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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2008  |  Volume : 19  |  Issue : 2  |  Page : 260-267
Hepatitis B Infection among Patients Receiving Chronic Hemodialysis at the Royal Medical Services in Jordan

1 Department of Internal Medicine, Royal Medical Services; Nephrologist, King Hussein Medical Center, Jordan
2 Department of Internal Medicine, Royal Medical Services; Gastroenterologist, King Hussein Medical Center, Jordan

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Hepatitis B virus (HBV) infection is a major clinical problem in patients on maintenance hemodialysis (HD) and can lead to many serious consequences. This study was carried out in order to determine the prevalence of HBV infection and the possible risk factors for acquiring it, in patients on maintenance HD. All patients on regular HD in seven hospitals of the Royal Medical Services, Amman, Jordan, were studied during the period between July and December 2006. The medical history and records of these patients were reviewed for the presence of hepatitis B surface antigen (HbsAg), and possible risk factors for acquiring this infection. A total of 430 patients on HD with a mean age of 47.3 years were studied. Three patients, who were positive for HBsAg before starting dialysis, were excluded from the study. The remaining 427 patients, who were HBsAg negative before starting dialysis were included. Of these, 25 (5.9%) became HbsAg-positive during the study period. Being on HD for longer than two years and positive history of blood transfusion(s) were more frequently noticed in the HbsAg­positive group (88% and 60% respectively) compared with the HbsAg-negative group (43% and 56% respectively). Of 379/402 (94%) patients who remained Hbs Ag-negative and 1/25 (4%) of those who converted to Hbs Ag-positive were reportedly vaccinated. Our study suggests that the prevalence of HbsAg positivity in our HD patients was 5.9%. Dialysis for more than two years, but not history of blood transfusions, was noted to be a significant risk factor for acquiring this infection. Vaccination against the HBV gives good protection against this virus.

Keywords: Hemodialysis, Hepatitis B Virus infection, Blood Transfusion, HBsAg

How to cite this article:
Al Hijazat M, Ajlouni YM. Hepatitis B Infection among Patients Receiving Chronic Hemodialysis at the Royal Medical Services in Jordan. Saudi J Kidney Dis Transpl 2008;19:260-7

How to cite this URL:
Al Hijazat M, Ajlouni YM. Hepatitis B Infection among Patients Receiving Chronic Hemodialysis at the Royal Medical Services in Jordan. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2022 Jan 23];19:260-7. Available from: https://www.sjkdt.org/text.asp?2008/19/2/260/39043

   Introduction Top

Hepatitis B virus (HBV) infection is a major clinical problem, as it can lead to many serious consequences, including acute and chronic hepatitis, cirrhosis, hepatocellular car­cinoma and hepatic failure. [1] Among patients on dialysis, HBV infection remains a major issue. It is associated with a high risk of hepatic complications and decreases the chance for kidney transplantation. [2] Liver disease runs a unique clinical course in dialysis patients, as it can progress with modest hepatic inflammation to prominent fibrosis. Liver biopsy appears to be the only definitive means to establish the activity of liver disease in dialysis patients. [3] Preliminary reports have shown that lamivudine is effec­tive against HBV and well tolerated in these patients. [4] Additionally, universal precaution measures should be strictly observed and the segregation of hepatitis B surface antigen (HbsAg)-positive patients on hemodialysis (HD) should be practiced. [5],[6] Early vaccina­tion against HBV before the development of end-stage renal failure remains the best way to secure immunological protection against HBV infection in dialysis patients. [7]

We report the results of a retrospective study of the frequency of HBV infection in patients on maintenance HD and the possible risk factors for acquiring this infection.

   Methods Top

We retrospectively studied 427 patients with chronic renal failure who were undergoing maintenance HD at seven dialysis centers of the Royal Medical Services, Amman, Jordan, between July and December 2006. There were 226 males (53%) and 201 females (47%) with a mean age of 47.3 years. The patients had been on HD for a mean of 81 months (range, 2-231 months). Data was collected from the study participants with regard to the risk factors under study including duration on dialysis, history of blood transfusion, and HBV vaccination. All patients were reviewed for the presence or absence of HBsAg. Other markers of HBV infection, serum creatinine and alanine aminotransferase levels were tested when needed. Patients were divided into two groups: HbsAg-positive, and HbsAg­negative for comparison.

HBsAg was tested by Murex HBsAg version 3-enzyme immunoassay (Abbott Laboratories, USA). The positive samples were confirmed by confirmatory neutralization enzyme immunoassay (Abbott Laboratories, USA).

The ethical committee of Royal Medical Services approved the study.

Chi Square and P- value were used for statistical analysis. P value of less than 0.05 was considered significant.

   Results Top

Overall, the records of 430 patients on long­term HD were reviewed. Three patients who were HbsAg-positive before starting on dia­lysis were excluded from the study. Thus, 427 patients who were HbsAg-negative before starting dialysis were included. Twenty-five of them (5.9%) were found to be HbsAg­positive at the end of the study period. Additionally, 154 (36%) were positive for hepatitis C virus antibody (HCV-Ab), and nine (2%) tested positive for both HBsAg and HCV-Ab [Table - 1]. Out of the 25 patients who were HBsAg positive, 19 were males (76%). The pattern of infection with HBV was most frequent in the age-group between 35-45 years.

Anti-HBs and IgG anti-HBc were detected in the absence of HBsAg in 12 patients (2.8%), representing a resolved HBV infec­tion. Dialysis duration of more than two years was recorded in 22 of the 25 patients (88%) who were HbsAg-positive compared with 172 patients (43%) who were HbsAg­negative. Positive history of blood transfu­sion(s) was reported in 15 HbsAg-positive patients (60%) and in 232 HbsAg-negative patients (56%). Vaccination was reported in one HbsAg-positive patient (4%) and in 379 HbsAg-negative patients (94%).

The association of various risk factors studied in relation to HbsAg-positivity status among HD patients is shown in [Table - 2],[Table - 3]. History of dialysis more than two years was found to be significantly associated with HbsAg-positivity (P values = 0.006, 0.008). History of blood transfusions was more in HbsAg-positive patients, but the difference was not statistically significant (P values = 0.1, 0.048). Vaccination against the HBV offered significant protection against acquiring the infection (P values = 0.007, 0.003).

   Discussion Top

The implementation of universal screening of blood products for HBsAg has reduced transmission of the HBV significantly. [8] Nevertheless, new infections are still occurring and HBV infection is still a significant cause of liver disease worldwide. [9] The key to further reducing disease burden is to understand the current modes of trans­mission and device and implement appro­priate preventive measures. However, most infections do not have an acute symptom­matic phase and thus, are only identified years after the infective event. This is true for all but a small proportion of infections, the exact size of which is yet to be defined. [10]

In our study, the prevalence of anti-HBV in HD patients was 5.9%. This higher than that in the USA, [11] Croatia, [12] Japan, [13] Casablanca, [14] and Iran, [15] and lower than that in different countries in the far east and the middle east [Table - 4]. [16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27] Our study could be of particular interest because of the low prevalence of hepatitis B, which may related to the religious culture of the study population that restricts extra-marital sexual relations and intravenous (IV) drug abuse.

The incidence of HBV infection has been minimized in our units by the imple­mentation of universal precautions; for example, avoidance of sharing multi-dose vials or blood-contacted equipment, routine screening of blood products, routine vacci­nation of dialysis patients, and the use of dedicated dialysis machines for infected patients. At the same time, regular six­monthly HBsAg screening, and monthly screening for serum transaminases is per­formed on all HD patients. The second cause for transmission of hepatitis B in Jordan after peri-natal may be through using unsterile dental and surgical equipments, and was not addressed in this study.

We found that, positivity of HBsAg gene­rally was noted to increase with increasing duration on dialysis. Various studies [28],[29] have shown that history of HD and previous blood transfusions are associated with in­creased positivity for HBV, and the risk of infection correlates with the duration on HD and the number of transfusions. Our study showed that duration on HD, but not the number of transfusions was a risk factor for acquiring HBV infection. Local endemicity, presence of HBsAg-positive patients in the units and non-separation of infected from non-infected patients are also associated with an increased risk of HBV infection. [30]

In general, the overall incidence of HBV infection in dialysis patients is decreasing over the years as a result of routine screening of blood products for HBsAg and anti­hepatitis B core (anti-HBc) antibody, the advent of recombinant human erythropoietin, HBV vaccination and the implementation of infection control measures. [31]

A molecular biological study of patients receiving treatment in the same HD units showed a relative homogeneity of HBV sub­types, which supports the existence of patient­to-patient transmission of HBV infection in HD units. [32] There are certain characteristics of HBV that render it particularly susceptible to environmental contamination, especially nosocomial transmission. HBV is relatively stable in the environment and can remain viable for at least seven days on environ­mental surfaces at room temperature. [33] HBsAg has been detected on various environ­mental surfaces, such as clamps, scissors, door knobs and dialysis machine control knobs, in dialysis centers with HBsAg­positive patients. [34] The HD procedure itself poses an exceptional risk to patients for acquiring the infection. Patients on peritoneal dialysis are reported to have a lower pre­valence of HBV infection compared with HD patients. [35] During HD, patients could be injected with contaminated material, have mucosal membrane or breached skin exposed to infective material, or be dialyzed with contaminated equipment. In this regard, HBV-DNA has been detected in the dialysate and ultrafiltrate of HBsAg-positive patients undergoing high-flux HD; thereby, the risk of environmental contamination and nosocomial transmission of the infection among other HD patients could be further increased. [36]

To reduce the risk of nosocomial infection, it is of paramount importance to ensure strict adherence to universal precautions for all patients regardless of their HBsAg and sero­logical status because HBV genomes can be present in the serum, liver or peripheral blood mononuclear cells in the absence of serological markers of infection. [37] Vaccina­tion of non-immune patients also plays an important role in preventing the spread of infection within dialysis units. [38]

Under most circumstances, HBV is not a cytopathic virus. Therefore, with a compro­mised immune system, it is not surprising that acute HBV infection in dialysis patients is often mild or asymptomatic, and a high percentage of between 30 and 72% of these patients might become chronic carriers because of an impaired viral clearance. [39] However, the exact impact of HBV infection on the clinical outcome of infected dialysis patients remains controversial. A retrospec­tive study performed in India reported a higher mortality among HBV-positive dia­lysis patients compared with their HBsAg­negative counterparts, and there are also studies that showed no difference in the morbidity and mortality rates between HBsAg-positive and HBsAg-negative dialysis patients. [40]

Dialysis patients who test positive for HBsAg should be closely monitored for clinical signs and symptoms of active and chronic liver disease. Liver biopsy may be required to confirm the diagnosis and to determine the need for treatment. Dialysis patients with positive HBsAg pending a living-related renal transplant should also undergo a liver biopsy to determine the suitability for an isolated kidney transplan­tation, and lamivudine therapy, before or immediately after transplantation, should be considered. In patients showing advanced liver cirrhosis or severe active liver disease on liver biopsy, lamivudine should be given, and the kidney transplant should be deferred or combined as liver-kidney transplantation instead. At the moment, lamivudine appears to be the best possible treatment for dialysis patients with significant active liver disease on liver biopsy and evidence of active HBV replication, although the long-term outcome is unclear and the emergence of lamivudine­resistant mutants remains a real concern.

It appears from the present study that the frequency of HBV in HD patients at the Royal Medical Services is low, and this emphasizes the necessity of keeping it low. We recommend that: First; greater emphasis should be laid on public health education particularly creating awareness about the risk factors for hepatitis B, its prevention and control to minimize its transmission. Second; health-care professionals doing invasive procedures in general and dental surgeons in particular, should be advised to use sterilized instruments and equipment to eliminate the chances of transmitting these infections. Third; only screened blood pro­ducts should be transfused. Fourth; periodic screening for HbsAg should be performed, and vaccination should be administered to all patients with chronic kidney disease who might need HD.

We did not have enough documented data about the percentage of patients who under­went surgery, dental manipulations, IV drug abuse, HBsAg status of the other family members, or the history of extra-marital sexual relations before or during HD.

   Conclusions Top

Hepatitis B surface antigen was positive in 5.9% among patients on HD in our study. Although this figure is in the medium range of seropositivity, it is higher than the posi­tivity of virus in general population. Preven­tion remains a priority, and vaccination of non-immune renal patients, especially before they develop advanced renal failure, is considered crucial in order to decrease the magnitude of the HBV-related problem in the dialysis population.

   References Top

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Correspondence Address:
Munther Al Hijazat
Nephrologist, Sweilleh 11910, Amman
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  [Table - 1], [Table - 2], [Table - 3], [Table - 4]

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