HEPATITIS C AND B VIRUS INFECTION AMONG CHRONIC RENAL FAILURE PATIENTS UNDERGOING HAEMODIALYSIS IN CALICUT, KERALA STATE, INDIA.

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1 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 M.Reenaa*, Department of Microbiology, Ethiraj College for Women, Chennai Vishnu Prasad, Laboratory Science Department (MIMS),Calicut, Kerala P.Rajendran, Department of Microbiology, Sri Ramachandra Medical College & *Corresponding author Research Institute, Chennai 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 11

2 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. 12

3 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 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 13

4 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): Lai KN. Hepatitis C infection screening in HD units. Am J Kidney Diseases 2001; 38: 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): 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): 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:

5 Table.1 Age and Sex distribution of patients on dialysis Age Male Female (7.4%) (29.6%) 4(3.7%) (20.31%) 4(3.7%) (18.52%) 8(7.4%) (7.4%) 2(1.85%) Total 90(83.3%) 18(16.7%) Table.2 Diabetes type II and Renal failure Cause No. Of Percentage patients Diabetic Non - diabetic Table.3 History of hypertension before onset of renal failure Cause No. Of Percentage patients Hypertensive Non hypertensive

6 Table.4 HCV positive cases with age group Age Male Female group Total 9 0 Table.5 Liver enzyme level in HCV positive patients HCV positive cases ALT AST ALP Normal Range ALT 3-37IU/L AST 5-30IU/L ALP 30-90IU/L 16