|ORIGINAL RESEARCH REPORT
|Year : 2017 | Volume
| Issue : 2 | Page : 58-61
Seroprevalence of hepatitis B and C infection among Nigerian subjects with chronic kidney disease
Christiana Oluwatoyin Amira1, Oluwafunmilayo Adenike Lesi2
1 Department of Medicine, Nephrology Unit, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
2 Department of Medicine, Gastroenterology Unit, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
|Date of Web Publication||18-Apr-2017|
Christiana Oluwatoyin Amira
Department of Medicine, College of Medicine, University of Lagos, PMB 12003, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Background and Objective: The prevalence of hepatitis virus infection in subjects with chronic kidney disease (CKD) has important implications for the etiology of kidney disease, infection safety in hemodialysis, and increases challenges in management consideration. The aim of this study was to determine the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection among our patients with CKD before the commencement of dialysis. Methods: All CKD patients (n = 1388) dialyzed between January 1996 and December 2012 were enrolled into the study. Demographic data and etiology of CKD were extracted from case records. Patients were screened for HBV and HCV at initiation of dialysis. Hepatitis B surface antigen (HBsAg), HCV antibodies were measured using specific enzyme-linked immunoassay kits (Bio Rad Monalisa HBsAg ULTRA kit, Marnes–la-Coquette, France; HCV Dia.Pro Diagnostics Milano Italy, respectively). All subjects with HIV infection were excluded from the study. Results: The studied group comprised 511 (36.8%) females; the mean age of the patients was 46.1 ± 15.3 years. Eighty-three (6.0%) patients were HBsAg positive, whereas 16 (1.2%) were HCV antibody positive. No difference was observed in gender occurrence. Patients with chronic glomerulonephritis (GN) were significantly more likely to be HBsAg positive (9%) compared with those with hypertension (5.5%) or diabetes (5.3%) (P = 0.015). Conclusion: The prevalence of HBV in CKD patients was high, whereas HCV was low. HBV was significantly associated with chronic GN. Routine screening of all patients with CKD and before hemodialysis for HBV should be mandatory, especially in HBV endemic regions of the world.
Keywords: Chronic kidney disease, hemodialysis, hepatitis B virus, hepatitis C
|How to cite this article:|
Amira CO, Lesi OA. Seroprevalence of hepatitis B and C infection among Nigerian subjects with chronic kidney disease. J Clin Sci 2017;14:58-61
| Introduction|| |
Hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is a global health problem. According to the World Health Organization more than two billion people worldwide have serological evidence of current or resolved infection of HBV and 150 million people are chronically infected with HCV., HBV infection is highly endemic in Asia and sub-Saharan Africa with prevalence rates above 7%.,
End-stage renal disease (ESRD) patients are at increased the risk of acquiring HBV and HCV infections as compared with the general population due to their deficient immune response and exposure to blood transfusions and hemodialysis equipment. Hemodialysis, being a blood handling procedure, also affords an opportunity for transmission of HBV and HCV between patients, and between patients and staff. Reports from various studies did show a higher seroprevalence of HBV and HCV infections in dialysis patients.,, In developed countries, the overall incidence of HBV infection in dialysis patients has decreased over the years, consequent to routine screening of blood products for hepatitis B surface antigen (HBsAg) and anti-hepatitis B core antibody, advent of recombinant human erythropoietin, HBV vaccination and implementation of infection control measures. However, in many developing countries, HBV infection remains highly prevalent in dialysis units due to the lack of implementation of all these measures. Apart from the high risk of complications associated with HCV and HBV infections in dialysis patients, both viruses have been implicated in the pathogenesis of glomerulonephritis (GN) and chronic kidney disease (CKD).,,
The aim of this study was to determine the frequency of HCV and HBV infections among subjects with CKD before commencement of hemodialysis using a large data base from a hemodialysis (HD) unit in Lagos, Nigeria and to determine if there is any association of CKD etiology and viral hepatitis.
| Methods|| |
This was a retrospective single center study conducted over a 17-year period (1996–2012) at the dialysis center of the Lagos University Teaching Hospital (LUTH), Lagos South West Nigeria. The LUTH dialysis center was the first to be established in the West African sub-region in 1981. Currently, the unit has eight HD machines one of which is dedicated for treatment of patients infected with HBV or HCV viruses. The unit does not routinely provide treatment for HIV infected individuals for constraint of space and machines. To date, the unit has treated over 2000 patients with renal failure.
All the patients who dialyzed in the center were routinely screened for blood borne infections (HCV, HBV, and HIV) at the initiation of dialysis treatment. A volume of 5 ml blood samples were collected from each patient before HD in plain universal bottles. Samples were immediately sent to the central laboratory of the hospital for analysis. Samples were tested using specific enzyme-linked immunoassay kits: (Bio Rad Monalisa HBsAg ULTRA kit, Marnes–la-Coquette, France and HCV AbDia. Pro Diagnostics Milano Italy). Sero-positivity to HBV was defined by the detection of HBsAg and seropositivity to HCV by detection of anti-HCV antibodies. The patients' demographic data and etiology of CKD were recorded. Excluded were patients with acute renal failure and those with known hepatic disease.
Data analysis was performed with Epi Info version 6 (Centers for Disease Control and Prevention Atlanta, GA). Proportion, Chi-square analysis and prevalence rates were calculated. Statistical significance was assumed at P< 0.05.
| Results|| |
A total of 1414 patients with CKD were referred for dialysis treatment during the period under review; 26 pediatric subjects under age 16 years were excluded from further analysis. Among the 1388 subjects included, there were 877 (63.2%) males and 511 (36.8%) females. The mean age was 46.1 ± 15.3 years; age of patients' ranges from 16 to 93 years. The most common causes of CKD were hypertension (39.3%), chronic GN (26.7%), diabetic nephropathy (13.4%), obstructive uropathy (10.5%), other conditions accounted for 4.3% (these include sickle cell disease [SCN] [n = 23], systemic lupus erythematosus [n = 19], autosomal polycystic kidney disease [n = 11], chronic pyelonephritis and chronic tubulointerstial nephritis , multiple myeloma ) and etiology was unknown in 5.8%. Subjects with diabetes, hypertensive renal diseases and obstructive uropathy were significantly older than those patients with chronic GN, SCN and lupus nephritis. A female predominance was seen in subjects with lupus nephritis [Table 1].
Eighty-three (6.0%) patients were HBsAg positive, 16 (1.2%) were anti HCV positive while 1 (0.1%) patient tested positive for both HBsAg and HCV. In terms of etiology, patients with chronic glomerular diseases were 2.1 fold more likely to be HBsAg positive compared with the other CKD patients (odds ratio [OR] 2.1, P = 0.001). Subjects with SCN had a higher prevalence of HCV than other etiologies. This difference however failed to reach statistical significance [Table 2].
|Table 2: Frequency and risk of viral hepatitis B and C according to chronic kidney disease etiology|
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| Discussion|| |
In this study, hypertension was the most prevalent cause of CKD while chronic GN was the etiology in one quarter of the cases seen. It is notable that the subjects with GN were mostly in the third decade and were significantly younger than the subjects with diabetes and hypertension. Other important causes of ESRD in this series included obstructive uropathy and sickle cell nephropathy. The subjects with lupus nephritis were almost exclusively females as reported in most publications from developed countries.
A high prevalence of viral hepatitis B is noted in this population. This prevalence is not surprising and is similar to comparisons from the general population which is endemic for hepatitis B infection.,,, Various other studies suggest that a high prevalence of HBV prior to dialysis is a high risk factor for transmission of infection in the dialysis setting., In view of this, it is recommended that all CKD patients who are HBV negative should routinely be immunized preferably before commencing dialysis in line with current guidelines.
GN is an important extrahepatic manifestation of chronic HBV infection. Chronic HBV infection has been associated with pathogenesis of certain types of glomerulonephritides commonly membranous GN, membranoproliferative and mesangial proliferative GN. A study from South Africa found that 24% of black children with nephrotic syndrome were HBsAg positive and they all had membranous GN. In the study by Akinsola et al. 33% of the patients with GN were HBsAg positive compared with 6% in controls. Our finding of the significant association of HBV infection and CKD due to GN corroborate these observations. 35 (9.5%) of the patients with CKD from GN were HBsAg positive and were 2 times more likely to have HBV infection, than subjects with hypertension, diabetes or other CKD. The main pathogenic mechanism in HBV-related glomerular diseases is through deposition of immune complexes in the glomerulus. The immune complexes then activate complements and glomerular injury occurs through the formation of membrane attack complex and other downstream events such as the induction of proteases, oxidation injury, and disruption of cytoskeleton.
The prevalence of HCV infection among our study population was low compared with reports in the literature.,, Salako et al. reported a prevalence of 9% among predialysis CKD patients in South West Nigeria, Ummate et al. from North East Nigeria found a prevalence of 15% in hemodialysis requiring CKD patients, whereas Rinonce et al. in Indonesia reported a prevalence of 80.7% in their patients on dialysis. The prevalence of HCV infection varies widely according to geographical regions, subjects studied and the diagnostic methods used. High prevalence has been reported from HD centers in North Africa.,, In Nigeria, the reported prevalence varies between 1.5% and 2.5% among the general population, but much higher among high risk populations such as subjects with SCD and chronic liver disease., Lesi and Kehindereported a prevalence of 5% among children with SCD in Lagos. In this study, 4.4% of subjects with SCD were positive for HCV. These subjects were nearly 4 times more likely to test positive for HCV than the other subjects with CKD (OR 3.8). This association however failed to reach statistical significance (P = 0.20). Risk factors associated with HCV infection in CKD patients include younger age, longer time on dialysis and multiple blood transfusions. Even though, we could not ascertain the relationship of blood transfusion with HCV infections because of the retrospective nature of our study but we had in another study reported high blood transfusion rates among our patients. Viral hepatitis is considered a problem for HD patients because 1.9% of all deaths among this population were related to the consequences of viral hepatitis and also contributes to significant morbidity posttransplant. Therefore all CKD patients should be screened for HBV and HCV infection before the initiation of HD and monitored every 3–6 months thereafter. All HBV positive patients should receive appropriate treatment and those who are negative should be immunized. This study has some limitations; being a retrospective study we could not test the patients' full hepatitis B serologic status or quantitatively measure HBV-DNA and HCV-RNA by polymerase chain reaction.
| Conclusion|| |
The prevalence of HBV infections among our CKD patients was high which reflects the prevalence rate in the general population, whereas HCV prevalence was low. HBV was significantly associated with chronic GN. Effective strategies to reduce the prevalence as well as nosocomial transmission of HCV and HBV infections among the dialysis patients should be implemented.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]