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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 548-554
Prevention of hepatitis C virus in hemodialysis patients: Five years experience from a single center


Nephrology Division, Medical Department, Dawmat Aljandal General Hospital, Aljouf, Saudi Arabia

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Date of Web Publication26-Apr-2010
 

   Abstract 

Hepatitis C virus (HCV) has been a significant problem in hemodialysis (HD) pa­tients. In general, it carries significant morbidity including liver cirrhosis, liver cell failure and hepa­toma. The study was conducted on 36 seronegative HD patients. All patients were managed with strict application of infection control guidelines as well as isolation of HCV-positive patients. None of the patients received any blood transfusions and were managed with iron and erythro­poietin. After five years of follow-up, we found that the incidence of HCV seroconversion was zero. Our study further suggests that following infection control guidelines, isolation of sero­positive patients and minimizing blood transfusions can help in prevention of HCV transmission among HD patients.

How to cite this article:
Mohamed WZ. Prevention of hepatitis C virus in hemodialysis patients: Five years experience from a single center. Saudi J Kidney Dis Transpl 2010;21:548-54

How to cite this URL:
Mohamed WZ. Prevention of hepatitis C virus in hemodialysis patients: Five years experience from a single center. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Dec 11];21:548-54. Available from: http://www.sjkdt.org/text.asp?2010/21/3/548/62724

   Introduction Top


Hepatitis C virus (HCV) infection is a major public health problem, with an estimated global prevalence of 3% occurring in about 170 million persons worldwide. [1] Patients with renal disease are at an increased risk of acquiring HCV be­cause of prolonged vascular access and the po­tential for exposure to infected patients and contaminated equipment. [2] An estimated 5-20% of HCV-infected patients have, or will develop cirrhosis, 1-4% of whom will annually develop hepatocellular carcinoma. [2]

Hepatitis C is the most common cause of li­ver disease in patients on HD, while liver di­sease itself is a significant cause of morbidity and mortality in patients with end-stage renal disease (ESRD) treated by dialysis or trans­plantation. [3]

We implemented and followed a protocol for prevention and control of HCV in our HD unit with follow-up for five years and are herewith reporting our findings.


   Patients and Methods Top


In November 2003, an outbreak occurred in our unit during which, five HCV-negative pa­tients out of 13 got seroconverted to HCV­positive status and investigations revealed that the outbreak was caused by a breach in applica­tion of standard infection control precautions in daily HD practice. Thus, from December 2003, we ensured that infection control guidelines are strictly followed in our HD unit, which ca­tered to 16 patients at that time. During the pe­riod of five years, 36 patients who were HCV­negative underwent HD at our unit. Seroposi­tive patients were dialyzed in a separate hall consisting of five machines and HD session was performed by two nurses for 3-4 hours, three times per week. Seronegative patients underwent dialysis in an adjacent hall that con­tained seven HD machines and were managed by four to five nurses. In general, the patient/ nurse ratio was 2:1. We established a training program for implementing infection control guidelines in dialysis units, with special con­cern to the standard precautions (hand washing/ alcohol-based hand rub, wearing personal pro­tective equipment, proper waste and sharp dis­posal, environmental cleaning, disinfection of common equipment shared by patients and ap­plying a protocol for use of multi-dose vials along with direct strict observation and reporting.

However, the construction of our HD unit is not ideal regarding the area and availability of hand washing facilities as recommended; it con­sists of two halls which are continuous with each other.

All patients were interviewed for risk factors to HCV infection including general risk factors like acupuncture, tattooing, illicit drug abuse, sexually transmitted diseases, any blood con­tact e.g. dental clinic, multiple partners and risk factors related to HD like minimizing blood transfusions, management of anemia using iron and erythropoietin, standard precautions and treatment in multiple units.

A standardized form was used to collect data on age, sex and blood transfusions between 2004 and 2008 (mandatory screening for anti­HCV in blood banks). A protocol for any new patients or a visitor-patient to the unit was ap­plied so that the patient had to be screened for HCV Ab, HBsAg and HIV Ab irrespective of his/her previous results, and to do proper dis­infection of the area including machine as per infection control protocol and manufacture ins­tructions.

A protocol for patients who traveled to ano­ther area for dialysis, regarding monthly scree­ning for HCVAb, HBsAg and HIVAb, in addi­tion to monthly regular evaluation of liver func­tion tests, bilirubin (total and direct) and liver enzymes, was followed strictly. Additionally, we also started application of the K-DOQI guidelines in management of anemia by res­tricting blood transfusions which was restric­ted for only emergency use.

The HD machines (Fresenius AG, Homburg, Germany), were disinfected with chemical (Pu­risteril; 340, Fresenius AG, Homburg, Germany) after each session and, at the end of each day, with heat and chemical as per instructions of the manufacturers.

Seronegative patients were screened regularly for HCV-antibody at the Dawmat Aljandal Ge­neral Hospital laboratory using ELISA tech­nique second generation, every three months.

Standard descriptive statistical tests were performed as indicated using SPSS (Statistics Program for Social Sciences) version 16.0, SPSS Inc., Chicago, IL, USA


   Results Top


During the period of five years, 36 patients who were HCV-negative [16 female (44.4%) and 21 male (55.6%)] with mean age of 56.36 ± 21.38 years (range 16-89 years) underwent HD at our center. Of them, 11 (30.6%) patients expired, three (8.3%) underwent renal trans­plantation, one patient (2.8%) converted to CAPD and 21 patients (58.3%) continue to be on HD in December 2008.

We found that the incidence of HCV sero­conversion during this period (1 st December 2004 - 31st December 2008) in these 36 patients was zero, while the prevalence showed a dec­line with each passing year; thus, it decreased from 50% in November 2003 to 23% in De­cember 2008 [Figure 1].

The duration on dialysis of the study patients is shown in [Figure 2]. By the end of the study period, ten patients (27.8%) were on HD for less than one year, 12 (33.3%) were on HD for 1 - 3 years, 12 others (33.3%) for 3 - 5 years while two patients (5.6%) were on HD for more than five years. During their dialysis period, a mean of 5 ± 2.97 transfusions were adminis­tered to the study patients [Figure 3].


   Discussion Top


The prevalence of HCV infection varies greatly among patients on HD from different geogra­phic regions. In a review of data published in 1999, Wreghitt [4] described a range from 4% in the UK to 71% in Kuwait for HCV prevalence among the HD population. Since 1999, the re­ported anti-HCV seropositivity has ranged from 1.9% in the Slovenian 2001 annual report, [5] to 84.6% in Saudi Arabia. [6]

HCV infection still remains a major problem among patients on maintenance HD. The im­mune suppression seen in this patient popu­lation, resulting in an absence of clinical and biochemical evidence of liver disease, is be­lieved to accelerate further dissemination of the virus. [7] The importance of prevention of HCV infection and control is due to its well documented progression to hepatic cirrhosis, liver malignancies and liver failure. [8] HCV in­fection is considered to be of particular rele­vance in this group of patients and can result in disastrous sequelae after kidney transplan­tation due the immunosuppressive therapy used. [9]

This study showed that successful prevention and control of HCV transmission is multifac­torial including un-modifiable factors like du­ration of the patients on dialysis and modi­fiable factors including:

  1. implementation of infection control guide­lines including standard precautions,
  2. isolation if feasible and,
  3. minimizing blood transfusions.
Almost all recent surveys have congruently suggested the length of time on HD as a risk factor for HCV seropositivity. [10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21] A relatively large study in Brazil demonstrated that patients on HD for more than three years had a 13.6­fold greater risk of HCV-positivity compared to subjects with less than one year HD treat­ ment. [20]

Several recent studies [22],[23],[24],[25],[26] have reported noso­comial patient-to-patient transmission of HCV infection among HD patients. Some investi­gators have suggested that the decline in HCV prevalence among HD patients in recent years is mostly attributable to strict adherence to standard precautions. [27],[28],[29],[30],[31],[32],[33] Thus, lack of strict adherence to standard precautions by the staff and sharing of articles such as instruments or multi-dose drugs might be the main mode of nosocomial spread of HCV among HD pa­tients. [34],[35],[36] In addition, Piazza et al showed that HCV RNA was resistant to drying at room temperature for at least 48 hours. [37] Also, re­cently Froio et al suggested the importance of environmental contamination of surfaces for HCV transmission. [38]

As a result, the CDC recommends that spe­cial precautions should be observed in dialysis units, including wearing and changing of gloves and water-proof gowns between patients, sys­tematic decontamination of the equipment cir­cuit and surfaces after each patient treatment, and no sharing of instruments (e.g., tourniquets, stethoscope, blood pressure cuff) or medica­tions (e.g., multiuse vials of heparin) among patients. [39]

Although some studies found that nosocomial spread of HCV declined when HCV-infected patients were treated in dedicated HD units, [28],[30] other investigators could control nosocomial spread of HCV by strict application of hygie­nic precautions without isolation of HCV-in­fected subjects or machine segregation. [40],[41]

In this study, none of the transfused patients developed HCV seroconversion. Historically, the number of blood transfusions received has been consistently reported in the literature to be associated with an increased prevalence of HCV-positive dialysis patients. [4] However, se­veral recent reports could not recognize blood transfusion as an independent risk factor in HCV spread among HD subjects. [15],[17],[18],[19],[23],[42],[43],[44],[45],[46],

Indeed, the wide use of erythropoietin from the late 1980s reduced the need for blood trans­fusions among HD patients. Furthermore, the introduction of nucleic acid amplification tes­ting for the screening of blood donors has markedly reduced the risk of HCV transmi­ssion through blood product transfusion. The current risk of transfusion-associated hepatitis C is approximately one in every two million people. [47]

A history of organ transplantation, [10],[17],[44],[45] older age, [46],[48] younger age, [49] dialysis in multiple cen­ters, [20],[44],[50],[51] associated hepatitis B infection, [21] human immunodeficiency virus infection, and diabetes mellitus, [52] are other factors that have been suggested to be associated with HCV­positivity.

Nakayama et al, found that Anti-HCV sero­positivity was an independent risk factor for death.

In conclusion, isolation and proper applica­tion of infection control guidelines in HD units is recommended to avoid burden of virus trans­mission and morbidity.


   Acknowledgment Top


The author would like to thank the hospital administration and nursing team at the AKU in Dawmat Aljandal General Hospital.

 
   References Top

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Correspondence Address:
Waleed Z Mohamed
Nephrology Division, Medical Department, Dawmat Aljandal General Hospital, Dawmat Aljandal, Aljouf
Saudi Arabia
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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Acknowledgment
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