Effect of isolation measures on the incidence and prevalence of hepatitis C virus infection in hemodialysis

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

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

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.

Mortality in Hepatitis C-Positive Patients Treated with Peritoneal Dialysis

Objective

The published mortality data for patients with hepatitis C virus (HCV) infection and being treated with peritoneal dialysis (PD) are not available. The aim of this study was to determine the mortality of HCV patients undergoing PD.

Methods

We retrospectively reviewed 538 PD patients in our hospital from 1996 to 2005. Of these patients, 75 (13.9%) were anti-HCV positive at the beginning of PD. We used Kaplan–Meier analysis to compare mortality between patients with and patients without HCV infection. The association between HCV infection and mortality was analyzed using multivariate Cox regression with adjustment for age, gender, residual renal function, and cardiovascular disease.

Results

A total of 157 patients (39 HCV positive, 118 HCV negative) died during the 10-year follow-up period. The mortality rate (52%, 39/75) of HCV-positive patients was significantly higher than that of HCV-negative patients (25.5%, 118/463; p < 0.001). Cardiovascular mortality was 57.6% (68/118) among HCV-negative patients and 56.4% (22/39) among HCV-positive patients. Kaplan–Meier estimate showed that patients with HCV infection had higher mortality than those without ( p < 0.001, log-rank). The result of Cox regression suggested that chronic HCV infection, independent of diabetes, was associated with 10-year mortality. The adjusted hazard ratios (HRs) of HCV infection and diabetes for mortality were 2.195 (95% CI: 1.486 – 3.243, p < 0.001) and 2.242 (95% CI: 1.533 – 3.277, p < 0.001).

Conclusion

Our results show that the HCV-positive PD patients had a higher 10-year mortality rate than the HCV-negative PD patients. The association between HCV infection and mortality was independent of diabetes. Cardiovascular mortality, infection, and arrhythmia were the leading causes of death among the PD patients with HCV infection.

Clinical practice guideline management of blood borne viruses within the haemodialysis unit

Some people who are receiving dialysis treatment have virus infection such as hepatitis B, hepatitis C and/or HIV that is present in their blood. These infections can be transmitted to other patients if blood is contaminated by the blood of another with a viral infection. Haemodialysis is performed by passing blood from a patient through a dialysis machine, and multiple patients receive dialysis within a dialysis unit. Therefore, there is a risk that these viruses may be transmitted around the dialysis session. This documents sets out recommendations for minimising this risk.There are sections describing how machines and equipment should be cleaned between patients. There are also recommendations for dialysing patients with hepatitis B away from patients who do not have hepatitis B. Patients should be immunised against hepatitis B, ideally before starting dialysis if this is possible. There are guidelines on how and when to do this, for checking whether immunisation is effective, and for administering booster doses of vaccine. Finally there is a section on the measures that should be taken if a patient receiving dialysis is identified as having a new infection of hepatitis B, hepatitis C or HIV.

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

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

Transmission of hepatitis C virus infection in hemodialysis: Current concepts

A variety of epidemiological data provides evidence for the occurrence of nosocomial transmission of hepatitis C virus (HCV) infection to hemodialysis (HD) patients. The most important factor implicated in HCV transmission between patients treated in the same dialysis unit is cross-contamination from supplies and surfaces as a result of failure of staff to follow infection control procedures. Parts of the HCV genome are highly variable and lend themselves to fingerprinting of each isolate using nucleic acid testing (NAT) and sequencing. This approach has permitted investigation of possible transmission routes within HD units. A systematic review of molecular virology papers revealed transmission of HCV via internal fluid pathways of the dialysis machines in a minority of reports only. Dialyzer reuse was not identified as a risk factor for HCV acquisition in multicenter databases. No randomized controlled trials exist on the impact of isolation on the risk of transmission of HCV to hemodialysis patients. A Belgian prospective multicenter study showed a reduction from 1.4% to 0% in the annual incidence of seroconversion for HCV without any isolation measures, by implementation of strict infection control procedures designed to prevent transmission of blood-borne pathogens, including HCV. However, an isolation policy for HCV-infected dialysis patients should be considered in dialysis units where nosocomial transmission of HCV persists despite reinforcement and audit of hygienic precautions for hemodialysis. Routine audit precautions (general and for dialysis machines) are recommended on a regular basis within HD units.

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

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

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Natural evolution of hepatitis C virus infection in hemodialysis Tunisian patients and CTLA-4 SNP's

AIM: To analyze the polymorphisms of CTLA-4 gene involved in the response against hepatitis C virus (HCV) infection.

METHODS: We recruited 500 hemodialysed patients from several hemodialysis centers, all HCV-antibody positive, spread over different regions of Tunisia, as part of a national survey in 2008 conducted in the laboratory of immunology at the Charles Nicolle hospital Tunisia, classified into two groups G1 (PCR+) and G2 (PCR-) according to the presence or absence of viral RNA. Of these patients, 307 were followed prospectively on a viral molecular level over a period from 2002 to 2008, divided into two groups based on the persistence and viral clearance. PCR-RFLP was performed for the analysis of SNPs (+49) A/G and (+6230) G/A CTLA-4 for these 500 patients and 358 healthy controls.

RESULTS: Analysis of clinical and virological characteristics of our cohort suggests a nosocomial infection in our hemodialysed patients with transfusion history as a primary risk factor and a predominance of genotype 1b. The haplotype analysis revealed an increase of frequencies of GG (+49)/(CT60) CTLA-4 in the entire patients group compared to controls (P = 0.0036 and OR = 1.42; 95%CI: 1.12-1.79, respectively). This haplotype is therefore associated with susceptibility to HCV infection.

CONCLUSION: Our study suggests a possible role of CTLA-4 polymorphisms in the outcome of HCV infection in the Tunisian hemodialysed population.

Viral hepatitis in hemodialysis: An update

Hepatitis outbreaks in hemodialysis (HD) patients and staff were reported in the late 1960s, and a number of hepatotropic viruses transmitted by blood and other body fluids have been identified. Hepatitis B virus (HBV) was the first significant hepatotropic virus to be identified in HD centers. HBV infection has been effectively controlled by active vaccination, screening of blood donors, the use of erythropoietin and segregation of HBV carriers. Hepatitis delta virus is a defective virus that can only infect HBV-positive individuals. Hepatitis C virus (HCV) is the most significant cause of non-A, non-B hepatitis and is mainly transmitted by blood transfusion. The introduction in 1990 of routine screening of blood donors for HCV contributed significantly to the control of HCV transmission. An effective HCV vaccine remains an unsolved challenge; however, pegylation of interferon-alfa has made it possible to treat HCV-positive dialysis patients. Unexplained sporadic outbreaks of hepatitis by the mid-1990s prompted the discovery of hepatitis G virus, hepatitis GB virus C and the TT virus. The vigilant observation of guidelines on universal precaution and regular virologic testing are the cornerstones of the effective control of chronic hepatitis in the setting of HD. Major recent advances in the viral diagnosis technology and the development of new oral, direct-acting antiviral agents allow early diagnosis and better therapeutic response. The current update will review the recent developments, controversies and new treatment of viral hepatitis in HD patients.

Management of patients with hepatitis C infection and renal disease

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

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.

Evaluation of an isolation program of hepatitis C virus infected hemodialysis patients in some hemodialysis centers in egypt

Introduction. Hepatitis C virus (HCV) infection is a significant cause of morbidity and mortality in hemodialysis (HD) patients. Several studies demonstrated nosocomial transmission of HCV among HD patients. Aim. We aimed to evaluate the isolation program of HCV seropositive patients among a group of Egyptian haemodialysis patients to decrease the incidence of HCV seroconversion. Methods. One hundred and fourteen HCV seronegative patients who were receiving regular haemodialysis in different four haemodialysis units in Egypt. The first group included forty six patients on regular hemodialysis in two centers following strict isolation of the HCV seropositive patients, and the second group included sixty eight patients on regular hemodialysis in the other two centers not following this strict isolation. All these patients were followed up over a period of 36 months. Results. There was a significantly higher incidence of HCV seroconversion of patients on hemodialysis in units not following strict isolation of HCV seropositive patients (42.9%) than those on regular hemodialysis in units following strict isolation (14.8%). Conclusions. In HD units with a high prevalence of HCV+ patients, strict isolation of HCV+ patients in combination with implementation of universal prevention measures can limit the spread of HCV infection in HD patients.

Hepatitis C virus infection in hemodialysis patients in Maracaibo, Venezuela

Over a two year period, the incidence of hepatitis C virus (HCV) infection was evaluated in 29 hemodialysis patients, aged between 15 and 75 years (mean ± SD: 45 ± 39.5 years), from the University Hospital Hemodyalisis Unit, Maracaibo, Zulia State, Venezuela. Anti-HCV antibodies were determined using a fourth generation ELISA (Innotest HCV Ab IV) kit and positive blood samples were tested using a recombinant assay kit (Inno-LIA HCV Ab III), both kits from Innogenetics N.V., Belgium. The findings indicate a lack of HCV seroconversion in the hemodialysis patients over the study period, confirmed by the recombinant assay. Risk factors for HCV infection were 0.3270 (95% confidence interval: 0.01323-8.080) in patients undergoing hemodialysis. The findings suggest a lack of significant sources for HCV infection due to the preventive measures to avoid its transmission in the hemodialysis unit.

Effects of oral levamisole as an adjuvant to hepatitis B vaccine in adults with end-stage renal disease: a meta-analysis of controlled clinical trials

BACKGROUND

Many patients receiving long-term dialysis do not produce protective antibodies to hepatitis B virus (HBV) surface antigen (HBsAg) after HBV vaccination. The results from several studies have suggested benefit of oral levamisole as an adjuvant to HBV vaccination in patients with end-stage renal disease (ESRD). However, reliable information is still lacking.

OBJECTIVE

This meta-analysis assessed the efficacy and safety profile of oral levamisole as an adjuvant to HBV vaccine in patients with ESRD.

METHODS

This meta-analysis included prospective controlled clinical trials identified using literature searches of MEDLINE, SCOPUS, Institute for Scientific Information bibliographic database, and Cochrane Collaboration's Central Register of Controlled Clinical Trials for controlled clinical trials that weighted the seroprotection rate in patients with ESRD who received oral levamisole + HBV vaccine versus those who received the HBV vaccine alone (control). The fixed-effects Mantel-Haenszel model was applied with the heterogeneity and sensitivity analyses. The response rate, defined as the proportion of patients with seroprotective concentrations of antibodies to HBsAg (>10 mIU/mL) at completion and 6 to 10 months after completion of the HBV vaccine schedule, was the end point of interest and was also analyzed separately. For the tolerability assessment, studies that reported dose reduction, levamisole discontinuation, and their adverse effects including laboratory abnormalities were included.

RESULTS

The literature search identified 4 studies that fulfilled the inclusion criteria (328 patients). The mean ages of the patients in these studies ranged from 41 to 53 years, and sex distribution ranged from 52.6% to 68.0% male. Twenty-two patients received oral levamisole 100 mg/d for 12 days (from 6 days before to 6 days after each vaccination). A total of 106 patients received oral levamisole 80 to 120 mg for 4 to 6 months. Aggregation of study results suggested a significant increase in response rate in the group that received levamisole + HBV vaccine compared with the control group (pooled odds ratio [OR] = 2.77 [95% CI, 1.56-4.94]) after completion and 6 to 10 months after the vaccination period (pooled OR = 3.96 [95% CI, 1.71-9.18]). The test of heterogeneity was not statistically significant in either group. Five patients underwent dose reduction due to mild adverse events. In one trial, 3 patients died, 1 of whom was receiving levamisole; however, the authors did not provide the causes of death. No other serious adverse events were reported with levamisole administration.

CONCLUSION

The results from this meta-analysis suggest significant benefit in the administration of levamisole as an adjuvant to HBV vaccine to increase seroprotection in patients with ESRD.

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.

Standardized prevalence ratios for chronic hepatitis C virus infection among adult Japanese hemodialysis patients

Background

Many studies have estimated the prevalence of anti-hepatitis C virus (HCV) antibody among hemodialysis (HD) patients; however, the prevalence of HCV core antigen—which indicates the presence of chronic HCV infection—is not known.

Methods

Standardized prevalence ratios (SPRs) for anti-HCV antibody and HCV core antigen among HD patients (n = 1214) were calculated on the basis of data from the general population (n = 22 472) living in the same area.

Results

The prevalences of anti-HCV antibody and HCV core antigen were 12.5% and 7.8%, respectively, in male hemodialysis patients, and 8.5% and 4.1% in female hemodialysis patients. The SPRs (95% confidence interval) for anti-HCV antibody and HCV core antigen were 8.39 (6.72–10.1) and 12.9 (9.66–16.1), respectively, in males, and 5.42 (3.67–7.17) and 8.77 (4.72–12.8) in females.

Conclusions

The prevalences of chronic HCV infection among male and female HD patients were 13-fold and 9-fold, respectively, those of the population-based controls. Further studies should therefore be conducted to determine the extent of chronic HCV infection among HD patients in other populations and to determine whether chronic HCV infection contributes to increased mortality in HD patients.

Lack of de novo hepatitis C virus infections and absence of nosocomial transmissions of GB virus C in a large cohort of German haemodialysis patients

To determine the prevalence and incidence of hepatitis C virus (HCV) infections among haemodialysis patients, a large prospective multicentre trial was conducted in the German Federal State of North Rhine-Westphalia. Sera obtained from the recruited patients in two separate sampling rounds run 1 year apart were analysed for both anti-HCV antibodies and HCV RNA. HCV RNA positive samples were also genotyped by direct sequencing of an HCV core fragment. In the first and second rounds, 150 (5.2%) of 2909 and 114 (5.4%) of 2100 patients were anti-HCV positive, respectively, and 4% of individuals were viraemic. Evaluation of potential risk factors in a case-control study indicated that the factors 'foreign country of birth', 'blood transfusions given before 1991' and 'duration of treatment on haemodialysis' were associated with the risk of HCV infection. Among the 2100 patients of whom 'paired' serum samples from both rounds were available for testing, not a single 'de novo' HCV infection could be recorded. The fact that in a subset of about 20% of these patients no nosocomial GB virus C (GBV-C) transmission occurred during the observational period suggests that the lack of HCV seroconversions was not only attributable to the isolation of HCV-infected patients but also to the strict adherence to so-called universal hygienic precautions for infection control maintained in the participating dialysis centres.

A shield against a monster: Hepatitis C in hemodialysis patients

Hepatitis C virus (HCV) infection is highly prevalent among patients on hemodialysis (HD). The prevalence of HCV infection in HD patients varies markedly from country to country. Some factors are especially related to these high prevalence rates, such as blood transfusions and length of dialysis time. Nosocomial routes of transmission including the use of contaminated equipment and patient-to-patient exposure is considered more important. Several prophylactic measures have been suggested to avoid infection by HCV in the HD environment.

Hepatitis C virus infection in haemodialysis: the 'no-isolation' policy should not be generalized

Hepatitis C virus (HCV) infection is the most common blood-borne viral infection in haemodialysis. It causes significant morbidity and long-term mortality. Practice of universal precautions has been reported to be sufficient to prevent HCV seroconversion in dialysis units. However, the seroconversion rate remains very high in many dialysis units. A previous study from 1995 to 1998 at our own hospital without isolation showed that nosocomial transmission is the major cause of HCV seroconversion. The present study was therefore conducted with the aim to study the impact of isolation on HCV seroconversion. In this prospective cohort study, with non-probability consecutive sampling, patients with HCV infection were dialysed in an isolated room. In addition, standard universal precautions were practiced. HCV seroconversion rate was compared with the previous study. All patients with end-stage kidney disease (ESKD) admitted to our hospital for renal replacement therapy were included in the present study. At the time of admission, HCV screening was done. All anti-HCV-positive patients were dialysed in an isolated room. While on maintenance haemodialysis, all patients were monthly tested for anti-HCV, aspartate aminotransferase and alanine aminotransferase. Any patient who had HCV seroconversion was transferred to an isolated room for maintenance haemodialysis. Patients with HCV infection were managed by further testing for HCV-RNA and liver biopsy. Every patient who ultimately received renal transplantation at our hospital was also tested for HCV just prior to renal transplantation as well as 3 months after renal transplantation. HCV infection was diagnosed by detecting anti-HCV antibodies using an ELISA-based third-generation diagnostic test kit. Serum bilirubin, aspartate aminotransferase and alanine aminotransferase were assayed using standard laboratory techniques. From March 2003 to February 2006, 1,417 patients were admitted for haemodialysis in our unit. Of these 1,077 (76%) had ESKD. Mean age of patients was 42.47 +/- 16.2 (14-94) and 70.39% were males. Patients with ESKD had had more dialysis sessions (10.9 +/- 39.5 vs. 4.4 +/- 5.95, p = 0.009), more blood transfusions and more pre-existing HCV infections (4.72 vs. 1.5%, p = 0.009) than patients with acute renal failure. Of the ESKD patients, 65.7% were discharged, 9.47% died, 1.85% were shifted to chronic ambulatory peritoneal dialysis and 22.46% patients received renal transplantation. Of the patients who received renal transplantation, HCV seroconversion was detected in 2.75%. In the previous study without isolation practices, the HCV seroconversion rate in transplanted patients was 36.2%. The hazard of HCV seroconversion was 0.97 (95% CI 0.93-1.02, p = 0.2) for each additional dialysis and 1.09 (95% CI 0.88-1.36, p = 0.37) for each additional blood transfusion. The study concludes that isolation of HCV-infected patients during haemodialysis significantly decreases the HCV seroconversion rate.

Prevalence, genotypes and risk factors associated with hepatitis C virus infection in hemodialysis patients in Campo Grande, MS, Brazil

A survey was conducted among the hemodialysis units of the city of Campo Grande, located in the state of Mato Grosso do Sul in the Mid-west region of Brazil, with the aim of investigating the prevalence, risk factors, and genotypes of hepatitis C virus (HCV) infection. A total of 163 patients were interviewed in five dialysis units. Serum samples were screened for anti-HCV. Positive samples were tested for HCV RNA and genotyped. The prevalence of anti-HCV was 11% (95% CI: 6.8-17.1). A history of transfusion with blood that was not screened for anti-HCV and length of time on hemodialysis were associated with HCV infection. HCV RNA was detected in 12 samples: ten were of genotype 1, subtypes 1a (75%) and 1b (8.3%), and two were of genotype 3, subtype 3a (16.7%).

Prevention of hospital-acquired infections: review of non-pharmacological interventions

Hospital-acquired (nosocomial) infections (HAIs) increase morbidity, mortality and medical costs. In the USA alone, nosocomial infections cause about 1.7 million infections and 99 000 deaths per year. HAIs are spread by numerous routes including surfaces (especially hands), air, water, intravenous routes, oral routes and through surgery. Interventions such as proper hand and surface cleaning, better nutrition, sufficient numbers of nurses, better ventilator management, use of coated urinary and central venous catheters and use of high-efficiency particulate air (HEPA) filters have all been associated with significantly lower nosocomial infection rates. Multiple infection control techniques and strategies simultaneously ('bundling') may offer the best opportunity to reduce the morbidity and mortality toll of HAIs. Most of these infection control strategies will more than pay for themselves by saving the medical costs associated with nosocomial infections. Many non-pharmacological interventions to prevent many HAIs will also reduce the need for long or multiple-drug antibiotic courses for patients. Lower antibiotic drug usage will reduce risk of antibiotic-resistant organisms and should improve efficacy of antibiotics given to patients who do acquire infections.

Hepatitis C in hemodialysis patients: current global magnitude, natural history, diagnostic difficulties, and preventive measures

Hepatitis C virus (HCV) infection is a significant cause of morbidity and mortality in hemodialysis (HD) patients. The reported prevalence of HCV among the HD population has varied greatly from 1.9 to 84.6% in different countries in recent years. The length of time on HD is generally believed to be associated with HCV acquisition in HD subjects. Nevertheless, several recent reports failed to recognize any significant role of blood transfusion. Although there are some considerations about the accuracy of serologic testing in detecting HCV in HD patients, the accumulated data in this review suggest the false-negativity rate to be not more than 1.66% (153/9,220). Therefore, substituting virologic for serologic testing in the routine diagnosis of HCV infection in HD patients seems unreasonable. Several phylogenetic analyzes of viral isolates suggested nosocomial patient-to-patient transmission of HCV among HD patients for which the main potential source is believed to be contaminated hands and articles. However, isolation of HCV-infected HD patients and use of dedicated machines are currently unjustified while strict adherence to universal precautions seems to be enough to control disease spread in HD units. The present article is an update on epidemiological and clinical features of HCV in HD population.

[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.

Hepatitis C in dialysis units: the Saudi experience

Hepatitis C virus (HCV) infection is a significant health problem, as it can lead to chronic active hepatitis, liver cirrhosis, and hepatic carcinoma. Patients undergoing hemodialysis treatment are at increased risk of contracting HCV and other viral infections. This is primarily due to their impaired cellular immunity, underlying diseases, and blood exposure for a prolonged period. Transmission of viral hepatitis, and in particular HCV in dialysis units, has been showing a progressive increase worldwide, ranging between 5% in some western countries and up to 70% in some developing countries. The annual rate of HCV seroconversion in Saudi Arabia is 7% to 9%, while its prevalence is variable between 15% and 80%. This prevalence remained at almost 50% in recent years, despite the further increase in number of patients with end-stage renal disease and the expansion of dialysis services. The most prevalent genotypes in Saudi Arabia are genotype 4 followed by genotypes 1a and 1b, whereas genotypes 2a/2b, 3, 5, and 6 are rare. Genotypes 1 and 4 were associated with different histological grades of liver disease. Mixed infections with more than one genotype were observed in some studies. Isolation of dialysis machines and infected patients, together with strict application of infection-control policies and procedures and continuous education and training of nursing staff, remain the cornerstone in prevention and control of the spread of HCV infection in dialysis units. Interferon (INF)-alpha or pegylated INF, alone or in combination with ribavirin, have shown great promise in the treatment of chronic HCV in dialysis patients.

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.

Treatment of HCV in patients with renal failure

There continues to be a high prevalence of hepatitis C virus infection in patients with chronic kidney disease (CKD) on maintenance hemodialysis, despite screening of blood products and precautions to prevent the transmission of viral hepatitis within dialysis units. In addition, an increased rate of mortality from liver disease has been observed in infected patients on long-term dialysis, despite the frequent absence of biochemical dysfunction. Hepatitis C-infected renal transplant recipients have diminished patient and graft survivals compared to uninfected controls. Treatment with interferon in renal transplant candidates has resulted in sustained viral responses that have been long lasting even after subsequent renal transplant. A major concern limiting the use of interferon following renal transplant is graft dysfunction due to rejection. Ribavirin's induction of hemolytic anemia is the major reason why it is avoided in patients with CKD. Cautious use of reduced-dose ribavirin in small studies has been promising in these patients with close monitoring of hematocrit and additional measures to enhance compensatory erythropoiesis.

Hepatitis C virus infection in dialysis patients

Hepatitis C virus (HCV) infection is a global health problem, common worldwide, leading to acute and chronic hepatitis and its consequences of hepatocirrhosis and hepatocellular carcinoma. Patients on hemodialysis belong to the high-risk group of HCV infection. The prevalence of HCV infection in dialysis patients ranges from 4% to more than 70% in some countries. The main reasons for such a high incidence of infections are a high prevalence of HCV infection in the general population, lack of standard infection precautions and effective vaccination, inadequate disinfection procedures of dialysis machines and other medical equipment, as well as spread of infection from patient to patient, especially in dialytic centers with a high percentage of infected patients. The diagnostic procedures useful in the evaluation of HCV infection are detection of anti-HCV antibodies, identification of HCV RNA, counts of virus copies, and identification of its genome. From the 6 major genotypes and multiple subtypes of the HCV, genotypes 1a and 1b are the most common in Europe and Japan, and 1b is responsible for more severe liver disease and aggressive course leading to liver fibrosis. Antiviral therapy of HCV+ dialysis patients with interferon-alpha (INF-alpha) gives slightly better results than in the general population, but is poorly tolerated and associated with side effects. Although ribavirin in not recommended for dialysis patients, the addition of small doses of this compound to pegylated INF is discussed, especially for patients in whom previous infection treatment failed.

Hepatitis C in dialysed patients--what is the current optimal treatment?

Hepatitis C virus (HCV) infection is an important cause of morbidity and mortality in the dialysis population. The problem is more pronounced after renal transplantation. It seems that immunosuppressive drugs facilitate HCV replication and accelerate hepatic lesions. Interferon is not recommended after renal transplantation because of the risk of acute rejection and graft dysfunction, and for this reason it is important to eradicate HCV RNA before transplantation. Prevention is the most important treatment measure. Good clinical practice together with screening of blood products and organs is of outstanding importance. Pegylated interferon (PEG-INF) and ribavirin are currently considered to be optimal therapy for HCV infection. Pegylation delays clearance of interferon, which leads to a more potent and longer antiviral effect. The two PEG-INF formulations (alfa-2a and alfa-2b) with different pharmacokinetic characteristics are currently available. Their clearance is reduced by almost 45% in patients with end-stage renal disease. Taken together with the high prevalence of adverse effects associated with the PEG-INF, an increased awareness of their use in dialysis patients is reasonable. There are few published studies on interferon and PEG-INF therapy in uremic patients. These studies confirm that the rate of response to different interferon formulations in dialysis is much higher than in the general population, but with a higher rate of adverse events. Ribavirin increases the response rate to treatment with PEG-INF. Great caution is warranted on its use in dialysis patients, whereas in patients with renal disease it accumulates and causes a dose-related haemolysis. Current results are encouraging but limited by a small number of patients and short follow-up. Multi-centre, controlled studies with longer follow-up are needed to establish an optimal protocol for the treatment of chronic HCV infection in dialysis patients.