 1.917, 95% CI 1.111-3.306, p=0.019) and hepatitis C (AOR 2.323, 95% CI 1.395-3.870, p=0.001) among the patients studied.

Conclusion

The study concluded that longer duration of hemodialysis in patients with chronic renal failure was significantly associated with both hepatitis B and hepatitis C infections in the study population. A myriad of patient and environmental factors can contribute to this finding in patients with chronic renal insufficiency. Therefore, periodic monitoring of liver function tests and routine surveillance for viral hepatitis can help establish an early diagnosis of infection, potentially improving patient outcomes improving patient outcome.

Hemodialysis at Doorstep - "Hub-and-Spoke" Model of Dialysis in a Developing Country

End-stage kidney disease has become a huge burden in our country. There has been an increase in dialysis centers across the country. State-funded dialysis has been initiated in many states of India. However, most of the centers are concentrated in the cities. Patients living in the peripheral districts have to travel long distance to reach the dialysis centers. In addition, there is a dearth of nephrology services in the peripheral areas. To address this problem, the hub-and- spoke model of dialysis has been initiated in Telangana state in South India, which has brought dialysis at the doorstep for people residing in remote districts. This study highlights the important features of this model.

Successful Treatment of Hepatitis C Virus Infection Using Direct-Acting Antiviral Agents (DAAs) in Adolescents with Kidney Transplantation: A Case Series

INTRODUCTION

Hepatitis C virus (HCV) infection is common among end-stage renal disease patients undergoing hemodialysis. The standard treatment for HCV infection has been interferon-ribavirin combination prior to renal transplantation. However, compared to direct-acting antiviral agents (DAAs), the risk of graft rejection is higher with interferon therapy. Many recent studies have investigated the efficacy and safety of DAAs for treating HCV infection in kidney disease in adults; however, it has not been established in pediatric patients. To the best of our knowledge, this is the first report describing successful treatment using the DAAs sofosbuvir/daclatasvir in two pediatric kidney transplant recipients who had HCV genotype 1a infection without liver fibrosis.

CASE PRESENTATION

Case 1 describes a 13-year-old Indonesian boy who had undergone hemodialysis since 2014 after being diagnosed with end-stage renal disease (ESRD) secondary to bilateral renal hypoplasia. Later, he had HCV infection and was treated with interferon-based therapy with ribavirin prior to living-related renal transplantation (LRRT). The HCV was undetected and his liver function normalized six months after treatment initiation. However, 10 months after treatment initiation, he had HCV virological breakthrough, leading to cessation of interferon therapy. Plans for LRRT were continued and HCV treatment using DAAs was set up to be given post LRRT. Case 2 describes a 14-year-old Indonesian girl who also had hemodialysis prior to LRRT after she was diagnosed with ESRD secondary to nephrotic syndrome. Later, she had HCV infection and was treated with interferon and ribavirin prior to the live-unrelated renal transplantation. HCV infection did not resolve, in addition, she experienced thrombocytopenia-which is a side effect of interferon-resulting in termination of interferon treatment. Both cases were treated with DAAs one year following renal transplantation after reaching stable graft function, leading to achievement of sustained virological response at 24 weeks.

CONCLUSION

Post-transplantation treatment of chronic HCV is preferred in KTRs. The sofosbuvir/daclatasvir regimen as an interferon-free therapy is a safe, effective option for HCV infection in pediatric KTRs, who can tolerate sofosbuvir/daclatasvir well and respond favorably without significant adverse events.

Elbasvir/grazoprevir for hepatitis C virus genotype 1b East-Asian patients receiving hemodialysis

Data regarding the efficacy and tolerability of elbasvir/grazoprevir (EBR/GZR) for East-Asian hepatitis C virus genotype 1b (HCV GT1b) patients receiving hemodialysis were limited. We prospectively recruited 40 HCV GT1b hemodialysis patients who received EBR/GZR for 12 weeks at 6 academic centers in Taiwan. The efficacy endpoints were sustained virologic response 12 weeks off-therapy (SVR₁₂) by intention-to-treat (ITT) modified ITT (mITT) analyses. Patients’ baseline characteristics, early viral kinetics and HCV resistance-associated substitutions (RASs) at HCV non-structural 3 and 5 A (NS3 and NS5A) regions potentially affecting SVR₁₂ were analyzed. The tolerability for EBR/GZR was also assessed. The SVR₁₂ rates by ITT and mITT analyses were 95% (38 of 40 patients; 95% confidence interval (CI): 83.5–98.6%) and 100% (38 of 38 patients; 95% CI: 90.8–100%), respectively. Patients’ baseline characteristics, on-treatment viral decline, and baseline HCV RASs did not affect SVR₁₂. All patients tolerated treatment well. Among 5 patients who had serious adverse events (AEs) including one death due to on-treatment suicide and the other death due to off-therapy acute myocardial infarction, none of these events were judged related to EBR/GZR. The common AEs included upper respiratory tract infection (7.5%), fatigue (5.0%) and anorexia (5.0%). Nine (22.5%) and 8 (20.0%) patients had on-treatment hemoglobin levels of 9.0–10.0 g/dL and 7.0–9.0 g/dL. Three (7.5%) patients had on-treatment elevated alanine aminotransferase (ALT) quotient > 2.5, in whom one (2.5%) had EBR/GZR-induced late ALT elevation. No patients developed hyperbilirubinemia or hepatic decompensation. In conclusion, treatment with EBR/GZR is effective and well-tolerated for East-Asian HCV GT1b patients receiving hemodialysis.

2018 Kidney Disease: Improving Global Outcomes (KDIGO) Hepatitis C in Chronic Kidney Disease Guideline Implementation: Asia Summit Conference Report

In 2018, Kidney Disease: Improving Global Outcomes (KDIGO) published a clinical practice guideline on the prevention, diagnosis, evaluation, and treatment of hepatitis C virus (HCV) infection in chronic kidney disease (CKD). The guideline synthesized recent advances, especially in HCV therapeutics and diagnostics, and provided clinical recommendations and suggestions to aid healthcare providers and improve care for CKD patients with HCV. To gain insight into the extent that the 2018 guideline has been adopted in Asia, KDIGO convened an HCV Implementation Summit in Hong Kong. Participants included nephrologists, hepatologists, and nurse consultants from 8 Southeast Asian countries or regions with comparable high-to-middle economic ranking by the World Bank: mainland China, Hong Kong, Japan, Malaysia, Singapore, South Korea, Taiwan, and Thailand. Through presentations and discussions, meeting participants described regional practice patterns related to the KDIGO HCV in CKD guideline, identified barriers to implementing the guideline, and developed strategies for overcoming the barriers in Asia and around the world.

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.

Prevalence, mortality and healthcare utilization among Medicare beneficiaries with Hepatitis C in Haemodialysis units

Hepatitis C (HCV) is more common among patients with end-stage renal disease requiring haemodialysis compared to the general population. Thus, we aimed to assess trends in prevalence, health resource utilization and mortality among Medicare beneficiaries with HCV on haemodialysis. This is a retrospective study of outpatient and inpatient claims for Medicare beneficiaries receiving haemodialysis (2005-2016). A total of 291 663 subjects on haemodialysis were included (67.3 ± 15.2 years, 55% male, 55% white, 49% age-based eligibility). The prevalence of HCV in subjects on haemodialysis was stable and was significantly higher (mean 4.2% in 2005-2016, P = 0.50 for the trend) than in subjects not on haemodialysis (<1%). In multivariate analysis, liver cirrhosis (odds ratio = 3.4 (95% CI = 3.3-3.6)) was an independent predictor of 1-year mortality among haemodialysis patients. Mean total inpatient payments in dialysis patients with HCV remained stable during 2005 ($73 803) through 2016 ($72 133) (trend P = 0.54) while mean total outpatient payment decreased from 2005 ($53 497) to 2016 ($35 439; trend P = 0.0013). In multivariate analysis, after adjustment for age, gender, race and location, both HCV and cirrhosis remained significant contributors to greater spending [HCV: inpatient +22.1% (+19.2%-25%), HCV: outpatient +18.4% (+14.6%-22.2%), cirrhosis: inpatient +59.7% (+56.9%-62.6%), cirrhosis: outpatient +9.4% (+6.2%-12.6%)]. In conclusion, HCV-infected Medicare patients receiving haemodialysis incur greater resource utilization; mortality is higher in patients with cirrhosis only. Although HCV prevalence in Medicare haemodialysis recipients is higher than in patients without haemodialysis, these rates are lower than reported, suggesting potential under-screening for HCV in this high-risk population.

Paritaprevir/ritonavir, ombitasvir plus dasabuvir for East Asian non-cirrhotic hepatitis C virus genotype 1b patients receiving hemodialysis

BACKGROUND AND AIM

Data regarding the efficacy and safety of paritaprevir/ritonavir, ombitasvir plus dasabuvir (PrOD) for East Asian non-cirrhotic hepatitis C virus genotype 1b (HCV GT1b) patients receiving hemodialysis were limited.

METHODS

Forty-six HCV GT1b non-cirrhotic patients receiving hemodialysis who received PrOD for 12 weeks were prospectively enrolled in seven academic centers in Taiwan. The primary efficacy endpoint was sustained virologic response 12 weeks off-therapy (SVR₁₂ ). Patients' baseline characteristics, early virokinetics, and HCV resistance-associated substitutions (RASs) potentially related to SVR₁₂ were analyzed. The safety profiles were also assessed.

RESULTS

The SVR₁₂ rate was 100% (46 of 46 patients). Patients' baseline characteristics, on-treatment viral decline, and baseline HCV resistance-associated substitutions did not affect SVR₁₂ . All patients tolerated treatment well. One patient with folliculitis temporarily discontinued treatment, and another two patients had serious adverse events (SAEs), which were considered not related to PrOD treatment. The common adverse events were pruritus (19.6%), fatigue (15.2%), and upper respiratory tract infection (6.5%). Twelve (19.6%) and one (2.2%) patients had hemoglobin levels < 10 and 8.5 g/dL, respectively, which were related to renal impairment. Five (10.9%) patients had on-treatment total bilirubin level of 1.5-3.0 mg/dL, but none developed hepatic decompensation. The bilirubin levels peaked at week 1 of treatment and then declined with continuous treatment.

CONCLUSION

Treatment with PrOD for 12 weeks is efficacious and well-tolerated for East Asian non-cirrhotic HCV GT1b patients receiving hemodialysis.

Successful Hepatitis C Virus Eradication in a Hemodialysis Patient With 2k/1b Chimera Genotype: A Case Report and Literature Review

Treatment of hemodialysis patients infected with two or three hepatitis C virus (HCV) genotypes (Gt) with interferon-free regimens has not been possible until the recent introduction of pan-genotypic next generation therapy. The main reason is that sofosbuvir (SOF)-containing regimens are contraindicated in patients with low glomerular filtration rate. We describe here a case of a chronic HCV infection in a patient with end-stage renal disease, successfully treated with gleсaprevir/pibrentasvir (GLE/PIB). Limited published data are available regarding the efficacy of antiviral therapy in patients with rare HCV recombinant Gt 2k/1b. We were not able to identify any reports describing treatment of hemodialysis patients with this recombinant type of HCV. We present a 57-year-old patient with autosomal-dominant polycystic kidney disease with liver involvement with end-stage of kidney disease. He was infected with HCV Gt 2k/1b variant after initiation of hemodialysis. This subtype appeared in Russia (Soviet Union that times) as a result of high frequency of virus mutations, and actually is widely spread in some states of the post-Soviet space, as well as in the countries with intensive migration from Russia and other former Soviet republics. In this particular case, we observed a tendency to a rapid progression of liver fibrosis despite mild clinical activity of chronic hepatitis C. A 12-week course of GLE/PIB allowed achieving sustained virologic response (SVR) and was well tolerated.

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.

Efficacy and Safety of Daclatasvir and Asunaprevir in Patients with Hepatitis C Virus Genotype 1b Infection on Hemodialysis

Background/Aims

We evaluated the efficacy and safety of daclatasvir (DCV) and asunaprevir (ASV) in patients with chronic hepatitis C virus (HCV) infection on hemodialysis.

Methods;

We performed a single-arm, multicenter prospective study. Twenty-one chronic hemodialysis patients with HCV infection were prospectively enrolled from February 2016 to April 2017. We evaluated the virological responses at weeks 4, 12, and 24 (end of treatment [EOT]) and the sustained virological response at 12 weeks after the EOT (SVR12). The tolerability and safety of the drugs were also assessed.

Results

None of the 20 patients had the NS5A resistance-associated variant (NS5A RAV), and one patient was indeterminate for the NS5A RAV. Seventeen patients (80%) completed the 24 weeks of treatment with DCV and ASV. Four patients discontinued the study prior to week 12. In an intention-to-treat analysis, the SVR12 was 76.1%. In a per-protocol analysis, patients who completed DCV and ASV treatment achieved an SVR12 of 100%. DCV and ASV were well tolerated by the majority of patients. Three patients discontinued treatment due to adverse events (AEs) including dizziness, dyspnea, and neutropenia. The patient with indeterminate NS5A RAV showed viral breakthrough and discontinued treatment.

Conclusions

DCV and ASV combination therapy in chronic hemodialysis patients with HCV infection achieved a high SVR12 rate with few AEs. To maximize the SVR12 rate, it is important to identify candidates by baseline RAV testing. Close monitoring of the safety and tolerability of DCV and ASV may be necessary in HCV-infected patients on hemodialysis. (ClinicalTrials.gov ID NCT02580474).

Sero Conversion of Viral Hepatitis among End Stage Renal Disease Patients on Hemodialysis in Kashmir: Results of a Prospective Study

BACKGROUND

The seroconversion is a significant health concern in patients with end-stage renal disease undergoing hemodialysis particularly in high endemic zones of HBV and HCV.

PATIENTS AND METHODS

This prospective study was conducted from January 2009 to April 2018 at Sheri Kashmir Institute of Medical Sciences, Srinagar, Kashmir. A cohort of 459 end-stage renal disease patients on hemodialysis was enrolled from four dialysis centres and followed in a longitudinal manner. Their seroconversion rates, risk factors were studied. Positive patients were treated and followed up.

RESULTS

This study demonstrated HBV seroconversion rate of 7.4 % (n = 34) and HCV seroconversion rate of 10% (n = 46) in a cohort of 459 patients on hemodialysis attending four dialysis centres of Kashmir. Patients with diabetes mellitus outnumbered in seroconversion rates of (43.75%) followed by patients with glomerulonephritis (23.75%). Of 15 patients who had undergone renal transplantation 10 (66.67%), patients had seroconversion on hemodialysis which was statistically significant (P < 0.001). Patients who were dialysed at multiple HD centres had significant seroconversion than those who followed up at a single center. Seroconversion was associated with longer duration of dialysis (80.30 ± 30.92 vs 61 ± 9.41months, P < 0.000). HBV vaccination of the ESRD patient on hemodialysis was significantly protective against seroconversion (P = 0.000).

CONCLUSIONS

Hepatitis B vaccination, stringent precautions in all dialysis centres could help to reduce the high seroconversion rates which have a high financial burden on ESRD patients. Intense health education to both patients and medical staff will be beneficial to lower the seroconversion rates.

The changing epidemiology of liver diseases in the Asia-Pacific region

This Review presents current epidemiological trends of the most common liver diseases in Asia-Pacific countries. Hepatitis B virus (HBV) remains the primary cause of cirrhosis; despite declining prevalence in most Asian nations, this virus still poses a severe threat in some territories and regions. Mortality resulting from HBV infection is declining as a result of preventive measures and antiviral treatments. The epidemiological transition of hepatitis C virus (HCV) infection has varied in the region in the past few decades, but the medical burden of infection and the prevalence of its related cancers are increasing. The lack of licensed HCV vaccines highlights the need for novel treatment strategies. The prevalence of nonalcoholic fatty liver disease (NAFLD) has risen in the past decade, mostly owing to increasingly urbanized lifestyles and dietary changes. Alternative herbal medicine and dietary supplements are major causes of drug-induced liver injury (DILI) in some countries. Complications arising from these chronic liver diseases, including cirrhosis and liver cancer, are therefore emerging threats in the Asia-Pacific region. Key strategies to control these liver diseases include monitoring of at-risk populations, implementation of national guidelines and increasing public and physician awareness, in concert with improving access to health care.

Common viral infections in kidney transplant recipients

Infectious complications have been considered as a major cause of morbidity and mortality after kidney transplantation, especially in the Asian population. Therefore, prevention, early detection, and prompt treatment of such infections are crucial in kidney transplant recipients. Among all infectious complications, viruses are considered to be the most common agents because of their abundance, infectivity, and latency ability. Herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, hepatitis B virus, BK polyomavirus, and adenovirus are well-known etiologic agents of viral infections in kidney transplant patients worldwide because of their wide range of distribution. As DNA viruses, they are able to reactivate after affected patients receive immunosuppressive agents. These DNA viruses can cause systemic diseases or allograft dysfunction, especially in the first six months after transplantation. Pretransplant evaluation and immunization as well as appropriate prophylaxis and preemptive approaches after transplant have been established in the guidelines and are used effectively to reduce the incidence of these viral infections. This review will describe the etiology, diagnosis, prevention, and treatment of viral infections that commonly affect kidney transplant recipients.

Hepatitis C virus infection and chronic renal disease: A review

Hepatitis C virus (HCV) is a parenterally-transmitted hepatotropic virus that often causes chronic infection, which can progress to cirrhosis and hepatocellular carcinoma. Development of highly effective direct-acting anti-viral agents (DAAs) has led to a paradigm change in the treatment of HCV infection over the last 4-5 years. Patients with chronic kidney disease (CKD) are at a higher risk of acquiring HCV infection. In these patients, diagnosis of HCV infection, assessment of the consequent liver disease and management of HCV infection pose some specific problems. This article reviews the available recent information on HCV infection and CKD, including the association between these conditions and their effect on each other, and prevention, evaluation, and management of HCV infection in persons with CKD. This review looks at this issue particularly from the perspective of readers in Asia, especially India, since the epidemiology of HCV-CKD association and the repertoire of anti-HCV drugs available in this region differ from those elsewhere.

Hepatitis C virus-infected kidney waitlist patients: Treat now or treat later?

Currently many but not all centers transplant hepatitis C virus (HCV) viremic positive (+) donor kidneys into HCV+ recipients. Directed donation of HCV+ organs reduces the wait time to transplantation for HCV+ patients. Direct-acting antiviral (DAA) therapy can cure HCV in virtually all who are infected. Some have suggested that treatment of HCV+ waitlisted patients be deferred with the hope that earlier transplantation will provide better outcomes than early DAA therapy. However, there are not enough organs to guarantee prompt transplantation for the current waitlist of infected candidates. A Markov medical decision analysis model was created to compare the overall outcomes of delayed DAA therapy (Option 1) to immediate DAA therapy (Option 2) in waitlisted HCV+ patients. Option 1 patients were modeled to be transplanted 1 year earlier, with a higher cumulative transplant incidence (54% at 5 years post-listing vs 45% for Option 2). Despite this, Option 2 provided 0.43 (95% confidence interval [CI] 0.38-0.49) more life years than Option 1. However, Option 1 was preferred for regions with much greater access to HCV+ organs or in patients with very low HCV+-associated mortality. The best option from an individual patient's perspective will differ by region and candidate.

Multidisciplinary predialysis education reduces incidence of peritonitis and subsequent death in peritoneal dialysis patients: 5-year cohort study

Background

Technique failure secondary to peritonitis is a grave impediment to remain in peritoneal dialysis (PD) therapy leading to high mortality. Multidisciplinary predialysis education (MPE) has shown improvement in outcomes of chronic kidney disease (CKD) patients. However, the legacy effects of MPE in PD patients remain unclear.

Methods

All patients who started PD at single hospital in 2007–16 were enrolled. The incidences of peritonitis and peritonitis-related mortality were compared between MPE recipients and non-recipients. The content of the MPE was standardized in accordance with the NKF/DOQI guidelines. Kaplan-Meier analysis and Cox proportional hazards model were applied to identify the prognostic factors associated with peritonitis-free survival.

Results

Of 398 PD patients, 169 patients had received MPE before starting PD. The patients of MPE group had a lower peritonitis rate [median (IQR) 0 (0.29) versus 0.11 (0.69) episodes/person-year, P< 0.001] and a lower percentage of peritonitis-related deaths (3.6% versus 8.7%, P = 0.04) compared with the non-MPE group. The median time to the first episode of peritonitis in the non-MPE and MPE groups was 33.9 months and 46.7 months, respectively (Cox-Mantel log rank test, P = 0.003). Cox regression analysis revealed that MPE assignment (HR: 0.594; 95% CI: 0.434–0.813, P< 0.001) were significant independent predictors for peritonitis-free survival.

Conclusions

An efficient standardized MPE program may prolong the time to the first episode of peritonitis and reduce peritonitis rate, independent of age, gender, diabetes, hypertension, educational status and PD modality. Subsequently, decreased peritonitis-related death.

Hepatitis C virus infection in chronic kidney disease: paradigm shift in management

Hepatitis C virus (HCV) infection in chronic kidney disease (CKD) is associated with increased liver-related morbidity and mortality rates, accelerated progression to end-stage renal disease, and risk of cardiovascular events. CKD patients with HCV infection require antiviral therapy. Pegylated interferon (peg-IFN) plus ribavirin was the standard of care for HCV-infected CKD patients before the introduction of first-generation direct-acting antiviral (DAA) oral anti-HCV agents. Peg-IFN-based treatment has a low virologic response rate and poor compliance, resulting in a high dropout rate. Recently, several clinical trials of all-DAA combination regimens have reported excellent antiviral efficacy and few adverse drug reactions in HCV-infected patients with CKD. These positive results have revolutionized the treatment of chronic HCV infection in this population. In this review, we address the impact of chronic HCV infection in CKD patients, and discuss their management using next-generation DAAs.

Outcomes of kidney transplantation in patients with hepatitis B virus infection: A systematic review and meta-analysis

AIM

To assess outcomes of kidney transplantation including patient and allograft outcomes in recipients with hepatitis B virus (HBV) infection, and the trends of patient's outcomes overtime.

METHODS

A literature search was conducted using MEDLINE, EMBASE and Cochrane Database from inception through October 2017. Studies that reported odds ratios (OR) of mortality or renal allograft failure after kidney transplantation in patients with HBV [defined as hepatitis B surface antigen (HBsAg) positive] were included. The comparison group consisted of HBsAg-negative kidney transplant recipients. Effect estimates from the individual study were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42017080657).

RESULTS

Ten observational studies with a total of 87623 kidney transplant patients were enrolled. Compared to HBsAg-negative recipients, HBsAg-positive status was significantly associated with increased risk of mortality after kidney transplantation (pooled OR = 2.48; 95%CI: 1.61-3.83). Meta-regression showed significant negative correlations between mortality risk after kidney transplantation in HBsAg-positive recipients and year of study (slopes = -0.062, P = 0.001). HBsAg-positive status was also associated with increased risk of renal allograft failure with pooled OR of 1.46 (95%CI: 1.08-1.96). There was also a significant negative correlation between year of study and risk of allograft failure (slopes = -0.018, P = 0.002). These associations existed in overall analysis as well as in limited cohort of hepatitis C virus-negative patients. We found no publication bias as assessed by the funnel plots and Egger's regression asymmetry test with P = 0.18 and 0.13 for the risks of mortality and allograft failure after kidney transplantation in HBsAg-positive recipients, respectively.

CONCLUSION

Among kidney transplant patients, there are significant associations between HBsAg-positive status and poor outcomes including mortality and allograft failure. However, there are potential improvements in patient and graft survivals in HBsAg-positive recipients overtime.

Prevalence of hepatitis C infection in Iranian hemodialysis patients: An updated systematic review and meta-analysis

BACKGROUND

Hepatitis C virus (HCV) is a major cause of liver disease and a potential cause of substantial morbidity and mortality. This study aims to provide a comprehensive evidence on HCV Infection in Iranian hemodialysis (HD) patients we conducted a systematic review.

MATERIALS AND METHODS

In this systematic review and meta-analysis, through a comprehensive search of literature until January of 2016, we estimated the pooled prevalence of hepatitis C infection in Iranian HD patients. Using Medical Subject Headings terms, Emtree, and related equal Persian key words for Iranian databases and also international databases of PubMed and NLM Gateway (for MEDLINE), and SCOPUS. Interest outcome of HCV infection prevalence was confirmed based on positive hepatitis B surface antigen of blood samples. Random effect meta-analysis was used to estimate pooled prevalence of HCV infection in Iranian HD patients, date and language, HD patients, in adult HD patients, Institute of Scientific Information, Iran-doc, irrespective of age, living in Iran. Searches run through main domestic databanks of Iran-Medex, renal transplantation, Scientific Information Database, the relevant literature-searched concentrating on HCV infection.

RESULTS

Through searching steps, 305 publications were found from them following the excluding duplicates and overlapping studies 54 studies relevant to HCV prevalence in Iranian HD zcxw patients, with number of 23921 participants, remained in our analyses. The overall results of test of heterogeneity demonstrate sever heterogeneity between reported prevalence (I2 = 96.62%, Chi-square = 1566, P < 0.001). Due to sever heterogeneity results of random effect meta-analysis showed that the estimated pooled prevalence was 11% (95% confidence interval [CI] =10%-13%). The pooled prevalence base on polymerase-chain reaction, recombinant immunoblot assay, and enzyme-Linked Immunosorbant Antibody method were 11% (95% CI = 6%-15%), 9% (95% CI = 5-13) and 12% (95% CI = 10-14), respectively. In line with previous studies, the present finding shows the significant variation in the rate of HCV in dialysis units among the regions in Iran.

CONCLUSION

Present paper is the comprehensive updated systematic review on HCV prevalence in the Iranian HD patients. Our findings provide the reliable evidence for promotion of policies and interventional programs.

Epidemiology of hepatitis C virus among hemodialysis patients in the Middle East and North Africa: systematic syntheses, meta-analyses, and meta-regressions

We aimed to investigate hepatitis C virus (HCV) epidemiology among hemodialysis (HD) patients in the Middle East and North Africa (MENA). Our data source was an HCV biological measures database populated through systematic literature searches. Descriptive epidemiologic syntheses, effects meta-analyses and meta-regressions, and genotype analyses were conducted. We analyzed 289 studies, including 106 463 HD patients. HCV incidence ranged between 0 and 100% as seroconversion risk, and between 0 and 14·7 per 1000 person-years as incidence rate. The regional pooled mean estimate was 29·2% (95% CI: 25·6–32·8%) for HCV antibody positive prevalence and 63·0% (95% CI: 55·4–70·3%) for the viremic rate. Region within MENA, country income group, and year of data collection were associated with HCV prevalence; year of data collection adjusted odds ratio was 0·92 (95% CI: 0·90–0·95). Genotype diversity varied across countries with four genotypes documented regionally: genotype 1 (39·3%), genotype 2 (5·7%), genotype 3 (29·6%), and genotype 4 (25·4%). Our findings showed that one-third of HD patients are HCV antibody positive and one-fifth are chronic carriers and can transmit the infection. However, HCV prevalence is declining. In context of growing HD patient population and increasing HCV treatment availability, it is critical to improve standards of infection control in dialysis and expand treatment coverage.

Hepatitis B in renal transplant patients

Hepatitis B virus (HBV) poses a significant challenge for both dialysis patients and kidney transplant recipients despite its decreasing rates, especially in developed countries. The best preventive method is vaccination. Patients with chronic renal disease should ideally be vaccinated prior to dialysis, otherwise, reinforced vaccination practices and close antibody titer monitoring should be applied while on dialysis. HBV infected dialysis patients who are renal transplant candidates must be thoroughly examined by HBV-DNA, and liver enzyme testing and by liver biopsy. When needed, one must consider treating patients with tenofovir or entecavir rather than lamivudine. Depending on the cirrhosis stage, dialysis patients are eligible transplant recipients for either a combined kidney-liver procedure in the case of decompensated cirrhosis or a lone kidney transplantation since even compensated cirrhosis after sustained viral responders is no longer considered an absolute contraindication. Nucleoside analogues have led to improved transplantation outcomes with both long-term patient and graft survival rates nearing those of HBsAg(-) recipients. Moreover, in the cases of immunized HBsAg(-) potential recipients with concurrent prophylaxis, we are enabled today to safely use renal grafts from both HBsAg(+) and HBsAg(-)/anti-HBc(+) donors. In so doing, we avoid unnecessary organ discarding. Universal prophylaxis with entecavir is recommended in HBV kidney recipients and should start perioperatively. One of the most important issues in HBV(+) kidney transplantation is the duration of antiviral prophylaxis. In the absence of robust data, it seems that prophylactic treatment may be discontinued in selected stable, low-risk recipients during maintenance immunosuppression and should be reintroduced when the immune status is altered. All immunosuppressive agents in kidney transplantation can be used in HBV(+) recipients. Immunosuppression is intimately associated with increased viral replication; thus it is important to minimize the total immunosuppression burden long term.

Seroprevalence of human immunodeficiency virus, hepatitis B and C viruses among haemodialysis patients in two newly opened centres in Cameroon

Introduction

Haemodialysis (HD) patients are potentially susceptible to infection with blood borne viral agents especially; Human Immunodeficiency Virus (HIV), hepatitis B (HBV) and hepatitis C Viruses (HCV), compared to the general population. We described their epidemiology in two newly created haemodialysis units in Cameroon: the Buea and Bamenda haemodialysis centres.

Methods

A cross sectional study: included were patients who had spent at least three months in haemodialysis. HBV, HCV and HIV serologies were determined and patients' characteristics extracted from patient's records.

Results

We included 104 participants (44 in Buea and 60 in Bamenda). Mean age was 48 years and 65.4% were men. Median duration in dialysis was 14 months. One of the three viral markers was present in 40.1% of patients. The hepatitis B surface antigen, anti-HCV and anti-HIV antibody prevalence were respectively 10.6%, 19.2%, 13.5%. A history of sexually transmitted infection was the only variable associated with anti-HIV antibody positivity

Conclusion

The sero-prevalence of HBsAg, HCV and HIV are high in the two centres. HIV prevalence may have reflected its etiology as a cause of ESKD. HCV remains a cause for concern and needs further evaluation. There is urgent need for the implementation of preventive and control measures.

Hepatocellular carcinoma in hemodialysis patients

We investigated the rates and predictors of mortality in hepatocellular carcinoma (HCC) patients who were or were not undergoing long-term hemodialysis. The participants in this retrospective observational study were 1298 HCC patients (60.0 ± 12.1 years old, 72% male), of whom 172 were undergoing hemodialysis and 1126 were not. HCC patients on hemodialysis exhibited a higher hepatitis C virus carrier rate (49.4% versus 39.3%, P = 0.012), lower hepatitis B virus carrier rate (37.2% versus 58.3%, P < 0.001) and lower hepatitis B or C virus carrier rate (77.9% versus 89.3%, P < 0.001) than those not on hemodialysis. Serum alkaline phosphatase levels were higher in the hemodialysis than non-hemodialysis group (162.8 ± 141.1 u/l versus 124.6 ± 102.5 u/l, P < 0.001). By the end of the analysis, 32.0% of HCC patients on hemodialysis and 28.0% of those not on hemodialysis had died. Kaplan-Meier analysis confirmed that cumulative survival was poorer in HCC patients on hemodialysis (P = 0.004). In a multivariate Cox regression model, hemodialysis (P < 0.001), older age (P < 0.001) and advanced tumor stages (P < 0.001) were found to be risk factors for mortality. HCC patients on hemodialysis had a 2.036-fold greater chance of death than HCC patients not on hemodialysis. Prospective studies with longer follow-ups and larger samples are warranted.

Current challenges and possible solutions to improve access to care and treatment for hepatitis C infection in Vietnam: a systematic review

Background

Hepatitis C infection is a major public health concern in low- and middle-income countries where an estimated 71.1 million individuals are living with chronic infection. The World Health Organization (WHO) has recently released new guidance for hepatitis C virus (HCV) treatment programs, which include improving the access to new direct-acting antiviral agents. In Vietnam, a highly populated middle-income country, the seroprevalence of HCV infection is approximately 4% and multiple genotypes co-circulate in the general population. Here we review what is currently known regarding the epidemiology of HCV in Vietnam and outline options for reducing the significant burden of morbidity and mortality in our setting.

Methods

We performed a systematic review of the currently available literature to evaluate what has been achieved to date with efforts to control HCV infection in Vietnam.

Results

This search retrieved few publications specific to Vietnam indicating a significant gap in baseline epidemiological and public health data. Key knowledge gaps identified included an understanding of the prevalence in specific high-risk groups, characterization of circulating HCV genotypes in the population and likely response to treatment, and the extent to which HCV treatment is available, accessed and utilized.

Conclusions

We conclude that there is an urgent need to perform up to date assessments of HCV disease burden in Vietnam, especially in high-risk groups, in whom incidence is high and cross infection with multiple genotypes is likely to be frequent. Coordinating renewed surveillance measures with forthcoming HCV treatment studies should initiate the traction required to achieve the WHO goal of eliminating HCV as a public health threat by 2030, at least in this region.

Outcomes of hepatitis B surface antigenaemia in patients with incident end-stage renal disease

AIM

Hepatitis B virus (HBV) infection is an important risk factor for morbidity and mortality in the general population. However, limited data are available on the progression of HBV infection in patients with end-stage renal disease (ESRD), and available data are controversial. Therefore, we investigated the association between hepatitis B surface antigen (HBsAg) seropositivity and mortality in patients with incident ESRD.

METHODS

All adult patients (≥18 years of age) starting dialysis for ESRD from January 2000 to December 2011 were included. A total of 1090 patients with ESRD were analyzed. HBsAg-positive patients were paired 1:6 with HBsAg-negative patients using propensity score matching.

RESULTS

Eighty one (7.4%) patients were HBsAg positive. No differences in the survival rates of the HBsAg-positive and HBsAg-negative patients with ESRD were detected in either the entire cohort or the propensity score matched cohort. No differences in survival were detected between the groups of HBsAg-positive patients based on the hepatitis B envelope antigen, hepatitis B envelope antibody, HBV DNA status, or use of antiviral agents. No difference in mortality was found between the haemodialysis (HD) and peritoneal dialysis (PD) subgroups among HBsAg-positive patients.

CONCLUSION

Our results suggest that hepatitis B surface antigenaemia is not related to increased mortality in patients with incident ESRD. Survival of HBsAg-positive patients undergoing PD was comparable to that of patients undergoing HD.

Mortality, Hospitalization, and Quality of Life among Patients with Hepatitis C Infection on Hemodialysis

BACKGROUND AND OBJECTIVES

Hepatitis C virus (HCV) infection is widely prevalent among patients on hemodialysis (HD), but very rarely treated. The aim of our study is to evaluate the burdens of HCV suffered by patients on HD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Dialysis Outcomes and Practice Patterns Study is an international, prospective, cohort study of patients on HD. We reviewed the HCV status of 76,689 adults enrolled between 1996 and 2015. We compared HCV-positive (HCV+) with HCV-negative (HCV-) patients for risk of mortality, hospitalization, decline in hemoglobin concentration <8.5 g/dl, and red blood cell transfusion. We also compared health-related quality of life scores using the Kidney Disease Quality of Life instrument and the Center for Epidemiologic Studies Short Depression Scale. We adjusted for age, sex, race, years on dialysis, 14 comorbid conditions (including hepatitis B infection), and serum albumin, phosphorus, and creatinine concentrations.

RESULTS

A total of 7.5% of patients were HCV+ at enrollment. Serum concentrations of alanine aminotransferase and aspartate aminotransferase were not markedly elevated in HCV+ patients on HD; the mean concentrations were only 22.6 and 21.8 U/L, respectively. Median follow-up was 1.4 years. Case-mix adjusted hazard ratios (95% confidence intervals) for HCV+ versus HCV- patients were 1.12 (1.05 to 1.20) for all-cause mortality, 5.90 (3.67 to 9.50) for hepatic-related mortality, 1.09 (1.04 to 1.13) for all-cause hospitalization, and 4.40 (3.14 to 6.15) for hepatic-related hospitalization. Quality of life measures indicated significantly worse scores for physical function, pain, vitality, mental health, depression, pruritus, and anorexia among HCV+ patients. The adjusted hazard ratio for transfusion was 1.36 (95% CI, 1.20 to 1.55) and incidence of hemoglobin concentration <8.5 g/dl was 1.12 (95% CI, 1.03 to 1.21). Only 1.5% of HCV+ patients received antiviral medication.

CONCLUSIONS

HCV infection among patients on HD is associated with higher risk of death, hospitalization, and anemic complications, and worse quality of life scores. Internationally, HCV infection is almost never treated in patients on HD. Our data provide a rationale for more frequent treatment of HCV in this population.

Hepatitis C virus infection in maintenance hemodialysis patients: recommendations for diagnostics and treatment

Hepatitis C virus (HCV) infection is highly prevalent among patients treated with maintenance hemodialysis and is an important cause of morbidity and mortality. It is necessary to determine the HCV genotype and the viral load to monitor the clinical and laboratory features and to establish an optimal antiviral treatment strategy. Antiviral treatments are presented with a standard interferon-based regimen and new direct-acting antiviral agents. The advent of direct-acting antivirals has improved the efficacy and safety of HCV treatment for most patients, even in difficult-to-treat populations such as patients on hemodialysis. HCV treatment with direct-acting antivirals in hemodialysis patients is highly effective, with viral eradication rates similar to those seen in patients without chronic kidney disease and with acceptable adverse event profiles.

Seroprevalence of hepatitis B and C virus in patients who undergo hemodialysis in Antalya province, Turkey

Background

Chronic hepatitis B (HBV) and C virus (HCV) infections are important causes of morbidity and mortality in patients who undergo hemodialysis (HD).

Objectives

To define seroprevalence of HBV and HCV in patients who underwent HD in Antalya province, Turkey.

Methods

We included 1347 patients with end-stage renal failure who underwent HD at one of the 23 centers in Antalya province from January 01 to March 31, 2014 in this retrospective cross-sectional study. Hepatitis B surface antigen (HBsAg) and anti-HCV seropositivity were assessed clinically using a third-generation enzyme-linked immunosorbent assay. HBV DNA and HCV RNA were determined in HBsAg positive and anti- HCV positive HD patients respectively.

Results

Of the patients included, 805 (59.8%) were male. Mean age (± standard deviation) of the patients was 53.9 ± 17.0 (range 17–89) years. The sera of 2.4% patients was positive for HBsAg, and the sera of 5.5% of the patients was positive for anti-HCV. The sera of 56% of patients positive for HBsAg was also positive for HBV DNA, and the sera of 43% of patients positive for anti-HCV was also positive for HCV RNA. Coexistence of HBsAg and anti-HCV was 1.02%.

Conclusions

The present study showed that the prevalence of chronic HBV and HCV infection in patients who underwent HD in Antalya province was moderate-to-low for Turkey. Compliance of HD centers with infection control rules, isolation of HBsAg positive patients, isolation of the equipment used for HBV susceptible patients, and active surveillance of the HD patients may have resulted in lower prevalence rates.