Risk factors
-Blood transfusion was once thought to be the leading cause of blood-borne pathogen infection in maintenance hemodialysis patients.
-Now, nosocomial cross-infection is considered to be the main cause of hepatitis virus infection in maintenance hemodialysis patients
-Duration of dialysis is an independent influence on HBV and HCV infections
-Long-term dialysis is a major risk factor for increased HCV infection, with anti-HCV positivity rising from 12% to 37% with longer dialysis duration
-A study found that HBV and HCV serological subtypes were relatively homogeneous in the same dialysis center
-About 102-103copy/ml HBV is present in the environment and on the surface of devices in HBV-positive dialysis centers
-The rate of hepatitis B infection in North American HD patients is 4-5 times higher than the positive rate of HBsAg testing
-The probability of occult HBV infection is greater in HBcAb-positive patients than in those who are negative.
Clinical features
-HBV
-Incubation period 45-160(120) days
-Mostly asymptomatic
-Lethargy, poor appetite, nausea, abdominal pain, jaundice, skin rash, arthralgia
-15-25% cirrhosis or liver cancer
-Adults recover from infection, chronic in hemodialysis patients
-HCV
-Incubation period 14-180(45) days
-Mostly asymptomatic
-Often has elevated blood ALT and precedes HCV serology positivity
-10-20% cirrhosis after 20-30 years
-75-85% become chronic
Domestic monitoring norms
- New patients starting dialysis for the first time or patients transferred from other centers must be tested for hepatitis B, hepatitis C, syphilis and HIV infection prior to treatment. For HBV antigen-positive patients, further tests of HBV-DNA and liver function indexes should be performed, and for HCV antibody-positive patients, further tests of HCV-RNA and liver function indexes should be performed. Keep original records and register the results of the patient’s examination.
Domestic monitoring norms
-Dialysis consent form
-Patients with hepatitis B and C must be separated from each other for isolated dialysis
-Patients with hepatitis B virus, hepatitis C, HIV and syphilis infection are not allowed to reuse dialyzers.
Domestic monitoring norms
-Patients on long-term dialysis should be checked for hepatitis B and C viral markers once every 6 months; original records should be kept and registered.
-Quantitative HBV-DNA and HCV-RNA should be performed for hemodialysis patients with abnormal elevation of liver transaminases that cannot be explained.
Domestic monitoring norms
-If any patient becomes positive for hepatitis B or C during dialysis, close contacts should be tested immediately for hepatitis B and C markers.
-For patients exposed to hepatitis B or C with suspected possible infection, repeat viral marker testing after 1 to 3 months if the viral test is negative.
CDC Standard Precautions – Hemodialysis Applications
-Gloves should be worn when touching patients, and gloves should be routinely changed after handling a patient
-Should not touch any environmental surface before puncturing the patient
Avoid sharing non-disposable items such as trays, blood pressure cuffs, forceps, and clippers as much as possible
-Strict separation of clean and contaminated areas in the dialysis center
-Clean and disinfect dialysis units, including instruments, environmental surfaces, and dialysis machines, between dialysis shifts
-Dialyzer reuse follows relevant procedures
KDIGO – A Different Voice
-KDIGO Guidelines for the Management of CKD Complicated by Hepatitis C
-Isolation of HCV-infected patients is not recommended as an alternative to strict infection control procedures to avoid transmission of bloodborne pathogens, realizing that receiving isolation makes it impossible to fully implement basic health precautions, which may lead to transmission of pathogens other than HCV. Dedicated dialysis machines are not recommended for HCV-infected patients.
-If dialyzer reuse is unavoidable, it is recommended that dialyzers for HCV-infected patients may be reused, but infection control procedures must be strictly enforced and followed.
Vaccination
-Hepatitis B vaccine produces protective antibodies in 95% of those vaccinated
-Only 50-60% of hemodialysis patients produce protective antibodies
-Recommended routine vaccination in month 0.1.6, 40ug per injection, intramuscularly in the deltoid muscle of the upper arm. Double dose booster in month 9.
-No vaccine is available for HCV infection.
Precautions for health care workers
-Staff should master and follow the infection control system and specification of blood purification room (center).
-Hepatitis B and C markers should be monitored regularly (before initiation and every 6 months-1 year) for staff in blood purification centers. Hepatitis B vaccination is recommended for hepatitis B negative staff.
Medical Staff Precautions
After a staff member has a needle stick injury
Squeeze, flush, disinfect, dress, medicate, fill out form
Injuries from sharp instruments contaminated with blood or body fluids of HBV or HCV positive patients are recommended to be injected with hepatitis B immune high-valent globulin within 24 hours, while blood hepatitis B markers are checked.
Asia-Pacific Hepatology Consensus on Hepatitis C
-Evidence Rating
- Level I randomized controlled trials
Level II-1 Non-randomized controlled trials
Level II-2 Cohort or case-control analysis studies
-Grade II I 3 Multi-temporal case-series analyses with apparently uncontrolled outcomes
-Grade III Authoritative opinion and descriptive epidemiological studies
Consensus
-Specimens negative by approved EIA methods may be reported as anti-HCV negative, with the caveat that patients on hemodialysis or with overlapping HIV infections may be HCV-RNA positive and anti-HCV negative (II I 2)
-HCV-RNA qualitative and quantitative tests should avoid contamination (II I 2)
-On ALT:Chronic HCV infection with elevated serum ALT suggests progressive liver damage. However, normal ALT does not exclude significant liver disease, and a fibrosis score (Metravir score >2 or Ishak score >3) suggests progressive liver disease.
-It should be clear that excessive alcohol consumption and insulin resistance are associated with disease progression, and patients are advised to consume less alcohol up to the amount recommended in the WHO guidelines. Obesity and insulin resistance are recommended to be controlled by exercise and dietary interventions to achieve an ideal body mass index (BMI) (II-2).
Chronic HCV infection is complicated by HCC and is life-threatening. Patients with cirrhosis should be monitored for early detection of HCC (II I-2)
-Interferon therapy improves the natural history of HCV-associated cirrhosis. The 5-year incidence of failure to compensate is 1% in patients who achieve sustained viral response (svn) and 9.1% in biochemical responders (II I 1).
-Treatment of acute hepatitis C should be delayed for 8 to 16 weeks to allow for observation of the presence of spontaneous clearance, especially for symptomatic patients (II I 1).
- HCV genotype testing is more important to assess the course of treatment and antiviral efficacy
is more important. (II.1.2).
Consensus – Hemodialysis and Hepatitis C
-Dialysis is a high risk factor for nosocomial infections and therefore, routine precautions must be strictly followed to prevent nosocomial infections (II.1.2);
-Serology and PCR testing should be routinely performed in dialysis patients (II.1.2);
-Serological screening should be done regularly for staff on dialysis (II-2);
Liver biopsy is not required for chronic hepatitis C patients on dialysis, but is recommended especially when histologic findings affect treatment decisions (II-2);
Consensus – Hemodialysis and Hepatitis C
IFN monotherapy is recommended for chronic hepatitis C patients with end-stage renal disease maintained on dialysis (II.I.1);
-Peg-IFN or ribavirin therapy is not recommended for chronic hepatitis C patients with end-stage renal disease maintained on dialysis therapy except in clinical trials (1I-1);
Interferon therapy is contraindicated after renal transplantation (II-2).
Consensus – overlapping infections
-Recommend routine screening for HBsAg in persons with chronic HCV infection, especially in intravenous drug addicts or other high-risk groups;
-Routine screening for serum HBV DNA is not recommended in patients with chronic HCV infection and negative HBsAg;
-Screening for HCC, including liver ultrasound and AFP, should be performed in patients with overlapping infections;
-Recommendations for antiviral therapy in patients with overlapping HBV and HCV infection are the same as those for patients with single infection;
Consensus-overlap infection
-Prior to treatment, it is helpful to know which virus is predominant in overlapping infections;
-Peg-IFN in combination with ribavirin is recommended for those with positive anti-HCV and HBsAg and positive HCV PCR;
-Anti-HCV and HBsAg positive but HCV PCR negative and HBVDNA significantly positive can be treated with Peg-IFN and/or nucleoside analogues;
-Hepatitis B vaccination is recommended for HBsAg-negative patients with hepatitis C.
Timing of domestic antiviral treatment
-HBV-DNA>105copy/ml (HBV-DNA>104copy/ml in HBeAg-negative patients)
-ALT>2 times the upper limit of normal; if treated with interferon, ALT should be <10 times the upper limit of normal and serum total bilirubin level should be <2 times the upper limit of normal
-If ALT is <2 times the upper limit of normal, but liver histology shows significant inflammatory necrosis.
Patients with ① and have ② or ③ should be treated with antiviral therapy
—– Guidelines for the management of chronic hepatitis B
Keefe -Indications for antiviral therapy
-Keefe recommends the use of PCR for HBV-DNA levels to help determine the indication for antiviral therapy
-Patients with normal ALT and HBV-DNA <105 copies/mL require liver DNA biopsy to evaluate histological lesions;
-Patients with e antigen-positive serum HBVDNA ≥ 20,000 IU/mL, patients with e antigen-negative serum HBV ≥ 2,000 IU/mL, and patients with hepatic decompensation and serum HBV ≥ 200 IU/mL need to start antiviral therapy;
All HBV-infected patients need to be treated with lamivudine or lamivudine plus adefovir after transplantation.
The “standard” treatment
-Hemodialysis + hepatitis B: nucleotide antivirals
-Hemodialysis + Hepatitis C: a-INF 3 million U subcutaneously 3 times a week for one year