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Saudi Journal of Kidney Diseases and Transplantation
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Year : 1995  |  Volume : 6  |  Issue : 2  |  Page : 157-162
Hepatitis C Virus Infection Among Dialysis Patients in United Arab Emirates


Department of Nephrology, Al Jazierah and Central Hospitals, Abu Dhabi, United Arab Emirates

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   Abstract 

To evaluate the incidence of positivity of anti-hepatitis C virus (anti-HCV) antibodies in the hemodialysis (HD) patients, and the impact of isolation of the anti-HCV positive patients, we studied 262 HD patients in our unit between January 1991 and December 1993. There were 64 patients with anti-HCV positivity. Forty nine of them were males, and 15 were females, with mean ages of 41.8 ± 8.6 years. The mean dialysis period was 20.9 ± 2.5 months. The serum anti-HCV antibodies were detected with second generation HCV enzyme linked immunosorbent assay. The test was repeated every three months for the patients, and every six months for the dialysis staff members. Dialyzers were not reused. Isolation of the positive patients by using designated HD machines was performed, besides adopting the universal precautions of infection. At the time of the inclusion to the study 45 patients out of 64 (70.3%) were anti-HCV positive. In this group 42% received blood transfusions, 17.5% started hemodialysis in another dialysis unit. Nineteen patients (29.7%) seroconverted during the study period. In this group, nine patients (47.6%) received blood transfusions (1.7 + 0.5 units). Of the seroconverted patients, eight (42%) travelled abroad and received HD during their holidays. Eight of the seroconverted patients did not have identifiable risk factors except HD. The overall seroconversion rate was 0.95 per 100 patient months. The rate decreased to 0.4 per 100 patient months if the identifiable causes for seroconversion (blood transfusion, duration of dialysis, holiday dialysis) were excluded. We conclude that HCV infection is frequent in hemodialysis patients. Strict follow up of the universal precautions together with isolation of anti-HCV positive patients with designated machines may be sufficient to prevent nosocomial transmission of HCV infection. The risk of transfusion may be minimized by using r-Human erythropoietin in the treatment of anemia in this population.

Keywords: Hepatitis C, UAE, Hemodialysis

How to cite this article:
El Shahat YI, Varma S, Bari M Z, Shah Nawaz M, Abdulrahman S, Pingle A. Hepatitis C Virus Infection Among Dialysis Patients in United Arab Emirates. Saudi J Kidney Dis Transpl 1995;6:157-62

How to cite this URL:
El Shahat YI, Varma S, Bari M Z, Shah Nawaz M, Abdulrahman S, Pingle A. Hepatitis C Virus Infection Among Dialysis Patients in United Arab Emirates. Saudi J Kidney Dis Transpl [serial online] 1995 [cited 2020 Jul 5];6:157-62. Available from: http://www.sjkdt.org/text.asp?1995/6/2/157/40859

   Introduction Top


Following identification of the Hepatitis C Virus (HCV), and the development of an assay for antibody detection for this virus [1] many reports implicated HCV as the main causative agent for non-A, non-B hepatitis (NANBH) in the dialysis population [2],[3] . The reported prevalence of anti HCV in the hemodialysis (HD) patients in various countries varies greatly, ranging from 16% to 87% [4],[5],[6],[7],[8],[9],[10],[11] . The major risk factors for acquisition of the infection seem to be the length of time on dialysis, and previous blood transfusion [12] . Although isolation of anti-HCV positive hemodialysed patients with isolated machines, and strict enforcement of universal precautions to reduce transmission of infection within a unit would appear justified, many dialysis units are skeptical and do not undertake these precautions [13] .

The aim of our study was to assess the incidence of anti-HCV in our hemodialysis population, the impact of isolation of anti­HCV positive dialysis patients, and the other factors on transmission of the infection within the dialysis units.


   Patients and Methods Top


The inclusion criteria to our study were: being on regular hemodialysis and the presence of anti-HCV antibodies. Between January 1991 and December 1993, 262 end­stage renal failure (ESRF) patients were treated by regular HD in our unit. During this period of observation 64 patients were found to have anti-HCV seropositivity. There were 49 males and 15 females. Forty five patients were seropositive at the time of inclusion and seroconversion occurred in 19 patients, who were negative at the time of entry into the study.

The mean age was 41.8 + 8.6 years. The mean dialysis period was 20.9 ± 2.5 months. 28 patients (43.8%) received blood transfusion (2.5 ± 1.5 units/patient).

Serum antibodies to HCV were detected by a second generation HCV enzyme linked immunosorbent assay (ELISA II Abbott Lab.) according to the manufacture's instructions. This was followed by a confirmatory testing by immunoblot assay (Lia Tech Organons). This test for detection of antiHCV was done every three months for all patients. Serum transminase levels were measured in every case on a monthly basis. Hypertransminasemia was arbitrarily defined as a value over 1.5 fold the upper limit of normal. All anti-HCV positive patients were dialysed on designated machines. We did not reuse dialyzers. Dialysis machines were cleaned with aldehyde-free cleaning and disinfecting agent (Paracetic acid formula) after each dialysis session, and with formaldehyde once a week.

Only four patients (6.3%) received three sessions of HD and 60 patients (93.7%) received only two sessions weekly. All the patients were dialysed by hollbw fiber cuprophane dialyzers of lm2 surface area. Six patients (9.4%) with anti-HCV positive had renal transplants prior to starting treatment by HD, and eight patients (12.5%) had undergone surgical interventions. Our staff were screened for anti-HCV every six months.


   Results Top


The overall prevalence of anti-HCV among the patients studied was 64 out of 262 (24%). Clinical details of these sero-positive patients are shown on [Table - 1]. There was a seropositive male predominance with ages ranged between 25 and 55 years. Anti-HCV was positive in 45 patients (70.3%) at the time of inclusion. In this group of patients 19 (42%) received blood transfusion prior to HD treatment, eight patients (17.8%) started dialysis treatment in other centers, of uncertain practices, before transference to our unit. Five patients were also HBsAg seropositive. The mean time of dialysis of these 45 patients was 17.8 months with a range of (1-25 months).

During the period of observation, 19 patients (29.7%) became anti-HCV positive. Nine patients of this group (47.6%) were transfused with a mean of 1.7 ± 0.8 units. Eight patients (42%) travelled abroad for holidays, and were treated by dialysis in centers with uncertain practices. Fifteen patients (78.9%) were dialyzed twice weekly and only four patients (21.1%) were dialyzed thrice weekly. One patient in this group became positive forr HBsAg. In eight patients (42.1%) no identifiable risk factor except HD was found.

Serum transaminases were elevated in 18 out of 64 seropositive patients (28.1%). This rise was not accounted for by hepatitis B virus infection or hepatotoxic drugs. Twelve patients were from the seropositive patients group at the time of inclusion, and 8 patients were from the seroconverted group. The overall seroconversion rate was 0.95/100 patient­ months, and if the identifiable causes for seroconverstion were excluded, then the rate was 0.4/100 patient months.

By analysis of the risk factors for seroconversion for HCV, and by comparison with the seronegative population treated by HD, a significant correlation was found with the rate of blood transfusion. In the seroconverted patients, a significant correlation was found with the time spent on HD. The incidence of seroconversion did not correlate with a lack of sterilization of the dialysis machine after each session. No correlation was found between the incidence of antiHCV and the cause of renal failure, presence of HBsAg, a history of previous surgery, or renal transplantation. Of 64 seropositive patients, 24 received renal transplants, nine left for their country of origin, and nine died from causes other than liver disease.


   Discussion Top


Hepatitis C is now considered the major cause of liver disease in the dialysis population [14],[15] . At present, there is a considerable variation in the rate of hepatitis C in HD patients. The prevalence rates vary widely among various countries and even among the different centers in the same country [4],[5],[6],[7],[8],[9],[10],[11] . In our group of hemodialysis patients the prevalence of positive anti-HCV was 24%. The type of confirmatory tests used, the geographical location, the partial immunodeficiency of HD patients and the presence of variant strains of HCV have major influences in this regard, and a direct bearing on the number of HCV positive patients in any center.

In our study HCV infection was significantly more common in the male HD patients, as reported by others [4],[7],[12]. As shown by other reports [4],[16] a significant correlation was found between the history of blood transfusion and the prevalence of anti HCV in our HD patients. Also a correlation was found with the number of the transfused blood units. There is no doubt that blood transfusion is a source of HCV-infection, but this risk factor is expected, in the future, to be of minimal importance due to the wideuse of recombinant human erythropoietin (rHuEPO) in dialysis patients. In our group of the seroconverted patients, wefound a significant correlation between the duration of HD and the incidence of anti­HCV. Several authors have also identified the duration of dialysis therapy as an important risk factor [4],[5],[11],[16] . This correlation implies nosocomial transmission of HCV infection. Although the length of time on dialysis correlated with anti-HCV antibody, we could not confirm this as an independent risk factor, since most of the patients who stayed on dialysis for over 12 months had either received a transfusion or a holiday dialysis elsewhere. Unlike others [4],[6],[7],[17] , we found no correlation between the presence of HBsAg and anti-HCV. This relation may be explained by a common transmission mode for HBV and HCV.

We did not find any correlation between the prevalence of anti-HCV and previous renal transplant. The prevalence in our transplanted patients was the same as reported by others [18],[19],[20] . Most of the HCV infections occur prior to transplantation. However, HCV can also be acquired at the time of transplantation owing to exposure to multiple blood transfusions or infected donated organs [21],[22] . Elevated serum transaminase level was found to be an associated factor in some of the studied patients. This probably reflected HCV infection as a cause of ongoing hepatitis among the dialysis patients [5],[6] . Holiday dialysis was a major risk factor for seroconversion of anti-HCV in our study patients, even when they were not transfused. When those patients who received dialysis abroad during their holidays were excluded, the seroconversion rate became very low. Holiday HD was a unique problem in our study because of the large expatriate dialysis patient group.

Our study showed that the seroconversion rate was 0.95/100 patients months (to be 0.4/ 100 patient-months after exclusion of identifiable risk factors) which was much lower than that reported by others [12],[13],[23],[24] . This low rate of seroconversion was attributed to the isolation of anti-HCV positive patients with designated dialysis machines. This isolation strategy is not universally accepted.

Those who were against isolation of anti­HCV positive patients, found it of unknown effectiveness and of difficult implementation [13],[25],[26] . Effectiveness is limited by the delay, up to one year, between HCV infection and the detection of antibodies by ELISA tests. Furthermore, the possibility of a lack of cross immunity between different strains of HCV must be borne in mind (HCV exhibits a major genuine variability). So, grouping anti-HCV positive patients in the dialysis units might increase their risk of acquiring multiple HCV strains. Implementation of a rigorous separation between patients according to their HCV status is rather cumbersome, especially if HBsAg positive patients are treated in the same unit. Also, it is not clear from the antibody tests alone which patients may be infective. Positive polymerase chain reaction results in the blood of the anti-HCV positive patients reflect viremia, chronic HCV infection and infectivity of blood [27] . This test is expensive and is not easily available.

Out study, together with other reports [28],[29],[30] showed that isolation was very effective in lowering the seroconversion of HD patients. Isolation of anti-HCV positive patients together with strict adhesion to the universal precautions may prevent the nosocomial HCV transmission in the HD units. It was found that the rate of seroconversion observed in units applying seriously the measures to prevent cross­contamination was much lower than the rate observed in units which did not apply them. Such measures were detailed in the "universal precautions for prevention of transmission of blood borne pathogens in health care settings" [31] , and also in the "recommended precautions for patients undergoing hemodialysis who have AIDS or non A, non B hepatitis" [32] . The risk of the staff and the family members acquiring hepatitis c from the dialysis patients has not been clearly defined. In our study, and due to the strict precautions with the isolation of the anti-HCV positive patients, we did not record any case of seroconversion in the staff, unlike what was reported by others, who recorded more than 10% of staff who developed anti-HCV positivity due to needle-stick accidents from anti-HCV positive patients [33],[34] .


   Conclusion Top


Infection by the HCV is frequent in hemodialysis patients and worrisome, as it often becomes chronic and induces chronic liver disease. Prevention is therefore a major challenge to nephrologists. This study shows that strict adhesion to the universal precautions, together with isolation of anti­ HCV positive patients with designated machines may be sufficient to prevent nosocomial transmission, and can be recommended to reduce the spread of HCV in dialysis units. Blood transfusion and holiday dialysis emerged as major risk factors. The estimated risk of transfusion related hepatitis C should reduce gradually because of the use of rHuEPO.

 
   References Top

1.Kuo G. Choo QL, Alter HJ, et al. An assay for circulating antibodies to a major etiologic virus of human non-A, non-B hepatitis. Science 1989;244:362-4.  Back to cited text no. 1    
2.Alter JH. The Hepatitis C virus and its relationship to the clinical spectrum of NANB hepatitis. J Gastroenterol Hepatol 1990;l:78-94.  Back to cited text no. 2    
3.Weiner AJ, Kuo G, Bradley DW, et al. Detection of hepatitis C viral sequences in non-A, non-B hepatitis. Lancet 1990;335:l-3.  Back to cited text no. 3    
4.Elisaf M, Tsianos E, Mavridis A, Dardamanis M, Pappas M, Siamopoulos KC. Antibodies against Hepatitis C virus (anti-HCV) in haemodialysis patients: association with hepatitis B serological markers. Nephrol Dial Transplant 1991;6:476-9.  Back to cited text no. 4  [PUBMED]  
5.Mondelli MU, Smedile V, Piazza V, et al.Abnormal alanine aminotransferase activity reflects exposure to hepatitis C virus in haemodialysis patients. Nephrol Dial Transplant 1991;6:480-3.  Back to cited text no. 5  [PUBMED]  
6.Oguchi H, Terashima M, Tokunage S, et al. Prevalence of anti-HCV patients on long-term hemodialysis. Nippon Jinzo Gakkai Shi 1990;32:313-7.  Back to cited text no. 6    
7.Jeffers LJ, Perez GO, de Medina MD, et al. Hepatitis C infection in two urban hemodialysis units. Kidney Int 1990;38:320-2.  Back to cited text no. 7  [PUBMED]  
8.Fathalla SE, Al-Jama AA, Badawy MS, et al. Prevalence of hepatitis C virus infection in the Eastern province of Saudi Arabia by RE-DNA second generation and supplemental EIA Tests. Saudi Med J 1994;15:281-5.  Back to cited text no. 8    
9.Ayoola EA, Huraib S, Arif M, et al. Prevalence and significance of antibodies to hepatitis C virus among Saudi haemodialysis patients. J Med Virol 1991;35:(3):155-9.  Back to cited text no. 9    
10.Shaheen FAM, Huraib S, Al-Rasheed RS, Aldrees A. Hepatitis C antibodies among hemodialysis patients. Prevalence in the Western province of Saudi Arabia. First Int Conference on Dialysis in Developing Countries, Singapore, Abstract, 1994.  Back to cited text no. 10    
11.Padmanabhan R. Hepatitis C virus infection in hemodialysis patients in Saudi Arabia. Saudi J Kidney Dis Transplant. 1994;5:157-8.  Back to cited text no. 11    
12.Chan TM, Lok AS, Cheng IK, et al. Prevalance of Hepatitis C virus infection in hemodialysis patients: a longitudinal study comparing the results of RNA and antibody assays. Hepatology 1993;17:5-8.  Back to cited text no. 12  [PUBMED]  
13.Jadoul M, Cornu C, van Ypersele de Strihou C. Incidence and risk factors for hepatitis C seroconversion in hemodialysis a prospective study. Kidney Int 1993;44:1322-6.  Back to cited text no. 13  [PUBMED]  
14.Bruguera M, Vidal L, Sanchez-Tapias JM, Costa J, Revert L, Rodes J. Incidence and features of liver disease in patients on chronic hemodialysis. J Clin Gastroenterol 1990;12:298-302.  Back to cited text no. 14  [PUBMED]  
15.Pol S, Romeo R, Zins B, et al. Hepatitis C virus RNA in anti-HCV positive hemodialyzed patients: significance and therapeutic implications. Kidney Int 1993;44:1097-100.  Back to cited text no. 15  [PUBMED]  
16.Schlipkoter U, Roggendor M, Ernest G,et al. Hepatitis C virus antibodies in hemodialysis patients. Nephron 1990;335:1409.  Back to cited text no. 16    
17.Perez-fontan M, Moncalian J, Rodriguez-Carmona A, Arrojo F. Prevalence of anti-hepatitis C antibodies in patients treated with continuous ambulatory peritoneal dialysis and hemodialysis. Nephron 1991;58:381-2.  Back to cited text no. 17    
18.Akpolat T, Arik N, Arinsoy T, et al. High prevalance of antibodies to hepatitis C virus among renal transplant recipients: correlation with chronic liver dysfunction. Nephron 1993;64:163-4.  Back to cited text no. 18  [PUBMED]  
19.Morales JM, Munoz MA, Castellano G, et al. Impact of hepatitis C in long­functioning renal transplants: a clinico­pathological follow-up. Transplant Proc 1993;25:1450-3.  Back to cited text no. 19  [PUBMED]  
20.Alfurayh O, Ellis M, Al Shaibani K, et al. Kidney transplantation after successful therapy with inter feron Alpha in hemodialysis patients infected with hepatitis C virus. J Am Soc Nephrol 1993;4:922.  Back to cited text no. 20    
21.Chan TM, Lok AS, Cheng IK, Chan RT. A prospective study of hepatitis C virus infection among renal transplant recipients. Gastroenterology 1993;104:862-8.  Back to cited text no. 21  [PUBMED]  
22.Pereira BJ, Milford EEL, Kirkman RL, et al. Prevalance of hepatitis C virus RNA in organ donors positive for hepatitis C antibody and in the recipients of their organs. N Engl J Med 1993;327:910-5.  Back to cited text no. 22    
23.Guiberti T, Ferrari C, Marchelli S, et al. Long-term follow-up of anti-hepatitis C virus antibodies in patients with acute non-A, non-B hepatitis and different outcome of liver disease. Liver 1992;12:94-9.  Back to cited text no. 23    
24.Alfurayh O, Sobh M, Buali A, et al. Hepatitis C virus infection in chronic haemodialysis patients, a clinicopathologic study. Nephrol Dial Transplant 1992;7:327-32.  Back to cited text no. 24  [PUBMED]  [FULLTEXT]
25.Niu MT, Alter MJ, Kristensen C, Margolis HS. Outbreak of hemodialysis-assooiated non-A, non-B hepatitis and correlation with antibody to hepatitis C virus. Am J Kidney Dis 1992;19:345-52.  Back to cited text no. 25  [PUBMED]  
26.Lorenzo I, Lazaro R, Nakamura N, et al. How to prevent the transmission of the hepatitis C virus, the first Int Conference on Dialysis in Developing Countries, Singapore (A), 1994.  Back to cited text no. 26    
27.Garson JA, Tedder RS, Briggs M, et al. Detection of hepatitis C viral sequences in blood donations by "nested" polymerase chain reaction and prediction of infectivity. Lancet 1990;335:1419-22.  Back to cited text no. 27  [PUBMED]  [FULLTEXT]
28.Garcia-Valdecasas J, Bernal MC, Cerezo S, et al. Strategies to reduce the transmission of HCV infection in hemodialysis (HD) units. J Am Soc Nephrol 1993;4:347.  Back to cited text no. 28    
29.Vandilli L, Medici G, Swazzi AM, et al. Emergence of hepatitis C virus in hemodialysis units: must the patients be dialysed in segregated sections? J Am Soc Nephrol 1990;1:380.  Back to cited text no. 29    
30.Roggendorf M. Diagnostic and epidemiologic der Hepatitis C virus infection mittilungen der Dentschem arbeitsgemeinse fur Klinische Nephro­logie. 1992;21:99-107.  Back to cited text no. 30    
31.Leads from the MMWR. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. JAMA 1988;260:462-5.  Back to cited text no. 31  [PUBMED]  
32.Favero MS. Recommended precautions for patients undergoing hemodialysis who have AIDS or non-A, non-B hepatitis. Infect Control 1985;6:301-5.  Back to cited text no. 32  [PUBMED]  
33.Mitsui T, Iwano K, Masuko K, et al. Hepatitis C virus infection in medical personnel after needle stick accidents. Hepatology 1992;16:1109-14.  Back to cited text no. 33  [PUBMED]  
34.Schlipkoter U, Gladziwa U, Cholmakov K, et al. Prevalence of hepatitis C virus infection in dialysis patients and their contacts using a second generation enzymed-linked immunosorbent assay. Med Microbiol Immunol Bed 1992;181:173-80.  Back to cited text no. 34    

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Correspondence Address:
Yassin I El Shahat
Department of Nephrology, Central Hospital, P O. Box 233, Abu Dhabi
United Arab Emirates
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