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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ARAB WORLD Table of Contents   
Year : 2003  |  Volume : 14  |  Issue : 2  |  Page : 206-211
Hepatitis C Virus Among Hemodialysis Patients in Najran: Prevalence is More Among Multi-Center Visitors


1 Artificial Kidney Unit, Prince Sultan Kidney and Heart Center, Saudi Arabia
2 Department of Pediatrics, King Khalid Hospital, Saudi Arabia
3 Department of Medicine, King Khalid Hospital, Saudi Arabia
4 Sharorah Artificial Kidney Center, Sharorah General Hospital, Najran, Saudi Arabia

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   Abstract 

We studied a population of hemodialysis (HD) patients in the Najran region of Saudi Arabia to assess the prevalence of hepatitis C virus (HCV) and to evaluate the possible risk factors associated with this infection. The records of 90 patients undergoing dialysis in two centers of this region were reviewed. Blood samples were screened for anti­HCV antibodies by enzyme linked immunosorbent assay (ELISA) and positive samples were tested for confirmation by recombinant immunoblot assay. Liver transaminases were measured to assess the activity of the virus. In this study, an overall HCV prevalence of 46.7% was found among the HD patients. Statistical analysis showed that the number of previous blood transfusions, duration of dialytic age and dialysis treatment in multi-centers were associated significantly with HCV seropositivity. Although the mean levels of liver enzymes were significantly higher in HCV-positive than in HCV-negative patients, enzyme levels were raised above normal in only 29% of the patients.

Keywords: Hepatitis C virus, Hemodialysis, Najran region.

How to cite this article:
Kashem A, Nusairat I, Mohamad M, Ramzy M, Nemma J, Karim M, Divakaran M P, Tayaab AS. Hepatitis C Virus Among Hemodialysis Patients in Najran: Prevalence is More Among Multi-Center Visitors. Saudi J Kidney Dis Transpl 2003;14:206-11

How to cite this URL:
Kashem A, Nusairat I, Mohamad M, Ramzy M, Nemma J, Karim M, Divakaran M P, Tayaab AS. Hepatitis C Virus Among Hemodialysis Patients in Najran: Prevalence is More Among Multi-Center Visitors. Saudi J Kidney Dis Transpl [serial online] 2003 [cited 2020 Aug 11];14:206-11. Available from: http://www.sjkdt.org/text.asp?2003/14/2/206/33033

   Introduction Top


With the increased facilities and improved techniques of hemodialysis (HD), patients with end-stage renal disease (ESRD) are living longer. Consequently, the chance of acquiring infection is increased in these immunocompromised patients. Hepatitis C virus (HCV) infection is one of them, which is seen more frequently in HD patients than in the general population. The prevalence of HCV is particularly higher in the developing countries, [1] and it has become a major cause of increased mortality and morbidity in ESRD patients. [2] The mode of transmission of this virus is still not conclusively defined. Factors such as blood transfusion, partial immunosuppression, and frequent parenteral interventions have been shown to be associated with an increased risk for this infection. [3] The duration of HD treatment, and the possibility of nosocomial HCV transmission have also been suggested as additional contributing factors. [4],[5] In this study, we evaluated the current status of HCV infection among patients on maintenance HD in the Najran region of Saudi Arabia. The possible risk factors associated with HCV infection were also studied, and virus activity was assessed by measuring liver enzymes. The Najran region is located in the south-western part of Saudi Arabia and there are two hospitals with dialysis facilities serving about one million people. The hospitals are: Prince Sultan kidney and heart center (PSKHC), Najran, and the Sharorah general hospital (SGH), Sharorah.


   Materials and Methods Top


Study

The study comprised a total of 90 patients (74 from PSKHC and 16 from SGH) who were registered in the artificial kidney units of the two hospitals until August, 2002 (Jam-II 1423) and have been on long-term HD. A standardized, unified form was used to collect the following data: age, sex, dialytic age, number of blood transfusions received, history of treatment in multiple dialysis units, any intravenous drug use, time of HCV positivity (before HD or during dialytic age), and the association between the seropositivity of HCV and the above variables. Liver enzymes (transami­nases) were also studied to assess the activity of virus in these patients. The study was approved by the Ethical Committees of the hospitals and informed consent was obtained from each patient.

Patients

The mean age of the study patients was 45 ± 16 years (range 18 to 75); there were 47 males (52.2%) and 43 females (47.8%). The etiology of renal failure was chronic glome­rulonephritis in 22 (24.5%), hypertension in 21 (23.3%), diabetic nephropathy in 16 (17.8%), obstructive uropathy in eight (8.9%), Alport's syndrome in four (4.4%), polycystic kidney disease in three (3.3%), miscellaneous and unknown causes in six patients each (6.7%). Seventy-seven patients were Saudi (36 males and 41 females) and 13 patients were non-Saudi (4 males and 9 females) of whom there were 11 Yemenis and two Palestinians.

Dialysis

All the 90 patients were receiving regular dialysis of 2-3 sessions (8-12 hours) per week for a mean duration of 48.0 ± 42.0 months (range 3 to 205) using polysulfone membrane dialyzer. Dialyzers were not reused and dialysis was performed with disposable kits, syringes, and needles. Disinfection of the dialysis machines was done routinely according to the recommen­dations of the manufacturer. Patients who were HCV- positive were dialyzed in a separate room in each center.

Laboratory tests

Antibodies against HCV were tested by using Murex anti-HCV (ELISA 4), Abbot Murex Laboratories. Positive cases were confirmed by recombinant immunoblot assay (Chiron 3), having a specificity of 99%. Hepatitis B surface antigen (HbsAg) was checked by using the Auszyme monoclonal, Abbot Lab., and confirmed by the neutrali­zation method. All tests were carried out in the laboratory of the hospitals.

The serum alanine (ALT) and aspartate aminotransferases (AST) were measured routinely by a standard laboratory technique (automated analyzer technique). Mean of the successive three months measurements was calculated for every patient. The enzyme level was considered elevated when it was above 40 U/liter.

Statistics

For quantitative variables Student's t-tests were used in comparing two groups. Chi­square was carried out to analyze group difference for categorical variables. All tests were two tailed and P value of <0.05 was considered significant.


   Results Top


The patient distribution in the two study hospitals and the prevalence of HCV and HBsAg seropositivity are shown in [Table - 1]. Seropositivity for HCV antibody was seen in 42 patients (46.7%) and for HbsAg in four (4.4%); among them there were 20 males (46.5%) and 23 females (53.5%). Among the HCV positive patients, there were 32 Saudis and nine non-Saudis. Thirty three of the 42 HCV patients were in PSKHC (43%) while nine were in SGH (56%).

The association of HCV seropositivity with variables such as patient age, hemodialytic age, number of blood transfusions received, multi-center and unicenter ratio, and Saudi and non-Saudi ratio is shown in [Table - 2]. Analysis of all risk factors studied showed that the number of previous blood transfu­sions, hemodialytic age, dialysis treatment in multi-centers and non-Saudi nationals were associated with higher HCV positivity. There was a significant difference in the number of blood transfusions between HCV- positive and HCV- negative patients (10.5 ± 6.7 vs. 4.0 ± 4.3 transfusions, p<0.01). Of the 42 HCV positive patients, 34 (80%) had history of blood transfusions (2 to 26 times). Anti-HCV positive patients had been on dialysis for a longer period than the anti-HCV negative patients (65.8 ± 44.8 vs. 15.3 ± 14.0 months, p<0.01). The pro­portion of HCV seropositivity was signi­ficantly higher (76%) in patients having dialysis treatment in multi-centers than those who received dialysis in a single center (42.5%) [Table - 3]. Twelve patients were HCV positive before entering the HD-program and 30 patients acquired HCV positivity during their dialytic age, and among them, 22 (76%) patients were multi-center visitors.

At the PSKHC, the prevalence rate of anti­HCV positivity was significantly higher among non-Saudi (69.2%) than in the Saudi patients (41.6%) and higher in female patients (52.5%) than in males (47.5%).

The mean values of ALT and AST in the HCV- positive group were 41.8 ± 36.3 units /L and 29.5 ± 17.0 units/L respectively, which were significantly higher than the mean values of 19.4 ± 16.0 units/L and 16.3 ± 10.3 units/L respectively, in the negative group (p=<0.05). However, only 13 (29%) patients were found with ALT and AST values above the normal value. Besides the elevated transaminase levels, no other biochemical changes suggestive of liver disease (alteration in serum albumin, prothrombin time, platelet count etc.) were noted in these patients.


   Discussion Top


Hepatitis C has been reported from different parts of the world as a common infection in ESRD patients on dialysis. In this study, we observed a high prevalence of HCV antibody (46.7%) among HD patients in the Najran region. This value is higher than those observed in the central region, [6] almost similar to that observed in other southern regions, [7],[8] and lower than the prevalence found in the western region as well as the mean national rate. [8],[9] Indivi­dually, the seropositivity rate of HCV was comparatively less at the PSKHC (43%) than at the SGH (56%). Strict isolation of HCV- positive patients and dedicated dialysis machines and nursing staff at our new dialysis set-up, with strict adherence to the recommended universal precautions and meticulous regular disinfection of the HD machines, could possibly be a reason for the relatively low prevalence at our center. However, only the molecular method [poly­merase chair reaction (PCR)] can conclude the exact prevalence rate, as 10% of serone­gative patients may become HCV positive by this method. [10]

Although the route of HCV transmission in HD patients is not yet fully elucidated, previous studies suggest that dialytic age and number of blood transfusions are closely associated with HCV seropositivity. [3] Our present study further strengthens this notion with additional evidence that patients with dialysis treatment in multi-centers are also more prone to acquiring HCV infection. Contaminated HD-machines, dialyzers, bloodline surfaces and hands of the caring staff and possibly, sharing of multi-dose heparin vials, are the possible factors that can contribute to the transmission of HCV among the multi-center visitors.

Non-uniform adherence to the universal precautions and disinfection procedures in different centers as well as practice of dialyzing both HCV positive and negative patients in the same room, with or without separate machines, might be the underlying reasons to make these patients more prone to acquire HCV. However, dialysis of HCV positive patients in a separate designated room is not recommended by the Center for Diseases Control (CDC). [11] Multivariate analysis has revealed that seropositivity of HCV increases with the increased dialytic age of the patient and the number of blood transfusions. However, reports to the contrary have also been published regarding the association of blood transfusion and HCV transmission. [12],[13] Although the incidence of HCV among HD patients has decreased significantly after starting HCV screening in blood donors, majority of the HCV­positive patients (80%) in our study had a history of multiple blood transfusions. However, positive anti-HCV antibodies in eight patients (20.4%) who never received previous blood transfu-sions and negative anti-HCV in 40% patients with evidence of previous blood transfusions (1~17 times) in our study, points to an alternative or additional mode of HCV transmission in HD patients. Moreover, the prevalence rate of anti-HCV positivity among the blood donors in this region is reportedly low (1.2%) (King Khalid Hospital record 2001; unpublished data).

Although isolation of HCV positive patients is being practiced at our center, the majority of our patients (71%) acquired anti-HCV antibody during their dialytic age, which suggests that the HD procedure itself is a specific potential risk factor to acquire HCV infection as observed previ­ously. [13] Increased nosocomial transmission due either to prolonged immunocompro­mized state or breaches in the universal infection control measures during dialytic age, may be the factors responsible for this. Recently, nosocomial transmission of HCV among HD patients has been documented by the molecular analysis, [4],[14] which raises the question of how HCV- positive patients should be handled in dialysis units.

The mean levels of liver enzymes, ALT and AST, were significantly higher in the HCV- positive group. However, only 13 patients (29%) showed increased enzyme levels elevated above normal and these findings are in agreement with published data. [15] A recent study on non-uremic HCV­positive patients has shown the presence of cirrhotic changes in patients with elevated liver enzymes, while variable degrees of only chronic inflammatory changes were observed in patients with normal enzyme levels. [16] Although, it has been showed that 50-70% of HCV-positive patients progress, over a period of 10-40 years, to chronic hepatitis with increased risk of cirrhosis, liver failure and liver cancer, [17] the long­term outcome of untreated patients chronic HCV infection having normal or elevated liver enzymes is still unknown.

In conclusion, HCV infection is of great clinical importance since; a) majority of the patients acquire this infection during their dialytic age and in many patients, no specific source for their infection can be identified, b) it is commonly associated with chronic liver disease, cirrhosis and hepato-cellular carcinoma; c) there is increased risk of developing chronic liver disease in renal transplant recipients; and d) till date, no vaccine has been developed against HCV. Thus, observation of appropriate preventive measures by all the HD-centers is paramount. Strict adherence to the universal precautions combined with proper disinfection procedures, combined with increasing awareness among the HD­staff and patients that their blood/body fluids are potentially infective in spreading HCV infection to others, may reduce the spread of HCV infection in the dialysis units.


   Acknowledgement Top


The authors would like to thank the head nurse, sister Tankam Philip and all other dialysis staff for their contribution to this study; and to Manara Mahmood for her secre­ tarial assistance in preparing the manuscript.

 
   References Top

1.Alter HJ. Transmission pattern in hepatitis C virus infection. In: Nishioka K, et al. (eds). Viral hepatitis and liver disease. Springer Verlag 1993;p:445-9.  Back to cited text no. 1    
2.Huraib S, Al-Rashid R, Aldrees A, et al. High prevalence and risk factors for hepatitis C in Saudi Arabia: a need for new strategies in dialysis practice (Abst). Saudi Kidney Dis Transplant Bull 1993; 4:S73.  Back to cited text no. 2    
3.Olmer M, Bouchouareb D, Zandotti C, De Micco P, Lamballeric X. Transmission of the hepatitis C virus in an hemodialysis unit: evidence for nosocomial infection. Clin Nephrol 1997;47:263-70.  Back to cited text no. 3    
4.De-Lamballerie X, Olmer M, Bouchouareb D, Zandotti C, De Micco P. Nosocomial trans­mission of hepatitis C virus in hemodialysis patients. J Med Virol 1996;49: 296-302.  Back to cited text no. 4    
5.Sandhu J, Preiksaitis JK, Campbell PM, Carriere KC, Hessel PA. Hepatitis C prevalence and risk factors in the northern Alberta dia­lysis population. Am J Epidemiol 1999;150:58-66.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Anonymous. Dialysis in the Kingdom of Saudi Arabia (SCOT data). Saudi J Kidney Dis Transplant 2001;12(3):421-34.  Back to cited text no. 6    
7.Saxena AK, Panhotra BR, Naguib M, et al. Prevalence of hepatitis C antibodies among hemodialysis patients in Al-Hasa region of Saudi Arabia. Saudi J Kidney Dis Transplant 2001;12(4):562-5.  Back to cited text no. 7    
8.Shaheen FAM, Huraib SO, Al-Rashed R, et al. Prevalence of hepatitis C antibodies among hemodialysis patients in western province of Saudi Arabia. Saudi J Kidney Dis Transplant 1995;6:136-9.  Back to cited text no. 8    
9.Khan LA, Khan SA. Prevalence of hepatitis B and C markers in patients on maintenance hemodialysis in Najran. Saudi Med J 2001;22(7):641-2.  Back to cited text no. 9    
10.Carneiro MA, Martins RM, Teles SA, et al Hepatitis C prevalence and risk factors in hemodialysis patients in central Brazil: a survey by polymerase chain reaction and serological methods. Mem Inst Oswaldo Cruz 2001;96:765-9.  Back to cited text no. 10    
11.Saxena AK, Panhotra BR. Nosocomial transmission of hepatitis C virus; impact of strict isolation on annual seroconversion rate in a hemodialysis unit. Saudi J Kidney Dis Transplant 2002;13:186-7.  Back to cited text no. 11    
12.Lin HH, Huang CC, Sheen IS, Lin DY, Liaw YF. Prevalence of antibodies to hepatitis C virus in the hemodialysis unit. Am J Nephrol 1991;11:192-4.  Back to cited text no. 12  [PUBMED]  
13.Dandrani S, Hardy N, Danielson S, Wilson B. Risk of hepatitis C increases with duration of dialysis (abstract). J Am Soc Nephrol 1991;2:348.  Back to cited text no. 13    
14.Grethe S, Gemsa F, Monazahian M, Bohme I, Uy A, Thomssen R. Molecular epidemiology of an outbreak of HCV in a hemodialysis unit: direct sequencing of HCV-HVRI as an appropriate tool for phylo­genetic analysis. J Med Virol 2000;60:152-8.  Back to cited text no. 14    
15.Mondelli MU, Smedile V, Piazza V, et al. Abnormal alanine aminotransferase activity reflects exposure to hepatitis C virus in hemodialysis patients. Nephrol Dial Transplant 1991;6:480-3.  Back to cited text no. 15  [PUBMED]  
16.Akbar HO. Treatment of patients with chronic hepatitis C with normal liver enzymes. Saudi Med J 2002;23(3):301-4.  Back to cited text no. 16    
17.Kew MC, Houghton M, Choo QL, Kuo G. Hepatitis C virus antibodies in southern African blacks with hepatocellular carcinoma. Lancet 1990;335:873-4.  Back to cited text no. 17  [PUBMED]  

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Correspondence Address:
Abul Kashem
Consultant Nephrologist, Artificial Kidney Unit, Prince Sultan Kidney and Heart Center, Najran-1120
Saudi Arabia
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PMID: 18209450

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