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Saudi Journal of Kidney Diseases and Transplantation
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EDITORIAL Table of Contents   
Year : 1995  |  Volume : 6  |  Issue : 2  |  Page : 115-117
Hepatitis C Infection: The Subject of this Issue

Department of Nephrology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

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How to cite this article:
Al-Khader AA. Hepatitis C Infection: The Subject of this Issue. Saudi J Kidney Dis Transpl 1995;6:115-7

How to cite this URL:
Al-Khader AA. Hepatitis C Infection: The Subject of this Issue. Saudi J Kidney Dis Transpl [serial online] 1995 [cited 2020 Jun 1];6:115-7. Available from: http://www.sjkdt.org/text.asp?1995/6/2/115/40848
The impact of hepatitis C viral (HCV) infection in Nephrology practice cannot be over emphasized. The proliferation of papers published and read about it, in meetings of nephrology and organ transplantation attest to this fact. The Editorial team of the Saudi Journal of Kidney Diseases and Transplantation felt that it was timely and important, to set aside an issue on this subject due to its importance in the field of kidney diseases and transplantation in general and the Arab world in particular, where the prevalence of hepatitis infection appears to be common in the general population and particularly in the dialysis and the renal transplant populations. It has been noted for some time that liver disease is quite widespread among dialysis and transplant patients. This has been attributed to non-A, non-B factor(s). With the advent of ways of detecting hepatitis C antibodies, it is now clear that hepatitis C is the most important cause of liver disease in the dialysis and the transplant populations. Moreover, hepatitis C infection is a major cause of liver disease in the general population, leading in 50% of the cases, to chronic active hepatitis (CAH) with or without cirrhosis and being a major cause of primary hepatic carcinoma.

In this issue, Dr. Ramia (Riyadh) describes molecular virology and its implications on the serologic diagnosis of HCV infection. The virus is shown to contain a single strand of Ribonucleic acid (RNA) molecule encodes glycoprotein composed of structural and non­structural protein. RNA virus has similarities to Flavi and Pesti viruses. The virus has been shown to have a number of genotypes, possibly as many as 12, according to the amino-acid sequence. This variability will have implications on diagnosis, infectivity, prognosis, method of spread and development of a vaccine.

Dr. Ramia describes the tests available for diagnosis of HCV infection. First generation ELISA has many drawbacks, including the late detection of infection and high incidence of false positivity. Second generation ELISA incorporates more antigens of the virus with better sensitivity and specificity. The sensitivity of the test is further increased by the use of a second generation recombinant immuno-blot assay. The use of polymerase chain reaction (which is not widely available) increases the sensitivity further and defines infectivity.

From Dr. Al Faleh's (Riyadh) paper we learn that there are varied routes of transmission notably parenteral, hence the increased incidence in hemophiliacs, thalasse-mics and patients on hemodialysis. However, this route accounts for only 40% of cases. Sexual, perinatal and intrafamilial transmission are uncommon routes of transmission of the HCV infection. The prevalence of HCV antibodies in the general population varies from one region to another.

Dr. Shakil (Makkah) shows the prevalence in a cohort of 1439 blood donors, to be 3.61%. It was 1.7% among Saudis, and was the highest among Egyptians (27.2%).

It appears from the papers in this issue, that there is a high prevalence of HCV infection in dialysis patients in the Arab world ranging between 24% and 83%. This prevalence varies in other countries as Dr. Huraib describes, being 1-29% in Western Europe, 8­36% in North America, 39% in South America and 44-60% in Far East countries. Even within Saudi Arabia, the prevalence varies. Dr. Huraib (Riyadh) describes also the prevalence in the hemodialysis patients in Saudi Arabia to be 83.9% in the Central region, 94.7% in Southern region, and 15% in Northern region.

The duration of dialysis correlated positively with the presence of the infection. Another point emerges here that a rise in liver enzymes is not a consistent finding, and that liver biopsies of the affected patients may not correlate with the presence of elevated enzymes, although persistently highly elevated enzymes generally indicate severe histology. Dr. Abboud (Qatar) found chronic active hepatitis in liver biopsies of six out of eight HCV antibodies positive dialysis patients with abnormal liver enzymes. Dr. El Reshaid (Kuwait) found similar findings in five out of six HCV antibodies positive patients with persistently elevated liver enzymes.

Dr. Ramzay (Egypt, personal communi­cation) reported a high prevalence of anti­HCV antibodies in the hemodialysis population in Egypt ranging from 75% to 85%. He biopsied 25 HCV antibodies positive patients in preparation for transplantation and found chronic active hepatitis in eight of them, and cirrhosis in one.

Dr. Souqiyyeh (SCOT) describes a comprehensive survey which highlights the serocon-version rate in the dialysis units in the Kingdom of Saudi Arabia. He found a high annual seroconversion rate to positive HCV antibodies of 7 to 9%. There was no correlation with the size of the dialysis unit, but correlations with the history of blood transfusion and the duration of dialysis were found with the increased rate of seroconversion.

A number of authors tested their hemodialysis staff for HCV antibodies and the prevalence found was no different from that of the general population.

In many studies, there is a general agreement that blood transfusion is not the only risk factor, as there was no significant difference, in the prevalence of HCV infection, between those transfused and those not transfused. Dr. El Shahat, United Arab Emirates, by using an isolation .policy and strict aseptic techniques, managed to reduce the seroconversion rate significantly. Dr. El Reshaid (Kuwait) using a similar technique decreased the prevalence from 83.6% to 20.1%.

Professor Al Faleh (Riyadh) outlines the methods of prevention, including better aseptic techniques, public health education, donor blood screening and possible development of a vaccine, although this may be difficult in view of the heterogeneity of the virus genome. Dr. Huraib (Riyadh) describes fully the importance of proper sterilization and aseptic techniques in the hemodialysis units and puts a case for a machine isolation policy, although he describes in detail the difficulties and drawbacks of doing this and points out that proper universal precautions may be the only measure needed. According to Dr. Huraib, chronic ambulatory peritoneal dialysis and home hemodialysis carry less risk of infection than hospital based dialysis.

The treatment of HCV infection is still unsatisfactory, as Professor Al Faleh outlines. With interferon therapy the initial response varies between 40-70%, which is sustained in only 10-20% of the patients. A combination of Interferon and Ribavarin is under study at present.

Dr. Alfurayh (Riyadh) found 20.7% of 140 post renal transplant patients to be positive for HCV antibodies after a mean follow-up period of 27.8 months. Of these 58.6% had persistently raised liver enzymes. The rate of graft loss was higher in the HCV positive patients, but this may be due to the use of lower doses of immunosuppressors in them. He did liver biopsies on 13 HCV antibodies positive patients after a mean follow-up period of 34 months. Eight out of nine patients with persistently elevated liver enzymes showed CAH; two of these patients were re-biopsied and showed progression of the liver histopathology. The four patients with persistently normal liver enzymes showed normal or mild changes of histology.

Dr. Abdalla (Riyadh) had a similar study on 340 post-transplant patients. The prevalence of HCV antibodies positivity was 54%. Twenty three liver biopsies were carried out after a mean follow up period of 53 + 7.84 months. The liver biopsy findings were normal in six (26%) patients, fatty changes in two (8.7%) patients, CAH with or without cirrhosis in six (20.2%) patients, and chronic nonspecific in nine (39.2%) patients.

The case report by Dr. Abdallah (Riyadh) is informative. It clearly underlines the seriousness of HCV infection in post­transplant patients. The patients underwent serial liver biopsies which demonstrated progression of the liver disease, from CAH to cirrhosis to hepatocellular carcinoma. Interferon therapy improved the liver enzymes but led to severe rejection of the transplanted kidney, which was reversed by cessation of Interferon therapy and treatment with An-tithymocyte globulin.

The other case reported by Dr. Al Meshari (Riyadh) discussed the progression of the hepatic histopathology, the response to Interferon, and the relapse of the liver disease after renal transplantation. Dr. Al Meshari advised a strategy of avoiding aggressive immunosuppression, hepatotoxic drugs (e.g., Azathioprine), and alpha-Inter-feron after renal transplantation.

In conclusion, at present we know more about the behavior of the HCV infection in the hemodialysis and the renal transplantation populations. In order to minimize the deleterious effects of the HCV infection, we should concentrate in the future prospective studies on the effect of the various interventional therapies, the effect of isolation in hemodialysis, on the prognosis of the dialysis and the renal transplantation patients.

Correspondence Address:
Abdullah A Al-Khader
Director of Renal Medicine, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159
Saudi Arabia
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PMID: 18583846

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