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RENAL DATA FROM THE ARAB WORLD |
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| Year : 2008 | Volume
: 19
| Issue : 1 | Page : 110-115 |
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| Prevalence and Risk Factors for Hepatitis C Virus Infection in Hemodialysis Patients in an Iraqi Renal Transplant Center |
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Omar Salem Khattab
Lecturer of Surgery, College of Medicine, Baghdad University, Baghdad, Iraq
Click here for correspondence address and email
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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 2020 Nov 24];19:110-5. Available from: https://www.sjkdt.org/text.asp?2008/19/1/110/37449 |
| Introduction | |  |
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 | | |
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 | | |
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 | | |
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 | | |
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 | | |
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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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