Coronavirus Disease 2019 and Kidney Transplantation in Saudi Arabia: Outcomes and Future Opportunities

BACKGROUND Kidney transplant services all over the world were severely impacted by the coronavirus disease 2019 pandemic. The optimum management of kidney transplant recipients with coronavirus disease 2019 remains uncertain. MATERIAL AND METHODS We conducted a multicenter cohort study of kidney transplant recipients with coronavirus disease 2019 infection in Saudi Arabia. Multivariable Cox regression analysis was used to study predictors of graft and patient outcomes at 28 days after coronavirus disease 2019 diagnosis. RESULTS We included 130 kidney transplant recipients, with a mean age of 48.7(±14.4) years. Fifty-nine patients were managed at home with daily follow-up utilizing a dedicated clinic, while 71 (54.6%) required hospital admission. Acute kidney injury occurred in 35 (26.9%) patients. Secondary infections occurred in 38 (29.2%) patients. SARS-CoV-2 antibodies testing was carried out in 84 patients, of whom 70 tested positive for IgG and/or IgM. Fourteen patients died (10.8%). A multivariable Cox regression analysis showed that age, creatinine at presentation, acute kidney injury, and use of azithromycin were significantly associated with worse patient survival. Graft loss was associated with requiring renal replacement therapy and development of secondary infections. CONCLUSIONS Despite kidney transplant recipients with coronavirus disease 2019 infection having higher rate of hospital admission and mortality compared to the general population, a significant number of them can be managed using a telemedicine clinic. Most kidney transplant patients seem to mount an antibody response following coronavirus disease 2019 infection, and it remains to be seen if they will have a similar response to the incoming vaccines.

Longitudinal proteomic profiling of dialysis patients with COVID-19 reveals markers of severity and predictors of death

End-stage kidney disease (ESKD) patients are at high risk of severe COVID-19. We measured 436 circulating proteins in serial blood samples from hospitalised and non-hospitalised ESKD patients with COVID-19 (n = 256 samples from 55 patients). Comparison to 51 non-infected patients revealed 221 differentially expressed proteins, with consistent results in a separate subcohort of 46 COVID-19 patients. Two hundred and three proteins were associated with clinical severity, including IL6, markers of monocyte recruitment (e.g. CCL2, CCL7), neutrophil activation (e.g. proteinase-3), and epithelial injury (e.g. KRT19). Machine-learning identified predictors of severity including IL18BP, CTSD, GDF15, and KRT19. Survival analysis with joint models revealed 69 predictors of death. Longitudinal modelling with linear mixed models uncovered 32 proteins displaying different temporal profiles in severe versus non-severe disease, including integrins and adhesion molecules. These data implicate epithelial damage, innate immune activation, and leucocyte-endothelial interactions in the pathology of severe COVID-19 and provide a resource for identifying drug targets.

Coronavirus-associated kidney outcomes in COVID-19, SARS, and MERS: a meta-analysis and systematic review

OBJECTIVES

A meta-analysis and systematic review was conducted on kidney-related outcomes of three recent pandemics: SARS, MERS, and COVID-19, which were associated with potentially fatal acute respiratory distress syndrome (ARDS).

METHODS

A search of all published studies until 16 June 2020 was performed. The incidence/prevalence and mortality risk of acute and chronic renal events were evaluated, virus prevalence, and mortality in preexisting hemodialysis patients was investigated.

RESULTS

A total of 58 eligible studies involving 13452 hospitalized patients with three types of coronavirus infection were included. The reported incidence of new-onset acute kidney injury (AKI) was 12.5% (95% CI: 7.6%-18.3%). AKI significantly increased the mortality risk (OR = 5.75, 95% CI 3.75-8.77, p < 0.00001) in patients with coronavirus infection. The overall rate of urgent-start kidney replacement therapy (urgent-start KRT) use was 8.9% (95% CI: 5.0%-13.8%) and those who received urgent-start KRT had a higher risk of mortality (OR = 3.43, 95% CI 2.02-5.85, p < 0.00001). Patients with known chronic kidney disease (CKD) had a higher mortality than those without CKD (OR = 1.97, 95% CI 1.56-2.49, p < 0.00001). The incidence of coronavirus infection was 7.7% (95% CI: 4.9%-11.1%) in prevalent hemodialysis patients with an overall mortality rate of 26.2% (95% CI: 20.6%-32.6%).

CONCLUSIONS

Primary kidney involvement is common with coronavirus infection and is associated with significantly increased mortality. The recognition of AKI, CKD, and urgent-start KRT as major risk factors for mortality in coronavirus-infected patients are important steps in reducing future mortality and long-term morbidity in hospitalized patients with coronavirus infection.

Detection of SARS-CoV-2 in Hemodialysis Effluent of Patient with COVID-19 Pneumonia, Japan

We report detection of severe acute respiratory syndrome coronavirus 2 RNA in hemodialysis effluent from a patient in Japan with coronavirus disease and prolonged inflammation. Healthcare workers should observe strict standard and contact precautions and use appropriate personal protective equipment when handling hemodialysis circuitry from patients with diagnosed coronavirus disease.

[Managing patients in dialysis and with kidney transplant infected with Covid-19]

We are in the midst of a health emergency that is totally new for us all and that requires a concerted effort, especially when it comes to safeguarding patients on hemodialysis, and kidney transplant recipients. Brescia is currently a very active cluster of infections (2918 cases on the 17/03/2020), second only to Bergamo. The way our structure is organised has allowed us to treat nephropathic patients directly within the Nephrology Unit, following of course a great deal of reshuffling; at the moment, we are treating 21 transplanted patients and 17 on hemodialysis. This has led us to adopt a systematic approach to handling this emergency, not only in managing inpatients, but also in researching the new disease. Our approach is mirrored in the guidelines attached to this article, originally intended for internal use only but potentially very useful to our colleagues, as they face the same exact problems. We have also started collecting data on our positive patients with the aim of understanding better the functioning of this disease and how best to manage it. If anyone is interested, we ask you to please get in touch with us, so we can coordinate our efforts.

Cytomegalovirus seropositivity is independently associated with cardiovascular disease in non-dialysis dependent chronic kidney disease

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of early death in patients with chronic kidney disease (CKD). Previous work has described an association between Cytomegalovirus (CMV) seropositivity and CVD amongst patients with dialysis dependent end stage renal disease. Whether CMV seropositivity is associated with CVD in non-dialysis dependent CKD has not been established.

AIM

Investigate whether past CMV infection is associated with prevalent CVD in patients with non-dialysis dependent CKD.

DESIGN

A retrospective observational study using the Renal Impairment in Secondary Care cohort, a study evaluating bio-clinical determinants of outcomes in patients with progressive CKD.

METHODS

We assayed cryopreserved serum samples collected at inception for anti-CMV IgG antibodies from 764 patients with stages 2 to 5 CKD (pre-dialysis) and investigated its relationship with prevalent CVD.

RESULTS

Median estimated glomerular filtration was 24 ml/min/1.73 m2 (IQR 19-32). Sixty-eight percent of patients were CMV seropositive. CMV seropositivity was associated with older age, non-Caucasian ethnicity, diabetes and higher social deprivation index score. On univariable analysis, CMV seropositivity correlated with higher systolic blood pressure (P = 0.044), prevalent CVD (P < 0.001), ischaemic heart disease (P < 0.001) and cerebrovascular disease (P = 0.022). On multivariable analysis, CMV seropositive patients nearly twice as likely to have CVD compared to seronegative patients [Odds Ratio (OR) = 1.998, CI 1.231-3.242, P = 0.005].

CONCLUSIONS

In patients with non-dialysis CKD, CMV seropositivity is independently associated with a higher prevalence of CVD.

COVID-19 Infection in a Patient with End-Stage Kidney Disease

Since December 2019, the epidemic of coronavirus disease 2019 (COVID-19) has spread very rapidly in China and worldwide. In this article, we report on a 75-year-old man infected with 2019 novel coronavirus who has end-stage kidney disease (ESKD). COVID-19 patients with ESKD need isolation dialysis, but most of them cannot be handled in time due to limited continuous renal replacement therapy (CRRT) machines. CRRT provided benefits for this patient by removing potentially damaging toxins and stabilizing his metabolic and hemodynamic status. With the control of uremia and fluid status, this patient ended up with an uneventful post-CRRT course, absence of clinical symptoms, and negative PCR tests. Greater efforts are needed to decrease the mortality of COVID-19-infected ESKD patients.

Serum albumin and mortality in patients with HIV and end-stage renal failure on peritoneal dialysis

Background

Peritoneal dialysis (PD) is an easily implementable dialysis modality in end-stage renal disease (ESRD). PD may improve access to renal replacement therapy in low- and middle-income countries; however, these countries have a higher prevalence of protein-energy wasting in patients and poorer socioeconomic conditions. We evaluated the effects of HIV infection on serum albumin levels in ESRD patients starting continuous ambulatory PD (CAPD) and mortality outcomes.

Methods

We conducted a single-center prospective cohort study of consecutive incident CAPD patients recruited from two hospitals in Durban, South Africa, from September 2012 to February 2015. Seventy HIV-negative and 70 HIV-positive ESRD patients were followed monthly for serum albumin levels and mortality events during the first 18 months of CAPD therapy.

Results

The HIV-positive cohort recorded 28 deaths (40%) among patients with a functional CAPD catheter at 18 months and 13 deaths (18.6%) in the HIV-negative cohort (p = 0.005). The mean serum albumin levels were lower in the HIV-positive cohort than in the HIV-negative cohort during the 18-month follow-up. The mean difference in serum albumin levels between the two cohorts was 4.24 g/L (95% confidence interval [CI] 2.02–6.46, p<0.001) at baseline and 3.99 g/L (95% CI 1.19–6.79, p = 0.006) at 18 months. HIV-positive status (adjusted regression coefficient -2.84, CI -5.00–-0.67, p = 0.011), diabetes (adjusted coefficient -2.85; CI, -5.58–-0.12; p = 0.041), and serum C-reactive protein and blood hemoglobin levels were independent predictors of serum albumin levels on multivariable linear regression. Baseline serum albumin <25 g/L (subdistribution-hazard ratio [SHR] 13.06, 95% CI 3.09–55.14, p<0.001) and CD4⁺ cell count <200 cells/μL (SHR 3.2, CI 1.38–7.45, p = 0.007) were independent predictors of mortality in our competing risk model.

Conclusions

HIV infection can adversely affect serum albumin levels in ESRD patients managed with CAPD, while low baseline serum albumin levels and impaired immunity reliably predict mortality.

Sofosbuvir-based regimen is safe and effective for hepatitis C infected patients with stage 4-5 chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Whether sofosbuvir is suitable for hepatitis C virus (HCV) infected patients with severe renal impairment is inconclusive. This systematic review aims to evaluate the safety and effectiveness of SOF-based regimen in the setting of stage 4 and 5 chronic kidney disease (CKD).

METHODS

We conducted a systematic literature search in PubMed, Web of Science, EMBASE and Google Scholar with searching strategy: (sofosbuvir OR Sovaldi OR Harvoni OR Epclusa OR Vosevi) AND (severe kidney impairment OR severe renal impairment OR end-stage renal disease OR dialysis OR renal failure OR ESRD OR renal insufficiency OR hepatorenal syndrome OR HRS). Sustained virological response (SVR12/24) rate and serious adverse event (SAE) rate with 95% confidence intervals were aggregated. Subgroup analysis was implemented to evaluate the impact of treatment strategy and patient characteristics.

RESULTS

Twenty-one studies met inclusion criteria, totaling 717 HCV infected patients with CKD stage 4 or 5 (58.4% on dialysis). Pooled SVR12/24 was 97.1% (95% CI 93.9-99.3%), and SAE rate was 4.8% (95% CI 2.1-10.3%). There was no significant difference at SVR12/24 (97.1% vs 96.2%, p = 0.72) or SAE rate (8.8% vs 2.9%, p = 0.13) between subgroups applying full or decreased dose of sofosbuvir. Cirrhotic and non-cirrhotic patients achieved comparable sustained virological response (RR 0.93, 95% CI 0.85-1.02). Four studies reported eGFR/serum creatinine pre- and post- treatment, with no significant modification.

CONCLUSIONS

Our study suggests SOF-based regimen might be used safely and effectively in patients living with HCV infection/stage 4-5 CKD, with normal and reduced dose of sofosbuvir. Prospective and well-controlled trials are needed to confirm these findings.

TRIAL REGISTRATION

PROSPERO CRD42018107440 .

Polyomavirus BK, BKV microRNA, and urinary neutrophil gelatinase-associated lipocalin can be used as potential biomarkers of lupus nephritis

Objective

Lupus nephritis (LN) frequently progresses to end-stage renal disease. Finding a biomarker for LN and a predictor for the development of chronic kidney disease (CKD) is important for patients with systemic lupus erythematosus (SLE).

Methods

Ninety patients with SLE were divided into biopsy-proven LN (n = 54) and no kidney involvement (non-LN) (n = 36) groups and followed up for 54 months.

Results

Of 36 patients with LN, 3 (5.6%) had class II disease, 3 (5.6%) had class III, 35 (64.8%) had class IV, 10 (18.5%) had class V, and 3 (5.6%) had class VI (advanced sclerosis). Compared to the non-LN group, patients in the LN group had higher autoimmunity evidenced by a higher proportion of low C3 and C4 levels, positive anti-double-stranded DNA antibody levels, and lower estimated glomerular filtration rates (eGFR). Urinary neutrophil gelatinase-associated lipocalin (uNGAL) levels were significantly higher in the LN group (LN vs non-LN, 670 vs 33 ng/mL, respectively). The patients with LN had a higher urinary polyomavirus BK (BKV) load (3.6 vs 3.0 log copies/mL) and a lower urinary BKV miRNA (miR-B1) 5p level (0.29 vs 0.55 log copies/mL, p = 0.025), while there was no significant difference in the level of miR-B1-3p. Urinary miR-B1-5p level but not urinary BKV load was negatively correlated with uNGAL level (r = -0.22, p = 0.004). At the cutoff value of 80 ng/mL, the receiver operating characteristic curve analysis showed that uNGAL level as a predictor of the presence of LN had a high sensitivity (98%) and specificity (100%) (area under the curve [AUC], 0.997; p < 0.001). During the 54-month follow-up period, 14 (7%) patients with LN and none of the non-LN patients developed CKD. Multivariate Cox regression analysis revealed that baseline uNGAL level was the only predictive factor for CKD development, while baseline serum creatinine level and eGFR were not.

Conclusion

An elevated urinary BKV viral load with a decreased level of miR-B1 implies the presence of LN. In addition, an increased uNGAL level is a good biomarker not only in predicting the presence of LN but also for prediction of CKD development in patients with SLE.

Varicella infections in patients with end stage renal disease: a systematic review

BACKGROUND

End stage renal disease (ESRD) is on the rise globally. Varicella infection among adult patients with ESRD has been reported to lead to multiple complications and even death. While varicella vaccination has been recommended in paediatric renal patients; recommendation on varicella vaccination among adult patients with ESRD remained sparse. This review is aimed at evaluating the impact of varicella infection among adult patients with ESRD and make a recommendation for vaccination.

METHODS

Three databases (PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched in April 2018 with keywords 'varicella, chronic kidney failure, chronic kidney disease, renal replacement therapy, kidney transplantation, end stage renal disease, end stage renal failure, chicken pox, vaccine, vaccination and complications'.

RESULTS

29 articles were selected for review. The studies were mainly case reports, and they included measured outcomes: prevalence of seronegativity, impact (morbidity, length of stay, and mortality) of varicella among patients with ESRD, seroconversion rates and safety of varicella vaccination. The prevalence of seronegativity among varicella-infected ESRD adults was found to be at 42 to 100%. Nineteen deaths were reported. At least 54 patients have had complications from varicella infection. Seroconversion rate post vaccination was found to be around 64-94%.

CONCLUSION

Varicella is associated with significant morbidity and mortality rates in adult patients with ESRD. Varicella vaccination should be considered for the vulnerable, seronegative patients.

Cost-effectiveness analysis of elbasvir-grazoprevir regimen for treating hepatitis C virus genotype 1 infection in stage 4-5 chronic kidney disease patients in France

Objective

To assess the cost-effectiveness of the elbasvir/grazoprevir (EBR/GZR) regimen in patients with genotype 1 chronic hepatitis C virus (HCV) infection with severe and end-stage renal disease compared to no treatment.

Design

This study uses a health economic model to estimate the cost-effectiveness of treating previously untreated and treatment experienced chronic hepatitis C patients who have severe and end stage renal disease with the elbasvir-grazoprevir regimen versus no treatment in the French context. The lifetime homogeneous markovian model comprises of forty combined health states including hepatitis C virus and chronic kidney disease. The model parameters were from a multicentre randomized controlled trial, ANRS CO22 HEPATHER French cohort and literature. 1000 Monte Carlo simulations of patient health states for each treatment strategy are used for probabilistic sensitivity analysis and 95% confidence intervals calculations. The results were expressed in cost per quality-adjusted life year (QALY) gained.

Patients

The mean age of patients in the HEPATHER French cohort was 59.6 years and 56% of them were men. 22.3% of patients had a F0 fibrosis stage (no fibrosis), 24.1% a F1 stage (portal fibrosis without septa), 7.1% a F2 stage (portal fibrosis with few septa), 21.4% a F3 stage (numerous septa without fibrosis) and 25% a F4 fibrosis stage (compensated cirrhosis). Among these HCV genotype 1 patients, 30% had severe renal impairment stage 4, 33% had a severe renal insufficiency stage 5 and 37% had terminal severe renal impairment stage 5 treated by dialysis.

Intervention

Fixed-dose combination of direct-acting antiviral agents elbasvir and grazoprevir compared to no-treatment.

Results

EBR/GZR increased the number of life years (6.3 years) compared to no treatment (5.1 years) on a lifetime horizon. The total number of QALYs was higher for the new treatment because of better utility on health conditions (6.2 versus 3.7 QALYs). The incremental cost-utility ratio (ICUR) was of €15,212 per QALY gained for the base case analysis.

Conclusions

This cost-utility model is an innovative approach that simultaneously looks at the disease evolution of chronic hepatitis C and chronic kidney disease. EBR/GZR without interferon and ribavirin, produced the greatest benefit in terms of life expectancy and quality-adjusted life years (QALY) in treatment-naïve or experienced patients with chronic hepatitis C genotype 1 and stage 4–5 chronic kidney disease including dialysis patients. Based on shape of the acceptability curve, EBR/GZR can be considered cost-effective at a willingness to pay of €20,000 /QALY for patients with renal insufficiency with severe and end-stage renal disease compared to no treatment.

A2 to B Blood Type Incompatible Deceased Donor Kidney Transplantation in a Recipient Infected with the Human Immunodeficiency Virus: A Case Report

BACKGROUND

With the introduction of the Kidney Allocation System in the United States in December 2014, transplant centers can list eligible B blood type recipients for A2 organ offers. There have been no prior reports of ABO incompatible A2 to B deceased donor kidney transplantation in human immunodeficiency virus-positive (HIV+) recipients to guide clinicians on enrolling or performing A2 to B transplantations in HIV+ candidates. We are the first to report a case of A2 to B deceased donor kidney transplantation in an HIV+ recipient with good intermediate-term results.

METHODS AND RESULTS

We describe an HIV+ 39-year-old African American man with end-stage renal disease who underwent A2 to B blood type incompatible deceased donor kidney transplantation. Prior to transplantation, he had an undetectable HIV viral load. The patient was unsensitized, with his most recent anti-A titer data being 1:2 IgG and 1:32 IgG/IgM. Induction therapy of basiliximab and methylprednisolone was followed by a postoperative regimen of plasma exchange, intravenous immunoglobulin, and rituximab with maintenance on tacrolimus, mycophenolate mofetil, and prednisone. He had delayed graft function without rejection on allograft biopsy. Nadir serum creatinine was 2.0 mg/dL. He continued to have an undetectable viral load on the same antiretroviral therapy adjusted for renal function.

CONCLUSIONS

To our knowledge, this is the first report of A2 to B deceased donor kidney transplantation in an HIV+ recipient with good intermediate-term results, suggesting that A2 donor kidneys may be considered for transplantation into HIV+ B-blood type wait list candidates.

Impact of HCV Infection on Diabetes Patients for the Risk of End-Stage Renal Failure

Both diabetes mellitus (DM) and hepatitis C virus infection (HCVI) are associated with chronic kidney disease (CKD). The aim of this study was to evaluate whether HCVI increases the risk of end-stage renal disease (ESRD) in patients with DM.The National Health Insurance Research database of Taiwan was used to conduct this study. After excluding patients with a prior history of CKD, all patients with a first diagnosis of DM from January 1, 2000 to December 31, 2002 were enrolled. The patients who also had HCVI were defined as index cases (HCV group, n = 9787). A comparison cohort at a 1:1 ratio of random incident patients with DM without HCVI matched by age, sex, age at the diagnosis of DM, duration between the diagnosis of DM and the index date, and various comorbidities through propensity score matching were recruited (non-HCV group, n = 9787). The patients were followed until December 31, 2011.The cumulative incidence rate of developing ESRD was significantly higher in the HCV(+) group than in the non-HCV group (P = 0.008). The incidence rate ratio (IRR) for the risk of ESRD was also significantly higher in the HCV(+) group (IRR: 1.44; 95% CI: 1.09-1.89) than in the non-HCV group, especially for those with a younger age (<50 years; IRR: 2.05; 95% CI: 1.22-3.45) and HCVI within 4 years after the diagnosis of DM (IRR: 1.85; 95% CI: 1.16-2.97). After adjusting for comorbidities in multivariate Cox proportional hazard regression analysis, HCVI (HR: 1.47; 95% CI: 1.11-1.93) was an independent factor for developing ESRD in the patients with DM. After starting dialysis for ESRD, the HCV(+) patients had a similar mortality rate to those without HCVI (P = 0.84).HCVI increases the risk of developing ESRD in patients with DM, especially in younger patients and in those who develop HCVI sooner after a diagnosis of DM.

Use of sofosbuvir-based direct-acting antiviral therapy for hepatitis C viral infection in patients with severe renal insufficiency

Sofosbuvir-based direct-acting antiviral therapy revolutionized the treatment of hepatitis C virus (HCV) infection. However, sofosbuvir use is not approved for patients with severe renal insufficiency (estimated glomerular filtration (eGFR) rate below 30 ml/min) or end-stage renal disease (ESRD) based on concerns raised during premarket animal testing over hepatobiliary and cardiovascular toxicity in this population. We report the first published data on use of sofosbuvir-based regimens in patients with severe renal insufficiency and ESRD, focusing on clinical efficacy and safety. Six patients were treated with full dose sofosbuvir; three received sofosbuvir and simeprevir, two received sofosbuvir and ribavirin, and one received sofosbuvir, ribavirin, and interferon. Three of the patients had cirrhosis. On-treatment viral suppression was 100% and sustained virological response (SVR) rate at 12 weeks was 67%. One patient had to discontinue antiviral therapy early due to side effects. No hepatobiliary or cardiovascular toxicity was reported.

Efficacy and tolerability of low-dose interferon-α in hemodialysis patients with chronic hepatitis C virus infection

AIM: To evaluate the efficacy and tolerability of low-dose standard or pegylated interferon (PEG-IFN) in hepatitis C virus (HCV)-positive hemodialysis patients.

METHODS: In total, 19 patients were enrolled in this study, of which 12 received PEG-IFNα-2a 67.5 μg 1 time/wk (Group 1) and 7 received standard interferon α-2b subcutaneously 1.5 × 10⁶ U 3 times/wk (Group 2). The treatment durations were 48 wk for patients infected with HCV genotype 1 and 24 wk for patients infected with HCV genotype 2/3. All patients were prospectively followed after the completion of therapy. The efficacy and tolerability of the treatment were evaluated based on the sustained virological response (SVR) and treatment-related drop-out rate.

RESULTS: In Group 1, 11 of the 12 patients completed the treatment. Early virological response (EVR) and sustained virological response (SVR) rates were 83.3% and 91.7%, respectively. One patient withdrew from treatment due to an adverse event (leukopenia). The drop-out rate was 8.3% in this group. In Group 2, 5 of the 7 patients completed the treatment with an EVR and SVR of 85.7% and 71.4%, respectively. Two patients withdrew due to treatment-related adverse events (nausea and depression). In this group, the drop-out rate was 28.6%. In total, 16 of the patients attained EVR, and 15 of them completed the treatment. The SVR rate for the patients who attained EVR was 93.7%. Anemia was the most frequent side effect and was observed in 10/19 patients (55.5%), but could be effectively managed with erythropoietin.

CONCLUSION: Low-dose interferon monotherapy, either with PEG-IFNα-2a or standard interferon α-2b, is an effective treatment option for hemodialysis patients with chronic hepatitis C.

High hepatitis B virus surface antigen levels and favorable interleukin 28B genotype predict spontaneous hepatitis C virus clearance in uremic patients

BACKGROUND & AIMS

Host and viral factors interplay in the spontaneous clearance of hepatitis C virus (HCV) infection. We aimed to explore the roles of IL28B genotypes and hepatitis B virus (HBV) infections in spontaneous HCV seroclearance.

METHODS

IL28B rs8099917 genotypes, HCV and HBV markers were determined in 290 patients who were seropositive for HCV antibodies from 1681 total uremic patients on maintenance hemodialysis.

RESULTS

Persistent HCV viremia was observed in 74.6% (214/287) of patients. Logistic regression revealed that the strongest factors associated with spontaneous HCV seroclearance were carriage of rs8099917 TT-type (odds ratio/95% confidence intervals [OR/CI]: 6.22/1.41-27.35, p=0.016), followed by concurrent hepatitis B surface antigen (HBsAg) seropositivity (OR/CI: 2.37/1.06-5.26, p=0.035). The clearance rate was highest among patients with both positive HBsAg/rs8099917 TT-type (44.8%, OR/CI: 20.88/3.5-402.5), followed by positive HBsAg/rs8099917 non-TT-type (28.6%, OR/CI: 8.86/1.8-160.8), and negative HBsAg/rs8099917 TT-type (26.7%, OR/CI: 12.75/1.0-319.4), compared to 4% of negative HBsAg/rs8099917 non-TT-type (trend p=0.0002). HBsAg levels, but not HBV DNA levels, were significantly associated with spontaneous HCV seroclearance. Spontaneous HCV seroclearance rate was 58.3% in patients with HBsAg>200IU/ml/rs8099917 TT-type (OR/CI: 42.54/5.7-908.4), 28.0% in patients with HBsAg<200IU/ml/rs8099917 TT-type or HBsAg>200IU/ml/rs8099917 non-TT-type (OR/CI: 11.12/2.3-201.0), compared to only 3.3% in those with HBsAg<200IU/ml/rs8099917 non-TT-type (trend p=0.0004). Five of 214 (2.3%) HCV viremic patients at enrollment had spontaneous HCV seroclearance during one-year follow-up, which was associated with baseline HCV RNA and HBsAg levels.

CONCLUSIONS

High HBsAg levels and favorable IL28B genotype were additively associated with spontaneous HCV seroclearance in uremic patients.

[Comparative evaluation of prevalence of infections caused by hepatitis B and C viruses among individuals of various groups with high risk of infection]

AIM

Determination of breadth of spread of hepatitis B and C viruses among members of 5 groups with high risk of infection.

MATERIALS AND METHODS

By enzyme immunoassay 3219 sera of members of groups with high risk of infection and 1541 sera of blood donors were studied for the presence of HBsAg and anti-HCV. In 5 risk groups were included: HIV-infected individuals, lung tuberculosis patients, hemoblastosis patients, chronic renal failure patients on hemodialysis and users of injectable drugs, permanently residing in Republic of Azerbaijan.

RESULTS

Frequency of detection of HBsAg and anti-HCV in these individuals was significantly higher than in control groups. HBsAg and anti-HCV most frequently occurred in HIV-infected individuals and users of injectable drugs--more than 50% of all the infected belonged to these groups. Average prevalence of these viruses was among hemoblastosis patients and chronic renal failure patients on hemodialysis--both markers were determined in approximately a third of patients of each group. The least prevalence was among lung tuberculosis patients--HBsAg and anti-HCV were determined in less than 25% of cases.

CONCLUSION

Serologic study carried out among members of groups of high risk residing in Azerbaijan allowed us to make a conclusion that all these individuals belong to groups with high prevalence of HBsAg and anti-HCV and by this be a collective reservoir of HVB and HVC in population.

Risk factors for herpes zoster reactivation in maintenance hemodialysis patients

OBJECTIVE

Herpes zoster (HZ) reactivation is common in immunocompromised patients. Advanced renal failure is also reportedly associated with impairment of cellular immunity. There is not any study yet assessing risk factors of HZ reactivation in hemodialysis patients.

METHODS

All patients undergoing maintenance hemodialysis for more than 3 months and who developed HZ between 2000/01/01 and 2009/12/31 in a tertiary referral medical center were identified, and matched 1:1 to hemodialysis patients without HZ by age and gender. Multivariate-adjusted conditional logistic regression model was constructed to determine possible risk factors.

RESULTS

Out of a total of 126 maintenance hemodialysis patients (65.3% female), 63 belonged to the HZ reactivation group and 63 to the age/sex matched control patients. Conditional logistic regression model linked corticosteroid use with heightened risk (odds ratio [OR] 20.2, 95% confidence interval [CI] 3.5-125.6; p=0.002), while iron therapy and 1α-hydroxylated vitamin D were associated with significantly lower likelihood of developing HZ (OR 0.12, 95%CI 0.0-0.6; p=0.01, and OR 0.06, 95% CI 0.0-0.4; p=0.005 respectively).

CONCLUSIONS

Use of iron preparations and 1α-hydroxylated vitamin D is potentially associated with less risk of developing HZ reactivation in maintenance hemodialysis patients.

Inauspicious contribution of hepatitis C virus and diabetes mellitus targeting kidneys: an update

Hepatitis C virus (HCV) infection and diabetes mellitus are frequent problems worldwide that induce high health and financial burden in different societies, both of which are also highly prevalent in patients with chronic kidney disease. Diabetes mellitus is a known underlying cause of end-stage renal disease, and on the other hand, HCV is responsible for a wide variety of renal manifestations, such as membranous nephropathy, cryoglobulinemia, and membranoproliferative glomerulonephritis. Moreover, along with its direct impact on kidney damage, HCV is also known to play a role in progression of other causes of kidney diseases. It is known that HCV infection is highly prevalent among patients with diabetic nephropathy. This article reviews the existing literature on the relationship between HCV infection and diabetes mellitus in patients with chronic kidney disease, and also overviews the interplay of these two factors in the transplantation era.

Varicella zoster virus reactivation in hemodialysis patients: manifestations, treatment, complications and outcome

Varicella zoster virus reactivation often occurs in the setting of impaired immunity, which is generally present in patients with end-stage renal disease (ESRD). Therapy for variceIla zoster virus infection is well established. However, it is often been forgotten that acyclovir dosage should be adjusted to renal function. We point to the problem encountered in clinical practice when ESRD patient presents with cutaneous herpes zoster and neurological symptoms. Clinical findings alone may prove inadequate to determine whether neurological deficit is caused by infection of the central nervous system or is a consequence of acyclovir induced neurotoxicity.

Hepatitis B virus-associated glomerular nephritis in East Asia: progress and challenges

BACKGROUND

Hepatitis B virus-associated glomerular nephritis (HBV-GN) is the most common secondary glomerulonephritis in East Asia. Part of the patients developed to renal insufficiency within 10 years, which cause a great burden for patients' family and society.

METHODS

We reviewed basic and clinical research work in China, Japan, Korea, and Mongolia, eastern part of Asia. Comparisons between data from East Asia and those from other regions were made.

RESULTS

The genetic variations conferring susceptibility to HBV-GN and disease progression as well as the pathogenic role in HBV-GN progression were investigated. Clinical features of HBV-GN in East Asia were different from that of other regions in the world. Clinical trials showed that treatment with anti-viral agents was effective to promote the disease remission.

CONCLUSION

HBV-GN remains a great challenge to East Asian nephrologists. In-depth basic studies and multi-centered clinical trials are needed in the future.

Prevalence of chronic renal failure stage 3 or more in HIV-infected patients in Antwerp: an observational study

The introduction of Highly Active Antiretroviral Therapy has transformed HIV-infection from an inevitably lethal disease to a chronic condition with a life expectancy comparable to that of people with diabetes mellitus. In recent years it has become evident that people living with HIV/AIDS have an increased risk of developing cardiovascular disease and it is expected that the prevalence of chronic kidney disease will rise accordingly. To investigate the prevalence of chronic kidney disease in patients with HIV, we conducted a retrospective observational analysis using the clinical database of a large centre (Institute of Tropical Medicine) in the urban area of Antwerp, Belgium. The prevalence of chronic kidney disease among HIV infected subjects was found to be 3.0%. The development of chronic kidney disease was associated with age above 50 years, lower CD4 cell counts and Caucasian origin. Screening for chronic renal disorders and prevention of evolution toward chronic renal failure is a crucial challenge in the management of people living with HIV/AIDS.

The influence of hepatitis C infection activity on oxidative stress markers and erythropoietin requirement in hemodialysis patients

We sought to expose the possible effect of hepatitis C virus (HCV) infection on oxidative stress indicators, nutritional status, and erythropoietin (rHuEPO) requirements in maintenance hemodialysis (MHD) patients. A total of 111 MHD patients (69 males, 42 females; mean age 51.3 +/- 13.0 years; MHD duration 78.5 +/- 52.1 months) and 46 healthy controls were enrolled in the study. We excluded patients with hepatitis B infection or malignancy. Indicators for oxidative status were studied in plasma samples obtained at the beginning of a clinically stable MHD session. Measurements were performed for plasma superoxide dismutase, glutathione peroxidase (antioxidative agents), and malonyldialdehyde (MDA; oxidative agent) by spectrophotometric methods. All patients were analyzed for the presence of anti-HCV; positive patients were also evaluated for the presence of HCV RNA. MHD patients were divided into three groups according to HCV infection status: group I (anti-HCV-positive, HCV-RNA-negative; n = 22); group II (anti-HCV-positive, HCV-RNA-positive; n = 22), and group III (anti-HCV-negative; n = 67). According to the analyses, MHD patients showed higher plasma oxidative stress indicators and lower antioxidative indicator levels compared to controls (P < .0001). MHD patients also displayed lower albumin and higher C-reactive protein (CRP) levels compared to controls (P < .0001). Antioxidant levels were decreased significantly from group I to III (P < .0001). MDA levels significantly increased from group I to III (P < 0.01). HCV-RNA-positive patients showed lowest albumin and highest CRP levels and rHuEPO requirements. Although alanine transferase (ALT) levels were in the normal range, group II patients had significantly higher ALT levels than the other groups (P < .01). In conclusion, we observed negative effects of active HCV infection on oxidative stress and rHuEPO requirements. In contrast, we detected that clinically inactive HCV infection was associated with reduced oxidative stress and rHuEPO requirements compared with active HCV infection and HCV-negative patients.

De novo thrombotic microangiopathy induced by cytomegalovirus infection leading to renal allograft loss

After kidney transplantation, thrombotic microangiopathy (TMA) can occur de novo or as recurrent disease. Risk factors for de novo posttransplant TMA include ischemia-reperfusion injury, immunosuppressive drugs, viral infections, acute humoral rejection, and complement gene abnormalities. Cytomegalovirus infection as a trigger for posttransplant TMA in kidney transplant recipients has only been reported in 7 cases, all of them between 4 weeks and 8 years after transplantation. We describe a new case of de novo TMA in association with cytomegalovirus infection 25 years after kidney transplantation.

Therapy with nucleos(t)ide analogues: current role in dialysis patients

Hepatitis B virus (HBV) infection persists among patients undergoing maintenance dialysis in the industrialized world. Knowledge of the epidemiology and the natural history of HBV infection in dialysis patients has markedly improved but antiviral therapy for hepatitis B remains a significant challenge in this population. A variety of therapeutic options are now available for the treatment of chronic hepatitis B, including potent new nucleos(t)ide analogues, along with standard and pegylated interferon. The most extensive experience in the dialysis population has been with lamivudine. Although several questions about lamivudine use in dialysis patients remain unanswered, it has shown potent antiviral activity: the range of clearance of HBV viremia (HBV DNA) from serum is between 56% and 100% in dialysis patients with chronic hepatitis B. Its major limitation is emergence of resistance. Tolerance to conventional or pegylated interferon monotherapy is poor in the dialysis population. There is limited data regarding adefovir dipivoxil (ADV) therapy in the dialysis population, while very little information is available about the use of the newer agents, tenofovir and entecavir, in patients with renal failure. It is recommended that dialysis patients with persistent HBsAg seropositive status be evaluated for antiviral treatment and that the decision to treat be based on the potential benefits and risks of therapy including life expectancy, candidacy for kidney transplantation, and comorbidities. Hepatitis B is relatively uncommon among patients undergoing dialysis in developed countries and this clearly hampers prospective clinical trials aimed to evaluate the efficacy and safety of therapy with nucleos(t)ide analogues for chronic hepatitis B in this population.

Prognostic value of quantitative-PCR versus serology for detection of CMV in pre- and post- transplantation patients

Two hundred-twenty six pre- and post- kidney transplantation patients were screened for CMV. They were categorized into three groups I: Eighty-five dialysis patients suffering from chronic renal failure, II: Sixty -two end stage renal disease patients prepared for transplantation, and III: Seventy-nine post-kidney transplant patients under immunosuppressive and cytotoxic therapy. The last group was subdivided according to clinical presentation into asymptomatic, mild, and invasive CMV disease subgroups. A control group comprised of fifty-two apparently healthy kidney and blood donors were also included. Serum and plasma samples were utilized for detection of anti-CMV antibodies by EIA, and determination of CMV viral load by quantitative-PCR respectively. QT-PCR results revealed high viral load; (4000-10.000 copy/ml) in 16 (100%) kidney recipient with invasive CMV disease, While only 4 (25%) of them were positive for IgM anti-CMV. Another ten patients with symptoms of CMV syndrome were found CMV-PCR positive with low viral load (436-3070 copy/ml) and all were negative for IgM anti-CMV. On the other hand, no CMV viral load was detectable among end-stage renal disease patients, although 6/62 (9.7%) were positive for IgM anti-CMV. All subjects were positive for IgG anti-CMV. It is concluded that QT-PCR rather than serology should be used for monitoring of CMV infection in pre- and post-transplantation patient.

Screening for hepatitis B, C and HIV infection among patients on haemodialysis (cross sectional analysis among patients from two dialysis units in the period January to July 2005)

The aim of the work was to detect the serum prevalence of HBV, HCV and HIV infections in patents with ESRD (end stage renal disease) on haemodialysis treatment from two dialysis units.

MATERIAL AND METHODS

178 patients from two haemodialysis units in Skopje (Department of Nephrology and HDC Zelezara) who received haemodialysis treatment over the period January to July 2005 were involved in a cross-sectional analysis. Patients were aged 31 to 77 (mean 54) years. Serum samples were used for: detection of markers for hepatitis B - HBs antigen (Ag), HBsT antibody (Ab) and HBcT Ab with chemiluminescent enzyme immunoassay; detection of HIV Ab and HCV Ab with the ELISA method; detection of HCV RNA with qualitative PCR. Statistical analysis was done only of patients with complete serological investigations (HCV, HBV and HIV).

RESULTS

Detectable markers for HBV infections were found in 43 patients (24.16%). Of these, 3 patients (1.68%) had positive HbsAg. Previous exposure to HBV was seen in 40 patients (22.47%). 57 patients (32.02%) had detectable markers (HCV Ab and/or HCV RNA) for HCV infections. 39 patients (21.91%) had detectable HCV RNA. 24 patients were positive for HBV and HCV markers. The total number of patients with anti HCV Ab was 56 (31.46%). All investigated patients were negative for anti HIV Ab. There is a positive correlation between AST elevation and HCV RNA (r = 0.342, p = 0.023) as well between AST elevation and HBsT (r = 0.300, p = 0.048). A positive correlation was found between ALT elevation and HCV RNA (r = 0.374, p = 0.012). A Chi square test found significance between the time on dialysis and detection of HCV RNA (chi-square 7.771, p = 0.05).

CONCLUSION

The results of our survey presented a prevalence of 24.16% of HBV and a prevalence of 32.02% of HCV in patients with renal failure on haemodyalisis programmes from two dialysis units for the six month period. HIV was not detected among the investigated patients. Immunoenzyme tests were the method of choice for the screening programme. The use of the PCR for detection of nucleic acid of viruses that can be the cause of infection for these persons is especially important. Timely detection of HBV, HCV and HIV infection among haemodyalisis patients is necessary for the due performance of therapy, as well as for taking preventive measures for the protection of other patients and staff in the haemodyalisis unit.

SEN virus infection in Egyptian patients undergoing maintenance hemodialysis: prevalence and clinical importance

BACKGROUND AND PURPOSE

SEN virus (SENV) is assumed to be responsible for post-transfusion non-A to -E hepatitis. Phylogenetic analysis of SENV has shown 9 different strains. Two strains, SENV-H and SENV-D, were described as possible candidates for post-transfusion hepatitis. This study examined the prevalence of SENV infection and its clinical importance for patients undergoing hemodialysis.

METHODS

Serum samples were obtained from 63 long-term hemodialysis patients, and examined for SENV-H and SENV-D viremia by polymerase chain reaction. Serum samples were also obtained from 20 patients with chronic kidney diseases (CKD) who were not undergoing hemodialysis and from 20 apparently healthy blood donors to act as controls. For SENV screening, a primer pair was used for the conserved ORF1 region among all SENV genotypes from A to I.

RESULTS

SENV infection was significantly more frequent among hemodialysis patients (33/63; 52.4%) and those with CKD (10/20; 50.0%) than among the control participants (2/20; 10.0%) [p = 0.003]. Twenty three of 33 hemodialysis patients had SENV-H or -D, 61% of whom were positive for SENV-H only, 4% were positive for SENV-D only, and 36% were positive for both SENV-H and SENV-D. SENV infection was not associated with age, sex, amount or duration of hemodialysis, or liver function test results. Elevated alanine aminotransferase was significantly associated with HCV viremia, but not with SENV infection.

CONCLUSIONS

Egyptian hemodialysis patients and those with CKD are at higher risk for SENV transmission. SENV-H is more prevalent than SENV-D.

Erythropoietin and the pro-inflammatory cytokines in chronic C hepatitis

BACKGROUND/AIMS

Erythropoietin has an antiinflammatory action. We proposed to study its effects on patients with chronic hepatitis C.

METHODOLOGY

We studied a group of 96 hospitalized patients. Those with viral chronic hepatitis C were divided into 2 groups: group A--41 patients with chronic renal failure, and group B--23 patients without renal failure. 32 patients without any hepatitis viruses formed the control group--C. We analyzed: the biochemical tests, the serum IL-6, IL-8, TNF-alpha, C reactive protein, and erythropoietin.

RESULTS

The levels of pro-inflammatory cytokines and of erythropoietin were higher in the patients from groups A and B, except the value of TNF-alpha from group B. The dialyzed patients had higherpro-inflammatory cytokines and lower erythropoietiin comparing with the non-dialyzed patients.

CONCLUSIONS

Erythropoietin levels and some proinflammatory cytokines increasein patients with chronic hepatitis C. Erythropoietin could have an anti-inflammatory effect on thepatients without renal failure.

HBV-DNA in hemodialysis patients infected by HCV

End-stage renal disease patients on chronic hemodialysis (HD) patients are at risk for both hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, and they may coexist. To determine the prevalence and clinical impact of HBV and HCV infection, we studied poly chain reaction (PCR) and reverse transcription (RT)-PCR on the blood samples of 90 HD patients in Kerman, Iran. ELISA test was used to detect anti-HBc, anti-HBs and HBsAg. We found that 30 out of 90 (33.3%) patients were PCR-RT-PCR positive for HCV-RNA. No HBV-DNA (0%) was detected through the PCR study in both positive and negative HCV-RNA patient groups. Though none of the samples was HBsAg positive, 10 (33.3%) HCV-RNA positive patients were anti-HBc positive, and 12 (40.7%) were anti-HBs positive. We conclude that prevalence of hepatitis C infection is high in HD patients in our region, but not associated with active HBV infection.

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.

Patterns of viraemia in haemodialysis patients with hepatitis C

Clinical features, aminotransferases levels, and antibody to HCV have only limited correlation with the activity of liver disease and cannot accurately predict persistence versus eradication of the virus in haemodialysis patients. Although permanent loss of serum HCV RNA appears to correlate with resolution of the disease, little is known about the predictive value of a single HCV RNA value. The aim of the study was to evaluate the viraemia in the serum of HCV antibody positive haemodialysis patients during a period of 3 years. The study group consisted of 65 HCV antibody positive patients from our dialysis unit. HCV antibodies were measured every 6 months by ELISA third-generation assay. The presence of serum HCV RNA was assessed by reverse-transcriptase polymerase chain reaction (RT-PCR) once a year during the period of 3 years. Serum levels of aminotransferases were measured monthly with standard automated analyzers. There were three different patterns of viraemia after the third assessment of the serum HCV RNA in HCV antibody positive patients: 47% (30/65) were persistently HCV RNA positive, 38% (25/65) were intermittently HCV RNA positive, and 15% (10/65) were persistently HCV RNA negative. The dominant genotype was 1a, detected in 97% of the patients positive for HCV RNA. The HCV RNA persistently positive patients had significantly higher levels of ALT compared to HCV RNA persistently negative patients (50.07 +/- 30.0 vs. 28.5 +/- 10.0 U/L, p < 0.027). There was no significant difference between the three groups of patients according to age, haemodialysis duration, and serum levels of AST. This pattern of intermittent viraemia clearly showed that a single negative result of the presence of serum HCV RNA in an HCV antibody positive patient should not be taken as a proof of a persistent resolution of HCV. Thus, repeated testing for HCV RNA is necessary to assess viraemia accurately in HCV antibody positive patients. HCV antibody positive patients who were persistently serum HCV RNA negative could be potentially infectious because of the possibility of the persistence of occult hepatitis C.

New approaches in the therapy of hepatitis C in dialysis patients

Patients with renal disease are at increased risk of acquiring hepatitis C virus (HCV) infection because of their frequent exposure to blood from transfusions or exposure to HCV-contaminated medical equipment during hemodialysis. The prevalence of anti-HCV antibodies among hemodialysis patients varies between 5-10% in the developed world, and 10-70% in developing countries. Acute hepatitis C is often mild and associated with few, if any symptoms. The major complication of acute HCV infection is chronic hepatitis, which occurs in up to 80% of the cases, the long-term outcome being cirrhosis, portal hypertension, hepatic failure, and hepatocellular carcinoma. Interferon alpha (IFN-alpha) has shown activity against HCV. Twenty four to 48 week course of therapy with interferon could lead to a sustained loss of HCV RNA, normalization of alanine aminotrasferase (ALT) levels, and resolution of the liver disease. Sustained viral response was achieved in approximately half of the treated patients. Therapy with interferon was associated with a number of adverse events such as: "flu-like" symptoms, neurological, gastrointestinal symptoms, anemia, fatigue, thrombocytopenia, leucopenia. A major advance in therapy came with the addition of ribavirin to interferon therapy. Peginterferon-alpha-2a (40KD) is a new 'pegylated' subcutaneous formulation of interferon-alpha-2a, that was developed to improve the pharmacokinetic profile and therapeutic efficacy of interferon-alpha-2a. In our study, fourteen hemodialysis patients with chronic hepatitis C received 135 microg PEG-IFN alpha-2a subcutaneously, once a week, after dialysis session for a period of 48 weeks. In the intention-to-treat analysis, sustained viral response was present in 36% of the patients (five out of fourteen patients) at the end of the follow up period. The biochemical response with normalization of serum ALT levels during the treatment was observed in all treated patients (83 +/- 20.1 U/L at base line vs. 23.4 +/- 4.6 U/L after the 48 weeks; p < 0.01). At present, therapy for hepatitis C should be considered in hemodialysis patients with significant liver disease, minimal other co morbidities, and a reasonable likelihood of prolonged survival or if renal transplantation is planned.

Gamma-glutamyltransferase activity in chronic dialysis patients and renal transplant recipients with hepatitis C virus infection

The prevalences of chronic infection by hepatitis C virus (HCV) and its genotypes vary among countries and ethnic groups. Among patients with end-stage renal disease (ESRD) and transplant recipients, the evolution of hepatic disease seems atypical and has not been established. In this study we compared the prevalence and HCV genotypic distribution among Brazilian patients with ESRD on dialysis or with transplantations. Moreover, we sought to compare the behavior of biochemical markers of hepatic activity of HCV infection in both groups. We prospectively evaluated 87 ESRD patients on dialysis and 105 transplant patients. Blood samples were obtained to perform qualitative HCV-RNA, genotyping, and, periodically, serum levels of aminotransferases (ALT, AST), gamma-glutamyltransferase (GGT), alpha-fetoprotein (AFT), and albumin. The prevalence of HCV in ESRD patients was similar to recipients (19.5% vs 25.7%; P = NS) and the most frequent genotype was 1a. There was no difference in the mean values of ALT, GGT, AFT, and serum albumin between both groups with HCV infection. The mean values of aminotransferases were slightly elevated and a high frequency of patients evolved with persistently normal parameters. In contrast, the mean values of the GGT were 3 or 4 times above the reference limit and a greater frequency of patients evolved with values persistently elevated in the 2 groups. In conclusion, in the 2 groups the prevalence of HCV infection was elevated; the most frequent genotype was 1a. Among the biochemical parameters, GGT seemed to be useful as an indirect marker of liver disease.

Hepatitis C virus genotypes in patients with end-stage renal disease in East Azerbaijan, Iran

Information about the genotypes and associated risk factors in hepatitis C virus (HCV) infected patients in Iran is limited. The aim of this study was to identify the HCV genotypes and associated risk factors in a group of HCV infected patients on dialysis therapy in Iran. The sera of 753 patients with chronic renal failure from fifteen dialysis units in East Azerbaijan Province were screened for anti-HCV antibodies as well as HCV RNA; viral RNA was extracted for the genotype specific primer approach. Patients were questioned concerning documented risk factors. Genotyping analysis was performed in 55 patients with positive anti-HCV and HCV-RNA. Genotypes 1 and 3 were found in 46 (83.7%) and three (5.5%) patients, respectively. The most frequent HCV subtype was 1a (76.4%), followed by 3a and 1b and 1b (5.5% each) while one patient was infected with both 1a and 1b. There was no statistically significant difference between the risk factors analyzed and the acquisition of HCV infection. This study gives added evidence of the predominant HCV genotypes in Iran, which is different than reports from other Arab countries and similar with the pattern of genotype in both Europe and United States.

Hepatitis C virus infection as a risk factor for increased aortic stiffness and cardiovascular events in dialysis patients

BACKGROUND

Although links have been found between microorganisms and cardiovascular diseases, the role of hepatitis C virus (HCV) infection in the pathogenesis of arteriosclerosis and cardiovascular events is unclear. The primary objective of this research was to examine whether HCV infection is associated with increased aortic stiffness and cardiovascular events in chronic hemodialysis patients.

SUBJECTS AND METHODS

A prospective cohort study was conducted in 94 dialysis outpatients from October 2002 to October 2004. Measurements included carotid-femoral pulse wave velocity (PWV), echocardiographic parameters, serum HCV-RNA (positive in 17 patients), and several items of biochemical data. Multiple logistic regression and the Cox proportional hazard model were used to assess independent determinants of high aortic PWV (> or =10.0 m/sec, mean) and cardiovascular events (including cerebral and peripheral vascular events), adjusting for several risk factors and duration of dialysis.

RESULTS

The HCV-positive group had higher aortic PWV and lower serum cholesterol levels. Multivariate analysis indicated mean blood pressure, hemoglobin A1c and HCV viremia to be independent determinants of high PWV. During the follow-up period, 13 patients suffered from cardiovascular events. Prevalence of the diseases at baseline, pulse pressure, left ventricular mass index, HCV viremia and aortic PWV were associated with cardiovascular events. The Kaplan-Meier analysis indicated a significant difference in event-free rates between HCV-positive and HCV-negative patients.

CONCLUSION

HCV infection is closely associated with increased aortic stiffness and cardiovascular event in dialysis patients.

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.

Infections in patients with chronic kidney disease

There has been a notable lack of research activity regarding major infections in patients with advanced chronic kidney disease. To an outsider, this might seem unexpected, because uremia has long been considered a state of immune hyporesponsiveness and rates of major bacterial infection, like septicemia and pneumonia, are known to be orders of magnitude more likely in dialysis populations than in the general population. This article reviews recent literature on the topic, focusing predominantly on the clinical epidemiology of major bacterial infections in dialysis patients, the links between bacterial infections and cardiovascular disease, and randomized trials of interventions designed to prevent these infections.

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.

The impact of HIV on chronic kidney disease outcomes

Chronic kidney disease (CKD) is a known complication of the human immunodeficiency virus (HIV) but outcomes among HIV-infected patients with kidney disease are unknown. We studied a national sample of 202,927 patients with CKD (stage 3 or higher) for death, end-stage renal disease (ESRD) and the mean annual rate of decline in estimated glomerular filtration rate (eGFR) over a median period of 3.8 years. Within this sample, 0.3% of the patients were diagnosed with HIV, 43.5% were diabetic, whereas the remainder had neither disease. In this national CKD cohort, HIV-infected black patients were at higher risk of death, a similar risk for ESRD and loss of eGFR than black patients with diabetes. HIV-infected white patients experienced higher rates of death but a lower risk of ESRD than their counterparts with diabetes. Our results highlight a need to study mortality and mechanisms of ESRD in the HIV infected population.

Similar HCV viral load levels and genotype distribution among end-stage renal disease patients on hemodialysis and HCV-infected patients with normal renal function

BACKGROUND

At present it is not clearly established if hepatitis C virus (HCV)-RNA levels and genotype distribution have any peculiar aspect in HCV-infected end-stage renal disease (ESRD) patients. The aim of this study was to evaluate in HCV-infected ESRD patients, the alanine aminotransferase (ALT) profile, HCV-RNA levels and genotype distribution, comparing them with HCV-infected patients with normal renal function.

METHODS

A cross-sectional study was performed in 66 hemodialysis patients (group 1) and 264 subjects with normal renal function (group 2). All participants in both groups had detectable HCV-RNA. Mean ALT levels were determined in all subjects as well the viral load and the genotype.

RESULTS

Groups were similar according to gender and age. ALT was normal in 74% patients in group 1 and in 23% in group 2 (p<0.001). The median viral load was 5.3 x 10(5) IU/mL in group 1 and 6.6 x 10(5) IU/mL in group 2 (p=0.23). Genotype 1b was the most prevalent in both groups (56% vs. 57%; p=0.38).

CONCLUSION

HCV-infected ESRD patients have lower ALT levels, but the viral load and the genotype distribution are similar to those observed in HCV-infected individuals with normal renal function.

End-stage renal disease due to polyomavirus in a cardiac transplant patient

BACKGROUND

A 51-year-old male orthotopic cardiac transplant recipient experienced a prolonged rejection episode immediately after transplantation. Three years and 5 months after transplantation, he presented with lower extremity swelling; at this presentation, the patient's serum creatinine level was 345 micromol/l (3.9 mg/dl), his urinalysis was trace positive for both protein and blood, the urinary sediment had no casts and his 24-hour urine collection showed 750 mg protein. The patient's renal function deteriorated over the next month, with his serum creatinine level reaching a peak of 530 micromol/l (6 mg/dl). He died 4 years and 3 months after transplantation as a result of an arrhythmia.

INVESTIGATIONS

Physical examination, urine and blood analyses, ultrasound-guided renal biopsy and autopsy.

DIAGNOSIS

Polyomavirus-associated nephropathy with the development of end-stage renal disease.

MANAGEMENT

Adjustment of immunosuppressive therapy and initiation of hemodialysis.

Prevalence of occult hepatitis B and hepatitis C virus infections in Turkish hemodialysis patients

BACKGROUND AND OBJECTIVE

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are important causes of morbidity and mortality in maintenance hemodialysis patients. Although their exact prevalence is not known, HBV and HCV viral infections and occult viral hepatitis are frequent in these patients. This study aimed to determine the prevalence of occult HBV and HCV infections in maintenance hemodialysis patients.

MATERIALS AND METHODS

One hundred and eighty-eight end-stage renal disease patients on maintenance hemodialysis (100 male, mean age 49+/-29 [16-80] years, and mean duration of hemodialysis 98+/-66 [12-228] months) were enrolled in this study. Serological markers for HBV and HCV were determined with immunoenzymatic assay (ELISA) by using commercial diagnostic kits (Access and BioRad, Beckman-Coulter). HCV-RNA (Cobas Amplicor HCV kit) and HBV-DNA (Artus GmbH HBV kit) were determined quantitatively by polymerase chain reaction.

RESULTS

Among the patients screened, 25 (13.3%) had HBV infection alone and 38 (20.2%) had HCV infection alone, while seven (3.7%) had dual infection of both viruses. Serological markers for occult hepatitis B and occult hepatitis C were positive in five (2.7%) and nine (4.8%) of the patients, respectively. Isolated anti-HBc was positive in 12 (6.4%) of all patients, three (7.9%) of the patients with anti-HCV and two (40%) of the patients with occult hepatitis B. Isolated anti-HBc positivity was more frequent in patients with occult hepatitis B than in those without (40% [2/5] vs. 5.5% [10/183], p=0.002). None of the patients with HCV had occult hepatitis B.

CONCLUSIONS

Both occult and non-occult forms of HCV infection are more prevalent than HBV infection in hemodialysis patients. Especially the patients with isolated anti-HBc positivity should be tested for probable occult hepatitis B infection.

Hepatitis C virus and death risk in hemodialysis patients

In maintenance hemodialysis (MHD) patients, hepatitis C virus (HCV) infection is common and may be associated with poor clinical outcomes. It was hypothesized that HCV infection would be associated with high all-cause and cardiovascular mortality in these patients after controlling for demographic and clinical characteristics, including surrogates of malnutrition-inflammation complex syndrome. A national database of 13,664 MHD patients who underwent HCV antibody serology testing at least once during a 3-yr interval (July 2001 through June 2004) was analyzed. Measurements included third-generation HCV enzyme immunoassay and routine laboratory measurements. The HCV enzyme immunoassay was reported positive in 1590 (12%) patients. In logistic regression models that included case mix and available surrogates of malnutrition-inflammation complex syndrome, HCV infection was associated with younger age, male gender, black race, Hispanic ethnicity, Medicaid insurance, longer dialysis vintage (duration), unmarried status, HIV infection, and smoking history. In proportional-hazards regressions, the mortality hazard ratio that was associated with HCV infection was 1.25 (95% confidence interval 1.12 to 1.39; P < 0.001). Mortality hazards were higher among incident (dialysis duration <6 mo) than prevalent HD patients. Subgroup analyses indicated that HCV was associated with higher all-cause and cardiovascular mortality across almost all clinical, demographic, and laboratory groups of patients. Hence, in MHD patients, HCV infection exhibits distinct demographic, clinical, and laboratory patterns, including associations with higher dialysis treatment vintage, and is associated with higher mortality. More diligent efforts to prevent and treat HCV infection may improve outcomes in MHD patients.

Clinical and histological efficacy of pegylated interferon and ribavirin therapy of recurrent hepatitis C after liver transplantation

Treatment of recurrent hepatitis C in liver transplant is controversial. The aim of our study was to evaluate the clinical and histological efficacy of pegylated interferon alpha 2b (PEG-IFN) and ribavirin therapy of recurrent hepatitis C after liver transplantation (LT). We prospectively included 47 liver transplant patients with: 1) a positive test for hepatitis C virus (HCV)-ribonucleic acid (RNA) in serum; 2) alanine aminotransferase (ALT) >45 UI/mL; and 3) a liver biopsy showing chronic hepatitis without rejection in the previous 2 months. Patients received PEG-IFN (1.5 microg/kg/week) and ribavirin (800-1,000 mg/day) for 12 months. Follow-up was based on biochemical (ALT), virological (RNA-HCV), and histological (liver biopsy) examinations. Follow-up lasted a minimum of 6 months after the end of antiviral therapy. Sustained virological response (SVR) was achieved in 23% of the patients. A total of 33 (70%) patients had normalized ALT levels at the end of therapy. Inflammatory portal and lobular score declined significantly in patients with SVR (P < 0.05) but not in nonresponder patients. Fibrosis did not change significantly in either group. SVR was significantly associated with low gamma-glutamyltransferase GGT (P = 0.04) and HCV-RNA levels (P = 0.03), a virological response at 12 weeks (P = 0.002) and patient's compliance (P = 0.04). Ten (21%) patients were withdrawn prematurely due to adverse effects. In conclusion, Therapy with PEG-IFN and ribavirin achieved SVR and a significant histological improvement in 23% of liver transplant recipients with chronic hepatitis C. Toxicity is an important drawback of this therapy.