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Saudi Journal of Kidney Diseases and Transplantation
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Year : 1997  |  Volume : 8  |  Issue : 2  |  Page : 134-137
Hepatitis C Virus Infection among Hemodialysis Patients in the Najran Region of Saudi Arabia


Department of Medicine, Najran General Hospital, Najran, Saudi Arabia

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   Abstract 

Forty seven patients with end-stage renal disease (ESRD) on maintenance hemodialysis at the Najran General Hospital, Najran, Saudi Arabia were studied for prevalence of hepatitis C virus (HCV) infection. A total of 24 patients (51.1%) were found to be positive for anti-HCV antibodies. Duration of hemodialysis was longer (p = < 0.025) in anti-HCV positive patients (4.9 ± 2.9 years) as compared to anti-HCV negative subjects (1.7 + 1.4 years). No significant relationship was found between blood transfusions and anti-HCV positivity. Ten (41.7%) of the anti-HCV positive patients showed elevated liver enzymes in comparison with two (8.7%) of the seronegative patients. This difference was statistically significant (p = <0.05). Liver biopsies from eight of the anti-HCV positive patients demonstrated cirrhosis in one, chronic active hepatitis in three, chronic persistent hepatitis in three and normal histology in one patient. There was no correlation between liver enzymes and the severity of histopathological findings on liver biopsy.

Keywords: Hepatitis C virus, Hemodialysis, Chronic liver disease.

How to cite this article:
Kumar R. Hepatitis C Virus Infection among Hemodialysis Patients in the Najran Region of Saudi Arabia. Saudi J Kidney Dis Transpl 1997;8:134-7

How to cite this URL:
Kumar R. Hepatitis C Virus Infection among Hemodialysis Patients in the Najran Region of Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2019 Aug 23];8:134-7. Available from: http://www.sjkdt.org/text.asp?1997/8/2/134/39386

   Introduction Top


Prevalence of antibodies to hepatitis C virus (anti-HCV) among hemodialysis patients in Saudi Arabia is reported to be 68% in a national multicenter study [1] . It is also observed that 50% of HCV infections lead to chronic liver disease including chronic active hepatitis with or without cirrhosis [2],[3] . This prompted us to study the prevalence of anti-HCV in patients on hemodialysis at our unit.


   Patients and Methods Top


A total of 47 patients with ESRD undergoing hemodialysis at Najran General Hospital, Najran. Saudi Arabia were studied during the period between August 1993 and July 1996. There were 26 males and 21 females with a mean age of 44.1 years (range 16 to 85 years). Medical records of all patients were examined for history of hepatotoxic drug intake, hepatitis, blood transfusion, duration on hemodialysis, and presence of jaundice, hepatomegaly, splenomegaly, ascites and other stigmata of chronic liver disease.

All patients had monthly estimations of serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels and the tests were considered abnormal if they were at least twice the normal values. Antibodies to HCV were looked for every three months using qualitative enzyme immuno assay (Abbott HCV, EIA), second generation test system. All patients were dialyzed for three to four hours per session in a thrice weekly regimen. There was no reuse of dialyzers and universal precautions for infection control were routinely practiced. Thermal and chemical disinfection of all the dialysis machines were performed at the end of each day. Liver biopsy was per­formed in eight of the anti-HCV positive patients as part of routine pre-renal transplant work-up. The significance of the data was determined by chi-square and Student's 't' test.


   Results Top


Twenty four (51.1%) of the 47 study patients were positive for anti-HCV antibodies. There were 15 males and nine females with a mean age of 41.5 years (range 16-85 years). The duration on hemodialysis was found to be significantly longer (p - < 0.025) in anti-HCV positive patients (4.9 ± 2.9 years) as compared to the seronegative patients (1.7 + 1.4 years). Twenty one (87.5%) of the anti-HCV positive and 18 (78.3%) of the anti-HCV negative patients had received multiple blood transfusions. The mean frequency of blood transfusion was 11.1 units in anti­-HCV positive patients while it was 5.4 units in the negative patients. Statistically this difference was not significant. On the other hand, three patients positive for anti-HCV had never received any blood transfusion.

Ten (41.7%) of 24 anti-HCV positive patients showed elevated ALT in comparison with two (8.7%) of 23 anti­-HCV negative patients. This difference was statistically significant (p = <0.05). Follow-­up of these patients for a mean period of 2.1 years showed either frequent fluctuations or persistent elevation of ALT levels in anti­-HCV positive patients. Periodic screening for anti-HCV antibodies revealed serological conversion from negative to positive in seven (23.3%) of the 30 initially anti-HCV negative patients. Dialysis during holidays at other centers could have been the probable source of infection in five patients, whereas in two patients no obvious risk factor(s) could be identified to account for seroconversion. Re-evaluation of patients who seroconverted from negative to positive showed that five of the seven had elevated liver enzymes levels during the period of observation. The elevation of liver enzymes preceded anti-HCV positivity in all these patients by a period ranging from six to nine months. None of them had clinical jaundice. Furthermore, after seroconversion, anti-HCV antibodies persisted for years. Only one patient became negative on repeated enzyme immunoassay testing.

Histological findings on liver biopsy from eight anti-HCV positive patients revealed cirrhosis in one, chronic active hepatitis in three, chronic persistent hepatitis in three and normal histology in one of them. Out of seven patients who had significant abnor­malities on liver histology only four had raised transaminase levels.


   Discussion Top


The overall prevalence of anti-HCV positivity in our hemodialysis patients of 51.1% is comparable to that reported by Shohaib, et al from Jeddah [4] and Muhanna from Al Khobar [5] but lower than that observed by Shaheen, et al from Western Province [6] and Omar, et al from Makkah region [7] of Saudi Arabia. Also, the prevalence of anti-HCV among our patients on dialysis is higher than that reported from Europe [3],[8] and North America [9],[10] . Non-adherence to universal infection control precautions uniformly in all centers and/or environmental, ethnic and other regional factors have been postulated to account for this variation in the prevalence of HCV infection [1],[6] .

Duration on hemodialysis was found to be significantly longer in anti-HCV positive patients as compared to anti-HCV negative patients. This is similar to the findings of Schlipliter, et al from West Germany [11] and Yamaguchi, et al from Japan [12] . This implies possible role of nosocomial trans­mission in spread of HCV infection. In our study, there was no relationship between blood transfusion and anti-HCV positivity. Similar results have been reported by Shaheen, et al [6] although Alfurayh, et al [13] observed significant relationship between blood transfusion and HCV infection in their study. Nevertheless, blood transfusion is an important factor in transmission of HCV infection, even though HCV may be acquired via other routes as well.

Ten (41.7%) of the anti-HCV positive patients showed elevated liver enzymes during the follow-up period. Half of these patients had seroconversion from HCV negative to positive during the observation period. Elevated liver enzymes in all these patients were persistent for more than six months. These patients were considered to have chronic liver disease due to HCV infection as other causes of chronic liver disease (e.g., drugs, alcohol and other viral infections) were apparently absent. All of these patients except one remained stable after a mean follow-up period of 2.1 years. One patient with elevated liver enzymes and anti-HCV positivity developed jaundice, marked ascites, encephalopathy and died three years after he became positive for HCV. These findings demonstrate that chronic liver disease due to HCV infection in hemodialysis patients tends to be slowly progressive.

Fourteen of the anti-HCV positive patients showed normal levels of liver enzymes. Liver biopsy in three of them demonstrated features of chronic hepatitis including cirrhosis in one patient. Similarly, it has been observed in asymptomatic anti-HCV positive subjects that between one third and one half, have chronic hepatitis on liver histology even when the liver enzymes were normal [14] .

In conclusion, our study shows a pre­valence of anti-HCV antibodies of 51.1% in our patients on hemodialysis. Duration of hemodialysis was longer in the anti-HCV positive patients as compared to the negative patients. There was no correlation between the extent of liver enzyme abnor­malities and the severity of histopatho­logical findings on liver biopsy in our study.


   Acknowledgment Top


Author would like to thank Dr. G. Ravi, consultant urologist for reviewing this article and making useful suggestions. I would also like to thank sister Tripta Sharma and Thankam Philip for collecting the data and Miss Leah Saclote for typing the manuscript.

 
   References Top

1.Huraib S, Al Rashed R, Aldrees A, Aljefry M, Arif M, Al-Faleh FA. High prevalence of and risk factors for hepatitis C in haemodialysis patients in Saudi Arabia: a need for new dialysis strategies. Nephrol Dial Transplant 1995;10:470-4.  Back to cited text no. 1    
2.Alter MJ, Hadler SC, Judson FN, et al. Risk factors for acute non-A, non-B hepatitis in the United States and association with hepatitis C virus infection. JAMA 1990;264:2231-5.   Back to cited text no. 2  [PUBMED]  
3.Esteban JI, Esteban R, Viladomiu L, et al. Hepatitis C virus antibodies among risk groups in Spain. Lancet 1989;2:294-7.   Back to cited text no. 3  [PUBMED]  
4.Al-Shohaib SS, Abdelaal MA, Zawawi TH, Abbas FM, Shaheen FAM, Amoah E. The prevalence of hepatitis C virus antibodies among hemodialysis patients in Jeddah area, Saudi Arabia. Saudi J Kidney Dis Transplant 1995;6(2):128-31.  Back to cited text no. 4    
5.Al-Muhanna FA. Hepatitis C virus infection among hemodialysis patients in the Eastern Region of Saudi Arabia: Saudi J Kidney Dis Transplant 1995;6(2):125-7.   Back to cited text no. 5    
6.Shaheen FAM, Huraib SO, Al-Rasheed R. Prevalence of hepatitis C antibodies among hemodialysis patients in Western province of Saudi Arabia, Saudi J Kidney Dis Transplant 1995;6(2):136-9.  Back to cited text no. 6    
7.Omar MN, Tashkandy MA, El Tonsy AH. Liver enzymes and protein electrophoretic patterns in hemodialysis patients with antibodies against the hepatitis C virus. Saudi J Kidney Dis Transplant 1995;6(2):163-6.   Back to cited text no. 7    
8.Conway M, Catterall AF, Brown EA, et al. Prevalence of antibodies to hepatitis C in dialysis patients and transplant recipients with possible routes of transmission. Nephrol Dial Transplant 1992;7(12):1226-9.   Back to cited text no. 8    
9.Evans AA, Cody H, Kuo G, et al. Seroepidemiology of hepatitis C virus (HCV) in selected populations. Hepatology 1989;10:644.   Back to cited text no. 9    
10.Hardy NM, Sandroni S, Danielson S, Wilson WJ. Antibody to hepatitis C virus increases with time on hemodialysis. Clin Nephrol 1992;38:44-8.  Back to cited text no. 10  [PUBMED]  
11.Schlipliter U, Roggenderf M, Ernst G, et al. Hepatitis C virus antibodies in hemodialysis patients. Lancet 1990;335:1409.   Back to cited text no. 11    
12.Yamaguchi K, Nishimura Y, Rukuoka N, et al. Hepatitis C virus antibodies in hemodialysispatients. Lancet 1990;335:1409-­10.  Back to cited text no. 12    
13.Affurayh 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. 13    
14.Dienstag JL, Isselbacher KJ. Chronic hepatitis. In: Harrison's Principals of Internal Medicine. McGraw Hill, Inc. Thirteenth edition 1994;2:1478-83.  Back to cited text no. 14    

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Correspondence Address:
Ramesh Kumar
Division of Nephrology, Department of Medicine, Najran General Hospital, Najran
Saudi Arabia
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PMID: 18417792

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Acknowledgment
    References
 

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