Hepatitis C virus infections in dialysis centers in The Netherlands: a national survey by serological and molecular methods

Hepatitis C virus (HCV) infection among patients with sickle cell disease at the Korle-Bu teaching hospital

Background

Hepatitis C virus (HCV) infection is a blood borne infection that remains potentially transmissible through blood transfusions. Sickle cell disease (SCD) is a common inheritable haemoglobinopathy in Ghana that requires multiple blood transfusions as part of its management. The SCD patient is therefore at a high risk of HCV infection; however, data on the occurrence of HCV in SCD patients has not been documented in Ghana. This study sought to determine the prevalence and genotypes of HCV infection in SCD patients.

Materials and methods

This was a cross-sectional study which enrolled 141 sickle-cell disease patients from the Ghana Institute for Clinical Genetics, Korle-Bu Teaching Hospital (KBTH). Patient information was obtained through a structured questionnaire. Aliquots of the plasma obtained was used for both serology with Advanced Quality Rapid Anti-HCV Test Strip and molecular testing by RT-PCR with primers targeting the HCV core gene. The amplified DNA were purified and subjected to phylogenetic analysis to characterize HCV genotypes.

Results

Twelve (9%) out of the 141 patients were sero-positive for HCV total antibodies. HCV RNA was amplified from 8 (6%) out of the total number of patients’ samples. One of the 12 sero-positives was HCV RNA positive. Five (63%) out of the 8 HCV RNA positive samples were successfully sequenced. The phylogenetic tree constructed with the study and GenBank reference sequences, clustered all five study sequences into HCV genotype 1.

Conclusion

The HCV seroprevalence of 9% among sickle cell disease patients is higher than reported for the general Ghanaian population which is 3%. Genotype 1 is the common HCV genotype infecting SCD patients. Sickle cell disease is likely to be a high-risk group for HCV inapparent infections in Ghana as seroprevalence does not correlate with viremia. However, even with higher seroprevalence, the group must be given priority in resource allocation for preventive, diagnostic and therapeutic strategies.

Prevalence, risk factors and impact of occult HCV infection on liver morbidity among haemodialysis patients: hospital-based cross-sectional study

OBJECTIVES

Haemodialysis (HD) patients are at risk for blood-borne infections as occult HCV infection, which justifies comprehensive studies. We aimed to determine the prevalence and risk factors of occult HCV infection (OCI) among HD patients.

MATERIAL AND METHODS

One hundred eligible HD patients, with no evidence of overt HCV or HBV and HBV vaccinated were recruited, and tested for HCV, HBV markers and HCV RNA. Two HCV-positive patients were excluded and peripheral mononuclear cells of 98 patients were verified for viraemia.

RESULTS

OCI was detected in eight (8.16%); with a median viral load of 7010copies/ml. Their mean age was 30.63 (±18.87 years) compared to others (41.73 ± 15.93) (p = .069). History of surgery, dental procedure, and blood transfusion was comparably high in both groups (p > .05). All OCI patients underwent dialysis twice weekly compared to 48.9% of non-OCI patients (p = .006). OCI patients had a significantly higher mean duration of dialysis (12.63 ± 6.74 years), and a significantly higher frequency (50%) of HCV Ab compared to 6.48 ± 4.76, and 10%, respectively, in non-OCI patients. None of OCI patients was reactive to HBcAb compared to 34 (37.8%) patients without (p = .048). Evidence of liver morbidity was detected in 5 (62.5%) OCI patients compared to 43 (47.7%) of non-OCI patients (p > .05).

CONCLUSION

Among our HD patients, OCI is considered a comorbid finding associated with mild liver morbidity that warrants strict infection control and periodic testing for blood borne infections.

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

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

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

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

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

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

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

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

Occult Hepatitis C Infection Among Hemodialysis Patients: A Prevalence Study

INTRODUCTION AND AIM

Occult hepatitis C infection (OHCI) is the presence of HCV-RNA in the liver or peripheral blood mononuclear cells (PBMC) accompanying with negative serologic results. The aim of this study was to evaluate the prevalence of OHCI among Iranian chronic hemodialysis (HD) patients.

MATERIAL AND METHODS

In this cross sectional study 200 chronic HD patients with negative HCV antibody enrolled the study. Blood sample of patients were obtained, followed by Polymerase Chain reaction (PCR) testing for detection of HCV RNA. Patients with positive serum HCV RNA were considered as manifest hepatitis C infection (MHCI). However, patients with negative serum HCV RNA underwent further tests on PBMCs for detection of OHCI.

RESULTS

Serum HCV RNA was positive in 2 (1%) patients whom considered as MHCI, and 6 (3.03%) patients had positive PBMC HCV RNA.

CONCLUSION

In conclusion, chronic HD patients have been considered as a high risk group for hepatitis C infection. The results of this study suggest that these patients are also at risk for OHCI. Furthermore, evaluating PBMCs to detect HCV RNA would be a sensitive diagnostic method to find OHCI patients.

Role of Direct Antiviral Agents in Treatment of Chronic Hepatitis C Infection in Renal Transplant Recipients

BACKGROUND

Since the introduction of direct antiviral agents (DAAs), morbidity of HCV has considerably decreased but still no guidelines have been formulated in renal transplant recipients (RTRs). We studied efficacy and tolerability of direct antiviral agents in RTRs.

METHODS

This prospective observational study was conducted at Army Hospital Research & Referral, Delhi, from June 2016 to May 2017. Forty-five HCV infected RTRs with stable graft function were included.

RESULTS

Median time between renal transplantation and the start of anti-HCV therapy was 36 months (1-120 months). The majority (66.7%) were infected with genotype 3. Baseline median HCV RNA level was 542648 IU/ml (1189-55028534 IU/ml). Sofosbuvir-Ribavirin combination (24 weeks) was given to 30 patients including 3 cirrhotics, Ledipasvir-Sofosbuvir combination to 8 patients, and Daclatasvir-Sofosbuvir combination to 7 patients, including 2 cirrhotics. Rapid virological response was observed in 29 patients treated with Sofosbuvir/Ribavirin, all 8 patients on Sofosbuvir/Ledipasvir, and all 7 patients on Sofosbuvir/Daclatasvir. End treatment response and sustained virological response (12 weeks) were achieved in all patients irrespective of genotype or treatment regimen. Decrease in mean HCV RNA level and transaminase level was statistically significant (p < 0.01). Ribavirin was significantly associated with anaemia (p = 0.032).

CONCLUSIONS

DAA regimens are well tolerated and highly efficacious. Response to DAA is good irrespective of genotype, drug combination, initial HCV RNA level, age or sex of patient, or graft age. However, Sofosbuvir/Ledipasvir and Sofosbuvir/Daclatasvir combination is preferable.

Hepatitis C viral load, genotype, and increased risk of developing end-stage renal disease: REVEAL-HCV study

The association between hepatitis C virus (HCV) infection and end-stage renal disease (ESRD) remains controversial without considering the role of HCV viral load and genotype. This study aimed to determine whether HCV RNA level and genotype affect the risk of developing ESRD. Between 1991 and 1992, 19,984 participants aged 30-65 years were enrolled in a community-based prospective cohort study in Taiwan. Chronic HCV infection was defined by detectable HCV viral load. ESRD was determined as the need for chronic dialysis or renal transplantation. Conventional Cox proportional hazard and competing risk models were used to determine the hazard ratio (HR) for ESRD. After a median follow-up of 16.8 years, 204 cases were detected during 319,474 person-years. The incidence rates of ESRD for nonchronically HCV-infected and chronically HCV-infected patients were 60.2 and 194.3 per 100,000 person-years, respectively. The multivariable HR was 2.33 (95% confidence interval [CI] 1.40-3.89) when comparing patients with and without chronic HCV infection. Patients with low and high HCV RNA levels were at higher risk of ESRD than those who were nonchronically HCV-infected (HR, 2.11, 95% CI 1.16-3.86, and HR, 3.06, 95% CI 1.23-7.58; P_trend < 0.001). This association remained robust after taking pre-ESRD death as a competing event for ESRD. Patients with HCV genotype 1 tended to have a higher risk of developing ESRD (HR, 3.60 95% CI 1.83-7.07) compared with nonchronically HCV-infected subjects.

CONCLUSIONS

This study reveals that chronic HCV infection is associated with an increased risk of developing ESRD and suggests that elevated serum levels of HCV RNA (>167,000 IU/mL) and HCV genotype 1 are strong predictors of ESRD, indicating clinical implications for the management of chronic HCV. (Hepatology 2017;66:784-793).

Diagnostic Dilemmas in Hepatitis C Virus Infection for Hemodialysis Patients

BACKGROUND

Hepatitis C virus (HCV) is a leading cause of chronic hepatitis in dialysis patients. The diagnosis of HCV infection in these patients is predominantly based on laboratory tests because of the specificity of the clinical course of the disease.

AIM

The present prospective study aimed at determining very accurately the prevalence rate of HCV infection in patients on dialysis by simultaneously testing them for anti-HCV and for HCV RNA levels.

MATERIALS AND METHODS

For the present cross-sectional longitudinal study we recruited and followed up 93 patients from St George University Hospital Hemodialysis Unit between July 2013 and December 2014. All patients were tested for anti-HCV and HCV RNA. The anti-HCV negative patients were tested for anti-HCV and HCV RNA at least twice at intervals of 6 months or more (up to 12 months). Anti-HCV antibodies were identified using a third generation ELISA assay. Commercial kits for real-time polymerase chain reaction (RT-PCR) were used to detect HCV RNA in the plasma and mononuclear cells. Aminotransferase and gammaglutamyl transpeptidase levels were studied to find if liver inflammation was present.

RESULTS

The total seroprevalence in 68 patients was 20.6% (14). Of these, 10 patients were viremic (HCV RNA+/anti-HCV+), and 4 patients (5.9%) had discordant results (anti-HCV+/HCV RNA-). Acute hepatitis was detected in one patient. Duration of dialysis in HCV viremic patients was longer than that in aviremic patients (p=0.005).

CONCLUSIONS

The present study suggests that HCV infection in dialysis patients can be diagnosed more accurately if these patients are tested using two diagnostic methods - a serological test and a biomolecular assay. Further studies with larger sample size may prove the feasibility of such approach for all dialysis patients in this country.

HCV Seroconversion in two Egyptian Hemodialysis Units: Role of Detection Method and Patients Isolation

Background: Hepatitis C virus (HCV) infection is a significant cause of morbidity and mortality in end stage renal disease (ESRD) patients on hemodialysis (HD).  Routine HCV viremia screening is recommended in those patients but it is not applied.Aim: To evaluate the seroconversion rate in HD patients based on viremia detection compared to antibody (Ab), and to assess the role of isolation on the rate of seroconversion in those patients.Materials and Methods: One hundred ESRD patients from two HD units using same infection control criteria were enrolled in the study; only one unit was applying isolation for HCV patients. Patients were followed up for 12 month; HCV positivity was tested at the begining of the study and after 12 month of HD. HCV Ab and viremia were detected by third generation ELISA and PCR respectively.Results: The seroconversion rate was 0% based on HCV Ab detection by ELISA, compared with the 16 % seroconversion rate based on viremia detection by PCR. Notably, viremia seroconversion was seen only in the HD unit lacking the isolation system.Conclusion: HCV screening in HD units should be based on viremia detection; isolation in HD units prevents HCV spreading.

Seronegative hepatitis C virus infection

Hepatitis C virus (HCV) is a major cause of liver disease worldwide. The routine diagnostics identifying HCV infection include testing for specific anti-HCV antibodies by enzyme-linked immnunosorbent assay and viral genetic material in serum or plasma. However, a small proportion of patients persistently infected with HCV, in whom anti-HCV are undetectable, constitute a serious diagnostic and possibly epidemiologic problem, as they could facilitate pathogen spread in the population. This type of infection is termed seronegative or serosilent. Seronegative HCV infection is currently of great interest to both scientists and physicians. The review presents epidemiological data concerning the prevalence of seronegative HCV infection in HIV/HCV co-infected individuals, hemodialysis patients, and blood and organ donors. The possible mechanisms behind this atypical course of infection are discussed. Furthermore, the differences between seronegative and occult infections and prolonged seroconversion are explained.

Hepatitis C infection and chronic renal diseases

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

Incidence of CMV-HCV coinfection in renal transplant recipient

The authors report a case of a 47-year-old cytomegalovirus (CMV) immunoglobulin G (IgG) seropositive male patient with end stage renal disease who received a live renal transplant from a CMV IgG seropositive donor. Six months post-transplantation, the patient presented with reduced renal allograft function associated with fever, severe breathlessness, new onset jaundice and pancytopenia. His CMV DNA PCR came positive. Hepatitis C virus (HCV) RNA PCR also came positive (genotype I) though anti-HCV test performed before and after transplantation was negative. The patient was treated with oral valganciclovir and showed improvement of his clinical condition and was subsequently discharged under supervised therapy. However, the patient could not be treated for HCV because of risk of renal allograft rejection. The authors suggest oral valganciclovir for management of CMV infection and proper detection and eradication of HCV before renal transplantation to avoid future complications and prolongation of allograft survival.

Management of hepatitis C in patients with chronic kidney disease

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

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

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

Improved detection of hepatitis C virus infection by transcription-mediated amplification technology in dialysis population

BACKGROUND

Hepatitis C virus (HCV) infection remains common among patients undergoing maintenance dialysis and plays an adverse effect on survival in this population. Accurate detection of HCV viremia (HCV RNA) in dialysis patients requires a sensitive and specific diagnostic test.

METHODS

The Versant HCV RNA Qualitative Assay, based on transcription-mediated amplification (TMA) technique, was prospectively evaluated in 112 dialysis patients. Performance characteristics of the Versant HCV TMA Assay were evaluated in comparison to the Amplicor((R)) 2.0 HCV test based on polymerase chain reaction (PCR) technique. In addition, anti-HCV serologic tests including third-generation enzyme immunoassay and Recombinant Immunoblot Assay were performed.

RESULTS

Of the 112 specimens tested, 29 were reactive by Versant HCV TMA Assay, yielding an overall prevalence of HCV viremia of 25.9%. The concordance between TMA and PCR techniques was excellent [91% (101/112)]. Eleven specimens (10%) were invalid or equivocal by PCR due to interference phenomena; all 11 specimens had valid TMA results (2 patients being TMA reactive and 9 nonreactive). Four specimens [3.6% (4/112)] that tested PCR-negative and HCV TMA nonreactive were anti-HCV seropositive, consistent with resolved HCV infection. In the group of seronegative samples, one was reactive by TMA Assay [1.25% (1/80)].

CONCLUSIONS

The HCV TMA technology seems a highly sensitive tool for detecting HCV RNA in the dialysis population, with no evidence of specimen interference. One EIA-negative but HCV-RNA-positive patient by Versant HCV TMA Assay was identified. Prospective clinical trials are under way to assess the clinical impact related to the use of HCV TMA technology in dialysis population.

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.

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.

Hepatitis C virus and kidney disease

Hepatitis C virus (HCV) infection remains frequent in patients on renal replacement therapy and has an adverse impact on survival in infected patients on chronic hemodialysis as well as renal transplant (RT) recipients. Nosocomial spread of HCV within dialysis units continues to occur. HCV is also implicated in the pathogenesis of renal dysfunction often mediated by cryoglobulins leading to chronic kidney disease as well as impairing renal allograft function. The role of antiviral therapy for hepatitis C in patients with renal failure remains unclear. Monotherapy with conventional interferon (IFN) for chronic hepatitis C is probably more effective in dialysis than in non-uraemic patients but tolerance is lower. Limited data only are available about monotherapy with pegylated interferon and combination therapy (pegylated IFN plus ribavirin) for chronic HCV in the dialysis population. Clinical experience with antiviral therapy for acute HCV in dialysis population is encouraging. Interferon remains contraindicated post-RT because of concerns about precipitating graft dysfunction. Sustained viral responses obtained by antiviral therapy in renal transplant candidates are durable after renal transplantation and may reduce HCV-related complications after RT (post-transplant diabetes mellitus, HCV-related glomerulonephritis, and chronic allograft nephropathy).

Kinetics of hepatitis C viral RNA and HCV-antigen during dialysis sessions: evidence for differential viral load reduction on dialysis

Hepatitis C infection is a common problem in dialysis units. The prevalence ranges from 3% to more than 50%. Several reports have described a variable reduction of HCV-RNA during hemodialysis treatment sessions. But so far nothing is known about the HCV antigenemia or the kinetics of the reduction of HCV-RNA and HCV antigenemia during these sessions. HCV-RNA was monitored using the VERSANT HCV bDNA assay 3.0 (Bayer Healthcare Diagnostics, Leverkusen, Germany) or the HCV-Monitor TaqMan (Roche Diagnostics). HCV antigenemia was tested by using Ortho-trac-C assay (Ortho Clinical Diagnostics, Neckargemünd, Germany). Kinetics of HCV-RNA were available in 15 dialysis sessions measured by bDNA assay and in 5 dialysis sessions measured by rt-PCR. Quantitative HCV-antigenemia was available in fourteen dialysis sessions. Not only HCV-RNA but as expected also the HCV-antigenemia fell during the dialysis session. However, while the average reduction of HCV-antigen appears steady and linear, the level of HCV-RNA seems to be stable during the first 3 hr of dialysis, and decreases rapidly during the last 2 hr. The results seem to be independent of the HCV-RNA detection method. The different kinetics of HCV RNA and HCV antigen load suggest that there are different mechanisms responsible for the reduction of the HCV antigen and HCV-RNA, respectively. Reduction of viral load during dialysis session indicates a potential benefit of dialysis in case of HCV associated antiviral therapy.

Hepatitis C infection in patients with chronic kidney disease

The management of hepatitis C virus (HCV)-infected patients with chronic kidney disease (CKD) is complex and represents a particular concern since numerous issues, such as antiviral therapy in dialysis patients and post renal transplant, and prevention of HCV spread within dialysis units, remain unresolved. An enormous body of literature has been published on HCV in the CKD population; however, clinical evidence on important issues is mostly based on uncontrolled clinical trials or retrospective surveys. The aim of this paper is to provide a systematic review of the literature. Responses to the critical issues have been developed by a consensus of experts, endorsed by the Italian Association for the Study of the Liver (AISF) and some clinical recommendations have been added.

Validation of a strategy for HCV antibody testing with two enzyme immunoassays in a routine clinical laboratory

BACKGROUND

Centers for Disease Control (CDC) guidelines require confirmation of hepatitis C virus (HCV) screening-test-positive sera with a low signal/cut-off (S/CO) ratio by recombinant immunoblot or PCR. The UK Health Protection Agency has suggested that a second enzyme immunoassay (EIA) could be used as an alternative for confirmation in non-immunocompromised patients.

OBJECTIVE

To evaluate the UK HPA approach in 17,936 consecutive in-house sera submitted for HCV testing.

STUDY DESIGN

AxSYM-positive sera (S/CO> or =1.0) were tested with Monolisa Plus. AxSYM-positive sera of patients that were confirmed PCR-positive were considered HCV+. All other AxSYM-positive sera were confirmed with immunoblot according to CDC guidelines.

RESULTS

17,299 sera were negative with AxSYM. Of the 637 AxSYM-positive sera, 384 were from patients confirmed as PCR-positive. Of other 250 sera, 120 were negative with immunoblot, 103 were positive and 30 were indeterminate. All 30 immunoblot-indeterminate sera were PCR-negative. Two patients were Monolisa Plus+ and immunoblot- and PCR-. One patient was known as immunoblot-, while the other patient was diagnosed with non-A non-B hepatitis in 1980s. Nine sera from HCV-positive patients were Monolisa Plus-. Two PCR- sera were from immunocompetent patients who were PCR- for > or =8 years and six PCR- sera and one PCR+ serum were from immunocompromised patients. Sensitivity and specificity of confirmation with Monolisa Plus were 98.15% and 98.33% and the positive and negative predictive values were 99.58% and 92.91% in AxSYM-positive sera (excluding immunoblot-indeterminate/PCR-negative sera). If immunocompromised patients that were false-negative were excluded, sensitivity was 99.58%.

CONCLUSION

Monolisa Plus can be used as an alternative to immunoblot for the confirmation of AxSYM-positive sera.

[Prevalence of anti-HCV antibodies and seroconversion incidence in five haemodialysis units in Morocco]

Dialysis patients are among groups at risk for development of hepatitis C infection (HCV). The aim of the study was to evaluate the prevalence and the incidence of seroconversion for HCV in five haemodialysis units in Morocco. The study was conducted during the period from September 2003 to September 2004. We studied 303 patients (148 females), mean age 49+/-16 years; dialysis duration was higher than five years in 64% of the cases. The prevalence of HCV infection was evaluated by using a fourth generation enzyme immunoassays. In the seronegative patients, we performed anti-HCV tests at three and six months intervals and monthly testing of alanine aminotransferase (ALT) activity and assessment of anti-HCV tests if the ALT activity was elevated. Moreover, risk factors, such as blood transfusion, surgery and other invasive procedures were recorded. Seroprevalence of HCV was 68.3%. Among 85 patients who were tested negative for anti-HCV at the entry of the study, four (4.60%) seroconverted in six month (estimated incidence: 9.41 new cases per year). HCV seropositivity was associated with longer duration of dialysis (p=0.000), and previous blood transfusions (p=0.047). The follow-up of the ALT in the seronegative patients did not show any significant variation. In conclusion, the prevalence and incidence of HCV infection in haemodialysis units in Morocco are dramatically elevated. High incidence seropositivity suggested nosocomial transmission of HCV; the dialysis processes itself, and blood transfusions are important risk factors for HCV transmission in these patients.

Efficacy and safety of pegylated-interferon α-2a in hemodialysis patients with chronic hepatitis C

AIM: To evaluate the efficacy and safety of pegylated-interferon alpha-2a in hemodialysis patients with chronic hepatitis C.

METHODS: Thirty-six hemodialysis patients with chronic hepatitis C were enrolled in a controlled and prospective study. All patients were treatment naive, positive tested for anti-HCV antibodies, and positive tested for serum HCV-RNA. Twenty-two patients received 135 &mgr;g peglyated-interferon α-2a weekly for 48 wk (group A). The remaining patients were left untreated, eleven refused therapy, and three were not candidates for kidney transplantation and were allocated to the control group (group B). At the end of the treatment biochemical and virological response was evaluated, and 24 wk after completion of therapy sustained virological response (SVR) was assessed. Side effects were monitored.

RESULTS: Of 22 hemodialysis patients, 12 were male and 10 female, with a mean age of 35.2 ± 12.1 years. Virological end-of-treatment response was observed in 14 patients (82.4%) in group A and in one patient (7.1%) in group B (P = 0.001). Sustained virological response was observed in 11 patients (64.7%) in group A and in one patient in group B (7.1%). Biochemical response parameters normalized in 10/14 patients (71.4%) at the end of the treatment. ALT levels in group B were initially high in six patients and normalized in one of them (25%) at the end of the 48 wk. In five patients (22.7%) therapy had to be stopped at mo 4 due to complications of weakness, anemia, and bleeding.

CONCLUSION: SVR could be achieved in 64.7% of patients on hemodialysis with chronic hepatitis C by a treatment with peglyated-interferon α-2a. Group A had a significantly better efficacy compared to the control group B, but the side effects need to be concerned.

Hepatitis C virus infection and the dialysis patient

Hepatitis C virus (HCV) remains common in patients undergoing regular dialysis and is an important cause of liver disease in this population both during dialysis and after renal transplantation (RT). Anti-HCV screening of blood products has almost eliminated posttransfusion HCV infection but acquisition of HCV continues to occur in dialysis patients because of nosocomial spread. The natural history of HCV in dialysis population is not completely understood though recent data show that HCV infection has a detrimental role on survival of chronic dialysis patients. Several clinical trials have suggested that the response rate to conventional interferon (IFN) is higher in dialysis patients than those with normal kidney function but tolerance is lower. There are only limited data about pegylated IFN alone or in association with ribavirin for hepatitis C in dialysis population. IFN remains contraindicated post-RT because of concern about precipitating graft dysfunction; however, preliminary evidence shows the durability of sustained response to antiviral therapy pre-RT after renal transplant. Successful pretransplant therapy is associated with several benefits after RT including reduced incidence of posttransplant diabetes mellitus and de novo glomerulonephritis in HCV-infected recipients.

[Clinical assessment of Monolisa HCV Ag-Ab ULTRA (Bio-Rad) in a general hospital]

INTRODUCTION

To evaluate a new test based on simultaneous detection of HCV antibodies and antigen (Monolisa HCV Ag/Ab ULTRA; Bio-Rad, Marnes la Coquette, France).

METHODS

We studied samples from two groups of patients and 7 commercial HCV seroconversion panels (75 samples). Group 1: 1360 serum samples from patients referred for routine testing of anti HCV antibodies. Group 2: 333 serum samples from 183 hemodialysis patients. All samples were tested by the Ortho HCV 3.0 technique (Ortho-Clinical Diagnostics, Amersham, UK) and the Monolisa HCV Ag-Ab ULTRA technique.

RESULTS

Group 1: Seventy-four of 1360 serum samples were positive by Ortho HCV and 77 by Monolisa. In 1353 samples, the results with the two tests were concordant: 1281 negative and 72 positive. Five samples were positive only by Monolisa and 2 only by Ortho (overall agreement: 99.5%). Group 2: Results were concordant in 325 samples, 308 negative and 17 positive. Seven samples were positive by Monolisa and negative by Ortho. The sensitivity of the Monolisa test in hemodialysis patients was clearly higher than that of the Ortho test (100% and 70.8%, respectively). Monolisa detected HCV infection in 43 of 75 samples from the seroconversion panels; only 18 positive samples were detected by Ortho HCV. Monolisa reduced the window period by up to 72 days.

CONCLUSIONS

Our data indicate high agreement between the Monolisa and Ortho tests in samples from the general population. In hemodialysis patients, however, Monolisa was more sensitive. In addition, the Monolisa test significantly reduced the window period of HCV infection.

Gamma glutamyltranspeptidase activity and viral hepatitis in dialysis population

BACKGROUND

Numerous investigations have reported that viral hepatitis is associated with significant hepatocellular damage, as expressed by raised aminotransferases in serum, in dialysis population. However, scarce information exists on the activity of gamma glutamyltranspeptidase (GGTP) in dialysis patients with infection by hepatotropic viruses.

OBJECTIVES

We measured serum GGTP values in a large cohort (n=757) of patients receiving long-term dialysis; healthy controls were also included. The relationship between GGTP values and a series of demographic, clinical, and biochemical parameters was analyzed.

METHODS

Serum GGTP levels were tested by spectrophotometry. A subset (n=333) of dialysis patients was tested by molecular technology (branched-chain DNA (bDNA) assay) to evaluate the relationship between serum GGTP and HCV viremia. A subgroup (n=78) of dialysis patients was analyzed by an ultrasound scan of gallbladder and biliary tract to assess the presence of gallstone disease. Multivariate analyses were made using regression models; serum GGTP values were included as a dependent variable. The usefulness of serum GGTP levels in detecting HBsAg and anti-HCV positivity was evaluated using receiver operating characteristics (ROC) curve analysis.

RESULTS

Univariate analysis showed that serum GGTP levels were significantly higher in HBsAg positive and/or anti-HCV positive patients than in HBsAg negative/anti-HCV negative patients on dialysis; 85.1+/-184.1 versus 25.86+/-23.9 IU/l (P=0.0001). The frequency of raised GGTP levels was 22.2% (41/184) among dialysis patients with chronic viral hepatitis. Multivariate analysis showed a significant and independent association between serum GGTP values and positive HBsAg (P=0.005) and anti-HCV antibody (P=0.0001) status. Mean GGTP values were significantly higher in study patients than controls, 32.32+/-60.02 versus 23.5+/-16.92 IU/L (P=0.01); however, no significant difference with regard to GGTP between study and healthy cohorts persisted after correction for age, gender, race, and viral markers. No relationship between gallstone disease and serum GGTP was found (NS). An independent and significant association (P=0.0291) between raised GGTP levels and detectable HCV RNA in serum was noted among patients tested by biology molecular techniques. ROC technology demonstrated that GGTP was equally useful for detecting HBV (P=0.0004) and HCV (P=0.0005) among dialysis patients.

CONCLUSIONS

We found an independent and significant association between serum GGTP values and HBsAg and/or anti-HCV antibody in dialysis population. Twenty-two percent of dialysis patients with chronic viral hepatitis had elevated GGTP. No difference in GGTP between HBsAg- negative/anti-HCV- negative dialysis patients and healthy individuals was found. Routine testing for serum GGTP levels to assess liver disease induced by hepatotropic viruses or other agents in dialysis population is suggested.

The kidney transplant recipient with hepatitis C infection: pre- and posttransplantation treatment

Liver disease secondary to chronic hepatitis C virus (HCV) infection is an important cause of morbidity and mortality in dialysis patients and kidney transplant recipients. Evaluation of patients with chronic HCV infection is warranted to determine stage of disease and the need for HCV therapy. Although combination therapy with interferon (IFN) plus ribavirin is the standard of care for chronic HCV infection, IFN monotherapy is recommended in dialysis patients because ribavirin is contraindicated in the presence of renal failure. The goals of pretransplantation HCV therapy are to decrease the risk for progression of HCV-associated liver disease, stabilize renal function in patients with HCV-related glomerulopathy, and prevent development of HCV-associated renal disease after transplantation. Posttransplantation HCV therapy is generally not recommended because of concerns regarding risk for precipitating acute rejection; however, antiviral therapy may be indicated to treat HCV-related glomerulopathy or prevent progression of chronic hepatitis C in patients with more advanced stages of fibrosis. When treatment is required, restored renal function allows use of combination therapy with IFN and ribavirin. Limitations of current HCV therapy include lack of tolerability and suboptimal response rates. New antiviral agents that can be used in dialysis patients (e.g., ribavirin alternatives) and in the posttransplantation setting (e.g., IFN alternatives) are needed to improve outcomes in these populations.

Pegylated-interferon alpha 2a treatment for chronic hepatitis C in patients on chronic haemodialysis

AIM: To evaluate the response to pegylated-interferon alpha 2a in chronic hepatitis C patients on chronic haemodialysis.

METHODS: Ten patients with chronic C hepatitis were enrolled in this study. All had increased aminotransferases for more than 6 mo, positive antiHCV antibodies and positive PCR HCV-RNA. We administrated Peg-Interferon alpha 2a 180 μg/wk for 48 wk. After 12 wk of treatment we evaluated the biochemical and early virological response (EVR). At the end of the treatment we evaluated the biochemical response and 24 wk after the end of the treatment we evaluated the sustained virological response (SVR). We monitored the side-effects during the treatment.

RESULTS: Two patients dropped out in the first 12 wk of treatment and 2 after the first 12 wk of treatment. After 12 wk of treatment, 7 out of 8 patients had biochemical response and EVR and 1 had biochemical response but persistent viremia. We had to reduce the dose of pegylated-interferon to 135 μg/wk in 2 cases. Three out of 6 (50%) patients had SVR 24 wk after the end of the treatment. Intention-to-treat analysis showed that 3 out of 10 patients (30%) had SVR. Side-effects occurred in most of the patients (flu-like syndrome, thrombocytopenia or leucopoenia), but they did not impose the discontinuation of treatment.

CONCLUSION: After 12 wk of treatment with Peg-Interferon alpha 2a (40 ku) in patients on chronic haemodialysis with chronic C hepatitis, EVR was obtained in 87.5% (7/8) of the cases. SVR was achieved in 50% of the cases (3/6 patients) that finished the 48 wk of treatment.

HCV-RNA qualitative assay based on transcription mediated amplification improves the detection of hepatitis C virus infection in patients on hemodialysis: results from five hemodialysis units in central Greece

BACKGROUND

End-stage renal disease patients (ESRD) on maintenance hemodialysis (HD) are at increased risk of acquiring hepatitis C virus (HCV) infection. An early and accurate diagnosis of HCV infection is important for the prevention of viral transmission and the management of ESRD patients on HD but conventional ELISA and PCR have often failed to reveal active HCV infection.

OBJECTIVES

This study evaluated the prevalence of HCV infection in ESRD patients from all HD units in central Greece using a sensitive HCV-RNA transcription mediated amplification (TMA) assay and compared its sensitivity with that of anti-HCV ELISA.

STUDY DESIGN

Anti-HCV antibody (third generation ELISA), HCV-RNA (TMA) and HCV genotypes (HCV TMA-LiPA) were determined in 366 ESRD Greek patients.

RESULTS

In total, 132 (36%) ESRD patients were HCV positive by ELISA or TMA; 44 by TMA alone, 16 by ELISA alone and 72 positive by both assays. More than half of the viraemic patients had genotype 3a.

CONCLUSIONS

HCV-RNA (TMA) assay appears to increase the accuracy in the diagnosis of HCV infection in HD patients compared to the anti-HCV ELISA and could serve as an additional screening tool in these patients.

Detection of multiple hepatitis C virus genotypes in a cohort of injecting drug users

Multiple genotypes of the hepatitis C virus (HCV) were detected in five of 138 HCV RNA positive injecting drug users (IDUs) recruited in Melbourne, Australia. Two were detected by combined LiPA and core and NS5a region sequencing, and three more (selected for testing due to their high-risk behaviour) by heteroduplex mobility analysis. We conclude that the true prevalence of mixed infection in IDUs is undoubtedly higher than the 3.6% (five of 138) we observed, and is underestimated by LiPA, the most common method of genotyping. As responsiveness to HCV treatment varies significantly with genotype, a high prevalence of mixed HCV infections in IDUs must diminish overall treatment efficacy and lessen our ability to reduce the burden of HCV-related disease.

Should patients with chronic hepatitis C infection be transplanted?

Chronic hepatitis C (HCV) infection affects more than 170 million people throughout the world and 2 to 3 million Americans. End-stage liver disease secondary to chronic HCV infection is the most frequent indication for liver transplantation in this country. Currently, the gold standard for treatment for immunocompetent patients is a combination of peginterferon (PEG-IFN) and ribavirin for 6 to 12 months depending on the genotype. This treatment achieves a sustained virological response (SVR) in 54% to 61% of patients overall. Almost 50% of patients do not respond or have recurrences posttreatment and progress in over 10 to 20 years into chronic liver disease and its complications. Liver transplantation is the only therapeutic modality that impacts on quality of life and survival of these patients. However, recurrence of HCV in the new allograft is universal with accelerated progression to cirrhosis in 5 to 10 years. Response to treatment is usually low (20% to 30%), and associated with significant side effects and depression. A significant percentage of patients with recurrent HCV after transplantation require retransplantation to control the complications of end-stage liver disease. Other solid organ transplants recipients already HCV-positive, or infected at the time of transplantation from blood transfusions or an infected graft, develop accelerated, progressive liver disease facilitated by the adverse effects of immunosuppression in addition to HCV replication. To prevent morbidity, mortality, and high costs related to the consequences of HCV infection, all solid organ transplant candidates should be tested for HCV infection and treated appropriately with PEG-IFN and ribavirin prior to transplantation.

Clinical usefulness of a new hepatitis C virus RNA extraction method using specific capture probe and magnetic particle in hemodialysis patients

Hemodialysis patients are a high-risk group for hepatitis C virus (HCV) infection. Assessment of HCV infection using HCV-RNA assay among dialysis patients is important for the issue of safety and environmental protection. However, polymerase chain reaction (PCR)-based methods are unsuitable for analyzing samples from dialysis patients because the conventional centrifugal extraction method fails to eliminate heparin, a potent inhibitor of PCR. In this study, we evaluated the usefulness of a HCV-RNA extraction method using probes and magnetic particles for hemodialysis patients in comparison with the centrifugal method. The study population consisted of 17 HCV antibody-positive patients undergoing hemodialysis. These 17 patients consisted of 12 HCV carrier patients and five patients with past HCV infection. One hundred and two samples from these patients were measured using the centrifugal and magnetic methods. Moreover, we prepared five standards that included theoretically 5 KIU/mL of HCV. One was made from non-HD patient's serum and the other four were from hemodialysis patients' serum. These standards were measured using the two methods. False-negative results were not observed with the magnetic method, but were observed in five out of 102 samples with the centrifugal method. Studies using standard samples revealed that accurate HCV-RNA measurement is achieved using the magnetic method. In conclusion, the present study showed that this magnetic extraction method is a highly reproducible and reliable assay to obtain correct information about the presence of the infective virus itself in the hemodialysis setting. Precise identification of HCV-RNA using this specific method is considered to be useful in preventing HCV infection in hemodialysis units.

Lymphocyte T helper-specific reactivity in sustained responders to interferon and ribavirin with negativation (seroreversion) of anti-hepatitis C virus

BACKGROUND

Seroreversion, negativation of anti-hepatitis C virus previously positive, is sometimes found in some chronic hepatitis C-sustained responders (SRs) to antiviral therapy.

AIMS

To determine the probability of seroreversion in SR treatment with Interferon and Ribavirin, and lymphocyte T helper (CD4+) reactivity to HCV antigens.

METHODS

Thirty SR were followed on average for 54.8 months. Anti-HCV was tested by third generation test. Peripheral blood mononuclear cells (PBMCs) were isolated from venous blood and cultured to evaluate CD4+ proliferation in response to 2 microg/ml of eight HCV recombinant antigens from core, NS3, NS4, NS5 regions.

RESULTS

Seroreversion was verified in 23% of patients (7/30), appearing at 47.5+/-24.0 months. The probability of anti-HCV loss in this group was 25% at 56 months after ending therapy. In 57% (4/7), anti-HCV returned to positive. These 7 SR patients with seroreversion also showed weaker CD4+ reactivity in 5% of tests (3/56) than the remaining 23 anti-HCV-positive SRs who showed stronger reactivity in 18% of tests (33/184), P=0.036.

CONCLUSIONS

One-quarter of the SR showed seroreversion of anti-HCV and weaker CD4+ specific HCV proliferation than those who remained anti-HCV positive. The data suggest that complete viral eradication is a possible and achievable clinical objective.

Meta-analysis: interferon for the treatment of chronic hepatitis C in dialysis patients

BACKGROUND

The efficacy of interferon monotherapy in dialysis patients with chronic hepatitis C remains unclear, although a number of small clinical trials have been published addressing this issue.

METHODS AND AIMS

We evaluated the efficacy and safety of initial interferon monotherapy 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 (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.

RESULTS

We have identified 14 clinical trials (269 unique patients); two were controlled studies. The mean overall estimate for sustained virological response (SVR) and drop-out rate was 37%[95% confidence interval (CI) 28-48] and 17% (95% CI 10-28), respectively. The most frequent side-effects requiring interruption of treatment were flu-like symptoms (17%), neurological (21%) and gastrointestinal (18%). The overall weighted estimate for SVR in patients with hepatitis C virus genotype 1 was 30.6% (95% CI 20.9-48). In the sub-group of clinical trials (n = 5) with standard interferon administration (3 million units [MUI] thrice weekly, subcutaneous route, 24-week treatment), the overall mean estimate of SVR was 39% (95% CI 25-56). The studies were heterogeneous with regard to SVR and drop-out rate.

CONCLUSIONS

Tolerance to initial interferon monotherapy was lower in dialysis than nonuremic patients with chronic hepatitis C. However, more than one-third of haemodialysis patients with chronic hepatitis C have been successfully treated with interferon. Longer duration of interferon monotherapy does not appear to have a beneficial effect on the response rate. Further studies are warranted to define the optimal anti-viral regimen for chronic hepatitis C in dialysis population.

Molecular features of non-B, non-C hepatocellular carcinoma: a PCR-array gene expression profiling study

BACKGROUND/AIMS

Hepatocellular carcinoma (HCC) usually develops following chronic liver inflammation caused by hepatitis C or B virus. Through expression profiling in a rare type of HCC, for which the causes are unknown, we sought to find key genes responsible for each step of hepatocarcinogenesis in the absence of viral influence.

METHODS

We used 68 non-B, non-C liver tissues (20 HCC, 17 non-tumor, 31 normal liver) for expression profiling with PCR-array carrying 3072 genes known to be expressed in liver tissues. To select the differentially expressed genes, we performed random permutation testing. A weighted voting classification algorithm was used to confirm the reliability of gene selection. We then compared these genes with the results of previous expression profiling studies.

RESULTS

A total of 220 differentially expressed genes were selected by random permutation tests. The classification accuracies using these genes were 91.8, 92.0 and 100.0% by a leave-one-out cross-validation, an additional PCR-array dataset and a Stanford DNA microarray dataset, respectively. By comparing our results with previous reports on virus-infected HCC, four genes (ALB, A2M, ECHS1 and IGFBP3) were commonly selected in some studies.

CONCLUSIONS

The 220 differentially expressed genes selected by PCR-array are potentially responsible for hepatocarcinogenesis in the absence of viral influence.

Virus-specific effector CD4+T-cell responses in hemodialysis patients with hepatitis C virus infection

Patients with chronic renal failure undergoing hemodialysis who are infected with hepatitis C virus (HCV) may test consistently anti-HCV negative. Because CD4(+) T-cells provide help for antibody production virus-specific effector CD4(+) T-cell responses were investigated in relation to anti-HCV positivity in 15 hemodialysis patients grouped according to HCV antibody and viremia. CD4(+) T-cell reactivity was studied in peripheral blood mononuclear cells by standard lymphocyte proliferation assay and phenotypic/functional characterization (cell-surface staining/cytokine secretion) by flow cytometry. HCV-specific CD4(+) T-cell proliferation in viremic hemodialysis patients was weak or absent independently of their anti-HCV status. Virus-specific CD4(+) T-cells displayed a memory phenotype and showed low to undetectable capacity to secrete effector interferon (IFN)-gamma. Impaired activation-induced cytokine secretion appeared to be Th1 (IFN-gamma) but not Th2 (interleukin-4)-directed and was virus-specific as cytomegalovirus responses were preserved. The frequency ex vivo of CD3(+)CD4(+)IFN-gamma(+) T-cells was independent of the HCV antibody status and comparable between viremic (range: 0.08-1.54%) or non-viremic (0.11-3.2%) hemodialysis patients and healthy donors (0.13-1.10%; P = 0.58). The numbers of CD3(+)CD4(+)IFN-gamma(+) T-cells augmented slightly (P = 0.047) in HCV-infected hemodialysis patients but markedly in only one (greater than ninefold) after HCV stimulation. In conclusion, hemodialysis patients show limited HCV-specific effector CD4(+) Th1-cell responses which nonetheless seem unrelated to the anti-HCV status and are not more impaired due to the ongoing hemodialysis.

Occult hepatitis C virus infection in type II mixed cryoglobulinaemia

Mixed cryoglobulinaemia, when not secondary to other well-defined immunological disorders, is commonly associated with hepatitis C virus (HCV) infection. However, a minority of cases lack evidence of HCV infection and are, therefore, defined as 'true essential' mixed cryoglobulinaemias. We thoroughly investigated three such patients to determine the aetiology of this disorder. Antibodies to HCV (anti-HCV) and HCV RNA, detected by sensitive enzyme-linked immunosorbent and polymerase chain reaction assays in serum and in concentrated cryoglobulins, were repeatedly negative in the three patients. Despite the lack of evidence for HCV infection, two of them were still treated with interferon alpha-2a assuming unrecognized viral infection. Both patients demonstrated excellent clinical and laboratory responses, but cryoglobulinaemia relapsed after the withdrawal of therapy. At the time of relapse, HCV RNA genomic sequences were detected for the first time in the cryoprecipitates of both patients. In the third case, HCV RNA was demonstrated for the first time during a flare of cryoglobulinaemia coincident with varicella infection. In all three patients anti-HCV antibodies remained negative throughout follow-up. We conclude that some apparently 'essential' forms of mixed cryoglobulinaemia can be caused by occult HCV infection. Interferon therapy can be taken into consideration in such HCV-negative cases.

Unexpected distribution of hepatitis C virus genotypes in patients on hemodialysis and kidney transplant recipients

The distribution of hepatitis C virus (HCV) genotypes in patients on hemodialysis and in kidney transplant recipients was compared with that observed in a control group composed of HCV-infected individuals from the general population. A total of 340 patients were included in the study: 46 with end-stage renal disease on regular hemodialysis treatment, 22 kidney transplant recipients and 272 controls matched for sex and age at a 4:1 ratio (controls to patient). HCV genotype was determined by sequencing of the 5' untranslated region of the HCV genome. No difference was observed in the distribution of HCV genotypes in hemodialysis patients and renal transplant patients (P = 0.47). However, when each of these groups was compared with the control group, a significant difference was detected in the genotype distribution (P < 0.001). In hemodialysis and renal transplant patients the most prevalent subtype was 1a, followed by 1b, 3, and other less prevalent genotypes (2, 4, and 5), whereas in the control group the most prevalent subtype was 1b, followed by 3, 1a, and others. That observation may reflect differences in the epidemiology of HCV infection, viral characteristics and host factors in renal patients in comparison to the control group.

A phylogenetic-tree analysis elucidating nosocomial transmission of hepatitis C virus in a haemodialysis unit

Nosocomial transmission of hepatitis C virus (HCV) subtype 1b involving 11 haemodialysis patients occurred in a haemodialysis unit in Japan in March 2000. Sequencing of the HCV-E1 region (411-bp) and phylogenetic-tree analysis showed near identity between HCV isolates derived from these patients and a haemodialysis patient who was known to be HCV-positive. The mode of transmission could not be conclusively established, but retrospective analysis suggested that the sharing of contaminated multidose vials of heparin-saline solutions, which were prepared in the Haemodialysis Center using accidentally contaminated instruments such as needles, may have been responsible for the outbreak. To prevent transmission of HCV in a haemodialysis unit, it may be important to observe strictly standard precautions and to prepare all medications in the Pharmacy. After these measures were taken, no new seroconversions and no new nosocomial transmissions of HCV have been observed in our haemodialysis unit.