| Abstract|| |
Hepatitis is emerging as a common serious problem in renal transplant patients. To determine the prevalence of viral hepatic in our transplant population, we screened the patients who received renal transplants in the period from 1979-1997, inclusive, for hepatitis B virus (HBV) and for hepatitis C virus (HCV) infection. Of those patients screened for HBV infection, seven o f101 recipients (6.9%) were found positive for HbsAg. During the follow up, one patient cleared HbsAg and one from the negative group acquired it. Of the recipients screened for HCV antibodies 32 of 78 patients (41%) had positive tests. Higher incidence of chronic liver disease (37.5%) was found in the HCV positive group, compared to zero in the negative group. However, no difference in the short-term graft loss (25%), was noted between these two groups. We conclude that prevalence of hepatitis C in our transplant patients is high and may have an impact on their long-term outcome.
Keywords: Hepatitis, Renal Transplant, HBV, HCV.
|How to cite this article:|
Bernieh B, Mohamed AO, Sirwal IA, Wafa A, Abbade M, Tabbakh A. Viral Hepatitis in Renal Transplant Patients. Saudi J Kidney Dis Transpl 1999;10:157-60
|How to cite this URL:|
Bernieh B, Mohamed AO, Sirwal IA, Wafa A, Abbade M, Tabbakh A. Viral Hepatitis in Renal Transplant Patients. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2020 Feb 26];10:157-60. Available from: http://www.sjkdt.org/text.asp?1999/10/2/157/37222
| Introduction|| |
The recipients of renal transplants are at increase risk of acquiring hepatitis B virus (HBV) and hepatitis C virus (HCV) infection from the dialysis procedures, blood transfusion or through the donated organ., The impact of renal transplantation and consequent immunosuppressive treatment on the liver disease is variable, ranging from minimal changes to chronic persistent hepatitis, chronic active hepatitis, and cirrhosis. , Furthermore, there is progressive worsening of liver damage in transplanted individuals with HBV or HCV infection with possible poor outcome. ,, In our center, we have previously reported a 60% prevalence of positive anti-HCV in patients on regular hemodialysis.  In this study, we attempt to determine the prevalence of viral hepatitis B and C and liver disease in antiHCV and HbsAg positive patients and their impact on patient and graft survival after renal transplant.
| Materials and Methods|| |
This is a retrospective study of patients who had renal transplantation during the 18-year period 1979 through 1997, and who were followed up after renal transplantation at King Fahad Hospital, Madina. One hundred and one renal transplant recipients wee screened for infection with HBV and 78 patients were screened for HCV infection. All patients were receiving prednisolone, Azathioproine, and Cyclosporin for immunosuppression.
Enzyme-linked immunosorbent assay (ELISA) was used for detection of antigen of HBV (HbsAg) and ELISA II for antibodies of HCV confirmed by recombinant immuno-blot assay (RIBA) II. Elevation of transaminases (alanine aminotransferase and aspartate transaminase) > twice the normal level on two or more occasions was considered abnormal Liver biopsies were performed and read in the pathology laboratory in our hospital.
| Statistical Analysis|| |
Comparison of the means was performed using the Student "t" test. The significance level was set to P<0.05.
| Results|| |
Out of the total 101 patients screened for HbsAg seven patients (6.9%) were positive. The mean duration of follow up of these patients was 51.7% ± 41 months. During this period, only one patient of he negative group converted to positive, while one patients of the positive group cleared this HbsAg.
Three of the seven positive patients had abnormal liver function test and one of them died of liver failure with normal kidney function.
Regarding the graft function in the HbsAg positive group, two patients (28.6%) had failure of their graft and returned to dialysis during the follow up period, while five patients (71.5%) remained with functioning allograft with mean serum creatinine of 120 ± 23 µmol/L.
Of the 76 patients screened for HCV antibodies 46 (60%) were before and 32 (40%) were after transplantation. There were a total of 32 patients with positive HCV antibodies. Fourteen of these (30.4%) were from the group screened before transplantation and 18 (56.3%) were from those screened for the first time after renal transplantation. The follow-up period of the HCV antibodies negative patients was not significantly different from the positive group (45 ± 53.8 months Vs 55.8 ± 48.6 months, respectively). During the follow up period, two patients (4%) of the HCV antibodies negative patients converted to HCV positive.
Loss of renal graft occurred in ten (22.7%) patients in the negative group compared to eight patients (25.6%) in the positive group (p=0.3). The average serum creatinine level in the remaining patients with functioning grafts was not significantly different in the HCV negative group Vs the HCV positive group (139 ± 62.6 Vs 131.6 ± 55.6 µmol/L, respectively). There was no clinical or biochemical liver function abnormality in any of he HCV negative group, while abnormal liver function tests were found in 12 (37.5%) of the positive HCV group.
Liver biopsy was done in five patients of this latter group. The results of the biopsies showed that two patients had liver cirrhosis, two patients had chronic active hepatitis and one patients had only fatty changes, one of the patients with cirrhosis died.
| Discussion|| |
Positivity for HbsAg at the time of renal transplantation is usually associated with chronic hepatitis even in the absence of abnormal liver function tests. ,, The clinical outcome of chronic hepatitis was found to be better among HbsAg-negative than in HbsAg positive individuals.  This study showed that 6.9% of our transplanted patients were positive for HbsAg. This figure is much higher than that in the western reports, , but is similar to the prevalence of 6.4% reported previously from this country.  The fact that four patients (40%) with positive HbsAg had abnormal liver functions and one died of liver failure suggests that renal transplantation may be associated with poor outcome in this group of patients. Recently, it has been recommended that liver biopsy should be done to any patient with HbsAg before transplantation and those with chronic active hepatitis and those with evidence of viral replication (HBeAg and HBV DNA) should be excluded form the transplantation program. 
The prevalence of HCV antibodies in renal transplant patients ranged from 10-54%. ,,, Some 30-54% of patients with anti-HCV antibodies can be expected to maintain normal liver function throughout their post transplant follow-up. However, as liver function could be normal in patients with chronic active hepatitis, live biopsy is the only way to give definitive information regarding chronic liver damage. ,, In our study, 30.4% of patients screened for HCV antibodies before transplantation were positive. This figure is about half the value we previous reported in our study on HCV serology in our dialysis population.  This suggests that transplantation may not be associated with increased incidence of HCV infection and that most of HCV positivity is acquired before transplantation.
The impact of pre-transplant HCV infection on the clinical outcome after transplantation is controversial. Many studies show that pre-transplant HCV infection associated with increased risk of adverse outcome after renal transplantation. ,, In sharp contrast, other studies have shown that the presence of HCV antibodies at the time of renal transplantation does not affect the graft or patients survival after transplantation. ,,, In our study, the graft survival was almost identical in the HCV positive and negative groups, and there was no significant difference in creatinine level in those who remained with functioning grafts. Only one patients of HCV positive group died of liver disease. Similar results were reported by many groups, suggesting that the graft or patients survival is probably not affected by the presence of HCV antibodies at the time of renal transplantation.  However, other workers in Saudi Arabia observed significant graft loss among the HCV positive group (27% vs. 1.8%). 
The differences in the findings of the various workers could be a reflection of the level of HCV antibodies in the different dialysis groups, the methods used in the studies and/or the differences in the populations studied.
We conclude that transplantation does not seem to be associated with increased incidence of HCV infection, most of HCV positivity being acquired before transplantation. However, renal transplantation is associated with an increased prevalence of liver disease in patients who are HCV positive before transplantation.
| Acknowledgement|| |
The authors would like to express great appreciation to Dr. Mohd. Allam for his statistical help and Mrs. Elena Canabe for preparing this manuscript.
| References|| |
|1.||Zeldis JB, Depner TA, Kuramoto IK, Gish RG, Holland OV. The prevalence of hepatitis C virus antibodies among hemodialysis patients. Ann Intern Med 1990;112:958-60. |
|2.||Bernieh B, Allam M, Halepota A, et al. Prevalence of hepatitis C virus antibodies in hemodialysis patients in Madina AlMunawarah. Saudi J Kidney Dis Transplant 1995;6(2):132-5. |
|3.||Roth D, Zucher K, Circocco R, et al. The impact of hepatitis C virus infection on renal allograft recipients. Kidney Int 1994;45:238-44. |
|4.||Morales JM, Munoz Ma, Castellano G, et al. Impact of hepatitis C in long-term functioning renal transplant: a clinicopathological follow-up. Transplant Pro 1993;25:1450-3. |
|5.||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. |
|6.||Abdallah AH, Al-Sulaiman MH, Mousa DH, et al. Hepatitis C associated chronic liver disease in renal transpaltn recipients. Saudi J Kid Transplant 1995;6(2):179-82. |
|7.||Parfrey PS< Forbes RD, Hutchmson Ta, et al. The impact of renal transplantation on the course hepatitis B liver disease. Transplantation 1985;39:610-5. |
|8.||Rao KV, Anderson WR, Kasiske BL, Dahl DC. Value of liver biopsy in the evaluation and management of chronic liver disease in renal transplant recipients. Am J Med 1993;94-241-50. |
|9.||Alfurayh OI, Sobh MAE, Chaudry TS, et al. Impact of hepatitis C virus infection on kidney transplant outcome. Saudi J Kidney Dis Transplant 1995;6(2):183-9. |
|10.||Degos F, Degott C, Bedrossian J, et al. Is renal transplantation involved in post transplantation liver disease? A prospective study. Transplantation 1980;29:100-2. |
|11.||Piron Y, Alexandre GP, Ypersele C. Longterm effect of HbsAg in patients survival after renal transplantation. N Engl J Med 1977;296:194-6. |
|12.||Parfrey Ps, Farge D, Forbes RD, Dandavino R, Henick S, Guttmann RD. chronic hepatitis in end-stage renal disease: comparison of HbsAg -negative and HbsAg-positive patients. Kidney Int 1985;28:959-67. |
|13.||Fairley CK, Mijch A, Gust ID, Nichilson S, Dimitrakakis M, Lucas CR. The increase risk of fatal liver disease in renal transplant patients who are hepatitis B antigen and/or HBV DNA positive. Transplantation 1991;52(3):497-500. |
|14.||Pereira BJ. Hepatitis C in transplantation. Nephrol Dial Transplant 1996;11(8):1520-2. |
|15.||Paparella M, Tarantino A, Poticelli C. How to manage the dialysis patient with chronic viral hepatitis who is considered for renal transplantation. Nephrol Dial Transplant 1996;11:2122-4. |
|16.||Periera BJ, Wright TL, Schmid CH, Levey AS. The impact of pre-transplantation hepatitis C infection on the outcome of renal transplantation. Transplantation 1995;60(8):799-805. |
|17.||Stempel CA, Lake J, Kuo G, Vincenti F. Hepatitis C: its prevalence in end-stage renal failure patients and clinical course after transplantation. Transplantation 1993;25:1466. |
|18.||Ynares C, Johnson HK, Kerlin T, Crowe D, MacDonnel R, Richie R. Impact of pretransplant hepatitis C antibody status upon long-term patient and renal allograft survival - a 5 -and 10-year follow up. Transplant Proc 1993;25:1466-8. |
|19.||Ponz E, Campistol JM, Bruguera M, et al. Hepatitis C virus infection among kidney transplant recipients. Kidney Int 1991;40(4):748-51. |
|20.||Roth D, Fernandez JA, Burke GW, Esquenazi V, Miller J. Detection of antibody to hepatitis C virus in renal transplant recipients. Transplantation 1991;51:396-400. |
|21.||Pereira BJ. Hepatitis C infection and post transplantation liver disease. Nephrol Dial Transplant 1995;10(Suppl):58-67. |
Dept. of Nephrology, King Fahad Hospital, Madina Al Munawarah