Hepatitis B virus infection and the dialysis patient

Prevalence of Hepatitis B Virus, Hepatitis C Virus, and HIV Infections in Hemodialysis Patients at Kano Kidney Center

Background Hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections are more prevalent in hemodialysis patients compared to the general population. The objective of this study was to evaluate the prevalence of HBV, HCV, and HIV infections in hemodialysis patients dialyzing regularly at Kano Kidney Center (KKC) in the Eastern Health Cluster of Saudi Arabia in 2022. Methods This retrospective study included all hemodialysis patients who were dialyzed regularly at KKC during 2022. Their electronic medical records were reviewed for the results of HBV, HCV, and HIV along with the patient's demographics, comorbid conditions, and dialysis history. The study was approved and monitored by the Institutional Review Board of Dammam Medical Complex. Results A total of 239 regular hemodialysis patients were included, consisting of 142 males and 97 females (59.41% and 40.59%, respectively), with a mean age of 52.71±15.83 years. Most of the patients were Saudis (156 patients, 65.27%) with the non-Saudi patients being composed mostly of Arabian patients. Nine patients (3.77%) tested positive for hepatitis B surface antigen (HBsAg), the serologic hallmark of HBV infection. Two patients (0.84%) had resolved HBV infections as evidenced by positive hepatitis B core antibody (anti-HBc) and hepatitis B surface antibody (anti-HBs). However, the majority (226 patients, 94.56%) were never tested for anti-HBc. Anti-HBs, which can imply long-term immunity against HBV from prior immunizations or infections, were positive in 165 patients (69.04%). A protective anti-HBs level of ≥ 10 IU/L was detected in 158 patients (66.11%) including 104 patients (43.51%) having ≥ 100 IU/L. Eighteen patients (7.53%) had reactive HCV antibodies. Four patients (1.67%) had chronic HCV infection as they had detectable HCV RNA. The remaining 14 patients (5.86%) cleared HCV either spontaneously (seven patients, 2.93%) or by medications (seven patients, 2.93%). HIV screening tests were negative in all 239 patients (100%). HBsAg-positive patients did not have any statistically significant differences from HBsAg-negative patients. On the other hand, the patients who were positive for HCV antibodies were older than the patients who were negative for HCV antibodies (60.66 vs 52.05 years on average, p-value <0.05). They also contained a statistically larger proportion of non-Saudi patients than the patients with no evidence of prior infections (61.11% vs 32.13%, p-value <0.05). Conclusions The study found that the prevalence of HBV and HCV infections among hemodialysis patients in KKC at 3.77% and 1.67%, respectively, is higher than that reported in the general population in Saudi Arabia, with non-Saudis having a higher prevalence rate of HCV infection than Saudis. However, the current prevalence rate is lower compared to the previous studies that were conducted in Saudi Arabia in the first decade of the 21st century, and there were no cases of HIV infections. Nevertheless, a significant proportion of patients had unprotective or negative anti-HBs antibody titers, indicating the need for strict vaccination protocols and monitoring of antibody titers to ensure optimal protection.

The Impact of Antiviral Treatment of Hepatitis B Virus after Kidney Transplant and the Latest Insights

BACKGROUND

The current frequency of hepatitis B virus infection in patients with advanced chronic kidney disease (CKD) (including patients on maintenance dialysis and kidney transplant recipients) is low but not negligible worldwide. HBV has a deleterious effect on survival after a kidney transplant; antiviral treatments improved the short-term outcomes of kidney transplant recipients, but their long-term impact remains uncertain.

AIM

The aim of this review is to assess the role of antiviral therapy for HBV in improving survival after a kidney transplant. The recent publication of large surveys has prompted us to update the available evidence on the impact of HBV on patient and graft survival after a kidney transplant.

METHODS

We have conducted an extensive review of the medical literature, and various research engines have been used.

RESULTS

We retrieved several studies (n = 11; n = 121,436 unique patients) and found an association between positive serologic HBsAg status and diminished patient and graft survival after a kidney transplant; the adjusted relative risk (aRR) of all-cause mortality and graft loss was 2.85 (95% CI, 2.36; 3.33, p < 0.0001) and 1.26 (95% CI, 1.02; 1.51, p < 0.0001), respectively. To our knowledge, at least six studies reported improved patient and graft survival after the adoption of antiviral therapies for HBV (this result was reported with both survival curves and multivariable regression). According to novel clinical guidelines, entecavir has been suggested as a 'first line' antiviral agent for the treatment of HBV after a kidney transplant.

CONCLUSIONS

The recent availability of safe and effective antiviral drugs for the treatment of HBV has meant that the survival curves of HBsAg-positive patients on antiviral therapy and HBsAg-negative patients after a kidney transplant can be comparable. Antiviral therapy should be systematically proposed to HBV-positive kidney transplant recipients and candidates to avoid the deleterious hepatic and extra-hepatic effects of chronic HBV replication.

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.

Long-term persistent immunogenicity after successful standard and triple-dosed hepatitis B vaccine in hemodialysis patients: A 3-year follow-up study in China

BACKGROUND

Although the efficacy of hepatitis B vaccines among hemodialysis patients has been documented, the long-term persistence of immunogenicity in this population remains largely unknown. We explored the long-term persistence of immunogenicity induced by different hepatitis B vaccine regimens in hemodialysis patients.

METHODS

In initial study, we conducted a randomized, multicenter, double-blind, parallel-controlled trial among hemodialysis patients in 13 hospitals in Shanxi Province, China. A total of 352 hemodialysis patients were allocated to receive 3-dose 20 μg (IM20 group) and 3-dose 60 μg (IM60 group) recombinant hepatitis B vaccine at months 0, 1, and 6. Vaccine-induced immune responses were measured at month 7. In this study, the responders (anti-HBs ≥ 10 mIU/mL) were followed up at months 18, 24, 30, 36 and 42, respectively. We used the generalized log-rank test and generalized estimating equations (GEE) to analyze the long-term durability of responses and the kinetics of anti-HBs levels, respectively.

RESULTS

A total of 284 patients were involved in the extended follow-up period. The duration of vaccine-induced response with 75% of patients maintained protective antibody were 12 months and 18 months in the IM20 group and IM60 group, respectively (P = 0.291). The long-term persistent immunogenicity induced by 3-dose 60 μg was more satisfactory than that by 3-dose 20 μg hepatitis B vaccine in patients with hemodialysis duration ≥ five years (P = 0.023). The peak anti-HBs levels in 100-1000 mIU/mL or ≥ 1000 mIU/mL were more likely to maintain long-term protective antibody compared to anti-HBs levels in 10-100 mIU/mL (P ＜ 0.05). The kinetic profile was similar between the two groups (P = 0.334).

CONCLUSION

High-dose 60 μg hepatitis B vaccine could lead a satisfactory long-term durability of immunogenicity among patients with hemodialysis duration of five years or more. Peak anti-HBs level after vaccination was associated with the long-term persistence of immunogenicity.

Clinicopathological features, risk factors, and outcomes of immunoglobulin A nephropathy associated with hepatitis B virus infection

BACKGROUND

Hepatitis B virus (HBV) infections are associated with an increased risk of kidney diseases. However, the effects of HBV infection on the prognosis of immunoglobulin A nephropathy (IgAN) are unclear.

METHODS

A total of 838 patients with biopsy-confirmed IgAN were enrolled in this retrospective cohort study. The patients were categorized into either affected by IgAN and HBV infection (HBsAg-IgAN) or by primary IgAN with no sign of HBV infection (P-IgAN). A 1:1 propensity-score matching was performed between the two groups, followed by a Kaplan-Meier survival analysis, to compare the prognoses, and a Cox regression analysis, to identify factors influencing the HBsAg-IgAN outcomes.

RESULTS

A total of 176 pairs of patients were successfully matched. A significant difference in the systolic blood pressure and urea, serum creatinine, uric acid, and 24-h urine protein levels was observed between the groups. A renal pathological analysis also revealed a significant difference in the mesangial hypercellularity between the groups. During a median follow-up period of 2.4 years, Kaplan-Meier analysis also revealed a significant difference in the renal survival between the groups. Furthermore, multivariate Cox analysis confirmed that HBV infection is an independent risk factor for IgAN progression (hazard ratio [HR] 2.096; 95% confidence interval [CI] 1.091-4.026). Finally, the HBsAg-IgAN patients who received treatment with renin-angiotensin-aldosterone system inhibitors had a better overall prognosis than those who received immunosuppressive therapy and antiviral treatment.

CONCLUSION

Our results indicate that the clinicopathological features and outcomes of patients with IgAN differ significantly between those with and without HBV infection, and that HBV is an independent risk factor for IgAN progression.

[Preparation of the dialysis patient with type 1 diabetes mellitus for kidney transplantation]

Kidney transplantation is unique method of renal replacement therapy, allowing to improve quality and duration of life for patients with diabetes mellitus type 1 (DM1) and end-stage renal disease (ESRD) on dialysis therapy. Recently using of innovation technologies for diabetes management and modern immunosuppression enable achieving better results of posttransplant rehabilitation for patients with DM1, especially if kidney transplantation is performed early after initiation of dialysis. Detailed examination of patient with DM1 before potential kidney transplantation is very important to reduce of early and late postoperative complications. Kidney transplantation preparation includes effective glycemic control, adequate dialysis therapy, treatment of diabetes and ESRD complications and concomitant conditions, especially cardiovascular diseases, accounting for kidney transplantation perspective. Furthermore, diagnostics and treatment of any infectious process, timely vaccination, cancer screening are basic approaches of kidney transplantation preparation program, providing the best survival rate of kidney graft and patient.

Prevalence of Occult Hepatitis B Virus Infection in Hemodialysis Patients Using Nested PCR

BACKGROUND

Occult hepatitis B infection (OBI) is defined as the lack of detectable HBsAg in serum, despite the presence of intrahepatic viral DNA, and low levels of covalently closed circular DNA (cccDNA). Since the hemodialysis patients are at a greater disadvantage if they are a carrier of Hep B, as it can lead to OBI this study was designed to determine the prevalence of OBI in hemodialysis patients residing in Zanjan, Iran.

METHODS

We conducted an anti-HBc test (ELISA) on 166 HBsAg negative hemodialysis patient samples. OBI was evaluated using seropositive (anti-HBc and/or anti-HBs) and seronegative (anti-HBc and anti-HBs) using nested PCR.

RESULTS

Out of the total hemodialysis patients sampled, the study consisted of 58.4% male and 41.6% female participants. The age of the study group ranged from 58.89±15.49, and had received approximately 28.27±27.43 years of dialysis. Additionally, 5.4% of patients had a history of blood transfusions, while 58.4% were vaccinated against the hepatitis B virus (HBV). Moreover, 23.5% patients were anti-HBc positive, while 76.5% patients tested negative. Lastly, 66.3% of the patients were positive for anti-HBs, whereas 33.7% were negative for anti-HBs. Overall, the study revealed that the prevalence of OBI was 6%, and HBV DNA was detected in 2.1% of individuals who were vaccinated against hepatitis B (p < 0.01).

CONCLUSION

Though no significant difference between the prevalence of OBI to the patients' age, sex, duration of dialysis, or history of blood transfusion was identified, however, a strong correlation between the prevalence of OBI to HBV vaccination was found.

INASL Guidelines on Management of Hepatitis B Virus Infection in Patients receiving Chemotherapy, Biologicals, Immunosupressants, or Corticosteroids

Hepatitis B Virus (HBV) reactivation in patients receiving chemotherapy, biologicals, immunosupressants, or corticosteroids is emerging to be an important cause of morbidity and mortality in patients with current or prior exposure to HBV infection. These patients suffer a dual onslaught of illness: one from the primary disease for which they are receiving the culprit drug that led to HBV reactivation, and the other from HBV reactivation itself. The HBV reactivation not only leads to a compromised liver function, which may culminate into hepatic failure; it also adversely impacts the treatment outcome of the primary illness. Hence, identification of patients at risk of reactivation before starting these drugs, and starting treatment aimed at prevention of HBV reactivation is the best strategy of managing these patients. There are no Indian guidelines on management of HBV infection in patients receiving chemotherapy, biologicals, immunosupressants, or corticosteroids for the treatment of rheumatologic conditions, malignancies, inflammatory bowel disease, dermatologic conditions, or solid-organ or bone marrow transplantation. The Indian National Association for Study of the Liver (INASL) had set up a taskforce on HBV in 2016, with a mandate to develop consensus guidelines for management of various aspects of HBV infection, relevant to India. In 2017 the taskforce had published the first INASL guidelines on management of HBV infection in India. In the present guidelines, which are in continuation with the previous guidelines, the issues on management of HBV infection in patients receiving chemotherapy, biologicals, immunosupressants, or corticosteroids are addressed.

Evaluation of Response to Hepatitis B Vaccination in Chronic Hemodialysis Patients

Background:

Hemodialysis (HD) patients are at an increased risk of acquiring hepatitis B virus (HBV) infection. Active HBV immunization in these patients is recommended. A response rate in HD patients is variable but generally lower than healthy individuals.

Objective:

The aim of this study is to assess the response of HD patients to the HBV vaccine and correlate response and long-term immunity to various clinical and biomedical factors.

Patients and Methods:

One hundred and one patients, with a mean age 48.7 ± 18.5 years, received 40 μg of HBV vaccine administered intramuscularly in the deltoid region at 0, 1, 2 and 6 months. The patients' responses to the vaccine were determined by measuring hepatitis B surface antibody (HBsAb) 6 weeks after the last injection and monitored thereafter at 3-month intervals.

Results:

Seventy-one patients (70.3%) mounted a response with HBsAb >10 mIU/ml 6 weeks following the fourth dose of vaccine, and thus were considered considered as adequate responders. Forty-nine (48.5%) patients mounted an excellent response with HBsAb >100 mIU/ml 6 weeks after the fourth dose. Thirty patients (29.7%) were nonresponders. Responders were significantly younger than nonresponders (P = 0.01). Gender, hemoglobin level, serum albumin, ferritin, parathyroid hormone level and hepatitis C virus infection had no effect on the response to the vaccine. Similarly, there was no difference in diabetic state and adequacy of HD between the two groups. Fifty-nine patients (88%) had persistent protective antibodies at 1 year, while eight (12%) lost such protection. Predictors of persistent immunity at 1 year were high HBsAb level at the completion of the vaccination regime and, to a lesser extent, young age.

Conclusion:

A 70% response rate to HBV vaccine was observed in the cohort of this study. Young age predicts a favorable response to HBV vaccine in HD patients. High (>100 mIU/ml) HBsAb levels achieved at vaccine completion predict persistent immunity at 1 year.

Prevalence of hepatitis B surface antigen among hemodialysis patients from Middle Eastern countries: a systematic review and meta-analysis

Aim: The aim of this study was to determine the overall prevalence of hepatitis B surface antigen (HBsAg) among hemodialysis patients reported from the Eastern Mediterranean Regional Office of the WHO (EMRO) countries and the Middle East. Methods: Several databases such as PubMed, ISI Web of Science, MEDLINE and Scopus were searched for publications reporting HBsAg prevalence among hemodialysis patients up to December 2016. Results: From all the samples, the pooled prevalence of HBsAg was estimated (95% CI) to be 4.4% (4.4–4.5%). Conclusion: The prevalence of HBsAg in hemodialysis units in the Middle Eastern countries is decreasing over the recent years. Nevertheless, it is important to conduct more studies in these regions to achieve more representative results.

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.

Epidemiological Aspects of Hepatitis B and C and Human Immunodeficiency Viruses Among Hemodialysis Patients in Mazandaran Province, Iran

BACKGROUND

Hemodialysis patients are potentially susceptible to infection with blood-borne viral agents, especially hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

OBJECTIVES

The aim of this study was to evaluate the prevalence and incidence of HBV, HCV, and HIV infections in hemodialysis patients.

PATIENTS AND METHODS

This study was carried out in 482 hemodialysis patients who had been referred to eight dialysis centers in the Mazandaran province in Iran from 2012 - 2014. HBs Ag, HCV Ab, HBs Ab and HIV Ab were assessed every three months for two years. The patients' demographic characteristics, including age, gender, area of residence, and duration of dialysis, were noted. The prevalence of each virus was also determined.

RESULTS

From a total of 482 patients, 253 (52.5%) males and 229 (47.5%) females were evaluated. The mean age of all patients was 54.96 ± 16.1 years, and all participants were HIV negative. One subject had both HBV and HCV infections. HBs Ag and anti-HCV were detected in 10 (2.1%) and 40 (8.27%) patients, respectively. The mean age of HCV-positive patients was 55.4 ± 16.4, while HCV-negative patients were an average of 51.6 ± 10.7 years old (P = 0.002). The incidence of HCV was higher in people from 40-59 years of age (P < 0.001). No patients had HBV, and incidence of HCV was 0.5% in the first year and 0.75 in the second year. No cases of HIV were identified.

CONCLUSIONS

The results show that the prevalence rates of HBV and HCV in hemodialysis patients were moderate to low in the Mazandaran province. Based upon the obtained levels of these viruses, these incidence rates are therefore reasonable.

Pretransplant Hepatitis B Viral Infection Increases Risk of Death After Kidney Transplantation: A Multicenter Cohort Study in Korea

Clinical outcomes in kidney transplant recipients (KTRs) with hepatitis B virus (HBV) have not been thoroughly evaluated. Here, we investigated recent posttransplant clinical outcomes of KTRs with HBV and compared them with KTRs with hepatitis C virus (HCV) and seronegative KTRs.Of 3855 KTRs from April 1999 to December 2011, we enrolled 3482 KTRs who had viral hepatitis serology data; the patients were followed up for 89.1 ± 54.1 months. The numbers of recipients with HBV and HCV were 160 (4.6%) and 55 (1.6%), respectively. We analyzed the clinical outcomes, including overall mortality and graft failure, among patients who had undergone kidney transplantation.Patients with HBV showed poorer survival (P = 0.019; adjusted hazard ratio [HR] = 2.370; 95% confidence interval [CI]: 1.155-4.865) than KTRs without HBV. However, the graft survival of patients with chronic hepatitis B did not differ from that of patients without HBV. Hepatic complications were the primary causes of mortality of KTRs with HBV. Mortality significantly correlated with a higher grade of inflammation (P = 0.002) and with the use of lamivudine or adefovir antiviral treatment (P = 0.016). HBV-positive KTRs treated with the new-generation antiviral agent entecavir showed improved patient survival compared with KTRs receiving lamivudine (log-rank P = 0.050). HCV did not affect patient survival; however, it increased the incidence of graft failure (P = 0.010; adjusted HR = 2.899; 95% CI: 1.289-6.519). KTRs with HCV had an increased incidence of acute rejection (log-rank P = 0.005, crude HR = 2.144; 95% CI: 1.341-3.426; P = 0.001).KTRs with chronic hepatitis B may exhibit poor survival due to post-transplantation hepatic complications. Pretransplant histological liver evaluations and adequate antiviral management with potent nucleoside/nucleotide analogues are needed to improve the survival of KTRs with chronic hepatitis B even when liver function is within the normal range.

[Management of hepatitis B virus and hepatitis C virus infection in chronic kidney failure]

Chronic infections by hepatitis B (HBV) and C virus (HCV) result in diagnosis and therapeutic issues in dialysis and kidney recipients patients. The exposure to nosocomial, including blood transfusion, risk explains the high prevalence of HBV and HCV infection in this setting. Chronic infection reduces the survival of both patients and allografts, including a specific risk of de novo glomerulonephritis. Cirrhosis was considered as a contra-indication to renal transplantation given the high risk of decompensation and death, questionning the indication of a combined liver and kidney transplantation. Thus, it is mandatory to screen HBV and HCV markers in all dialysis patients, whether or not they are candidates to transplantation. Liver biopsy allows evaluating the severity of the liver disease since the noninvasive markers of fibrosis appear to be less accurate in "renal" patients than in the general population and to better define antiviral therapeutic indications. HCV treatment was mainly based on pegylated interferon α (and low doses of ribavirin), which is contra-indicated in kidney recipients given the risk of graft rejection; HCV treatment is now based on the use of oral direct acting antivirals, which are very potent and well tolerated. HBV replication is now easily suppressed by second-generation nucleos(t)tidic analogues (entecavir and tenofovir), which will be indicated in all the dialysis patients with significant fibrosis (F2,3 or 4 according to the Metavir scoring system) and in any candidate to renal transplantation and to any HBsAg-positive kidney recipients. The best treatment remains preventive by anti-HBV vaccination for HBV and by the respect of universal hygiene rules for HCV.

Current Management of Chronic Hepatitis B and C in Chronic Kidney Disease

The landscape of therapeutic options for hepatitis B and C has changed drastically over the course of 2 decades. There are now novel, effective, well-tolerated, oral antiviral agents being used to successfully control chronic hepatitis B (HBV) infections and cure chronic hepatitis C (HCV) infections. However, patients with CKD were rarely included in the Phase II and III randomized trials for these medications. This paucity of data and the high prevalence of comorbidities associated with CKD pose distinct challenges to physicians treating chronic hepatitis B virus and hepatitis C virus infections in the setting of kidney insufficiency/failure. Thus, this review will attempt to summarize the current data regarding novel antiviral therapies for HBV and HCV in the CKD population.

Hepatitis B Virus Infection and the Kidney: Renal Abnormalities in HBV Patients, Antiviral Drugs Handling, and Specific Follow-Up

Chronic hepatitis B virus (CHB) infection is one of the most common causes of chronic liver disease, cirrhosis, and hepatocellular carcinoma (HCC) worldwide. Many patients with CHB have variable degrees of functional renal impairment, and approximately 2 to 15% of patients on hemodialysis have CHB. Several therapeutic regimens have been developed in the past years, among which oral nucleoside and nucleotide analogues have been demonstrated to be efficient and well tolerated. However, they all are excreted in the urine and may thus require dosage adjustment in patients with decreased renal function. Furthermore, a number of them may in addition be toxic to the kidneys, especially in those patients presenting with renal insufficiency.

Hemodialysis and hepatitis B vaccination: a challenge to physicians

Hepatitis B is responsible for the development of half of hepatocellular carcinoma cases and is a major cause of hepatic insufficiency. The vaccine against hepatitis B virus does not exhibit the same high efficacy in patients on hemodialysis as it does in immunocompetent individuals. The medical literature recommends vaccination with four doses (40 mg each) of the hepatitis B virus vaccine before beginning hemodialysis; however, approximately one-third of hemodialysis patients do not respond to this vaccination schedule. A new serologic test should be performed each year for individuals who respond adequately, whereas a booster dose should be offered to those with antibody titers below 10 mIU/mL. In this study, we followed 83 hemodialysis patients and collected quantitative serologic measurements every 2 months over a 1-year period. We made the measurements 1 month after the vaccination period. We found that 41% of the patients had antibody titers below 10 mIU/mL (nonresponders), 21.7% had antibody titers between 10 mIU/mL and 100 mIU/mL (poor responders), and 37.3% had antibody titers higher than 100 mIU/mL (good responders). Patients with diabetes and/or hypertension exhibited worse response to vaccination. All subjects displayed decreasing antibody titers during the observation period. The group of poorly responsive patients had antibody titers below 10 mIU/mL at the 6-month follow-up period.

Vaccination issues in patients with chronic kidney disease

Infections are an important cause of morbidity and mortality among patients at all stages of chronic kidney disease. Prevention through vaccination remains the best strategy to minimize the adverse consequences associated with these infectious diseases in this, and all, populations. Unfortunately, patients with chronic kidney disease demonstrate inadequacies of specific immune-cell function that are required for generating a protective vaccine response. Nevertheless, early vaccination of this high-risk population has demonstrated good clinical outcomes during progression to late-stage disease. We review the available evidence linking immune impairment in adult patients with late-stage chronic kidney disease to diminished vaccine responses. We highlight the importance of early vaccination in disease with high risk for development of CKD and novel vaccine approaches in development that may help to address improvement in protective boosting of immunity during late-stage disease.

Review article: nucleos(t)ide analogues in patients with chronic hepatitis B virus infection and chronic kidney disease

BACKGROUND

The treatment of chronic hepatitis B (CHB) in patients with chronic kidney disease (CKD) is based on nucleoside (lamivudine, telbivudine, entecavir) or nucleotide (adefovir, tenofovir) analogues (NAs), but it may be complex and the information is scarce. Entecavir and tenofovir represent the currently recommended first-line NAs for NA-naive CHB patients, while tenofovir is the NA of choice for CHB patients with resistance to nucleosides.

AIM

To review the efficacy and safety of NAs in adult CHB patients with CKD and to provide reasonable recommendations for their optimal management.

METHODS

Literature search in PubMed/Medline and manual search of relevant articles, reviews and book chapters.

RESULTS

NAs are cleared by kidneys and their dosage should be adjusted in patients with creatinine clearance <50 mL/min. There are concerns about nephrotoxic potential of the nucleotides, particularly adefovir, while improvements of creatinine clearance have been reported under telbivudine. Most existing data in CHB patients with CKD are for lamivudine and, less frequently, for other NAs, mostly entecavir. Besides CHB, NA should be used in case of immunosuppressive therapy in any HBsAg-positive patient with CKD including renal transplant (RT) recipients and in anti-HBs-positive recipients of kidney grafts from HBsAg-positive donors.

CONCLUSIONS

Chronic hepatitis B patients with chronic kidney disease receiving nucleoside analogues should be followed carefully for treatment efficacy and renal safety. Despite the absence of strong data, entecavir and telbivudine seem to be the preferred options for nucleoside analogue-naive CHB patients with chronic kidney disease, depending on viraemia and severity of renal dysfunction. More studies are certainly needed in this setting.

Naturally occurring polymerase and surface gene variants of hepatitis B virus in Turkish hemodialysis patients with chronic hepatitis B

The aim of this study was to assess the frequencies and patterns of naturally occurring genotypic resistance to nucleos(t)ide analogues (NUCs) and typical hepatitis B surface antigen (HBsAg) amino acid substitutions in naive hemodialysis (HD) patients with chronic hepatitis B. In order to achieve this, the genotypic resistance to NUCs and HBsAg amino acid substitutions were classified into primary/compensatory resistance mutation and antiviral drug-associated potential vaccine-escape mutation (ADAPVEM)/typical HBsAg amino acid substitution, respectively. Direct sequencing of polymerase (pol) gene of hepatitis B virus (HBV) was performed on DNA samples obtained from 248 HBsAg-positive Turkish patients. Overall, 38% (n = 94) of HBsAg-positive HD patients had detectable HBV DNA in their serum. Naturally occurring primary and compensatory resistance mutations to NUCs were detected in 30% (n = 28) and 52% (n = 49) of HD patients, respectively. However, 6 types of ADAPVEMs and 48 types of typical HBsAg amino acid substitutions were found in 10.6% (n = 10) and 46% (n = 43) of the HD patients, respectively. Our study suggests that every HD patient diagnosed with chronic hepatitis B, who is a potential candidate for NUCs treatment, should also be monitored for the baseline pol gene sequence changes before the initial treatment, for a more effective management of future treatment options. Further, a relatively higher frequency of ADAPVEMs variants needs to be addressed as a public health problem.

Outcomes and risk factors for hepatitis B virus (HBV) reactivation after kidney transplantation in occult HBV carriers

PURPOSE

The purpose of this study was to explore the outcomes and risk factors for hepatitis B virus (HBV) reactivation after kidney transplantation in occult HBV carriers, who are hepatitis B surface antigen (HBsAg) seronegative and hepatitis B core antibody (HBcAb) seropositive before kidney transplantation.

METHODS

We retrospectively analyzed 322 occult HBV carriers who received kidney transplantation in our hospital from January 1998 to June 2008. HBsAg and HBV DNA were routinely checked for diagnosis of HBV reactivation.

RESULTS

Our results showed that 15 cases (4.7%) of occult HBV carriers had HBV reactivation after kidney transplantation. Kaplan-Meier analysis showed that 1-, 3-, 5-, and 10-year patient survival was 86.7%, 79.4%, 72.2%, and 65.0%, respectively, in the HBV reactivation group, and was 96.1%, 93.8%, 91.5%, and 84.5%, respectively, in the non-HBV reactivation group (log-rank 4.12, P = 0.042). Graft survival showed no difference between these 2 groups (P > 0.05). The incidences of impairment of liver function, liver function failure, hepatocellular carcinoma, and acute rejection were significantly higher in the HBV reactivation group compared with the non-HBV reactivation group (P < 0.05). Logistic multivariate analysis showed that older age (>60 years) and using anti-T-cell antibodies were independent risk factors for HBV reactivation after kidney transplantation, while being hepatitis B surface antibody (HBsAb) seropositive and using lamivudine prophylaxis could protect occult HBV carriers from HBV reactivation after kidney transplantation (P < 0.05).

CONCLUSION

In conclusion, our data showed that HBV reactivation may diminish the patient survival but not graft survival. Older age and anti-T-cell antibodies may increase the risk of HBV reactivation, whereas lamivudine prophylaxis may prevent HBV reactivation after kidney transplantation.

Occult hepatitis B virus infection in hemodialysis patients in Recife, State of Pernambuco, Brazil

INTRODUCTION: Persistence of the hepatitis B virus (HBV) genome in individuals negative for the HBV surface antigen (HBsAg) reflects occult infection. The aim of this study was to identify occult HBV infection among hemodialysis patients at 5 clinics in Recife, State of Pernambuco, Brazil, between August 2006 and August 2007. METHODS: Serum samples underwent enzyme-linked immunosorbent assay to investigate total antibodies against HBcAg (anti-HBc), HBsAg, and antibodies against HBsAg (anti-HBs). Samples that were HBsAg-negative were tested for total anti-HBc, and those that were positive for total anti-HBc were tested for anti-HBs. HBV DNA was investigated with an in-house PCR technique to identify samples positive for total anti-HBc. Subsequently, the samples positive for HBV DNA were sequenced to identify the genotype and mutations. RESULTS: The study population (n = 752) had a mean age of 50 15.1 years and included both sexes. All samples analyzed were negative for HBsAg. The seroprevalence of total anti-HBc was 26.7% (201/752), while that of anti-HBs was 67.2% (135/201). Total anti-HBc alone was detected in 5.7% of the patients. Occult infection was found in 1.5%, comprising genotypes A (33.3%, 1/3) and D (66.7%, 2/3). No mutations were found. CONCLUSIONS: The study detected occult hepatitis B virus infection in hemodialysis patients. Molecular studies on HBV are of fundamental importance because they identify patients that had been considered virus-negative but who, in reality, host the virus and have the ability to transmit it to other patients and staff.

Positive hepatitis B surface antigen tests due to recent vaccination: a persistent problem

BACKGROUND

Hepatitis B virus (HBV) is a common cause of viral hepatitis with significant health complications including cirrhosis and hepatocellular carcinoma. Assays for hepatitis B surface antigen (HBsAg) are the most frequently used tests to detect HBV infection. Vaccination for HBV can produce transiently detectable levels of HBsAg in patients. However, the time course and duration of this effect is unclear. The objective of this retrospective study was to clarify the frequency and duration of transient HBsAg positivity following vaccination against HBV.

METHODS

The electronic medical record at an academic tertiary care medical center was searched to identify all orders for HBsAg within a 17 month time period. Detailed chart review was performed to identify all patients who were administered HBV vaccine within 180 days prior to HBsAg testing and also to ascertain likely cause of weakly positive (grayzone) results.

RESULTS

During the 17 month study period, 11,719 HBsAg tests were ordered on 9,930 patients. There were 34 tests performed on 34 patients who received HBV vaccine 14 days or less prior to HBsAg testing. Of these 34 patients, 11 had grayzone results for HBsAg that could be attributed to recent vaccination. Ten of the 11 patients were renal dialysis patients who were receiving HBsAg testing as part of routine and ongoing monitoring. Beyond 14 days, there were no reactive or grayzone HBsAg tests that could be attributed to recent HBV vaccination. HBsAg results reached a peak COI two to three days following vaccination before decaying. Further analysis of all the grayzone results within the 17 month study period (43 results out of 11,719 tests) revealed that only 4 of 43 were the result of true HBV infection as verified by confirmatory testing.

CONCLUSIONS

Our study confirms that transient HBsAg positivity can occur in patients following HBV vaccination. The results suggest this positivity is unlikely to persist beyond 14 days post-vaccination. Our study also demonstrates that weakly positive HBsAg results often do not reflect actual HBV infection, underscoring the importance of confirmatory testing. This study also emphasizes that vaccination-induced HBsAg positives occur most commonly in hemodialysis patients.

Improving hepatitis B vaccine efficacy in end-stage renal diseases patients and role of adjuvants

Hepatitis B virus (HBV) infection is a serious global health problem.The prevalence of viral hepatitis is higher in dialysis patients than in the general population because of the opportunity for exposure during the dialysis procedure. Immunization is the most effective way to prevent transmission of hepatitis B virus (HBV) and hence the development of acute or chronic hepatitis B. It is well established that patients with end-stage renal disease including dialysis-dependent patients, have an impaired immune response to hepatitis B vaccine. End stage renal diseases (ESRD) patients have lower seroconversion rates compared with the subjects with intact renal function. Moreover, even after the completion of vaccination schedule anti-hepatitis B (anti-HBs) titers of responder dialysis, patients are low and decline logarithmically with time. The impaired efficacy of HBV vaccine in patients with ESRD has been attributed to numerous factors such as immune compromise because of uremia and some other factors. One approach to improve the immunogenicity of existing HBV vaccines is adjuvantation, and it's very important to find more effective adjutants for improving HBV vaccine efficacy. In this paper we have a brief review on recently known new ways for improving HBV vaccine efficacy.

Molecular mechanisms underlying occult hepatitis B virus infection

Chronic hepatitis B virus (HBV) infection is a complex clinical entity frequently associated with cirrhosis and hepatocellular carcinoma (HCC). The persistence of HBV genomes in the absence of detectable surface antigenemia is termed occult HBV infection. Mutations in the surface gene rendering HBsAg undetectable by commercial assays and inhibition of HBV by suppression of viral replication and viral proteins represent two fundamentally different mechanisms that lead to occult HBV infections. The molecular mechanisms underlying occult HBV infections, including recently identified mechanisms associated with the suppression of HBV replication and inhibition of HBV proteins, are reviewed in detail. The availability of highly sensitive molecular methods has led to increased detection of occult HBV infections in various clinical settings. The clinical relevance of occult HBV infection and the utility of appropriate diagnostic methods to detect occult HBV infection are discussed. The need for specific guidelines on the diagnosis and management of occult HBV infection is being increasingly recognized; the aspects of mechanistic studies that warrant further investigation are discussed in the final section.

Molecular mechanisms underlying occult hepatitis B virus infection

Chronic hepatitis B virus (HBV) infection is a complex clinical entity frequently associated with cirrhosis and hepatocellular carcinoma (HCC). The persistence of HBV genomes in the absence of detectable surface antigenemia is termed occult HBV infection. Mutations in the surface gene rendering HBsAg undetectable by commercial assays and inhibition of HBV by suppression of viral replication and viral proteins represent two fundamentally different mechanisms that lead to occult HBV infections. The molecular mechanisms underlying occult HBV infections, including recently identified mechanisms associated with the suppression of HBV replication and inhibition of HBV proteins, are reviewed in detail. The availability of highly sensitive molecular methods has led to increased detection of occult HBV infections in various clinical settings. The clinical relevance of occult HBV infection and the utility of appropriate diagnostic methods to detect occult HBV infection are discussed. The need for specific guidelines on the diagnosis and management of occult HBV infection is being increasingly recognized; the aspects of mechanistic studies that warrant further investigation are discussed in the final section.

Viral hepatitis in solid organ transplantation other than liver

Transplantation is the best treatment for end-stage organ failure. Hepatitis virus infections, mainly hepatitis B virus (HBV) and hepatitis C virus (HCV) infections still constitute a major problem because they are common in allograft recipients and are a significant cause of morbidity and mortality after transplantation. Recently, hepatitis E virus infection has been added as an emergent cause of chronic hepatitis in organ transplantation. The prevalence of HBV and HCV infections has markedly decreased in patients who are candidates for transplantation since the introduction of screening, hygiene and prevention measures, including systematic screening of blood and organ donations, use of erythropoietin, compliance with universal hygiene rules, segregation of HBV-infected patients from non-infected patients and systematic vaccination against HBV. A liver biopsy is preferable to non-invasive biochemical and/or morphological tests of fibrosis to evaluate liver fibrosis before and even after transplantation. Treatment with entecavir or tenofovir is indicated in HBV-infected dialyzed patients who have moderate or severe disease (≥A2 or F2 on the Metavir scale) in preparation for renal transplantation. Due to the risks of severe reactivation, fibrosing cholestatic hepatitis or histological deterioration after transplantation, systematic use of nucleoside or nucleotide analogues shortly before or at the time of transplantation is recommended (tenofovir or entecavir are preferable to lamivudine) in all patients, whatever the baseline histological evaluation. In HCV-infected dialyzed patients who are not candidates for renal transplantation, the indication for antiviral therapy is limited to significant fibrosis (fibrosis ≥2 on the Metavir scale). Treatment must be proposed to all candidates for renal transplantation, whatever their baseline histopathology, and interferon-α should be used as monotherapy. After transplantation, interferon-α is contraindicated but may be used in patients for whom the benefits of antiviral treatment clearly outweigh the risks, especially that of allograft rejection. All cirrhotic patients, notably after solid organ transplantation, should be screened for hepatocellular carcinoma. Sustained suppression of necro-inflammation may result in regression of cirrhosis, which in turn may lead to decreased disease-related morbidity and improved survival. Finally, due to the high mortality after renal transplantation, active (namely without sustained viral suppression) cirrhosis should be considered a contraindication to kidney transplantation, but an indication to combined liver-kidney transplantation; on the contrary, inactive (namely with sustained viral suppression) compensated cirrhosis may permit renal transplantation alone. Organ transplantations other than kidney (cardiac or pulmonary transplantations) involve the same diagnosis and therapeutic issues.

Chronic viral hepatitis in kidney transplantation

Chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection in potential kidney transplant candidates-once considered absolute contraindications to kidney transplantation-no longer creates overt barriers to transplantation. Advances in the medical management of HBV and HCV infection have created opportunities for a substantial number of patients to be effectively treated with antiviral therapy before transplantation. For HBV infection, a number of new drugs enable clearance of the virus with minimal adverse effects and drug resistance. Pretransplantation antiviral therapy is advisable for patients with HCV infection, but adverse effects are common and viral eradication remains challenging. Regardless of viral clearance, pretransplant patients without bridging fibrosis (as confirmed by liver biopsy) or clinical stigmata of cirrhosis should be considered for kidney transplantation as survival is superior when compared to treatment with dialysis, and progression of liver disease is unlikely. For patients with advanced liver disease, simultaneous liver-kidney transplantation is an important consideration. These treatment advances further increase the burden of organ donor shortage; however, organs from deceased donors with chronic HBV or HCV infection could be efficiently allocated to certain individuals with a viral infection of the same type to increase the pool of available transplant organs.

Review article: Hepatitis B and dialysis

The incidence of hepatitis B virus (HBV) infection in dialysis populations has declined over recent decades, largely because of improvements in infection control and widespread implementation of HBV vaccination. Regardless, outbreaks of infection continue to occur in dialysis units, and prevalence rates remain unacceptably high. For a variety of reasons, dialysis patients are at increased risk of acquiring HBV. They also demonstrate different disease manifestations compared with healthy individuals and are more likely to progress to chronic carriage. This paper will review the epidemiology, modes of transmission and diagnosis of HBV in this population. Prevention and treatment will be discussed, with a specific focus on strategies to improve vaccination response, new therapeutic options and selection of patients for therapy.

Chronic viral hepatitis and chronic kidney disease

Chronic kidney disease (CKD) has become a major public health problem worldwide over the past few decades because of the increasing prevalence of hypertension, diabetes mellitus, and elderly individuals in most countries. Chronic viral hepatitis (due to hepatitis B virus (HBV) and hepatitis C virus (HCV)) also poses significant morbidity and mortality globally. Both these viruses can cause CKD and these infections can occur as a consequence of CKD management. CKD patients acquiring HBV or HCV infection have higher morbidity and mortality rates, and the management of these infections among CKD patients with antiviral agents is associated with high rates of adverse effects. The optimal management of CKD associated with HBV and HCV is not well defined because of insufficient data from clinical trials. This review discusses the pathogenesis, clinical characteristics and management issues related to chronic viral hepatitis and CKD.

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.

Comparing Survival between Peritoneal Dialysis and Hemodialysis Treatment in Esrd Patients with Chronic Hepatitis C Infection

Objective

End-stage renal disease (ESRD) patients with hepatitis C virus (HCV) infection are associated with an increasing mortality risk on hemodialysis (HD) and peritoneal dialysis (PD). The aim of this study was to compare patient survival between HCV-positive patients undergoing PD versus HD.

Methods

We reviewed 78 PD and 78 HD patients with chronic hepatitis C infection in China Medical University Hospital from 1996 to 2006. The HD patients were selected using the propensity score matching method. Kaplan–Meier analysis with log-rank test was used to compare patient survival between patients treated with PD and those treated with HD. Possible prognostic factors were analyzed using multivariate Cox proportional hazard regression with adjustments for age, sex, and propensity score.

Results

Mortality rate was 50% (39/78) for PD and 41% (32/78) for HD (chi-square test p = 0.26). Diabetes, hypertension, and cardiovascular disease were present in 43.6%, 25.6%, and 14.1% of patients, respectively. Kaplan–Meier estimate and univariate Cox regression with adjustments for age and propensity score showed that HCV patients treated with PD had a similar survival to those treated with HD ( p = 0.381 and p = 0.363). In forward stepwise Cox regression, positivity for hepatitis B virus surface antigen ( p < 0.001), diabetes ( p = 0.009), and serum albumin ( p = 0.032) were independently associated with higher mortality.

Conclusion

Patient survival is not different between ESRD patients with chronic hepatitis C treated with PD and those treated with HD. In ESRD patients positive for HCV, being positive for hepatitis B virus is an important prognostic factor.

Hepatitis B and C in dialysis units in Kosova

Background

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are important causes of morbidity and mortality of hemodialysis (HD) patients. This study aimed to investigate the epidemiological and clinical features of HCV and HBV infections in six different HD units in Kosova.

Five hundred and eighty-three end-stage kidney disease (ESKD) patients on maintenance HD from six HD centers in Kosova (358 female, 225 male, mean age 54,8 years (16–66) were included in this study. Data from databank of the National Blood Bank in Prishtina, as well as the data from the databank of the Transfusion Centers in Regional hospitals in Prizren, Peja, Gjilan, Mitrovica and Gjakova were taken in this study. Clinical data such as age, sex, HBsAg and anti-HCV antibody and primary causes of ESKD were examined.

Serological markers for HBV and HCV were determined with immunoenzymatic assay (ELISA).

Results

The T-test and x² test were used to analyze the significance of the results. Among our HD patients HBsAg and anti-HCV antibody prevalence rate was 12%, respectively 43%. Chronic nephritis was a more frequent cause of ESKD among our HD patients. With unknown etiology were 23, 5% from them.

Conclusion

HBV and HCV prevalence in our HD patients is still high. These data emphasize the need for stricter adherence to infection control, barrier precaution and preventive behaviors with all patients.