Viral hepatitis is a major public health problem and the main impact is not only on health but also on the national economic 1.
WHO estimated that about 170 million individuals are infected with hepatitis C virus (HCV), which is about 3% of the world population 2. HCV is an enveloped RNA virus of the flaviviridae family. An important feature of the virus is the relative mutability of its genome; HCV is clustered into several distinct genotypes that may be important in determining the severity of the disease and the response to treatment. About 80% of newly infected HCV patients progress to develop chronic infection. HCV is spread primarily by direct contact with human blood. Other modes of transmission such as social, cultural, and behavior practices using percutaneous procedures (e.g. ear and body piercing, tattooing) can occur if inadequately sterilized equipment is used. Acute HCV is frequently asymptomatic and unnoticed 3. Direct detection of the virus using PCR is needed in patients infected recently with the virus and in immune-suppressed individuals who may be antibody negative. Enzyme-linked immunosorbent assay (third generation) (ELISA-3) tests are the most widely used screening test for HCV. However, detection of antibody against the HCV does not distinguish between acute, chronic, or past infection.
Screening of donated blood for anti-HCV began in Egypt and many countries, but the delay in the appearance of this antibody poses a problem for blood bankers as the test may be negative in early acute hepatitis. Any practice that promotes transfer of blood or blood fluids should be entirely prohibited. This would include sharing of tooth brushes, dental appliances, razors, and nail grooming equipment 4.
HCV exists as a heterogeneous group of viruses showing 70% overall homology. HCV has been classified on the basis of various genomic regions into at least six major genotypes (1a–c, 2a–c, 3a–b, 4, 5, 6) and more than 40 subtypes. In Egypt, the most predominant is genotype 4. In infants born to hepatitis virus C positive mothers in vertical transmission, the virus appears to be inoculated during or postpartum and not through the placenta. The viral load in the inoculums includes the amount of leakage and the maternal viral titer 5. This study was carried out to determine the presence of hepatitis C in adolescent hemodialysis patients and to determine any association with other common parenterally transmitted hepatitis viruses in hemodialysis units.
Participants and methods
Seventy-one Egyptian adolescents were recruited from two private hemodialysis units that used to send their patients’ serum to Abbassia Fever Hospital at regular intervals of 3 months’ duration for testing of hepatitis B surface antigen (HBsAg), HCV, and HIV antibodies. The specimens were collected from the Egyptian Center of Nephrology (Heliopolis) and the International Kidney Center (Nasr City). All patients were subjected to hemodialysis three times weekly for 4 h in each setting. Forty normal healthy adolescents of the same age group were recruited from the clinic of child health in the National Research Center in Dokki, who were being followed up for vaccination and normal growth. Written consents were obtained from the parents of all the adolescents recruited. Adolescents who received hemodialysis for 12 months or more with no symptoms of liver impairment were included.
Written consent were taken from the parent or care giver of the adolescent and adolescent themselves accept to participate in this study.
All patients were subjected to clinical and laboratory investigations in the form of complete medical history, full clinical examination, and liver function tests including alanine aminotransferase (ALT), asparagine aminotransferase (AST) and serum alkaline phosphatase (ALP), serum creatinine, and HCV-RNA detection in serum by the ELISA technique. Samples were collected from patients as follows: (a) Venous blood (5 ml) was withdrawn from each participant under strict sterile conditions and was placed in a sterile vacutainer tube. (b) Serum was separated and stored in sterile Eppendorf tubes. Each sample was divided into two aliquots. One was stored at −20°C for testing ALT, AST, ALP, and creatinine. The other aliquot was stored at −80°C for testing hepatitis B virus (HBV) marker, HCV marker, and HIV antibody (Table 1).
Liver function tests
- Estimation of ALT level (Randox Laboratories Limited, USA): Glutamic-pyruvic transaminase is measures by monitoring the concentration of pyruvate hydrozone forrmed with 2,4- dinitrophenylhydrazine The reference value of the serum was up to 12 U/l.
- Estimation of AST level (Randox Laboratories Limited): The procedure, calculation, and reference value was similar to that of ALT.
- Serum ALP (Biomérieux Vitek Inc., France) phenyl phosphatase by alkaline phosphatase (PH10) produces phenol + phosphate. The phenol liberated is measured in the presence of amino-4 antipyrine and potassium ferricyanide. The presence of sodium arsenate in the reagent stops the enzymatic reaction.
- Estimation of creatinine level (Diamond Diagnostic-Kinetic method): Creatinine in an alkaline solution reacts with picrate to form a colored complex that is measured photometrically at 492 nm. The reference value of serum was 0.6–1.4 g/dl.
The following markers were tested within 1 week from sample collection:
- Hepatitis C antibody detection: this was done by an enzyme immunoassay for qualitative detection of antibody to HCV (anti-HCV) (Abbott HCV ELA3; Abbott Laboratories, France).
- HBsAg: this was done by Auszyme Monoclonal (Abbott Laboratories).
- Detection of antibodies against HIV (anti-HIV): this was done by Biotest Anti-HIV Tetra ELISA, which is an enzyme immunoassay for the in-vitro detection of antibodies against the HIV-1/2 in serum.
Data were collected, coded, entered, and analyzed using a personal computer with SPSS for Windows version 9.5 (SPSS, IBM, Chicago, Illinois, USA). Mean and SD were used to describe quantitative data. Student’s t-test and correlation r-test were carried out. P value less than 0.05 was considered to indicate a significant statistical difference between groups.
This study included 111 adolescents; their ages ranging from 15 to 18 years. Seventy-one were renal patients undergoing hemodialysis three times weekly for 4 h and with an average duration of dialysis 1.9±1 years. Of 71 adolescent renal patients, 43 were males (61%) and 28 were females (39%) (Fig. 1). The mean value of all laboratory tests was higher in cases than in controls. The P value was highly significant in serum AST, very highly significant in serum creatinine, calcium, phosphorous, and hemoglobin, and insignificant in serum ALP (Table 2). The cases studied showed a high prevalence of HCV (45%), HBV infection (5.1%), and combined infection (16.9%). The mean values of all laboratory tests in HCV-positive cases were higher than those in HCV-negative cases, except for hemoglobin and calcium. The differences between the mean values in HCV-positive cases versus HCV-negative cases were significant for serum phosphorous and serum creatinine (Table 3).
Viral hepatitis remains a major health problem worldwide 6. Patients undergoing chronic intermittent hemodialysis are at a variable risk for acquiring parenterally transmitted infections such as HCV or HBV 6. In this study, the anti-HCV prevalence rate in hemodialysis patients was 45%. A higher prevalence of 75% was reported in Egypt 6, which was almost similar to a recent study in India of 68% 7. However, a low prevalence has been reported in other studies, 19% in France 8 and 26.5% in Brazil 9. HBV in this study was found to be 5.1%, which is similar to that reported by another study in which the HBV rate was 5.9% 10. This low prevalence can be attributed to the fact that the risk of acquiring HBV infection in hemodialysis units has decreased partially after the isolation of HBsAg-positive patients in separated hemodialysis units and the vaccination of hemodialysis patients 11. Furthermore, a more recent study reported that the use of vaccination in hemodialysis patients before the start of treatment with dialysis resulted in a lower possibility of being exposed to the virus to the extent that no reports of new cases of HBV were found for the prevaccinated patients after a follow-up for 6 years 12. In this study, we could not establish whether HBV is a risk factor for HCV infection or not because of the few number of positive HBsAg cases in the samples studied. Moreover, other studies argued that the reason is a variation in enforcement of universal precautions and standard infection control measures including transfusion practices and hygienic standards between different hemodialysis units even within the same country or geographical region 13. Further explanation may be the variation in risk factors among different populations 14. Since the initiation of strict infection control practices and hepatitis B vaccination, the rate of HBV infection among patients undergoing hemodialysis has decreased by ∼95% 15. HBV infections become more frequent in immune-suppressed individuals 16, including hemodialysis patients. The advisory committee on immunization practices recommended universal vaccination to hemodialysis patients. Moreover, higher hepatitis B vaccine doses are recommended because hemodialysis is less likely to have protective levels of antibody after vaccination with the standard vaccine. Hemodialysis patients require hepatitis B booster doses when anti-HBsAg decreases to less than 10 mIU/ml (Table 4).
HCV is more prevalent than HBV in hemodialysis adolescent patients who are at risk of acquiring both by blood transfusion and dialysis equipment.
Further studies on a large scale are required to investigate other vulnerable groups in the community. In the absence of a vaccine for HCV, all precautions to prevent infection must be taken including the following: screening and testing of blood donors, implementation and maintenance of infection control practices in the healthcare setting including appropriate sterilization of medical and dental equipment, promotion of behavior change among the general public and healthcare workers to use safe injection practices, and virus inactivation of plasma-derived products (Fig. 2).
Conflicts of interest
There are no conflicts of interest.
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