| Abstract|| |
The aim of this study was to evaluate the prevalence of hepatitis C virus (HCV) in the hemodialysis (HD) population in Jeddah and its risk factors. We studied 248 patients on HD in the Jeddah Kidney Center, Jeddah, Saudi Arabia. The overall prevalence of HCV among these patients was 72.6%. Hepatitis C positive males (77.2%) were more than hepatitis C positive females (65.7%) (p<0.05). A significantly increasing annual prevalence of HCV infection among HD patients was found. It ranged from 16.4% among patients who were on HD for one year to 94.5% among those on HD for three or more years (p<0.05). Also, 78% of those who utilized more than one center acquired HCV infection compared to 64.3% of those who were treated exclusively at the Jeddah Kidney Center, (p<0.05). In this study, 75.8% of HCV positive patients had received blood transfusions while 61.1% of HCV positive patients had never received blood transfusion, (p<0.05).
Keywords: Hepatitis C, Hemodialysis, Jeddah.
|How to cite this article:|
Al-Jiffri AY, Fadag RB, Ghabrah TM, Ibrahim A. Hepatitis C Virus Infection Among Patients on Hemodialysis in Jeddah: A Single Center Experience. Saudi J Kidney Dis Transpl 2003;14:84-9
|How to cite this URL:|
Al-Jiffri AY, Fadag RB, Ghabrah TM, Ibrahim A. Hepatitis C Virus Infection Among Patients on Hemodialysis in Jeddah: A Single Center Experience. Saudi J Kidney Dis Transpl [serial online] 2003 [cited 2019 Dec 6];14:84-9. Available from: http://www.sjkdt.org/text.asp?2003/14/1/84/33095
| Introduction|| |
Hepatitis C virus (HCV) infection is very common among maintenance hemodialysis (HD) patients throughout the world. The prevalence seems to reflect the quality of medical practice being offered as well as the prevalence of anti-HCV among the general population in that area. ,
Hepatitis C infection is a major cause of liver disease among the general population, leading to chronic active hepatitis (CAH) with or without cirrhosis in 50% of cases.  If left untreated, chronic hepatitis C progresses to cirrhosis, and in certain countries, it is a major cause of primary hepatic carcinoma. 
Hepatitis C virus infection has been found to be significantly high among HD patients and is probably related to previous blood transfusions, the duration on HD, the number of HD centers, the number of surgical procedures the patient has undergone and nosocomial transmission. ,,,
The prevalence of anti-HCV in HD patients is quite variable ranging from 5% to over 50%. , In the Arab World, the prevalence ranges between 26.5% (Oman) and 80% (Egypt). This prevalence varies in the other continents as well, ranging from 1-29% in Western Europe, 8-36% in North America, and 44-60% in the Far East. 
Even within Saudi Arabia, the prevalence of HCV infection among HD patients varies from region to region. It was found to be 83.9% in the Central region, 94.7% in the Southern region, and 15% in the Northern region.  Also, the annual HCV seroconversion rate in the Kingdom of Saudi Arabia was 7 to 9%.  The aim of this study is to identify the risk factors for acquiring HCV infection among patients with end-stage renal disease (ESRD) on maintenance HD in our center.
| Patients and Methods|| |
The study population included all patients with ESRD registered in the HD unit of the Jeddah Kidney Center (JKC) at King Fahd General Hospital, which is a referral center for patients in the Western province. A total of 721 patients were admitted to the JKC since its start in the year 1991. Of these, a sample of 248 patients was selected through simple random sampling from the patient registry. The patients were identified and selected by patient name and medical record number.
A questionnaire was developed to collect information from the sample patients. The questionnaire included the following items:
- Data regarding date of data entry, serial number, medical record number, type of center and blood group.
- Socio-demographic data.
- Data such as serology at the start of maintenance HD (Hepatitis B and C and Human Immunodeficiency Virus), duration on HD in months, time interval from diagnosis of ESRD to initiation of HD in months, number of HD sessions per week, number of hours per session, number of blood transfusions, number of HD centers utilized, number of surgical procedures and history of kidney transplantation.
One of the researchers collected the data personally by interviewing with patients while they were receiving HD treatment. Additional information was obtained from the HD nurses, JKC medical records and hospital medical records.
| Statistical Analysis|| |
A computer program, "Statistical Package for Social Science (SPSS)", was used for data entry and statistical analysis. The data was checked and corrected for errors. Initially, the frequency distribution and simple descriptive statistical analysis were done for the study population. The statistical tests such as the Student's t test, chi-square test, Phi and Cramer's V correlation and logistic regression analysis were used to identify the risk factors that can be considered as predictors for the occurrence of hepatitis C infection among hemodialyzed patients. The level of significance was taken at < 0.05.
| Results and Discussion|| |
A retrospective analysis of HD patients was performed for the purpose of identifying the risk factors for the development of HCV infection.
The study showed that 180 patients had HCV infection accounting for 72.6% of the overall sample patients. This is in accordance with the findings of a study carried out in the Western province  where the prevalence of HCV infection was 72.3% and in another study that included 102 hospitals from all regions of the Kingdom of Saudi Arabia (KSA) that showed a prevalence of 70% for anti- HCV positivity.  Other studies carried out in the Gulf region also showed a high prevalence for HCV infection. ,,, In Egypt, a similar prevalence was also noted (approximately 75%).  These findings, however, are in contrast to those found in Spain, Germany and the UK where the prevalence of anti-HCV positivity was only 20%, 5.5% and 1% respectively.  This difference could be attributed to possibly poor application of universal precautions in the centers in our regions compare to the developed countries. Furthermore, the study found that the number of patients with positive HBsAg was relatively low (2%) which is similar to findings in Bahrain (3%).  The current study shows that there are statistically significant differences between males (77.2%) and females (65.7%) as regards to HCV infection. This finding is in accordance with studies conducted in Najran, Saudi Arabia,  the United Arab Emirates (UAE),  Taiwan  and France,  which reported similar findings. However, these results are in contrast to those in studies conducted in Medina, KSA  and Jordan,  where sero-positive females dominated over sero-positive males. On the other hand, review of other studies conducted in Jeddah,  Riyadh, KSA,  and Kuwait  revealed that there was no significant difference between female and male patients undergoing HD as regards to HCV infection.
No statistically significant difference regarding HCV infection was found between Saudi and non-Saudi patients, which is in agreement with the studies conducted in Jeddah and Riyadh. , Furthermore, there was no significant difference between the mean age of HCV positive and negative patients in our study which is in accordance with other studies in Jeddah and Kuwait. ,
The mechanism responsible for HCV transmission among HD patients is not entirely clear. Duration on HD is considered one of the risk factors for acquiring hepatitis C infection. We made a comparison between the mean duration on HD between HCV positive and negative patients. The mean duration in months on HD among HCV positive patients was much higher (70.37 months) than that for HCV negative patients (13.68 months). The difference was statistically significant p<0.05.
This is in agreement with a study conducted in Madina Al Munawarah, KSA  where they found that the duration on HD was longer in the anti-HCV positive group (mean 50 months) than in the negative group (mean 24 months) (p<0.001). Similarly, in Qatar  and Taiwan,  a significant relationship between the presence of anti-HCV antibody and longer duration on HD was found among the seropositive group (54 and 43 months respectively) compared to the seronegative group (22 and 32 months respectively) (p<0.05). However, in a study conducted in Spain,  the mean duration on HD did not show statistically significant differences between seroconverters and non-seroconverters (36 vs. 35 months respectively).
This study shows that there is a significantly increasing cumulative prevalence of HCV infection among HD patients. It ranges from 16.4% among patients on HD for one year, to a cumulative percentage of 94.5% among those on HD for three or more years (p<0.05). There was a strong positive correlation between the duration on HD and occurrence of HCV infection (r= 0.735, p<0.05). This trend of increasing cumulative prevalence of HCV seroconversion in HD patients is shown in other studies with some variability in the magnitude. In a study conducted in Taiwan,  the annual incidence of HCV infection was 14.6% reaching a cumulative prevalence of 60% after six years. In Kuwait,  it was estimated that there is an annual increment in the incidence of positive anti-HCV sero-conversion that is equal to 11.5% of patients on HD.
In the current study, 81.3% of HCV positive patients had been operated upon more than once compared to 67.8% who were operated only once and 69.2% who had no history of surgical procedures. However, these differences were not statistically significant. This is in accordance with studies conducted in UAE,  Spain  and The Netherlands where there was no data supporting HCV transmission by surgery or other invasive procedures.
Our study shows that 88% of HCV positive patients had history of kidney transplantation, compared to 68.7%, who had no history of kidney transplantation. The difference was statistically significant p<0.05. It is evident that although there is no significant difference between HCV positive and HCV negative patients in regards to history of surgical procedures in general, there is a significant difference with history of kidney transplantation. Blood transfusion needed during surgical operations might be considered as one of the hidden factors behind the difference. Therefore, the two groups were compared for history of blood transfusion. This revealed that 96% of patients who had undergone kidney transplantation received blood transfusion compared to 76.2% of those who had undergone surgical operations other than kidney transplantation. The difference was statistically significant (p<0.05) which indicates that blood transfusion required during kidney transplantation may be considered as a possible risk factor for HCV infection rather than the kidney transplantation itself. This finding is supported by the results of studies conducted in the Jeddah, (Saudi Arabia)  and The Netherlands  which stated that kidney transplantations were not associated with increased risk of acquiring HCV infection.
As the number of HD centers utilized by the patient plays an important role in increasing the risk of acquiring HCV infection, the summarized data for the number of HD centers visited by patients reveals that 78% of those who utilized more than one center acquired HCV infection compared to 64.3% for those who were treated exclusively at the JKC. The difference was statistically significant (p<0.05). There is a significant positive correlation between the number of centers utilized for HD and the occurrence of HCV infection (r= 0.532 p<0.05) reaching nearly perfect relations among those who utilize four or more centers. In a study carried out in the UAE,  the number of HD centers utilized was also a major risk factor for seroconversion of antiHCV, even among patients who were not transfused. Another study carried out in the KSA  also showed this positive relationship between the number of centers utilized and HCV-antibody seroconversion. Fourteen out of 17 (82%) of those who utilized more than one center acquired HCV infection compared to 18% of those who were never dialyzed outside the primary unit.
The study shows that 75.8% of HCV positive patients had received blood transfusions while 61.1% of HCV positive patients had never received blood transfusion. The mean number of blood transfusions for HCV positive patients (3.75) was higher than that for HCV negative patients (2.09), the difference was statistically significant (p<0.05). This finding is in agreement with studies conducted in Kuwait,  the UAE  and The Netherlands  where the prevalence of anti-HCV was higher in patients who received blood transfusion. The findings are also supported by another study conducted in 102 hospitals in KSA  where they found a positive correlation between annual incidence of anti-HCV seroconversion and history of blood transfusion but no correlation with the number of blood transfusions. However, in studies carried out in Jeddah,  the Western province  of Saudi Arabia and Qatar no association between anti-HCV positivity and blood transfusion were found.
The impact of the previous risk factors for HCV infection was tested using logistic regression [Table - 1]. The most significant risk factors for acquiring HCV infection among HD patients were duration of hemodialysis (p<0.05) followed by gender (being male) (p=0.034). The duration on HD as a risk factor of HCV infection points towards a nosocomial transmission and argues strongly in favor of isolation of anti-HCV positive patients during dialysis sessions.
| Acknowledgment|| |
We would like to express my thanks to the staff of the Jeddah Kidney Center.
| References|| |
|1.||Okuda K, Hayashi H. Hepatitis C virus infection among maintenance hemodialysis patients: a preventable problem of the world. Saudi J Gastroenterol 1996;2(1):1-7. |
|2.||Huraib SO. Hepatitis C in dialysis patients. Saudi J Kidney Dis Transplant 1995;6(2): 197-205. |
|3.||Al-Khader AA. Hepatitis C infection: the subject of this issue. Saudi J Kidney Dis Transplant 1995;6(2):115-7. |
|4.||Forns X, Fernandez-Llama P, Pons M, et al. Incidence and risk factors of hepatitis C virus infection in a haemodialysis unit. Nephrol Dial Transplant 1997;12(4):736-40. |
|5.||Chauveau P. Epidemiology of hepatitis C virus infection in chronic haemodialysis. Nephrol Dial Transplant 1996;11(Suppl 4): 39-41. [PUBMED] |
|6.||Keur I, Schneeberger PM, van-der Graaf Y, Vos J, Dijk WC, Doorn LJ. Risk factors for HCV infection in two haemodialysis units in the Netherlands. Neth J Med 1997; 50(3):97-101. |
|7.||El-Shahat YI, Varma S, Bari MZ, Nawaz MS, Abdulrahman S, Pingle A. Hepatitis C virus infection among dialysis patients in United Arab Emirates. Saudi J Kidney Dis Transplant 1995;6(2):157-62. |
|8.||Huang CC. Hepatitis in patients with endstage renal disease. J Gastroenterol Hepatol 1997;12(9-10):S236-41. |
|9.||Lin DY, Lin HH, Huang CC, Liaw YF. High incidence of hepatitis C virus infection in hemodialysis patients in Taiwan. Am J Kidney Dis 1993;21(3):288-91. |
|10.||Shaheen FAM, Huraib SO, Al-Rashed R, et al. Prevalence of hepatitis C antibodies among hemodialysis patients in the Western province of Saudi Arabia. Saudi J Kidney Dis Transplant 1995;6(2):136-9. |
|11.||Souqiyyeh MZ, Shaheen FAM, Huraib SO, Al-Khader AA. The annual incidence of seroconversion of antibodies to the hepatitis C virus in the hemodialysis population in Saudi Arabia. Saudi J Kidney Dis Transplant 1995;6(2):167-73. |
|12.||Soyarnwo MA, Khan N, Kommajosyula S, et al. Hepatitis C antibodies in haemodialysis and pattern of end-stage renal failure in Gassim, Saudi Arabia. Afr J Med Med Sci 1996;25(1):13-22. |
|13.||Al-Muhanna F. Hepatitis C virus infection among hemodialysis patients in the Eastern region of Saudi Arabia. Saudi J Kidney Dis Transplant 1995;6(2):125-7. |
|14.||El-Reshaid K, Kapoor M, Sugathan T, AlMufti S, Al-Hilali N. Hepatitis C virus infection in patients on maintenance dialysis in Kuwait: epidemiological profile and efficacy of prophylaxis. Saudi J Kidney Dis Transplant 1995;6(2):144-50. |
|15.||Abboud O, Rashid A, Al-Kaabi S. Hepatitis C virus infection in hemodialysis patients in Qatar. Saudi J Kidney Dis Transplant 1995; 6(2):151-3. |
|16.||Rashad B. Renal replacement therapy in Egypt. Saudi J Kidney Dis Transplant 1997; 8(2):152-4. |
|17.||Fakunle Y, Al-Mofarreh M, El-Karamany W, Ezzat H, Al-Shora B, El-Edrees A. Prevalence of antibodies to hepatitis C virus in hemodialysis patients in Riyadh. Ann Saudi Med 1991;11(5):504-6. |
|18.||Al-Arrayed S. Renal replacement therapy in Bahrain. Saudi J Kidney Dis Transplant 1998;9(4):457-8. |
|19.||Kumar R. Hepatitis C virus infection among hemodialysis patients in the Najran region of Saudi Arabia. Saudi J Kidney Dis Transplant 1997;8(2):134-7. |
|20.||El-Shahat YI, Varma S, Bari MZ, Nawaz MS, Abdulrahman S, Pingle A. Hepatitis C virus infection among dialysis patients in United Arab Emirates. Saudi J Kidney Dis Transplant 1995;6(2):157-62. |
|21.||Simon N, Courouce AM, Lemarrec N, Trepo C, Ducamp S. A twelve-year natural history of hepatitis C virus infection in hemodialyzed patients. Kidney Int 1994; 46(2):504-11. |
|22.||Bernieh B, Allam M, Halepota A, Mohammed AO, Parkar J, Tabbakh A. Prevalence of hepatitis C virus antibodies in hemodialysis patients in Madina Al Munawarah. Saudi J Kidney Dis Transplant 1995;6(2):132-5. |
|23.||Said RA, Hamzeh YY, Mehyar NS, Rababah MS. Hepatitis C virus infection in hemodialysis patients in Jordan. Saudi J Kidney Dis Transplant 1995;6(2):140-3. |
|24.||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. |
|25.||Saeed MG, Al-Harbi AS. Hepatitis C virus sero-status in hemodialysis patients returning from holiday: another risk factor for HCV transmission. Saudi J Kidney Dis Transplant 2001;12(1):14-20. |
Abdulla Mohammed Y Al-Jiffri
Department of Preventive Medicine, King Fahd Military Hospital, P.O. Box 40332, Jeddah 21499
[Table - 1]