RENAL DATA FROM ASIA–AFRICA
|Year : 2020 | Volume
| Issue : 3 | Page : 647-654
|Seroprevalence of Hepatitis B, C and coinfection among patients with chronic kidney disease in a Nigerian hospital
Adeyemi Ogunleye1, Tosin T Oluwafemi1, Akinwumi A Akinbodewa2, Victoria O Daomi1, Oluseyi A Adejumo2, Temitope C Omisakin3
1 Department of Medical Laboratory Services, University of Medical Science Teaching Hospital, Ondo, Ondo State, Nigeria
2 Department of Medicine, University of Medical Science Teaching Hospital, Ondo, Ondo State, Nigeria
3 Department of Hematology, Federal Medical Centre, Ido-Ekiti, Ekiti State, Nigeria
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|Date of Submission||18-Jul-2019|
|Date of Decision||01-Sep-2019|
|Date of Acceptance||24-Sep-2019|
|Date of Web Publication||10-Jul-2020|
| Abstract|| |
Infectious diseases remain a major health challenge in developing countries, compounding the woes of growing noncommunicable diseases such as chronic kidney disease (CKD). Increased morbidity and mortality have been reported among CKD patients with hepatitis infection and may necessitate protocol for treatment, follow-up, and prevention of spread. We aimed to determine the prevalence of viral hepatitis B and C infections among CKD patients and the effects on their liver enzymes. In this retrospective study, 314 CKD patients screened for hepatitis C virus (HCV) and hepatitis B surface antigen (HBsAg) were reviewed. Participants were screened at the time of diagnosis of CKD or referral, using qualitative enzyme immunoassay rapid test kits before the initiation of treatment. Individuals who were reactive to human immunodeficiency virus were excluded, and data were analyzed using IBM SPSS Statistics version 21.0. Participants included 206 males (65.6%) and 108 females (34.4%), with a mean age of 50.5 ± 16.3 years. The seroprevalence of HBsAg, HCV, and coinfection was seen in 15.6% (49), 4.8% (15), and 0.92% of the patients, respectively. More than half (63.6%) of the seropositive patients were below 50 years of age. Alanine transaminase (ALT) activity was higher in HCV seropositive than negative (10.5 ± 10.5 vs. 21.2 ± 35.9) (P = 0.001), while aspartate transaminase (AST) and alkaline phosphatase (ALP) were similar. ALT, AST, and ALP were also similar between HBsAg-seropositive and HBsAg-negative patients. The prevalence of hepatitis B and C is high among our CKD patients. This suggests the need for improved screening and treatment of hepatitis infection in this group. Immunization may also be essential to prevent its spread among patients requiring hemodialysis.
|How to cite this article:|
Ogunleye A, Oluwafemi TT, Akinbodewa AA, Daomi VO, Adejumo OA, Omisakin TC. Seroprevalence of Hepatitis B, C and coinfection among patients with chronic kidney disease in a Nigerian hospital. Saudi J Kidney Dis Transpl 2020;31:647-54
|How to cite this URL:|
Ogunleye A, Oluwafemi TT, Akinbodewa AA, Daomi VO, Adejumo OA, Omisakin TC. Seroprevalence of Hepatitis B, C and coinfection among patients with chronic kidney disease in a Nigerian hospital. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Dec 6];31:647-54. Available from: https://www.sjkdt.org/text.asp?2020/31/3/647/289451
| Introduction|| |
Viral hepatitis remains a major infectious disease of public health concern across the globe. Hepatitis B and C are significant contributors to the burden of communicable diseases, especially in sub-Saharan Africa, compounding the effects of noncommunicable diseases such as chronic kidney disease (CKD) which is reportedly on the increase. Hepatitis B and C are the most common viral infections among individuals with renal disease. They have been associated with poor prognosis and are significant independent risk factors for death in patients with CKD.
Renal disease is associated with reduced immunity; hence, these patients do not clear the viral infections efficiently. Consequently, CKD patients with hepatitis B and or C exhibit increased risk for chronic liver disease, complications in renal transplantation, and high mortality rate.
Glomerulonephritis (GN) associated with viral hepatitis B and C has been implicated as an important cause of glomerulopathy. While GN associated with the formation of immune complexes or effects of virus-induced cyto-kines/mediators on renal tissue is a well-described complication of chronic hepatitis B,, renal disease is also an established extrahepatic manifestation of hepatitis C virus (HCV) infection.
Although the mechanisms responsible for viral hepatitis-related renal disease are uncertain, a direct cytopathic activity of HCV on renal parenchyma, formation of immune complexes in the renal mesangium following HBV and HCV infections has been suggested. Hepatitis B surface antigen (HBsAg) is expressed in renal tubular epithelial cells where it is suggested to upregulate complement-mediated inflammation and enhance nephropathy. Polyarteritis nodosa, a vasculitis affecting medium-sized arteries, has been described in HBV infection, while some individuals may be genetically predisposed to nephropathy.,
Hepatitis B and C are implicated in renal injuries, and individuals requiring hemo-dialysis (HD) are also at increased risk of hepatitis infection. These patients, especially those with end-stage renal disease (ESRD), often require transfusions of blood or blood products which may be associated with a higher relative risk of HBV and HCV infection (associated with residual risk of transmission during the serological “window period”). Concern has also been raised about the possibility of exposure to contaminated HD equipment during treatment coupled with other at-risk activities such as injections due to frequent parenteral interventions and sexual intercourse. Patients with ESRD may also be at increased risk of HCV infection; this may be linked with impaired humoral and cellular immune system associated with renal insufficiency., This study set out to determine the seroprevalence of viral hepatitis and the possible effects on liver function.
| Methods|| |
This was a three-year retrospective study of patients with clinical and biochemical diagnosis of CKD between January 2015 and December 2017. A pro forma was used to extract the clinical and sociodemographic data of both inpatients and outpatients, who availed services at the center. The results of serology screening and biochemical tests were extracted from relevant documents.
Participants were screened for the presence of antibodies to HBsAg and HCV using one-stage enzyme immunosorbent assay (EIA) immunoassay rapid screening kits (DiaSpot Diagnostics, USA). All participants were screened before the commencement of treatment or HD, and individuals who were reactive to anti-HIV screening were excluded from the study. The diagnosis of CKD was based on the clinical history and estimated glomerular filtration rate (eGFR) according to the KDIGO classification. eGFR was determined using modification of diet in renal disease formula. The seropositivity to HBV was defined by the detection of HBsAg and seropositivity to HCV by the detection of anti- HCV.
This study was conducted at the Kidney Care Center (KCC) of the University of Medical Science Teaching Hospital Ondo, Ondo State, Nigeria. KCC is a government-owned 18- bedded multidisciplinary center that attends to patients with kidney diseases and other cardiovascular disorders. It is located in Ondo West Local Government, Ondo State, Nigeria.
Ethical approval was obtained from the hospital’s ethical committee before commencement of the research work.
| Statistical Analysis|| |
Data were analyzed using Statistical Package for the Social Sciences version 21.0 (SPSS Inc., Chicago, IL, USA). Numerical data were expressed as mean ± standard deviation. A comparison of data was done using the Student’s t-test and Chi-square test, and P <0.05 was taken to be significant.
| Results|| |
A total of 314 consecutive patients were reviewed; this included 206 males (65.6%) and 108 females (34.4%) (female-to-male ratio: 1:1.91), with a mean age of 50.5 ± 16.3 [Table 1]. Forty-nine participants (15.6%) were HBsAg positive, 15 (4.8%) were positive for HCV, while 3 (0.92%) had HBsAg and HCV coinfection [Table 2].
More than half (63.6%) of HBsAg-sero-positive patients were below 50 years of age [Table 3]. No significant difference was observed in the prevalence of HBsAg and HCV between males and females [Figure 1]. Higher mean alanine transaminase (ALT) was observed in HCV-positive patients than HCV-seronegative patients (10.5 ± 10.5 vs. 21.2 ± 35.9 IU/L) (P = 0.001). The mean aspartate transaminase (AST) and alkaline phosphatase (ALP) were similar. Furthermore, no significant difference was observed in the mean values of ALT, AST, and ALP between HBsAg-seropositive and HBsAg-negative patients [Table 4] and [Table 5].
|Figure 1: Distribution of viral hepatitis among chronic kidney disease patients.|
HBsAg: Hepatitis B surface antigen, HCV: Hepatitis C virus.
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|Table 4: Enzyme activities among hepatitis C virus and hepatitis B surface antigen patients.|
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|Table 5: Etiology of chronic kidney disease among seropositive participants.|
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A higher proportion of viral seropositivity was associated with chronic glomerulonephritis compared with other major etiologies. Furthermore, a greater proportion of seropositive patients had no history of previous blood transfusion [Table 6].
| Discussion|| |
This study observed a high prevalence of hepatitis B infection among individuals with CKD. The overall prevalence of hepatitis B infection in this study (15.6%) was higher than that described among the general population by Akinbolaji et al in the same geographical area. This further suggests a significant association of viral hepatitis with renal disease. This study is in tandem with a recent study by Nkup et al who observed a 15.5% prevalence among CKD patients in Northern Nigeria. It is, however, higher than 6% reported by a study conducted in Lagos. This difference may be partly attributable to the fact that our study center serves as a referral center to other renal centers in neighboring states, which do not have facilities to dialyze CKD patients with hepatitis infection.
A relatively higher prevalence of HCV (4.8%) was also observed in this study. Esan et al reported a 1.39% prevalence among pregnant women in Southwest Nigeria, while Akinbolaji et al reported a prevalence of 1.71% among apparently healthy individuals. Although the prevalence observed in this study is higher than the global prevalence of 3%, it is similar to 5.3% prevalence in sub-Saharan Africa according to data by the World Health Organization (WHO). On the contrary, it is lower than the prevalence reported in some earlier studies among predialysis and HD patients., The lower prevalence compared with other studies may likely be associated with the screening methods and exclusion of HIV reactive individuals. While we used rapid diagnostic kits which may miss the serological “window period,” a report by Salako et al employed ELISA screening techniques.
It is also worthy of note that a significantly higher burden of hepatitis B infection than hepatitis C was observed in this study, suggesting that HBsAg infection was more common than HCV among the CKD patients in Southwest Nigeria. This is, however, similar to the higher prevalence of hepatitis B than hepatitis C observed among the general population in Southwest Nigeria. It also agrees with the findings of Oluwatoyin and Lesi who also described higher HBsAg than HCV infection among CKD patients. However, there is increasing evidence of association between both hepatitis B and C infection and some forms of glomerular disease.,
The incidence of coinfection was low (0.92%), while no significant difference was observed in the prevalence of HBsAg and HCV between the male and female genders. The highest prevalence of HBsAg was found among individuals between ages 30 and 39 years, while more than half (65.3%) of seropositive were below 50 years of age. This agrees with a study in Libya that associated significant seropositivity with younger patients.
Although not statistically significant, a higher proportion of viral seropositivity was associated with chronic GN in this study. This further suggests the possible roles of hepatitis infection-causing glomerulopathy. This is in line with epidemiological studies which associated chronic carriage of HBV with membranous nephropathy., Hepatitis B virus (HBV) has been described to exhibit a complex relationship with kidney diseases. Extrahepatic manifestations of chronic HBV infection include glomerular diseases, while CKD may also predispose to increased risk of hepatitis as a result of parenteral intervention, altered immune system, and exposure to dialysis procedures. However, it is difficult to determine whether the infection preceded the onset of renal impairment since it is often mild and asymptomatic.
More than half of the seropositive patients had no history of previous blood transfusion which suggests that there are sources of infection other than blood transfusion. This is in tandem with the study by Othman and Monem who reported that blood transfusions were not an independent risk factor in HCV among HD patients. This may be explained by improved screening of blood before transfusion.
This study also observed a higher ALT activity among HCV-positive CKD patients, while AST and ALP were similar in sero-positive and negative individuals. ALT and AST activities were also similar between HBsAg-seropositive and HBsAg-negative CKD patients. This is similar to findings in earlier studies that described increased ALT activity in HCV antibody-positive dialysis patients than in HCV antibody-negative dialysis patients,,, while other studies observed normal or even lower ALT and AST activities in HCV- and HBsAg-seropositive HD patients., Although an increase in serum ALT is a nonspecific marker of liver damage, it has been shown to serve as a marker of liver tissue damage in HCV-RNA-positive recipients of kidney transplantation and an indicator of poor prognosis.
This study further reiterates the need for particular attention to prevent the spread of viral infections among these participants. The Centers for Disease Control recommends that meticulous precautions including changing of gloves and waterproof gowns between patients, systematic decontamination of the equipment circuit, and surfaces after each patient treatment be observed to prevent spread of hepatitis in dialysis units. It also brings to the fore the need to improve coverage of hepatitis immunization in Nigeria, as this may serve as primary prevention of certain glomerular disease, thus reducing the national burden of CKD.
| Conclusion|| |
Viral hepatitis is prevalent among CKD population in Nigeria. While hepatitis may play a role in glomerulopathy, CKD patients, especially those who undergo maintenance HD, are at increased risk of infections associated with frequent parenteral interventions and impaired immune function. It is, therefore, essential to improve screening and treatment of infected individuals to reduce morbidities and mortalities from liver diseases. Routine immunization of seronegative patients should be emphasized to prevent spread among CKD patients, especially those requiring HD.
| Acknowledgment|| |
We appreciate Miss Usman K. of Medical Laboratory Service UNIMEDTH Ondo for technical support during the study.
Conflicts of interest: None declared.
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Medical Laboratory Services, University of Medical Science Teaching Hospital, Ondo, Ondo State
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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