Hepatitis C virus infection and the dialysis patient

Occurrence and clinical characteristics of occult hepatitis C virus infection in hemodialysis units at Ismailia, Egypt

BACKGROUND AND AIMS

Occult hepatitis C infection is defined as the presence of hepatitis C virus RNA in peripheral blood mononuclear cells (PBMC) ± hepatocytes in the absence of HCV-RNA in serum. It has been a lot of debate and controversy in recent years and not discussed well. This issue has not been discussed or investigated in Egypt, especially in patients on hemodialysis in Ismailia. This study is the first one to investigate the prevalence of occult HCV infection in large populations of chronic hemodialysis (CHD) patients in Ismailia, Egypt.

METHODS

Our study is cross-sectional analytic and included 204 CHD patients; who are negative for HCV infection. Sensitive commercial real-time assay was used to detect HCV-RNA in PBMC. In our study, the presence of genomic HCV-RNA in PBMCs of all these patients was detected by real-time PCR. On the other hand, 22 patients on hemodialysis with an established diagnosis of chronic hepatitis C virus infection were included as a control group and examined by real-time PCR was used to evaluate HCV infection.

RESULTS

Occult HCV infection is defined as the presence of HCV-RNA in PBMNCs in patients on chronic hemodialysis, and it was found in 14/204 (7%) of the patients. Patients who were on CHD for a longer time are susceptible to occult HCV infection, and their mean alanine aminotransferase levels are significantly higher during the last 3 months before study entry. In comparison, chronic HCV patients have elevated bilirubin, aspartate transferase and alanine transferase than occult HCV infection.

CONCLUSIONS

The prevalence of occult HCV infection was 7% in our CHD patients. No available data are showing the virulence of this form of virus. However, further studies in other geographic populations with high HCV endemicity are needed to clarify the significance of occult HCV infection in these patient groups, in addition to test for the presence of negative antigenomic strand to confirm or disconfirm the reliability of occult HCV.

HCV core antigen comes of age: a new opportunity for the diagnosis of hepatitis C virus infection

The diagnosis of hepatitis C virus (HCV) infection has been traditionally based on the detection of the host antibody response. Although antibody assays are available in different formats and are fairly accurate, they cannot distinguish between an ongoing infection with HCV replicative activity and a past infection where HCV has been cleared, spontaneously or after a successful therapy. As a chronic infection is mostly asymptomatic until the late clinical stages, there is a compelling need to detect active HCV infection by simple and reproducible methods. On this purpose, the clinical guidelines have suggested to search for the HCV ribonucleic acid (HCV-RNA) after anti-HCV has been detected, but this second step carries several limitations especially for population screening. The availability of fast and automated serological assays for the hepatitis C core antigen (HCVAg) has prompted an update of the guidelines that now encompass the use of HCVAg as a practical alternative to HCV-RNA, both for screening and monitoring purposes. In this paper, we summarize the features, benefits and limitations of HCVAg testing and provide an updated compendium of the evidences on its clinical utility and on the indications for use.

AISF position paper on HCV in immunocompromised patients

This report summarizes the clinical features and the indications for treating HCV infection in immunocompromised and transplanted patients in the Direct Acting Antiviral drugs era.

Prevalence of hepatitis C virus infection and the IL28B genotype polymorphism among blood donors and high-risk populations

INTRODUCTION

To study the prevalence of hepatitis C virus (HCV) infection in blood donor (BD), haemodialysis (HD) and intravenous drug user (IVDU) populations in Singapore and assess the IL28B polymorphism if HCV positive.

METHODS

The BD population were healthy volunteers, the HD population were patients who were on haemodialysis for at least six months of follow-up between January 2009 and December 2014. IVDU population was from inmates at halfway houses who consented.

RESULTS

Between 2011 and 2014, of 161,658 individuals who underwent screening prior to blood donation, 95 (0.059%) were positive for HCV. Of the 42 sera available, common genotypes (GTs) were GT-3 (47.6%) and GT-1 (31.0%). Of 1,575 HD patients, 2.2% were anti-HCV positive. The HCV GT distribution was HCV GT-1 (32.4%), HCV GT-3 (20.5%) and GT-6 (8.8%). 83 halfway house inmates were screened. Of the 47 IVDUs, 36.2% were anti-HCV positive with predominant GT-3 (%). IL28B polymorphism was noted to be CC predominantly 85.3%.

CONCLUSION

Prevalence of HCV infection has decreased in both the BD and HD populations. However, it remains high in the IVDU population. GT-1 remains the most common in the HD population; however, GT-3 infection is now more common among the BD population in Singapore. IL28B - CC is the predominant variant among the HCV-infected individuals in Singapore.

Association of Renal Function and Direct-Acting Antiviral Agents for HCV: A Network Meta-Analysis

The effectiveness and safety of direct-acting antiviral agents (DAAs) in hepatitis C virus (HCV) patients with renal insufficiency remain controversial. Therefore, this network meta-analysis aims to assess effectiveness and safety of DAAs in populations with different renal function. The pooled data were obtained from Cochrane Library, EMBASE, PubMed, and Web of Science. Thirteen studies recruited 6884 patients with hepatitis C infection and reported their outcomes in relation to different levels of renal function after treatment with DAAs. The results showed no difference in the virologic responses among patients with different renal function. Regarding safety, whereas in patients without chronic kidney disease (CKD) or with early CKD DAAs were associated with a risk ratio (RR) of 0.14 (95% confidence interval (CI), 0.04 to 0.43) for renal disorder, increased risk of renal function deterioration was found in advanced-CKD patients, though this effect may be related to the natural course of advanced CKD. Similarly, patients without CKD or with early CKD showed a lower risk of anemia (RR, 0.34; 95% CI, 0.20 to 0.57) and discontinuation (RR, 0.41; 95% CI, 0.39 to 0.56) than patients with advanced CKD. The efficacy of DAAs for HCV treatment was comparable in patients with advanced CKD and in those with early CKD or without CKD. However, the safety of DAAs should be verified in future studies.

Noninvasive Fibrosis Assessment in Chronic Viral Hepatitis C associated with End Stage Renal Disease

INTRODUCTION

HCV is considered the most encountered viral infection that affect patients after hemodialysis sessions. Even though liver biopsy is considered the golden standard for hepatic diagnosis, additional methods have been used for assessing liver fibrosis. Transient elastography (TE) has evolved as a reference method in some European countries and allows the physician to carry out a fibrosis evaluation in a noninvasive, low-cost and rapid method. Our objective was to assess the efficacy of TE in staging patients with HCV liver disease associated with ESRD, thus choosing the correct moment to perform the procedure.

MATERIALS AND METHODS

We included 34 patients known with ESRD within the regional Nephrology Clinic of Olt County Hospital and also having positive hepatitis C viral liver marker. TE was performed before and hemodialysis and data was analyzed.

RESULTS

The patients where we have encountered significant changes were especially within the F0 and F1 stage with a decrease of fibrosis after hemodialysis. Thus, 7 patients which had no fibrosis (F0) went from 4,14±0,98kPa to 3,54±0,84 (p<0,05) and 12 patients from the F1 stage went from 6,22±0,39kPa to 5,47±0,58kPa. The other stages had no significant changes with F2 changing after hemodialysis from 8.03±0,62kPa to 7, 76±0,6kPa.

CONCLUSIONS

TE represents a valuable tool for stiffness assessment and should be taken into considerations as a major option for ESRD patients with liver disease. However, more patients should be enrolled to strengthen this theory and thus providing more reliable results.

Prevalence of occult hepatitis C virus among hemodialysis patients in Tanta university hospitals: a single-center study

Occult hepatitis C virus infection (OCI) is a newly defined type of infection by the chronic hepatitis virus (HCV) distinguished by the existence of HCV RNA in liver tissue and/or peripheral blood mononuclear cells (PBMCs) in patients whose plasma are devoid of both positive serology and RNA. Patients on maintenance hemodialysis evince a higher HCV prevalence than the general population due to high nosocomial transmission by the dialysis units. We investigated the prevalence of occult HCV infection in patients attending our university hemodialysis centers for maintenance hemodialysis. Sixty-two CHD patients negative for serum HCV tests were enrolled in the study. PMNCs were tested by real-time PCR for the presence of HCV RNA. For the 62 patients, the average duration since starting dialysis was 32.7 months and the mean (SD) alanine transaminase and aspartate transaminase were 25.74 ± 9.75 and 28.81 ± 11.32 IU/l, respectively. Out of the 62 CHD patients negative for serum anti-HCV and HCV RNA patients, only three (4.84%) were shown to have HCV RNA in their PBMCs implying the diagnosis of OCI; their viral load range was 1.24-4.15 IU/ml. All three OCI-proven patients gave no history of hepatic disease. In this study, we found that patients considered to be free of HCV can have HCV replicating in their PBMCs. This awareness points to the possibility of HCV being transmitted from apparently uninfected persons. A positive HCV RNA detection in PBMCs is dependable in determining OCI among high-risk subjects particularly when a liver biopsy is not an option. HCV transmission can occur through hemodialysis units signaling incorrect application of infection control measures in our Egyptian dialysis units. Additional studies on hemodialysis patients are necessary to realize the true magnitude of OCI among this patient group and to highlight the importance of incorporating HCV viral assays in PBMCs into the diagnostic algorithm.

Long-Term follow up of Sustained Viral Response after Treatment of Hepatitis C with Pegylated Interferon α-2a in Hemodialysis Patients

Purpose

The aim of this study was to evaluate the persistence of sustained viral response after treatment of hepatitis C with pegylated interferon α-2a in hemodialysis patients.

Methods

14 hemodialysis patients with chronic hepatitis C were treated with pegylated interferon α-2a for a period of 48 weeks. Achieved sustained viral response rate was 35.7% (5/14 patients) at week 72, i.e. 24 weeks after the treatment ended. All treated patients were then prospectively followed until week 144. Follow-up viral data, such as HCV antibodies, serum HCV RNA, and HCV RNA genotype, were determined at week 96 and week 144. HCV antibodies were determined by a 3rd-generation ELISA assay. The presence of HCV RNA was determined using reverse transcriptase polymerase chain reaction (AMPLICOR Hepatitis C Virus Test). HCV genotype was analyzed by reverse transcriptase polymerase chain reaction followed by hybridization of amplified products. The biochemical data were recorded every 24 weeks during the follow-up period.

Results

The 5 patients (35.7%), who achieved sustained viral response (SVR), remained HCV RNA negative at week 96. At week 144, 4 hemodialysis patients (28.6%) remained HCV RNA negative. There was a relapse of HCV infection in 1 patient after week 96 of the study. The patients who remained HCV RNA negative also maintained the achieved biochemical response throughout the follow-up period.

Conclusion

Long-term follow-up of treated hemodialysis patients with pegylated interferon α-2a showed persistence of the sustained viral and biochemical response.

Alterations of Hematological Parameters, Hemoglobin and Hematocrit With Liver Enzymes, Aspartate Transaminase and Alanine Transaminase Among Patients With Chronic Kidney Disease Undergoing Hemodialysis in Aljouf Region, Saudi Arabia

Background

Anemia results from low kidney production of the erythropoiesis-stimulant erythropoietin. Good liver function is crucial to patients with chronic kidney disease (CKD). This study analyzed two hematological parameters (hemoglobin (Hb) and hematocrit (Ht)) and two liver enzymes, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in patients with CKD undergoing hemodialysis (HD).

Methods

Three hundred and thirty individuals participated in this study. Of them, 159 patients with CKD undergoing HD and 171 healthy individuals as a control group were recruited between January and October 2017. Blood was collected into EDTA containers for complete blood count (CBC) and into additive plain containers for ALT and AST. Relevant case history data were also taken.

Results

Obtained results for first and second month of Hb, Ht, AST and ALT of CKD patients undergoing HD were lower (10.2 g/dL and 8.9 for Hb; 27.2% and 24.8% for Ht; 17.8 IU/L and 15.6 IU/L for ALT; 13.9 IU/L and 12.0 IU/L for AST, respectively) (P < 0.05) compared to healthy individuals (15.1 g/dL for Hb; 44.6% for Ht; 28.3 IU/L for ALT and 23.0 IU/L for AST). Furthermore, Hb, Ht, AST and ALT levels were significantly lower (P < 0.05) in their second month compared to the first month.

Conclusions

Anemia might emerge in CKD patients because of low Hb concentration and consequent low Ht. Advanced stage CKD causes decreased AST and ALT, as a result of lipid metabolism disturbances. Therefore, anemia and liver diseases are recommended to be treated in CKD patients to alleviate related complications. Renal transplantation must be performed earlier for them to avoid further complications.

Efficacy and safety of sofosbuvir and daclatasvir in treatment of kidney transplantation recipients with hepatitis C virus infection

AIM

To assess the efficacy and safety of sofosbuvir and daclatasvir regimens for kidney transplantation (KT) patients with hepatitis C virus (HCV) infection.

METHODS

This study enrolled a prospective cohort of consecutive Chinese KT patients with HCV infection. They were given sofosbuvir combined with daclatasvir, with or without ribavirin. They were monitored regularly during and after the treatment.

RESULTS

Six patients were recruited in our prospective study cohort. All patients were male and naive to direct-acting antiviral treatment. The treatment duration was 12 wk. Most patients (4/6) were infected with HCV genotype 1b. HCV RNA was undetectable at week 4 after treatment and at the end of treatment in all patients. Sustained virological response rate at 12 wk was 100% (6/6). Two patients had to accept a half dose of sofosbuvir due to serum creatinine elevation during treatment. Kidney function in the remaining patients was stable. No serious adverse events (AEs) were observed. No patient discontinued antiviral therapy due to side effects.

CONCLUSION

Sofosbuvir and daclatasvir for treatment of KT recipients with HCV infection are highly efficient and safe. Patients tolerated the medications well, and no serious AEs were observed. Larger prospective cohort studies are needed to validate these results.

Sofosbuvir-based regimens for the treatment of chronic hepatitis C in severe renal dysfunction

Sofosbuvir (SOF) is a nonstructural 5B polymerase inhibitor with activity in all hepatitis C virus (HCV) genotypes and is the backbone of many anti-HCV drug regimens. SOF is converted into inactive metabolites that undergo renal excretion. Patients with an estimated glomerular filtration rate (eGFR) < 30 mL/minute/1.73 m² may experience increased drug exposure and thus potential toxicities along with decreased efficacy due to dose reduction or drug discontinuation. This is a single-center study evaluating safety and effectiveness of SOF-based regimens in patients with severe renal dysfunction, defined as eGFR <30 mL/minute/1.73 m², including those receiving concurrent hemodialysis. Data were collected from patients with HCV and severe renal dysfunction who started full-dose (400 mg) SOF-based antiviral therapy ± ribavirin between April 2014 and February 2016. Medical records were reviewed for demographics, medical history, laboratory, radiologic imaging, echocardiography, transplant status, and liver pathologic findings. Twenty-nine patients were identified; 12 had cirrhosis and 4 of those had decompensated cirrhosis. Fourteen patients had undergone transplantation of liver and/or kidney and were on calcineurin inhibitors, with 42% requiring dose increases or decreases while on therapy. All patients attained viral suppression on treatment, and 97% had a sustained viral response at 12 weeks posttreatment. There were no early treatment discontinuations. One death occurred posttreatment from a non-ST elevation myocardial infarction in a patient with a history of coronary artery disease and ischemic cardiomyopathy. Conclusion: SOF-based regimens appear safe in a broad range of patients with severe renal dysfunction, including those with decompensated cirrhosis and liver transplant. To confirm these retrospective findings, prospective studies that include SOF and SOF metabolite measurements coupled with prospective serial monitoring of electrocardiograms and echocardiograms are needed. (Hepatology Communications 2017;1:248-255).

Sofosbuvir Use in the Setting of End-stage Renal Disease: A Single Center Experience

Background and Aims: Patients with chronic hepatitis C (CHC) and end-stage renal disease (ESRD) who are dialysis-dependent form a unique group, in which safety, tolerability and efficacy of sofosbuvir (SOF)-based direct-acting antivirals (DAAs) need further evaluation. Methods: We performed a retrospective analysis of 14 patients with CHC and ESRD on dialysis who received 15 courses of SOF-based therapy. We evaluated dose escalation to standard-dose SOF in this proof-of-principle experience. Results: Sustained virological response (defined as undetectable viral load at 12 weeks, SVR-12) was achieved in 13 out of the 15 (86.7%) treatment courses. Seven (46.6%) patients received reduced half dose as conservative proof-of-principal to mitigate potential toxicity. In 13 out of 15 treatment courses, patients completed the designated treatment duration. One patient was treated twice and developed SVR-12 with the retreatment. One patient was lost to follow-up and counted as a non-responder. Premature discontinuations were not due to DAA-related adverse effects. There were no reports of severe adverse effects or drug interactions. Conclusion: We treated CHC patients with ESRD using dose escalation to standard-dose SOF in this proof-of-principle experience and achieved SVR rates comparable to general 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.

Early Results of Pilot Study Using Hepatitis C Virus (HCV) Positive Kidneys to Transplant HCV Infected Patients with End-Stage Renal Disease Allowing for Successful Interferon-Free Direct Acting Antiviral Therapy after Transplantation

INTRODUCTION

Hepatitis C virus (HCV) infection in kidney transplant (KTX) patients reduces long-term patient and graft survival. Direct-acting antivirals (DAA) are > 90% effective in achieving sustained viral response (SVR); however, DAAs are not routinely available to patients with end-stage renal disease (ESRD). The University of Utah Transplant Program developed a protocol to allow HCV-positive potential KTX recipients to accept HCV-positive donors' kidneys. Three months after successful KTX, they were eligible for DAA therapy.

METHODS

HCV-positive patients approved for KTX by the University of Utah Transplant Selection Committee were eligible to be enrolled in this study. Patients consented for the use of HCV-positive donor organs. Three to six months after successful KTX, these patients were treated for HCV with interferon-free direct-acting antiviral regimens according to viral genotype and prior treatment experience.

RESULTS

Between 2014-2015, 12 HCV-positive patients were listed for KTX. Eight patients were kidney only eligible, seven patients received HCV-positive deceased donor kidneys, and one received an HCV-negative organ. Currently, six patients have completed treatment, all have achieved sustained viral response (SVR), and one patient is currently awaiting treatment. All seven patients have functioning kidney grafts. Wait time for KTX was reduced amongst all blood groups from an average of 1,350 days to only 65 days.

CONCLUSIONS

HCV-positive patients with ESRD can successfully receive an HCV-positive donor's kidney. Once transplanted, these patients can receive DAA therapy and achieve SVR. Use of HCV-positive organs reduced time on the waitlist by greater than three years and expanded the donor organ pool.

Occult hepatitis C virus infection among Egyptian hemodialysis patients

Occult hepatitis C virus (HCV) infection (OCI) was reported in an apparently disease-free state in the absence of liver disease, anti-HCV and HCV-RNA in the serum. The existing data examining the clinical significance of OCI and its potential as a source of HCV infection among hemodialysis patients are very limited. We examined the presence of OCI among patients on maintenance hemodialysis at Minia Governorate, Egypt; an HCV endemic country. A total of 81 subjects with negative markers for HCV were enrolled. HCV-RNA was tested in PBMCs by real-time PCR. For the 81 subjects, the average dialysis duration was 32.7 ± 21.7 months and the average ALT level (±SD) was 26 ± 12 U/L while that of AST was 29 ± 16 U/L. Out of the 81 subjects, three (3.7%) were HCV-RNA positive in PBMCs in the absence of serum anti-HCV and HCV-RNA indicating OCI. The viral load of the OCI subjects ranged from 172 to 4150 IU/ml. History of liver disease was positive in one of the three positive patients. These results highlight the potential risk of HCV transmission from patients within hemodialysis units in Egypt. J. Med. Virol. 88:1388-1393, 2016. © 2016 Wiley Periodicals, Inc.

Hepatitis C Virus Infection in Patients with End-Stage Renal Disease: A Study from a Tertiary Care Centre in India

BACKGROUND

Hepatitis C Virus (HCV) infection is common in patients with end stage renal disease (ESRD) and is an important cause of liver disease. We describe the demographic, clinical and biochemical profile of these patients from a tertiary care center of north India.

METHODS

Records of consecutive patients of HCV infection with ESRD on maintenance hemodialysis or with renal transplantation who presented to our unit from January 2009 to June 2013 were analyzed. The diagnosis of HCV was based on HCV-RNA positivity and/or positive anti-HCV serology. Those with positive anti-HCV serology and negative HCV-RNA on two occasions at 3-month interval, without treatment with interferon, were excluded.

RESULTS

140 patients (median age 44 years [range 18-68], 69% males) were included. Six patients had co-infections (HBV 5, HIV 1). Most (99, 71%) patients were asymptomatic for liver disease and HCV was identified either on routine screening (39, 28%) or during investigation for raised liver enzymes (60, 43%). Remaining 41 (29%) were symptomatic for liver disease, either in the form of jaundice alone (14, 10%), or decompensated liver disease (27, 19%). Median time between initiation of hemodialysis and HCV detection was 33 (range 0-124) months. Thirty-four (27%) patients had received renal transplantation. In 11 patients HCV was detected after renal transplantation. In 23 (18%) patients anti-HCV was falsely negative but HCV-RNA was positive. Nearly 35% patients had concomitant diabetes. Median Bilirubin, AST, and ALT were 1.1 mg/dL, 42 IU/L and 44 IU/L, respectively. HCV-RNA was more than 5 log in 49/88(59%) patients. Median HCV-RNA was 6.5 × 10(5) IU/ml (Range 650 to >10 million IU/ml). Genotype-1 was the commonest genotype (30/56, 54%) followed by genotype-3 (17/56, 30%).

CONCLUSION

HCV infection is usually asymptomatic in patients with ESRD, however, it may lead to jaundice and decompensated liver disease. False negative anti-HCV is quite common. We found that genotype-1 was commoner than genotype-3 in our cohort of ESRD patients. Most of the patients have high viral load.

Treatment of Chronic Hepatitis C in Special Populations

The management of hepatitis C virus (HCV) infection in special populations is challenging. The efficacy and safety data of the currently approved all-oral direct-acting antiviral combinations, including sofosbuvir, ledipasvir, daclatasvir, paritaprevir/ritonavir/ombitasvir plus dasabuvir (3D), and ribavirin, is compelling for use in special HCV populations, as has recently been recommended by expert guidelines. The treatment regimens and sustained virological response rates for special populations are nearly similar to those of the general HCV population. Sofosbuvir is not recommended in patients with severe renal impairment, and simeprevir and 3D regimen are not recommended for those with decompensated liver disease.

Hepatitis C virus infection in nonliver solid organ transplant candidates and recipients

PURPOSE OF REVIEW

Transplantation is the best treatment for many patients with end-stage organ failure. Hepatitis C infection is prevalent among solid organ candidates and recipients and continues to represent a major source of morbidity and mortality. Prior interferon (IFN)-based therapies have been associated with limited efficacy and high rates of adverse events. Furthermore, prior IFN-based regimens are associated with high rates of allograft rejection limiting their use post-transplant. This review will outline the limited experience with current treatment regimens and how to incorporate the new hepatitis C virus (HCV) treatment regimens.

RECENT FINDINGS

The introduction of new direct-acting antiviral (DAA) agents against HCV has dramatically altered the landscape of treatment for HCV. Different all-oral regimens are currently available and are rapidly becoming the standard for treating patients with chronic hepatitis C. Excluding patients with liver disease or those who received liver transplant, those regimens have not been studied in patients awaiting solid organ transplant, or those transplanted.

SUMMARY

The safety and efficacy of DAAs in patients awaiting liver transplant and liver transplant recipients provide us with some insight and guidance on how to use those all-oral IFN-free regimens to allow effective treatment for patients who received or are awaiting nonliver solid organ transplants.

Hepatitis E in hemodialysis and kidney transplant patients in south-east Italy

AIM: To investigate the serovirological prevalence and clinical features of hepatitis E virus (HEV) infection in end-stage renal failure patients and in the healthy population.

METHODS: HEV infection is a viral disease that can cause sporadic and epidemic hepatitis. Previous studies unexpectedly showed a high prevalence of HEV antibodies in immunosuppressed subjects, including hemodialysis (HD) patients and patients who had undergone kidney transplant. A cohort/case-control study was carried out from January 2012 to August 2013 in two hospitals in southern Italy (Foggia and S. Giovanni Rotondo, Apulia). The seroprevalence of HEV was determined in 801 subjects; 231 HD patients, 120 renal transplant recipients, and 450 health individuals. All HD patients and the recipients of renal transplants were attending the Departments of Nephrology and Dialysis at two hospitals located in Southern Italy, and were included progressively in this study. Serum samples were tested for HEV antibodies (IgG/IgM); in the case of positivity they were confirmed by a Western blot assay and were also tested for HEV-RNA, and the HEV genotypes were determined.

RESULTS: A total of 30/801 (3.7%) patients were positive for anti-HEV Ig (IgG and/or IgM) and by Western blot. The healthy population presented with a prevalence of 2.7%, HD patients had a prevalence of 6.0%, and transplant recipients had a prevalence of 3.3%. The overall combined HEV-positive prevalence in the two groups with chronic renal failure was 5.1%. The rates of exposure to HEV (positivity of HEV-IgG/M in the early samples) were lower in the healthy controls, but the difference among the three groups was not statistically significant (P > 0.05). Positivity for anti-HEV/IgM was detected in 4/30 (13.33%) anti-HEV Ig positive individuals, in 2/14 HD patients, in 1/4 transplant individuals, and in 1/12 of the healthy population. The relative risk of being HEV-IgM-positive was significantly higher among transplant recipients compared to the other two groups (OR = 65.4, 95%CI: 7.2-592.7, P < 0.001), but the subjects with HEV-IgM positivity were numerically too few to calculate a significant difference. No patient presented with chronic hepatitis from HEV infection alone.

CONCLUSION: This study indicated a higher, but not significant, circulation of HEV in hemodialysis patients vs the healthy population. Chronic hepatitis due to the HEV virus was not observed.

Management of patients with hepatitis C infection and renal disease

Hepatitis C virus (HCV) infection in patients with end-stage renal disease (ESRD) is associated with more rapid liver disease progression and reduced renal graft and patients' survival following kidney transplantation. Evaluations and management of HCV in patients with renal disease are challenging. The pharmacokinetics of interferons (IFN), ribavirin (RBV) and some direct acting antiviral (DAA), such as sofosbuvir, are altered in patients with ESRD. With dose adjustment and careful monitoring, treatment of HCV in patients with ESRD can be associated with sustained virological response (SVR) rates nearly comparable to that of patients with normal renal function. DAA-based regimens, especially the IFN-free and RBV-free regimens, are theoretically preferred for patients with ESRD and KT in order to increase SVR rates and to reduce treatment side effects. However, based on the data for pharmacokinetics, dosing safety and efficacy of DAA for patients with severe renal impairment are lacking. This review will be focused on the evaluations, available pharmacologic data, and management of HCV in patients with severe renal impairment, patients who underwent KT, and those who suffered from HCV-related renal disease, according to the available treatment options, including DAA.

Outbreak of hepatitis C among patients admitted to the Department of Gynecology, Obstetrics, and Oncology

BACKGROUND

In Poland, nosocomial infections account for 32% of all patients' claims against public hospitals, with hepatitis B virus and hepatitis C virus (HCV) being the most common causes. We present a major nosocomial outbreak of the HCV infection in the Department of Gynecology, Obstetrics, and Oncology and the results of detailed sanitary and epidemiologic research.

METHODS

A retrospective analysis of medicolegal opinions issued at the request of the civil court regarding the suspicion of HCV nosocomial infections was conducted.

RESULTS

The detailed medical data analysis proved 26 patients aged 19 to 72 years with recent HCV hepatitis hospitalized on the same gynecology ward. Twenty women were operated on for neoplasm. The State Sanitary Inspection's investigation revealed a number of malpractices: incorrect sterilization procedures, insufficient hygiene habits of health care workers, poor condition of premises, and equipment being in poor condition. Numerous cases of staff breaking basic sanitary rules and hygiene standards and a lack of crucial procedures were discovered. The high number of women infected and the multiple errors recognized led to closure of the ward.

CONCLUSION

Outbreaks of HCV hepatitis may be the result of ineffective infection control systems and remains a significant public health problem. Asymptomatic HCV nosocomial infections might go unnoticed or concealed and underreported. Auditing medical centers and health care workers for compliance with sanitary and epidemiologic requirements is an essential need.

A study of the immunoloregulation of double filtration plasmapheresis in maintenance hemodialysis patients with chronic hepatitis C

Although a large number of drugs have been used to treat chronic hepatitis C (CHC), there still remains a great challenge to treat maintenance hemodialysis (MHD) patients with chronic hepatitis C. To clarify the immunnoloregulation of double filtration plasmapheresis (DFPP) in MHD patients with CHC, DFPP was performed in 20 MHD patients with CHC (HCV-antibody positive, serum HCV RNA >500 IU/ml more than 6 months and HCV genotype 1b). The clinical data was collected and peripheral blood mononuclear cells (PBMCs) were analyzed by flow cytometry at the time of hour 0, hour 3, day 3, day 7 and day 28 after the DFPP, respectively. Serum HCV particles could be removed partially by the DFPP. The titer of serum HCV RNA could remain in a lower level even 28 days after the treatment. Compared to MHD patients without HCV infection, the frequencies of innate immune cells were similar in MHD patients with CHC, while Th1/Th2 was elevated and the frequencies of regulatory T (Treg) cells were higher in those MHD patients with CHC. The frequencies of monocytes and natural killer (NK) cells remained after the DFPP in MHD patients with CHC. There were no significant changes of Th1, Th2 and Th1/Th2 in PBMC after DFPP. DFPP could reduce the frequencies of Th17 cells and Treg cells in PBMC from 7 days after DFPP in MHD patients with CHC. DFPP could partially remove the serum HCV particles mechanically. The titer of HCV RNA could remain in a lower level at least for 28 days probably due to the redistribution of the immunocytes in circulation.

Association between human leukocyte antigen class I and II alleles and hepatitis C virus infection in high-risk hemodialysis patients awaiting kidney transplantation

Recent evidences have shown that several host genetic factors influence susceptibility or protection to hepatitis C virus (HCV) infection. There are controversial data regarding the associations of human leukocyte antigens (HLA) and the clearance or progression of HCV. The aim of this study was to investigate whether particular HLA molecules were associated with HCV infection in recipients awaiting kidney transplantation considered at high-risk to infection due to protracted hemodialysis treatment. To this purpose, 301 kidney recipients with HCV infection and 1103 uninfected recipients were examined for HLA class I and II molecules. In our case-control study, HLA-A(*)26 is positively associated with HCV infection while HLA-A(*)29, -B(*)40 and -DRB1(*)01 are negatively associated with HCV infection. Multiple logistic regression analysis demonstrated that age (OR = 1.02; 95% CI = 1.01-1.04; p < 0.00), HLA-A(*)26, -A(*)29, -B(*)40 and -DRB1(*)01 [(OR = 1.54; 95% CI = 1.03-2.30; p = 0.03); (OR = 0.50; 95% CI = 0.26-0.99; p = 0.05); (OR = 0.42; 95% CI = 0.23-0, 7; p = 0.01); (OR = 0.62; 95% CI = 0.41-0, 94; p = 0.03); respectively] are independent predictors of HCV infection. Our results suggest that particular HLA molecules, as host genetic factors, may have a relationship with susceptibility or protection to HCV infection also in recipients awaiting kidney transplantation.

Hepatitis C virus (HCV) Infection Rate among Seronegative Hemodialysis Patients Screened by Two Methods; HCV Core Antigen and Polymerase Chain Reaction

BACKGROUND

End-stage renal disease patients on chronic hemodialysis are among high risk groups for hepatitis C virus (HCV) infection for whom routine HCV screening is recommended. Anti-HCV antibody (ab) testing may not be reliable to detect all infected cases because of the blunted ab response due to depressed immune state in these patients. Using a more reliable, cost-effective and non-complex HCV screening test may be necessary in this group of patients for case finding and management, and also for prevention of infection spread.

OBJECTIVES

The aim of this study was to find the prevalence of HCV infection in HCV ab negative hemodialysis patients by Real time PCR and total HCV core antigen (ag) test and comparing the results of the two tests.

PATIENTS AND METHODS

From a single hemodialysis center, 181 anti- HCV ab negative patients were screened by total HCV core ag using an ELISA kit. Real time PCR was used for determination of the virus and viral load quantity.

RESULTS

Among the 181 anti-HCV ab negative patients, 13 (7.2%) were positive for HCV core ag and 11 (6%) had detectable HCV RNA with a range of 40-336543 IU/ml by PCR. The two tests had a high measurement agreement (Kappa=0.82, P<0.001). Of the 13 patients with positive HCV core ag test results, 3 were negative for HCV RNA. Considering real time PCR for HCV RNA as the gold standard for HCV infection determination in this patient population, HCV core ag assay yielded a sensitivity of 90.9%, specificity of 98.2%, positive predictive value of 76.9% and negative predictive value of 99.4%.

DISCUSSION

The rate of HCV infection among HCV ab negative hemodialysis patients was high. HCV core ag testing could be used as a sensitive method for HCV infection screening in this group of patients.

Interferon therapy of acute hepatitis C in dialysis patients: meta-analysis

The efficacy and safety of antiviral therapy in patients with acute hepatitis C on long-term dialysis remains unclear, although a number of small clinical studies have been published addressing this issue. We evaluated the efficacy and safety of interferon therapy in chronic dialysis patients with acute hepatitis C by performing a systematic review of the literature with a meta-analysis of clinical studies. The primary outcome was sustained virological response (SVR, as a measure of efficacy); the secondary outcome was dropout rate (as a measure of tolerability). We used the random effects model of DerSimonian and Laird, with heterogeneity and sensitivity analyses. We identified eight clinical studies (173 unique patients), three (37.5%) being controlled clinical trials (CCTs). Among CCTs, the viral response was much more common in study (patients on antiviral therapy) than control (patients who did not receive therapy) groups; the pooled odds ratio of SVR being 27.06, 95% Confidence Intervals (95% CI), 9.26; 79.1 (P = 0.00001). No difference in the dropout rate between study and control patients was shown, odds ratio = 0.920 (95% CI, 0.367; 1.92), NS. Pooling all study results (n = 8 studies) demonstrated that the summary estimate for SVR and dropout rate was 58% (95% CI, 38; 77) and 9% (95% CI, 4; 14), respectively. The most frequent side-effects requiring interruption of the treatment were flu-like symptoms (n = 4, 18%), followed by haematological changes and loss to follow-up. A strong relationship between increasing age and reported dropout rate was recognized (P = 0.001). The studies were heterogeneous with regard to SVR but not to dropout rate. Our meta-analysis of CCTs showed that the viral response after antiviral therapy was more common than the spontaneous viral clearance in dialysis patients with acute hepatitis C. Pooled analysis demonstrated that IFN-based therapy of acute hepatitis C in dialysis populations gives SVR in around one half of patients. These results support IFN-based therapy for acute hepatitis C in patients on maintenance dialysis.

Virological responses of pegylated interferon alpha-2a treatment in hemodialysis patients infected with hepatitis C

BACKGROUND

Hepatitis C is the most frequently encountered hepatic disease in dialysis patients. Data related to pegylated interferon alfa-2a (Peg-IFN-α-2a) use in hemodialysis patients with hepatitis C virus (HCV) are limited. The aim of this study was to evaluate the efficacy of Peg-IFN-α-2a among these patients.

METHODS

Forty-one IFN-naive hemodialysis patients infected by HCV were assessed. All patients had positive anti-HCV antibody and positive HCV-RNA. Peg-IFN-α-2a 135 mcg/week was given for 48 weeks. Biochemical and virological responses were evaluated at treatment weeks 12, 24, 48, and 72.

RESULTS

Thirty-eight of the 41 patients who completed the treatment enrolled in the study. Mean age of the 38 patients was 38.1 (range 23-65) years, and the study group was predominantly male (65.8 %). There was no statistically significant difference in mean age, gender, mean duration of hemodialysis, HCV infection, patient numbers with normal alanine aminotransferase (ALT) values and mean ALT, platelet, and HCV-RNA values between patients who achieved sustained virological response (SVR) and those who did not. Only the Knodell histology activity index correlated with SVR (P = 0.048). Biochemical and virological response rates at the 12th week (early response) were 94.7 % and 60.5 %, respectively. The 34 (89.5 %) patients achieved biochemical response at the end of therapy (48th week); 24 (63.2 %) remained HCV-RNA negative. At the 72nd week, biochemical and virological response rates were 84.2 % and 50 %, respectively.

DISCUSSION

According to results of this study, patients achieved good sustained viral and biochemical response rates with Peg-IFN-α-2a treatment. Histology activity index may be a predictor for SVR; but large randomized controlled trials are needed. Weekly 135 mcg dose of Peg-IFN-α-2a for 48 weeks is an effective treatment in HCV-infected hemodialysis patients.

Transcription-mediated amplification (TMA) for the assessment of viremia in hemodialysis patients with hepatitis C

The diagnosis of hepatitis C virus (HCV) infection in hemodialysis patients is difficult particularly due to the presence of intermittent viremia. The aims of this study were: (a) to determine the prevalence of intermittent viremia in hemodialysis patients with anti-HCV antibodies who tested negative for HCV RNA by PCR at the first evaluation and (b) to evaluate the contribution of the transcription-mediated amplification method (TMA) to the diagnosis of viremia in the PCR-negative samples. One hundred and six patients with anti-HCV antibodies and an initial negative result for HCV RNA by PCR were included. An additional sample was collected for a second HCV RNA test by PCR after a minimum interval of 3 months and a positive result characterized intermittent viremia. HCV RNA was investigated by TMA in the PCR-negative sample of patients with intermittent viremia, and in the most recent sample from patients with PCR-negative results in both determinations. Intermittent viremia was observed in 60/106 (57%) patients (57% men; age: 45 ± 10 years). Fifty-one of the 60 negative samples from patients with intermittent viremia and 29/46 double-negative patients were tested by TMA. This assay detected viremia in 20/51 (39%) samples of intermittent viremia and in 2/29 (7%) of double-negative samples. The results showed that intermittent viremia is frequent in hemodialysis patients who tested negative for HCV RNA by PCR. Therefore, a second HCV RNA test is necessary for all HCV RNA-negative patients. The TMA assay appears to be the best first screening test for viremia in this population.

Histological evolution of hepatitis C virus infection after renal transplantation

BACKGROUND

information regarding histological progression of hepatitis C after renal transplant (RTx) is scarce.

AIMS

To analyze clinical and laboratory evolution and histological progression of hepatitis C in patients evaluated before and after RTx.

METHODS

Twenty-two HCV-infected patients submitted to liver biopsy pre- and post-RTx were included. A semiquantitative analysis of necroinflammatory activity and fibrosis staging was performed and the two biopsies were compared.

RESULTS

Patients were mostly men (73%) with mean age of 36±9 yr. Time post-transplant was 4±2 yr and time between biopsies was 5±2 yr. An elevation of alanine aminotransferase (p=0.041) and aspartate aminotransferase (p=0.004) levels was observed in the post-transplant period. Fibrosis progression after renal transplantation was observed in 11 (50%) of the patients, and necroinflammatory activity worsening was observed in 7 (32%) of the patients. The histological progression occurred even among those without significant histological lesions in pre-transplant biopsy.

CONCLUSION

The findings of this study suggest that the practice of indicating treatment in the pre-transplant phase based mainly on histological disease should be revised, because a high proportion of patients present disease progression. Because interferon cannot be used safely after RTx, treatment should be indicated for all ESRD patients with hepatitis C.

High prevalence of hepatitis C virus-ribonucleic acid positivity in anti-hepatitis C virus negative renal transplant patients

BACKGROUND

Hepatitis C virus (HCV) infection is common in renal transplant (RT) patients. Some of these patients remain anti-HCV negative despite presence of infection and these are identified by a positive HCV-ribonucleic acid (RNA) test.

METHODS

We studied 404 RT patients for prevalence of HCV-RNA positivity in anti-HCV negative patients. Serum was tested for presence of anti-HCV antibodies using a third generation HCV micro-ELISA (enzyme-linked immunosorbent assay) test, which utilises a combination of HCV structural and nonstructural antigens. The RNA was extracted from patient serum for HCV viral quantification using Quiagen Ql Amp Viral RNA mini extraction kit. The HCV-RNA viral load was performed on Corbet Rotor Gene 3000 thermocycler using Taqman principle.

RESULTS

About 308 patients were anti-HCV negative and 96 were anti-HCV positive, resulting in prevalence of overt HCV infection of 23.7%. A total of 130 anti-HCV negative patients tested positive for HCV-RNA making a prevalence of occult HCV infection of 42.2%. There was no significant difference in the rate of overt or occult HCV infection between males and females. Patients with HCV infection (whether overt or occult) had received more number of dialysis sessions (62.5 vs 32.2) and blood transfusions (2.78 vs 1.99) when compared to those without HCV infection (P=0.001). The mean duration on dialysis was also longer (8.15 months vs 4.53 months) in patients with HCV infection (P= 0.0001).

CONCLUSION

A direct test for HCV viraemia is important to accurately determine the epidemiology of HCV infection in RT patients who remain anti-HCV negative despite harbouring active HCV infection.

Liver enzymes in patients with chronic kidney disease undergoing peritoneal dialysis and hemodialysis

OBJECTIVE

The present study was designed to analyze the serum levels of aspartate and alanine aminotransferases, gamma-glutamyl transferase, and the hematocrit in patients with chronic kidney disease who were undergoing peritoneal dialysis or hemodialysis.

PATIENTS AND METHODS

Twenty patients on peritoneal dialysis and 40 on hemodialysis were assessed, and the patients were matched according to the length of time that they had been on dialysis. Blood samples were collected (both before and after the session for those on hemodialysis) to measure the enzymes and the hematocrit.

RESULTS

In the samples from the patients who were undergoing peritoneal dialysis, the aspartate and alanine aminotransferase levels were slightly higher compared with the samples collected from the patients before the hemodialysis session and slightly lower compared with the samples collected after the hemodialysis session. The levels of gamma-glutamyl transferase in the hemodialysis patients were slightly higher than the levels in the patients who were undergoing peritoneal dialysis. In addition, the levels of aminotransferases and gamma-glutamyl transferase that were collected before the hemodialysis session were significantly lower than the values collected after the session. The hematocrit levels were significantly lower in the patients who were on peritoneal dialysis compared with the patients on hemodialysis (both before and after the hemodialysis session), and the levels were also significantly lower before hemodialysis compared with after hemodialysis.

CONCLUSION

The aminotransferase levels in the patients who were undergoing peritoneal dialysis were slightly higher compared with the samples collected before the hemodialysis session, whereas the aminotransferase levels were slightly lower compared with the samples collected after the session. The hematocrits and the aminotransferase and gamma-glutamyl transferase levels of the samples collected after the hemodialysis session were significantly higher than the samples collected before the session. Taken together, the present data suggest that hemodilution could alter the serum levels of liver enzymes.

Effect of dialysis modality on survival of hepatitis C-infected ESRF patients

BACKGROUND AND OBJECTIVES

Hepatitis C virus (HCV) infection is associated with increased mortality and morbidity in end-stage renal failure (ESRF) patients. Despite a lower incidence and risk of transmission of HCV infection with peritoneal dialysis (PD), the optimal dialysis modality for HCV-infected ESRF patients is not known. The aim of this study was to evaluate the impact of dialysis modality on the survival of HCV-infected ESRF patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The study included all adult incident ESRF patients in Australia and New Zealand who commenced dialysis between January 1, 1994, and December 31, 2008, and were HCV antibody-positive at the time of dialysis commencement. Time to all-cause mortality was compared between hemodialysis (HD) and PD according to modality assignment at day 90, using Cox proportional hazards model analysis.

RESULTS

A total of 424 HCV-infected ESRF patients commenced dialysis during the study period and survived for at least 90 days (PD n = 134; HD n = 290). Mortality rates were comparable between PD and HD in the first year (10.7 versus 13.8 deaths per 100 patient-years, respectively; adjusted hazard ratio [HR] 0.65, 95% CI 0.34 to 1.26) and thereafter (20 versus 15.9 deaths per 100 patient-years, respectively; HR 1.27, 95% CI 0.86 to 1.88).

CONCLUSIONS

The survival of HCV-infected ESRF patients is comparable between PD and HD.

Combined antiviral therapy of hepatitis C virus in dialysis patients: meta-analysis of clinical trials

The efficacy and safety of combined interferon (IFN) plus ribavirin in patients on long-term dialysis and chronic hepatitis C remains unclear, although a number of small clinical trials have addressed this issue. We evaluated the efficacy and safety of combination antiviral therapy (conventional or pegylated interferon plus ribavirin) in dialysis patients with chronic hepatitis C by performing a systematic review of the literature with a meta-analysis of clinical trials. The primary outcome was sustained virological response (SVR) (as a measure of efficacy); the secondary outcome was drop-out rate (as a measure of tolerability). We used the random effects model of Der Simonian and Laird, with heterogeneity and sensitivity analyses. We identified 10 clinical studies (151 unique patients), one (10%) of which was a controlled clinical trial. Most (97.4%) patients were on long-term haemodialysis. The summary estimate for SVR and drop-out rate was 56% [95% Confidence Intervals (95% CI) 28-84] and 25% (95% CI, 10-40), respectively. The most frequent side effects requiring interruption of treatment were anaemia (26%) and heart failure (9%). These results occurred irrespective of type of interferon (conventional or peg-IFN, peg-IFNalfa-2a or alfa-2b), trial design (controlled or cohort study), or clinical characteristics of patients (naïve, nonresponders or relapsers). The studies were heterogeneous with regard to SVR and drop-out rate. Combination antiviral therapy (interferon plus ribavirin) gives encouraging results in terms of efficacy and safety among dialysis patients even if the limited number of patients enrolled in our meta-analysis hampers definitive conclusions.

Hospitalization rates associated with hepatitis B and HIV co-infection, age and sex in a population-based cohort of people diagnosed with hepatitis C

To determine the extent age, sex and co-infection affect morbidity in people infected with hepatitis C virus (HCV), we performed a population-based study linking HCV notifications in New South Wales, Australia with their hospital (July 2000 to June 2006), hepatitis B virus (HBV) and HIV notification, and death records. Poisson models were used to calculate hospitalization rate ratios (RRs) for all-cause, illicit drug and liver-related admissions. Co-infection RRs were used to estimate attributable risk (AR). The 86 501 people notified with HCV contributed 422 761 person-years of observation; 0·8% had HIV, 3·7% HBV, and 0·04% had both. RRs for males were equal to or lower than for females in younger ages, but higher in older ages (Pfor interaction ⩽0·013). HBV/HIV co-infection resulted in ARs of over 70% for liver disease and 30–60% otherwise. However, at the cohort level the impact was minimal (population ARs 1·3–8·7%). Our findings highlight the importance and success of public health measures, such as needle and syringe exchange programmes, which have helped to minimize the prevalence of co-infection in Australia. The findings also suggest that the age of study participants needs to be considered whenever the burden of HCV-related morbidity is reported by sex. The results are likely to be representative of patterns in hospital-related morbidity for the entire HCV-infected population in Australia and the ARs generalizable to other developed countries.

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.

Pegylated interferon monotherapy of chronic hepatitis C in dialysis patients: Meta-analysis of clinical trials

The efficacy and safety of pegylated interferon monotherapy in patients with chronic renal failure and chronic hepatitis C remains unclear, although a number of small clinical trials have been published addressing this issue. A systematic review of the literature with a meta-analysis of clinical trials was performed in order to assess efficacy and safety of initial pegylated interferon monotherapy in chronic renal failure patients with chronic hepatitis C. The primary outcome was sustained virological response (as a measure of efficacy); the secondary outcome was drop-out rate (as a measure of tolerability). The random effects model of Der Simonian and Laird was used, with heterogeneity and sensitivity analyses. Sixteen clinical trials (254 unique patients) were identified, five (31%) being controlled studies; the majority (15/16 = 94%) regarded patients on long-term dialysis. The summary estimate for sustained virological response and drop-out rate was 33% [95% Confidence Intervals (95%CI) 24-43] and 23% (95%CI, 14-33), respectively. The most frequent side-effects requiring interruption of treatment were haematological (18%) and gastrointestinal (14%). In the group of controlled clinical trials, the summary estimate for sustained viral response and drop-out rate was 38% (95% CI, 18-59), and 15% (95% CI, 3-26), respectively. The studies were heterogeneous with regard to sustained virological response and drop-out rate. Pegylated IFN does not provide an added benefit in terms of virological response in comparison with standard IFN monotherapy. Tolerance to pegylated-IFN monotherapy was unsatisfactory. Prospective trials are in progress to assess the optimal antiviral therapy for chronic hepatitis C in dialysis patients.

Infecção pelo vírus da hepatite c em pacientes em hemodiálise: prevalência e fatores de risco

CONTEXTO: Doentes com doença renal crônica em tratamento hemodialítico apresentam risco aumentado de aquisição do vírus da hepatite C (VHC). Elevadas taxas de prevalência têm sido detectadas em unidades de diálise do mundo inteiro. Estudos recentes têm demonstrado que a infecção pelo VHC interfere de forma negativa na sobrevida dos pacientes em hemodiálise e naqueles submetidos ao transplante renal. OBJETIVOS: Determinar a prevalência e os fatores de risco da infecção pelo VHC em pacientes submetidos a hemodiálise. MÉTODOS: Realizou-se estudo transversal entre janeiro e dezembro de 2007. Neste período, 236 pacientes em hemodiálise foram testados pelo ELISA de terceira geração. Os casos positivos foram submetidos a pesquisa qualitativa do HCV-RNA pelo método de PCR. Consideraram-se como portadores de infecção pelo VHC aqueles pacientes com anti-VHC e HCV-RNA positivos. Dosagens mensais de ALT e a média do valor de 12 meses foram obtidas em 195 pacientes. Do total de pacientes, 208 (88,1%) responderam ao questionário padronizado visando a identificação de fatores de risco associados à infecção pelo VHC. RESULTADOS: A prevalência de pacientes anti-VHC positivos encontrada entre os 236 testados foi de 14,8% (35/236); destes, a pesquisa do HCV-RNA foi positiva em 71,6% (25/35). Portanto, a prevalência da infecção crônica pelo VHC foi de 10,6% (25/236) dos pacientes. Pela análise bivariada, os principais fatores de risco associados à infecção pelo VHC foram o tempo de hemodiálise, o número de transfusões de sangue, a realização prévia de diálise peritonial e história de doença sexualmente transmissível. Contudo, após análise multivariada, somente o tempo de hemodiálise e história de doença sexualmente transmissível foram significativamente associados à infecção pelo VHC. Pacientes com mais de 10 anos de hemodiálise apresentaram risco de aquisição do VHC 73,9 (IC de 17,5 a 311,8) vezes maior quando comparados a pacientes com até 5 anos de tratamento. Indivíduos com doença sexualmente transmissível prévia apresentaram risco 4,8 (IC de 1,1 a 19,9) vezes superior de contaminação pelo VHC quando comparados àqueles sem doença sexualmente transmissível. O valor médio da ALT foi significantemente maior nos pacientes infectados pelo VHC (44,0 ± 13,5 U/L versus 33,5 ± 8,0 U/L, P<0,001). CONCLUSÃO: A infecção pelo VHC apresentou elevada prevalência na unidade de diálise analisada. O tempo de tratamento dialítico e história prévia de doença sexualmente transmissível foram os principais fatores de risco associados à infecção pelo VHC. Indivíduos em hemodiálise com infecção crônica pelo VHC apresentaram maior atividade de ALT que pacientes sem hepatite C crônica.

Health care-associated transmission of hepatitis B and C viruses in hemodialysis units

Liver disease is a significant cause of morbidity and mortality in patients receiving long-term dialysis. This article summarizes the most recent information on epidemiology, clinical significance, and management of infection by hepatitis B and C viruses in this population.

Acute infection with a single hepatitis C virus strain in dialysis patients: Analysis of adaptive immune response and viral variability

BACKGROUND/AIMS

While the adaptive immune response is crucial for spontaneous resolution of acute hepatitis C virus (HCV) infection, it also constitutes the driving force for viral escape. For acutely HCV-infected dialysis patients, little is known about the host response and its impact on viral evolution.

METHODS

Four haemodialysis patients accidentally infected with the same HCV strain were prospectively investigated with respect to the clinical course, CD4+ and CD8+ T-cell responses, neutralizing antibodies, viral kinetics and sequence variability.

RESULTS

In one patient, a robust CD4+ T-cell response was associated with transient control of infection, while in the other patients, weak responses correlated with persistently high viremia. Despite the presence of CD8+ T-cell effectors in the first patient, no sequence differences were detected in targeted regions of the viral genome in any of the patients when viral persistence was established. Genetic stability in the envelope genes, including the hypervariable regions, correlated with low-level or absent neutralizing antibodies in all of the patients.

CONCLUSIONS

The establishment of viral persistence in the special patient group of dialysis patients is due to a failure of the adaptive immune system, as shown by the absence of significant T-cell and antibody responses, as well as viral variability.

Hepatitis C infection and chronic renal diseases

More than 170 million people worldwide are chronically infected with the hepatitis C virus (HCV), which is responsible for over 1 million deaths resulting from cirrhosis and liver cancers. Extrahepatic manifestations are also relevant and include mixed cryoglobulinemia, lymphoproliferative disorders, and kidney disease. HCV infection is both a cause and a complication of chronic kidney disease, occurring largely in the context of mixed cryoglobulinemia. This infection also represents a major medical and epidemiologic challenge in patients with end-stage renal disease on renal replacement therapy with dialysis or transplantation. In these settings the presence of HCV correlates with higher rates of patient mortality than in HCV-negative subjects on dialysis or undergoing kidney transplant. The major concern is the lack of safe and effective drugs to treat HCV-infected patients with chronic kidney disease. Unfortunately, there are no large-scale clinical trials in this population, especially those receiving renal replacement therapy, so that strong evidence for treatment recommendations is scant. This review article provides the readers with the most recent insights on HCV infection both as cause and complication of chronic kidney disease, discusses pitfalls and limitations of current therapies, and reports on preliminary experience with novel therapeutic agents, as well as directions for future research.

Serum alanine aminotransferase levels, hematocrit rate and body weight correlations before and after hemodialysis session

PURPOSE

To evaluate alanine aminotransferase levels before and after a hemodialysis session and to correlate these values with the hematocrit rate and weight loss during hemodialysis.

PATIENTS AND METHODS

The serum alanine aminotransferase levels, hematocrit rate and body weight were measured and correlated before and after a single hemodialysis session for 146 patients with chronic renal failure. An receiver operating characteristic (ROC) curve for the serum alanine aminotransferase levels collected before and after hemodialysis was plotted to identify hepatitis C virus-infected patients.

RESULTS

The mean weight loss of the 146 patients during hemodialysis was 5.3% (p < 0.001). The mean alanine aminotransferase levels before and after hemodialysis were 18.8 and 23.9 IU/, respectively, denoting a significant 28.1% increase. An equally significant increase of 16.4% in the hematocrit rate also occurred after hemodialysis. The weight loss was inversely correlated with the rise in both the alanine aminotransferase level (r = 0.3; p < 0.001) and hematocrit rate (r = 0.5; p < 0.001). A direct correlation was found between the rise in alanine aminotransferase levels and the hematocrit during the hemodialysis session (r = 0.4; p < 0.001). Based on the ROC curve, the upper limit of the normal alanine aminotransferase level should be reduced by 40% relative to the upper limit of normal if the blood samples are collected before the hemodialysis session or by 60% if blood samples are collected after the session.

CONCLUSION

In the present study, significant elevations in the serum alanine aminotransferase levels and hematocrit rates occurred in parallel to a reduction in body weight after the hemodialysis session. These findings suggest that one of the factors for low alanine aminotransferase levels prior to hemodialysis could be hemodilution in patients with chronic renal failure.

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

BACKGROUND

The impact of dialysis modality on the rates and types of infectious complications has not been well studied. The aim of the present investigation was to evaluate the rates of hepatitis C virus (HCV) and hepatitis B virus (HBV) infections in peritoneal dialysis (PD) and haemodialysis (HD) patients in the Asia-Pacific region.

METHODS

The study included the most recent period-prevalent data recorded in the national or regional dialysis registries of the 10 Asia-Pacific countries/areas (Australia, New Zealand, Japan, China, Taiwan, Korea, Thailand, Hong Kong, Malaysia and India), where such data were available. Longitudinal data were also available for all incident Australian and New Zealand patients commencing dialysis between 1 April 1995 and 31 December 2005. Rates of HCV and HBV infections were compared by chi-square, Poisson regression and Kaplan-Meier survival analyses, as appropriate.

RESULTS

Data were obtained on 201,590 patients (HD 173,788; PD 27,802). HCV seroprevalences ranged between 0.7% and 18.1% across different countries and were generally higher in HD versus PD populations (7.9% +/- 5.5% versus 3.0% +/- 2.0%, P = 0.01). Seroconversion rates on dialysis were also significantly higher in HD patients (incidence rate ratio PD versus HD 0.33, 95% CI 0.13-0.75). HCV infection was highly predictive of mortality in Japan (relative risk 1.37, 95% CI 1.15-1.62, P = 0.003) and in Australia and New Zealand (adjusted hazards ratio 1.29, 95% CI 1.05-1.58). HBV infection data were limited, but less clearly influenced by dialysis modality.

CONCLUSIONS

Dialysis modality selection significantly influences the risk of HCV infection experienced by end-stage renal failure patients in the Asia-Pacific region. No such association could be identified for HBV infection.

Occult hepatitis C virus infection among hemodialysis patients

Occult hepatitis C virus (HCV) infection (i.e., detectable HCV-RNA in the liver or peripheral blood mononuclear cells) in the absence of both serum HCV-RNA and anti-HCV antibodies has not been investigated in hemodialysis patients. In this study, real-time PCR and in situ hybridization was used to test for the presence of genomic and antigenomic HCV-RNA in peripheral blood mononuclear cells of 109 hemodialysis patients with abnormal levels of liver enzymes. Occult HCV infection, determined by the presence of genomic HCV-RNA, was found in 45% of the patients; 53% of these patients had ongoing HCV replication, indicated by the presence of antigenomic HCV-RNA. Patients with occult HCV infection had spent a significantly longer time on hemodialysis and had significantly higher mean alanine aminotransferase levels during the 6 mo before study entry. Logistic regression analysis revealed that mortality was associated with age >60 yr (odds ratio 3.30; 95% confidence interval 1.05 to 10.33) and the presence of occult HCV infection (odds ratio 3.84; 95% confidence interval 1.29 to 11.43). In conclusion, the prevalence of occult HCV infection is high among hemodialysis patients with persistently abnormal values of liver enzymes of unknown cause. The clinical significance of occult HCV infection in these patients requires further study.