International Journal of World Research
December 2013, Issue IXI: Volume: I
Print-ISSN: ISSN: 2347 – 937X
Impact Factor: 0.4327
HEPATITIS C AND B VIRUS INFECTION AMONG CHRONIC RENAL FAILURE
PATIENTS UNDERGOING HAEMODIALYSIS IN CALICUT, KERALA STATE,
INDIA.
Shabana Razmin, SRM Medical College Hospital and Research Centre,
Kattankulathur, Chennai- 603 203
M.Reenaa*, Department of Microbiology, Ethiraj College for Women, Chennai- 600 008
Vishnu Prasad, Laboratory Science Department (MIMS),Calicut, Kerala- 673 016
P.Rajendran, Department of Microbiology, Sri Ramachandra Medical College &
Research Institute, Chennai- 600 116
*Corresponding author
ABSTRACT
102 haemodialysis patients with chronic renal failure (CRF) and undergoing renal dialysis
were screened for hepatitis B and hepatitis C virus infections from a multispeciality hospital,
Calicut, Kerala State, India. 8.3% patients were positive for anti- HCV and only one patient
was positive for HBsAg (0.9%). Among various risk factors analysed hypertension and
diabetes were predominant factors. ALT and ALP levels are commonly elevated in most of
the HCV positive cases.
Key words: HCV, Haemodialysis.
Introduction:
The word “Hepa” means liver and “itis” means inflammation. Therefore inflammation of
liver is known as hepatitis. Hepatitis is caused by a heterogenous group of viruses consisting
of five families along with other infectious bacteria, fungi and chemical agents. Hepatitis C,
G, E and other unidentified hepatitis viruses comes under non A, non B hepatitis virus group.
Later in 1980s Michael Bradley and Daniel Bradley at CDC identified the Hepatitis C virus
as a relatively small lipid enveloped virus.
HCV is more commonly transmitted through body fluids, 90% of which are transfused
through blood from HCV positive donors and drug abuse. Very few acquire HCV infection
through sexual transmission, mother to infant transmission and other body fluids. HCV
infection is strongly associated with essential mixed cryoglobulinema, membranoproliferative
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International Journal of World Research
Print-ISSN: ISSN: 2347 – 937X
December 2013, Issue IXI: Volume: I
Impact Factor: 0.4327
glomerulonephritis and porphyria cutanea tarda. Upto half of HCV infected persons have
circulating cryoglobulin. HCV infection is also associated with B – cell lymphoprolifertive
disorder.
HCV infection is a major health problem among hemodialysis patients in developing
countries. This could either be due to the non- adherence to strict infection control measures
or the unavailability of vaccine to prevent hepatitis C infection. HCV prevalence differ
among haemodialysis units according to geographical location, health care procedure and
socioeconomic factors. It depends on sterilisation of equipments, hygiene of hospital, patient,
rotation of dialysis machine and the undertaking of rigorous universal precaution rules in the
dialysis unit.
In the past transmission of HCV in patients undergoing hemodialysis was associated with
blood transfusion. However even with increase in safety of blood products and decrease in
the need for transfusion in the population, HCV was proved to still circulate among patients.
Chronic renal failure is characterised by progressive destruction of renal mass irreversible
sclerosis and loss of nephrons over a period of at least few months to many years. In end
stage renal disease the patient has only one choice between maintenance of dialysis or renal
transplantation. With this background, in the present study the association of HCV infection
in CRF cases undergoing haemodialysis has been analysed from a hospital in Kerala.
Materials and Methods:
Study and design of patients:
The study was performed in the Department of Microbiology (MIMS) in collaboration with
the Department of Biochemistry at Malabar Institute of Medical Science Ltd (MIMS),
Calicut, Kerala. 108 patients with chronic renal failure on haemodialysis were screened from
April 2007 to June 2007 after obtaining all necessary permission and ethical clearance from
the institute. A questionnaire was designed for the study and basic data were also collected.
Specimen collection:
Blood samples were collected at every month of haemodialysis, serum was separated within
two hours after blood sampling and transported to laboratory.
Serology:
All the 108 CRF patients on haemodialysis in the department of Nephrology at MIMS were
included in the study. HCV antibody test was done using both ELISA ( Biomueriex kit) and
MEIA ( Micro particle Enzyme Immunoassay, Axsym Abbott HCV version 3.0) and HBsAg
antigen test was also performed using Abbott HBsAg kit. In the biochemistry section, liver
enzyme ALT, AST and ALP levels were evaluated by standard procedures.
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International Journal of World Research
Print-ISSN: ISSN: 2347 – 937X
December 2013, Issue IXI: Volume: I
Impact Factor: 0.4327
Results:
Out of 108 patients screened during the study period of three months, 83.03% were males
and 16.7% were females. The age of the patients varied from 24 to 76 with the mean of 42
and majority of cases were within the age group of 31 to 60 years (Table. 1). The duration of
dialysis ranged from 2 months to 84 months with a mean of 60. Out of 108 CRF cases 42.6%
had diabetes mellitus type II (Table.2) and 57.4% of the patients had hypertension before the
onset of renal failure (Table.3). Out of the 108 CRF patients 9 males were anti HCV antibody
positive and only one was positive for HBsAg (Table.4). Of the 9 patients tested positive for
anti HCV antibodies, one patient was a transplant patient and returned to dialysis following
chronic re-infection. In all the positive cases, patients were on dialysis for more than a year
and 75% of them had blood transfusion or packed cell transfusion. The liver enzyme in
positive cases showed increase in moderate level. This study revealed that there is a
considerable rise in ALT level. In most of the cases, ALP also showed elevation but to a
lesser extent than ALT and AST (Table.5).
Discussion:
CRF patients on haemodialysis were subjected for the study on HBV and HCV prevalence in
the HD unit. The outcome of this survey will be helpful to prevent the spread of nosocomial
infection of HCV in haemodialysis unit. Generally the prevalence of HCV infection among
patients on HD is considerably higher than in general population and range from 8% in North
America to 90% in some countries in the Middle East (Magdi M.Hussain et al 2007).
However the data of prevalence of anti HCV in India in HD cases is scanty. At the same time
it is better to keep in mind that the performance parameter of testing methods used have a
direct impact on hepatitis C infection and this can lead to differences in the prevalence data.
In our study we have used third generation ELISA method and MEIA. Both these methods
have high sensitivity and specificity. Moreover the detection of circulating virus by HCV
RNA measurement by RT PCR is more useful to detect Hepatitis C infection before sero conversion which was not done in this study. It is to be noted that some patients who are anti
HCV antibody negative may show HCV RNA positive which might be a risk. Never the less
routine HCV RNA PCR is not available in most dialysis centres and the high cost factors of
RNA detection stands in opting anti HCV ELISA as a screening test. In some cases a
possible explanation for absence of antibody may be due to suppressed cellular immunity in
dialysis population causing a reduced ability to mount a detectable response on the virus.
Hepatitis B vaccination has drastically brought down positive cases of HBV infection and all
the patients in the HD unit were given hepatitis B vaccine prior to starting of dialysis. Even
then in this study one patient was positive for HBsAg.
The possible explanation is that despite the isolation policies, a potential risk for spread of
infection always remains if some of HCV seronegative patient happens to be an active carrier
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International Journal of World Research
Print-ISSN: ISSN: 2347 – 937X
December 2013, Issue IXI: Volume: I
Impact Factor: 0.4327
of the virus. This explains why during the study despite adherence to and having separate
area to HCV positive patients, fresh cases of HCV infection are possibly dialysis related.
Though use of separate dialyzer for each patient was practiced, the machine and tubbings
were the same and therefore some amount of virus may be retained in the machine after
cleaning. This may be the cause of lateral spread of HCV infection in HD units. The present
study shows that prevalence of HCV seropositivity was less than that reported from many HD
centres. Longer dialysis duration and undergoing dialysis in multiple centre and receiving
transfusion of blood products were all associated risk factors. This study did not explore the
possibility of nosocomial infection.
Conclusion:
Hepatitis C infection is a major problem in CRF patient on haemodialysis with 8.33%
positive cases in the present study. On the other hand hepatitis B infection is now not a major
problem because of the availability of vaccination and only one case showed positive for
HBsAg. There is male preponderance (83.3%) in dialysis population. Diabetic mellitus type
II is the cause of renal failure in 42% of the cases. Nearly 57% of patients had hypertension
prior to diagnosis of end stage kidney failure and 91% had hypertension at the time of initial
dialysis. Liver enzyme level was moderately raised in 98% of HCV positive cases, serum
ALT level being the highly elevated enzyme. Strict adherence to minimal precaution
according to recommendation of prevention of infection by CDC decreases the lateral spread
of HCV infection in HD unit , but risk prevails if any sero negative patient act as HCV carrier
in the unit.
References
1. Hmaied F, Ben Mamou M, Saune SandresK. HCV infection among dialysis patients
in Tunisia: Incidence and molecular evidence for transmission. J.Med Virology2006;
78(2): 185-191.
2. Lai KN. Hepatitis C infection screening in HD units. Am J Kidney Diseases 2001;
38: 186-188.
3. Magdi M.H., Jaap M.M., Mohammed S.H. The impact of PCR assay for the
detection of HCV infection in HD unit. Saudi J. Kidney Dis Transplant 2007; 18(1):
107-113.
4. Mathai J, Sulochana PV, Sathyabama S. Profile of transfusion transmissible
infections and associated risk factors among blood donors of Kerala. Indian J Pathol
Microbiology 2002; 45(3): 319-322.
5. Reddy AK, Murthy KD, Lakshmi V. Prevalence of HCV infection of patients on HD,
Survey by Ab and core Ag detection. Indian Journal of Medical Microbiology 2005;
23: 106-110.
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International Journal of World Research
December 2013, Issue IXI: Volume: I
Print-ISSN: ISSN: 2347 – 937X
Impact Factor: 0.4327
Table.1
Age and Sex distribution of patients on dialysis
Age
20-30
31-40
41-50
51-60
61-70
Total
Male
8(7.4%)
32(29.6%)
22(20.31%)
20(18.52%)
8(7.4%)
90(83.3%)
Female
0
4(3.7%)
4(3.7%)
8(7.4%)
2(1.85%)
18(16.7%)
Table.2
Diabetes type II and Renal failure
Cause
Diabetic
Non diabetic
No. Of
patients
46
62
Percentage
42.2
57.8
Table.3
History of hypertension before onset of renal failure
Cause
Hypertensive
Non –
hypertensive
No. Of
patients
62
46
Percentage
57.4
42.6
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International Journal of World Research
Print-ISSN: ISSN: 2347 – 937X
December 2013, Issue IXI: Volume: I
Impact Factor: 0.4327
Table.4
HCV positive cases with age group
Age
group
20-30
31-40
41-50
51-60
Total
Male
Female
0
2
3
4
9
0
0
0
0
0
Table.5
Liver enzyme level in HCV positive patients
HCV
positive
cases
1
2
3
4
5
6
7
8
9
ALT
AST ALP
75
34
58
504
298
132
97
308
2934
47
32
25
185
40
118
44
43
1600
97
134
68
120
186
170
130
191
185
Normal Range
ALT – 3-37IU/L
AST – 5-30IU/L
ALP – 30-90IU/L
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