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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2008  |  Volume : 19  |  Issue : 1  |  Page : 110-115
Prevalence and Risk Factors for Hepatitis C Virus Infection in Hemodialysis Patients in an Iraqi Renal Transplant Center


Lecturer of Surgery, College of Medicine, Baghdad University, Baghdad, Iraq

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   Abstract 

Hepatitis C virus (HCV) infection has been recognized as an emerging problem in dialysis patients and its prevalence varies considerably among different areas of the world. The prevalence of HCV infection in hemodialysis (HD) patients and its associated risk factors is not well documented in our country. We therefore performed this study aiming to discuss prevention of further transmission of HCV infection among our patients. Between September 2003 and September 2005, 169 patients with end-stage renal failure on HD at the Renal Transplant Center, Medical City Teaching Hospital, Baghdad, were involved in this prospective study. There were 102 (60.4%) males, and 67 (39.6%) females, with age ranging from 14-67 years. Anti-HCV antibodies were positive in 12 of these patients (7.1%). Female gender, age > 60 years, dialysis duration < six months, history of having received blood transfusion(s), and < 9 hours per week of HD were significant predictors of anti-HCV positivity. We conclude that adherence to universal infection precautions, regular HCV screening of transfusions and of patients on HD and the use of separate machines for those who are anti-HCV positive, are important factors. To further reduce the prevalence in our patients, erythropoietin should replace blood transfusions as also testing for HCV RNA using polymerase chain reaction before starting HD.

Keywords: Hepatitis C, hemodialysis, Iraq

How to cite this article:
Khattab OS. Prevalence and Risk Factors for Hepatitis C Virus Infection in Hemodialysis Patients in an Iraqi Renal Transplant Center. Saudi J Kidney Dis Transpl 2008;19:110-5

How to cite this URL:
Khattab OS. Prevalence and Risk Factors for Hepatitis C Virus Infection in Hemodialysis Patients in an Iraqi Renal Transplant Center. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Jul 22];19:110-5. Available from: http://www.sjkdt.org/text.asp?2008/19/1/110/37449

   Introduction Top


Viral hepatitis remains a major hazard for both patients and medical staff of hemodialysis (HD) units.[1],[2],[3] The decline in the incidence of hepatitis B virus (HBV) infection due to many factors including application of universal infection precautions, vaccination and screening of transfused blood for HBV has lead to hepatitis C virus (HCV) becoming the major form of hepatitis in HD patients. [4],[5],[6] Non-A, non-B hepatitis was first described in 1975. [7] Fifteen years later, the HCV was identified as the leading cause of non-A non-B hepatitis. [8] Since then many reports reports have appeared describing variable prevalence rates of HCV infection in HD patients ranging between 2.9 and 68% [Table - 1], it is higher in the Middle East and Far East compared to the Western countries.[1],[3],[9],[10]

The prevalence of HCV infection and its associated risk factors among HD patients has not been well documented in Iraq. We therefore undertook this prospective study on patients on maintenance HD at the Renal Transplant Center, Medical City Teaching Hospital, Baghdad, Iraq. We also aim to discuss pre­vention of further transmission of HCV infection among these patients.


   Patients and Methods Top


This prospective study done was performed between September 2003 and September 2005 at the Renal Transplant Center, Medical City Teaching Hospital, Baghdad. A total of 169 patients with end-stage renal failure who had been on HD for at least three months were included in the study. There were 102 males (60.4%), and 67 females (39.6%), with age range of 14-67 years and a mean age of 36 ± 13.33 years [Table - 2]; 43 of them (25.4%) had undergone renal transplantation.

Routine HD techniques were used on all patients, with 3-4 hours of dialysis performed 1-3 times weekly using polysulfone dialyzers with acetate solution of standard composition. Patients who were hepatitis B surface antigen (Hbs Ag) positive, as well as those with anti­HCV antibody-positivity were dialyzed in separate rooms using separate machines. Disposable kits and needles were used, and universal precautions such as use of gloves, disinfection of surfaces were followed.

Disinfection of the dialysis machines included hot water rinsing between HD sessions and chemical disinfection at the end of the day or at the end of the week. Each patient was cared-for by a separate nurse. All patients and medical staff were vaccinated for hepatitis B. The patients were tested monthly for HbsAg, anti-HCV antibody by the third generation enzyme immunoassay (ELISA) (bioelisa HCV: Core, NS3, NS4, and NS5. Spain), and serum alanine aminotrans­ferase (ALT) levels, which were considered abnormal if they were at least 1.5 times the normal level (0-56 IU). The medical staffs were tested annually for HbsAg, and anti­HCV antibody. None of the patients was known to be an intravenous drug abuser. The chi-square test was applied for statistical analysis, and the results were considered significant if P value was < 0.05.


   Results Top


The prevalence of anti-HCV positive patients was 12 (7.1%); five (4.9%) were males, and seven (10.4%) were females. The prevalence was statistically significant in females (P <0.05). There was significantly high preva­lence of anti-HCV antibody in patients who were > 60 years of age ( P <0.05). The mean duration on HD in the study patients was 10.91 ± 5.95 months; 50 (29.6%) were on HD for < six months of whom seven (14%) became anti-HCV positive. 62 (36.7%) were on HD for 7-12 months of whom four (6.5%) became anti-HCV positive, and 57 (33.7%) were on HD for 13-24 months of whom one (1.8%) became anti-HCV positive. The increased prevalence rates among patients on HD for, six months was statistically significant (P <0.05). A total of 112 patients (66.3%) did not receive any blood transfusions; seven (6.3%) of them became anti-HCV positive, while 57 (33.7%) received blood transfusions of whom five (8.8%) became anti-HCV positive. Thus, blood transfusions played a significant role in the development of anti­HCV positive antibodies ( P <0.05). Fifty patients (29.6) received HD for < 4 hours per week, five (10%) of whom became anti­HCV positive; 73 (43.2%) received HD for 5-8 hours per week, six (16.2%) of whom became anti-HCV positive, while 46 (27.2%) other patients received HD for 9-12 hours per week, of whom one (2.3%) became anti-HCV positive. There was significant difference in HCV prevalence in those who received HD for < 4 hours per week ( P <0.05). In two patients (16.6%) who were anti-HCV positive, the ALT was > 80 IU, while in the remaining 10 (83.3%), the ALT was < 80 IU; all of them were asymptomatic. There was no correlation between positive anti-HCV and abnormal ALT levels [Table - 2].


   Discussion Top


HCV infection is common in patients with end-stage renal disease undergoing maintenance HD or peritoneal dialysis. [3],[11],[12],[13],[14] Many factors could be contributing towards this increased prevalence. Some of these have been well documented, while others are still awaiting further studies. Blood transfusion is an important factor in the transmission of HCV infection; we found a positive corre­lation between blood transfusions and the risk of HCV infection. This risk increased with the increase in the number of units which were transfused. Similar results have been reported by others. [13],[14],[15],[16],[17],[18] Nevertheless, seven (6.3%) of the 112 (66.3%) patients in our study who had never received any blood transfusions developed anti-HCV antibodies. This indicates that other factors were contri­buting to this infection in our patients. Some investigators found no correlation between blood transfusions and positive anti­-HCV. [19],[20]

Another important risk factor is the duration on dialysis; many reports indicate that the prevalence increases with longer duration on dialysis. [12],[13],[14],[15] Interestingly, we found an increased risk in those who were < 6 months duration on HD, which may reflect failure of proper screening for anti­HCV antibody and also because patients on HD may not be able to mount detectable antibody titers. [21] These patients can be identified by HCV RNA testing using poly­merase chain reaction. Also, the prevalence of anti-HCV decreased significantly after 12 months on dialysis; this reduction could be due to reduction of titer of anti-HCV with time, as was noted by others. [22],[23] The prevalence of anti-HCV was lower in our study among patients on three sessions of HD per week, which may be due to the use of polysulfone membrane which has rela­tively larger pore size in comparison with other dialyzer membranes, this may create a greater opportunity for escape of HCV to spent dialysate. [3] Hayashi et al suggested that viral particles are adsorbed onto the inner surface of the filter membrane during HD. [24]

Anti-HCV appeared to be more prevalent in females than males, which could be due to females being more exposed, particularly during labor. The higher prevalence among females has also been reported by others, [25] while some other studies have reported a higher prevalence in males. [15],[26]

No correlation was found between ALT and anti-HCV positivity, which has been reported by other investigators as well. [13],[15],[19] This could be because of non-virulent HCV strain, tolerance to HCV and/or immunosuppre­ssion. It is reported that patients can have positive anti-HCV and circulating HCV RNA with normal liver enzymes and liver histology. [27] Evaluation of HCV is further complicated by the observation that amino­transferase values are lower in dialysis patients than the non-uremic population. [28] The presence of HBs Ag was not a risk factor for the development of HCV anti­bodies, while some have said that it plays a role. [25]


   Conclusion Top


In this study, it appears that the prevalence of anti-HCV in our center is lower than the prevalence in other developing countries. This may be due to strict adherence to universal infection precautions, HCV screening of transfusions and of patients on HD and/or use of separate machines in separate rooms for those who are anti-HCV positive.

To further reduce the prevalence of dialysis­associated HCV, erythropoietin usage should be increased to replace blood transfusions. Also, test for HCV RNA using polymerase chain reaction should be performed on all patients before starting HD.

 
   References Top

1.Fehr T, Ambuhl PM. Chronic hepatitis virus infections in patients on renal replace ment therapy. Nephrol Dial Transplant 2004;19(5):1049-53.  Back to cited text no. 1    
2.Sammy S. Hepatitis C virus transmission in haemodialysis community. Am J Kidney Dis 2001;37(5):1052-5.  Back to cited text no. 2    
3.Fabrizi F, Bunnapradist S, Lunghi G, Martin P. Kinetics of hepatitis C virus load during haemodialysis: Novel perspectives. J Nephrol 2003;16(4):467-75.  Back to cited text no. 3    
4.Padmanabhan R. Hepatitis C virus infection in haemodialysis patients in Saudi Arabia. Saudi J Kidney Dis Transpl 1994;5(2):157-8.  Back to cited text no. 4    
5.Martin P, Friedman L. Chronic viral hepatitis and the management of chronic renal failure. Kidney Int 1995;47(5):1231-41.  Back to cited text no. 5    
6.Fabrizi F, Lunghi G, Poordad FF, Martin P. Management of hepatitis B after renal transplantation: An update. J Nephrol 2002; 15(2):113-22.  Back to cited text no. 6    
7.Feinstone SM, Kapikian AZ, Purcell RH, Alter HJ, Holland PV. Transfusion­associated hepatitis not due to viral hepatitis type A or B. N Engl J Med 1975;292(15): 767­-70.  Back to cited text no. 7    
8.Choo QL, Kuo G, Weiner AJ, Overby LR, Bradley DW, Houghton M. Isolation of a DNA clone derived from a blood borne none A non B viral hepatitis genome. Science 1989;244(4902):359-62.  Back to cited text no. 8    
9.Broumand B, Shamshirsaz AA, Kamgar M, et al. Prevalence of hepatitis C infection and its risk factors in hemodialysis patients in Tehran: Preliminary report from "the effect of dialysis unit isolation on the incidence of hepatitis C in dialysis patients" project. Saudi J Kidney Dis Transpl 2002;13(4):467-72.  Back to cited text no. 9    
10.Jaiswal S, Chitnis D, Salgia P, Sepaha A, Pandit C. Prevalence of hepatitis viruses among chronic renal failure patients on haemodialysis in Central India. Dial Transplant 2002;31:234-40.  Back to cited text no. 10    
11.Esteban J, Esteban R, Viladonin L, et al. Hepatitis C virus antibodies among risk groups in Spain. Lancet 1989;2(8658):294­-6.  Back to cited text no. 11    
12.Muller GY, Zabaleta ME, Arminio A, et al. Risk factors for dialysis associated hepatitis C in Venezuela. Kidney Int 1992;41(4): 1055-8.  Back to cited text no. 12    
13.Oguchi H, Miyasaka M, Tokunaga S, et al. Hepatitis virus infection (HBV and HCV) in eleven Japanese hemodialysis units. Clin Nephrol 1992;38(1):36-43.  Back to cited text no. 13    
14.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.  Back to cited text no. 14    
15.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(4):470-4.  Back to cited text no. 15    
16.Al Furayh O, Sobh M, Buali A, et al. Hepatitis C virus infection in chronic haemodialysis: A clinicopathological study. Nephrol Dial Transplant 1992;7(4):327-32.  Back to cited text no. 16    
17.Mitwalli A, al Mohaya S, al Wakeel J, et al. Hepatitis C in chronic renal failure patients. Am J Nephrol 1992;12(5):288-91.  Back to cited text no. 17    
18.Fakunla Y, Al Mofarreh M, El Karamany WM, Ezzat HO, Al-Shora B, El-Drees AZ. Prevalence of antibodies to hepatitis C virus in haemodialysis patients in Riyadh. Ann Saudi Med 1991;11(5):504-6.  Back to cited text no. 18    
19.Hardy NM, Sandroni S, Danielson S, Wilson WJ. Antibody to hepatitis C virus increase with time on hemodialysis. Clin Nephrol 1992;38(1):44-8.  Back to cited text no. 19    
20.Szmuness W, Prince AM, Grady GF, et al. Hepatitis B infection: A point prevalence study in 15 US hemodialysis centers. JAMA 1974;227(8):901-4.  Back to cited text no. 20    
21.Seelig R, Renz M, Bottner C, Seelig HP. Hepatitis C virus infection in German dialysis units; Prevalence of HCV-RNA and antibodies to HCV recombinant antigens. Ann Med 1994;26(1):45-52.  Back to cited text no. 21    
22.Pereira BJ, Milford EL, Kirkman RL,et al. Prevalence of hepatitis C virus RNA in organ donors positive for hepatitis C antibody and in the recipients of their organs. N Engl J Med 1992;327(13):910-5.  Back to cited text no. 22    
23.Chan TM, Lok AS, Cheng IK. Hepatitis C in renal transplant recipients. Transplantation 1991;52(5):810-3.  Back to cited text no. 23    
24.Hayashi H, Okuda K, Yokosuka O, et al. Adsorption of hepatitis C virus particles onto the dialyzer membrane. Artif Organs 1997;21(10):1056-9.  Back to cited text no. 24    
25.Dussol B, Berthezene P, Brunet P, Berland Y. Hepatitis C virus infection among chronic dialysis patients in the southeast of France. Nephrol Dial Transplant 1995;10(4):477-8.  Back to cited text no. 25    
26.Dentico P, Buongiorno R, Volpe A, et al. Prevalence and incidence of hepatitis C virus (HCV) in hemodialysis patients: Study of risk factors. Clin Nephrol 1992;38(1):49­-52.  Back to cited text no. 26    
27.Brillanti S, Foli M, Gaiani S, Masci C, Miglioli M, Barbara L. Persistant hepatitis C viraemia without liver disease. Lancet 1993;341(8843):464-5.  Back to cited text no. 27    
28.Fabrizi F, Poordad FS, Martin P. Hepatitis C infection and the patient with end stage renal disease. Hepatology 2002;36(1):3-10.  Back to cited text no. 28    

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Correspondence Address:
Omar Salem Khattab
General and Transplant Surgeon, College of Medicine, Baghdad University, PO Box: 19503, Baghdad
Iraq
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PMID: 18087139

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    Tables

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
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    References
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