|Year : 2014 | Volume
| Issue : 1 | Page : 19-22
Study of incidence of hepatitis C virus infection in hemodialysis patients
Pragati Chigurupati1, S Subbarayudu2, Sarath Babu3
1 Department of Microbiology, GSL General Hospital, Rajahmundry, Andhra Prdaesh, India
2 Department of Microbiology, ASRAM, Eluru, Andhra Prdaesh, India
3 Department of Nephrology, ASRAM, Eluru, Andhra Prdaesh, India
|Date of Web Publication||10-Mar-2014|
Departmnet of Microbiology, GSL General Hospital, Rajahmundry, Andhra Prdaesh
Source of Support: None, Conflict of Interest: None
Introduction: Hepatitis C virus (HCV) infection in patients undergoing hemodialysis (HD) is an emerging condition and constitutes a major problem complicating the dialysis process in dialysis units world-wide.
Aim: The present study was undertaken to determine the prevalence of HCV infection by antibody testing in hemodialysis patients.
Materials and Methods: A total of 102 chronic renal failure patients on HD were studied. All the patients were tested for anti-HCV antibodies.
Results: The overall prevalence of HCV infection was 23.5%. The longer the patient is on HD the more susceptible he/she is to HCV acquisition.
Conclusion: It is recommended that HD patients should be monitored in order to determine the full risk factors for HCV contamination observed in this study.
Keywords: Chronic renal failure, hemodialysis, hepatitis C virus
|How to cite this article:|
Chigurupati P, Subbarayudu S, Babu S. Study of incidence of hepatitis C virus infection in hemodialysis patients. J NTR Univ Health Sci 2014;3:19-22
|How to cite this URL:|
Chigurupati P, Subbarayudu S, Babu S. Study of incidence of hepatitis C virus infection in hemodialysis patients. J NTR Univ Health Sci [serial online] 2014 [cited 2020 Apr 4];3:19-22. Available from: http://www.jdrntruhs.org/text.asp?2014/3/1/19/128424
| Introduction|| |
Hepatitis C virus (HCV) infection in patients undergoing hemodialysis (HD) is an emerging condition and constitutes a major problem complicating the dialysis process in dialysis units world-wide. The prevalence of HCV among the HD patients varies in different countries world-wide from 1% to 85% respectively.  The prevalence of HCV is particularly high in developing countries like India and is a major cause of increased morbidity and mortality in patients with end stage renal disease. Cirrhosis, higher rate of graft loss, glomerulonephritis and hepatocellular carcinoma are some of the far reaching effects of HCV positivity in HD patients.
The mode of transmission of this virus is still not conclusively defined. Factors such as blood transfusion and frequent parenteral interventions have been shown to be associated with increased risk for this HCV infection.  The duration of HD treatment and the possibility of nosocomial HCV transmission have also been suggested as additional contributing factors for this emerging HCV infection in India.
It is with this background that this scientific work was taken up in order to know the incidence of HCV infection with a view to control the HCV infection among HD undergoing patients to reduce morbidity and mortality due to HCV infection.
| Materials and Methods|| |
Study design and patients
The study was performed in the Department of Microbiology in collaboration with Department of Nephrology of Alluri Sitaramaraju Academy of Medical Sciences (ASRAM) Hospital, Eluru. The study protocol was approved by the ethics committee of ASRAM. A total of 102 chronic renal failure (CRF) patients on HD were studied prospectively over a period of 1 year. Patients who had tested positive for anti-HCV antibodies at the beginning of the HD were excluded from the study. There were 82 male and 20 female patients.
Serum collection and serology
With the informed consent, blood samples were collected of a total 102 HD undergoing patients who constituted the test group. By following all the standard necessary precautions, 5 ml of whole blood was drawn from each of the suspected HCV patients undergoing HD under strict aseptic conditions. All the blood samples were transported to the Department of Microbiology and all the samples were allowed to clot. The clear serum was transferred into sterile test tubes. It was then centrifuged and the clear supernatant was transferred into lax brow vials for preservation at 4°C in refrigerator. All 102 blood samples sera were tested periodically for the incidence of HCV infection by determining the presence of anti-HCV antibodies using a third generation ERBA enzyme-linked immunosorbent assay (ELISA) hepatitis C test kit manufactured by Transasia Bio-Medicals Ltd., S.A. in Germany.
The HD unit has one routine HD area and two isolated areas, one for hepatitis B surface antigen (HBsAg) positive patients and other for anti-HCV positive patients. The routine HD area has seven HD machines, HBsAg positive area has one machine and anti-HCV positive area has one machine. All the patients who were proved negative for anti-HCV before initiating dialysis were dialyzed in routine HD unit. Patients who were positive for anti-HCV before initiating the dialysis were dialyzed on concerned machines in the respective isolated areas of HD unit. All the102 patients were received regular dialysis of 2-3 sessions/week.
| Results|| |
Maximum number of cases in this study was in the age group between 41 and 60 years (49.1%) and least number of cases were in the age group up to 20 years (2.9%) [Table 1] with a male preponderance (80.4%). Hypertensive nephropathy with CRF constituted the commonest disease group with incidence of 73.5% [Table 2]. Twenty four patients out of 102 screened tested positive for anti-HCV antibodies, incidence of 23.5%. Majority of the seropositive cases belonged to the 41-60 age group [Table 3].
Alanine aminotransferase (ALT) level of 1.5 times the normal level (40 u/l) was considered as abnormal. Levels were raised in 10 out of the 24 seropositive patients (41.6%). Levels were normal in the rest of the 14 seropositive patients. None of the patients in seronegative group had abnormal ALT levels.
The mean value of ALT in seropositive group was 75.0 ± 77.0 u/l. The mean value of ALT in seronegative group was 23.9 ± 12.0 u/l. This difference between the two groups was found to be statistically significant (P = 0.004, <0.01, Student's t-test).
The mean number of sessions in seropositive group was 85.4 ± 23.7 and in seronegative group was 60.1 ± 14.2. There was a significant difference in the number of sessions between seropositive and seronegative patients (P = 0.0001, <0.01, Student's t-test).
The mean average values of ALT levels and HD sessions were significantly high in HCV positive patients (P < 0.01).
| Discussion|| |
HD patients are at high risk for the development of hepatitis C infection. However, the data of prevalence of HCV infection among Indian HD patients is inadequate. In an article in 1992 Salunkhe et al.  reported 45%, Chadha et al.  in 1993 reported 12.1%, Sumathi et al.  in 1993 reported 37.5%, Agarwal et al.  in 1999 reported 42% and Jaiswal et al.  in a study from 1992 to 2000 reported prevalence of 30%. The prevalence of HCV infection among the HD patients at our institute is 23.5%.
The performance parameters of the testing method used have a direct impact on the detection of hepatitis C and thus can lead to differences in the prevalence data. In the early 1990's, the first generation HCV antibody testing kits were introduced using NS4 antigen. These tests were further improvised with the addition of NS3 and the core regions of the viral genome. This second generation ELISA assay had a higher sensitivity and specificity over the earlier one. , At present, the third generation ELISA assays use highly purified antigens with addition of NS5 region of HCV genome and have the highest sensitivity and specificity.  The kit used by us has a combination of recombinant and synthetic peptides as antigens with 100% sensitivity and 67% specificity.
With the advent of molecular techniques, the circulating virus can now be detected by HCV ribonucleic acid measurement using polymerase chain reaction (PCR) test.  This testing is used for early detection (before seroconversion) and is also essential for confirmation of active HCV infection and monitoring of antiviral therapy. However, the limitation of this test is the cost effectiveness and non-availability in most of the laboratories.
In our study, only anti-HCV was taken as criteria to diagnose HCV infection. PCR test is required if the patients are planned to be put on anti-viral therapy. This was definitely not the aim of the present study. Thus although the limitation exists for the use of single anti-HCV test, considering all factors, it is still the test of choice for HCV screening as recommended by Centers for Disease Control and Prevention (CDC). The current CDC recommendations for HCV screening in HD patients include testing for anti-HCV and serum ALT on admission, ALT every month and anti-HCV semiannually.
Lack of strict adherence to universal precautions by staff and sharing of articles such as multidose drugs might be the main mode of nosocomial HCV spread among HD patients.  Although some studies found that nosocomial spread of HCV declined when HCV - infected patients were treated in dedicated HD units, other investigators could control nosocomial spread by strict application of hygienic precautions without isolation of HCV - infected subjects or machine segregation. 
CDC recommends that special precautions should be observed in dialysis units. These include 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) or medications (e.g., multidose vials of heparin) among patients. 
To promote more efficient biosafety controls, quality programs must be implemented in dialysis centers addressing methodology training of technical teams and constant monitoring by epidemiological authorities.
It is recommended that HD patients should be monitored in order to determine the full risk factors for HCV contamination observed in this study.
| Conclusions|| |
HCV infection is more prevalent among HD patients in the developing countries. HCV infection prominently increases the burden of disease in the HD population. The longer the patient is on HD, the more susceptible he/she is to HCV acquisition. HD patients should be routinely screened for HCV infection, preferably using serological methods. Strict adherence to universal precautions without isolating HCV-infected dialysis patients seems to be enough to control disease spread in HD units.
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[Table 1], [Table 2], [Table 3]