Seroprevalence and risk factors for Hepatitis C virus among maintenance hemodialysis patients at a Tertiary Care Hospital in Puducherry, India

Latha Ragunathan; Kavitha Kannaiyan; Vithiavathi Subramanian; Marcella Sherin Samuel; Murugavel Mahendran

doi:10.4103/bbrj.bbrj_240_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 6 | Issue : 1 | Page : 122-125

Seroprevalence and risk factors for Hepatitis C virus among maintenance hemodialysis patients at a Tertiary Care Hospital in Puducherry, India

Latha Ragunathan¹, Kavitha Kannaiyan¹, Vithiavathi Subramanian², Marcella Sherin Samuel¹, Murugavel Mahendran¹
¹ Department of Microbiology, Aarupadai Veedu medical college& hospital, Vinayaka Mission's Research Foundation, Puducherry, India
² Department of General Medicine, Aarupadai Veedu medical college& hospital, Vinayaka Mission's Research Foundation, Puducherry, India

Date of Submission	21-Sep-2021
Date of Acceptance	22-Nov-2021
Date of Web Publication	11-Mar-2022

Correspondence Address:
Kavitha Kannaiyan
Department of Microbiology, Aarupadai Veedu Medical College and Hospital, Puducherry
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bbrj.bbrj_240_21

Abstract

Background: Hepatitis C virus (HCV) infection is a serious public health problem and the most significant cause of liver disease in patient receiving dialysis for a long term. The prevalence of HCV infections among dialysis patients varies markedly from country to country. Tight infection control measures implemented in developed countries have minimized the transmission rate, while the prevalence still remains high in the developing world. The aim of this study is to estimate the prevalence rate of HCV infection in hemodialysis patients, to describe demographic characteristics of individuals infected with HCV and to determine whether HCV-polymerase chain reaction (PCR) testing identifies HCV infections not detected by anti-HCV testing. Methods: This retrospective record-based study was carried in Aarupadai Veedu Medical College and Hospital, a Tertiary Care Center in Puducherry, A total of 258 chronic renal failure patients on hemodialysis were studied and tested for anti-HCV antibodies by 4^th generation HCV TRIDOT ELISA and real time-PCR. Results: Anti-HCV antibodies were positive in 34 (13.2%) patients, comprising 27 (79.4%) males and 7 (20.6%) females. The majority of patients were found to be positive; between 41 and 60 age 24 (70.5%). HCV RNA was detected in 38 (14.72%) patients. The mean age of patients undergoing dialysis was 45 years. 12 (35%) had raised aspartate transaminase (AST) levels and 14 (41%) had raised alanine transaminase (ALT) levels. Gamma-glutamyl transferase was found to be raised in 25 (73.5%) of the subjects. All the 34 HCV seropositive patients were hypertensive and 33% had diabetes mellitus. 23 (67.6%) patients had undergone dialysis in more than one center. Conclusions: Regular screening of patients for HCV is absolute necessity for early detection of HCV infection that could result in better management of patients and also stresses on the importance of HCV RNA detection by PCR. Strict adherence to universal precautions, the use of dedicated machines along with regular surveillance for HCV in HD units will dramatically decrease the risk of transmission of HCV.

Keywords: Chronic kidney disease, hemodialysis, hepatitis C virus, prevalence, Puducherry, seroprevalence

How to cite this article:
Ragunathan L, Kannaiyan K, Subramanian V, Samuel MS, Mahendran M. Seroprevalence and risk factors for Hepatitis C virus among maintenance hemodialysis patients at a Tertiary Care Hospital in Puducherry, India. Biomed Biotechnol Res J 2022;6:122-5

How to cite this URL:
Ragunathan L, Kannaiyan K, Subramanian V, Samuel MS, Mahendran M. Seroprevalence and risk factors for Hepatitis C virus among maintenance hemodialysis patients at a Tertiary Care Hospital in Puducherry, India. Biomed Biotechnol Res J [serial online] 2022 [cited 2023 Mar 23];6:122-5. Available from: https://www.bmbtrj.org/text.asp?2022/6/1/122/339373

Introduction

Hepatitis C virus (HCV) is a positive polarity, single-stranded RNA virus of the family Flaviviridae, genus Hepacivirus and is classified into six major groups (genotypes 1–6), each containing a variable number of more closely related distinct subtypes.^[1] In addition, the source of 70% non-A, non-B hepatitis around the world is Hepatitis C which causes chronic hepatitis and hepatocellular carcinoma.^[2],[3] The expression of HCV antibodies indicates HCV infection. With technological advances in studies concerning HCV, the elaboration and the implementation of diagnostic tests, such as triage in blood banks that began in 1990, has allowed professionals to understand the dimension of the Hepatitis C problem.^[4] HCV infection is a serious public health problem and the most significant cause of liver disease in patient receiving dialysis for a long term.^[5] The prevalence of HCV infections among dialysis patients varies markedly from country to country^[6] and also between different units within the same country.^[7]

The worldwide data suggest that the prevalence of hepatitis viruses among chronic renal failure (CRF) patients could be as high as 80%.^[8] Strict infection control measures implemented in developed countries have minimized the transmission rate, while the prevalence still remains high in the developing world.^[9]

The aim of the present study was to estimate the prevalence rate of HCV infection in hemodialysis patients, to describe demographic characteristics of individuals infected with HCV and to determine whether HCV-polymerase chain reaction (PCR) testing identifies HCV infections not detected by anti-HCV testing.

Methods

This retrospective record-based study was carried in Aarupadai Veedu Medical College and Hospital, a tertiary care center in Puducherry, India, by the Department of Microbiology in collaboration with Department of Medicine and Nephrology. The study protocol was approved by our Institutional Ethical Committee (IEC No- AV/IEC/2020/047).

Clinical, demographic, and geographical data of chronic kidney disease patients undergoing hemodialysis in our institution were retrieved from medical record section. Patients who attended our hospital for hemodialysis for 4 years (January 2016–December 2019) were included in this study. Patients who were positive for anti-HCV antibodies before starting hemodialysis were excluded from the study

A total of 258 CRF patients on hemodialysis were studied. A 5 mL of blood was collected before hemodialysis session using a vacuum tube containing ethylenediaminetetraacetic acid and immediately centrifuged. The serum was separated, and the sample was stored at −70°C until the analysis.

Patients on dialysis were tested for the following serological tests - All the patients were tested for anti-HCV antibodies by HCV-TRI-DOT, a rapid visual test for the qualitative detection of antibodies to HCV in human serum/plasma by 4^th generation HCV TRIDOT ELISA (Diagnostic Enterprises). The test was performed in accordance with the manufacturer's instructions. Hepatitis B surface antigen (HBsAg) (Diagnostic Enterprises) and Anti– HIV antibodies test by TRIDOT method. Reactive samples were also tested by real-time-PCR (RT-PCR) for HCV by ROCHE COBAS TAQMON 48 RT-PCR analyzer. Other laboratory tests - liver function tests, renal function tests, complete blood count, and urine analysis were done.

Results

A total of 258 patients on maintenance dialysis were included in this study. Two hundred and eight (81%) were male and 50 (19%) were female. The mean age of patients undergoing dialysis was 50.45 years [Table 1].

Table 1: Demographic features and risk factors of hepatitis C virus positive patients on hemodialysis

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Majority of the patients on HD were in the age group of 41–60 years 142 (63%), followed by above 60 years 67 (30%) and 21–40 years of age group 39 (18%).

Of 258 participants, anti-HCV antibodies were positive [Table 2] in 34 (13.2%) patients, comprising 27 (79.4%) males and 7 (20.6%) females. Majority of patients were found to be positive; between 41 and 60 age 24 (70.5%), followed by above 60 years 8 (23.5%) and 21 and 40 age Group 2 (6%).

Table 2: Hematological and biochemical parameters of hepatitis C virus-positive patients (n=34)

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Out of 258 patients, HCV RNA was detected in 38 (14.72%) patients. None of the HCV-positive patients were HBsAg positive and all subjects were HIV negative.

Biochemical parameters

Out of the 34 seropositive patients, 12 (35%) had raised aspartate transaminase (AST) levels and 14 (41%) had raised alanine transaminase (ALT) levels. Gamma-glutamyl transferase (GGT) was found to be raised in 25 (73.5%) of the subjects. Hypocalcemia was seen in 21 (62%) and hyperphosphatemia in 5 (15%).

Hematology parameters

All the patients were anemic and all of them were under erythropoietin treatment. Raised ESR was found in all the patients.

All the 34 HCV seropositive patients were hypertensive and 33% had diabetes mellitus. 23 (67.6%) patients had undergone dialysis in more than one center.

Discussion

This study was conducted in our hospital which is a rural-based 650 bedded tertiary care teaching hospital situated in Puducherry. Most of the patients who come for hemodialysis are from villages and belong to the farming community. Cases of chronic kidney diseases requiring dialysis have increased gradually over the last decades among farming communities. This has become an imperative issue in medical care. Our study included patients diagnosed with CRF coming for maintenance hemodialysis.

According to Kidney Disease Improving Global Outcomes guidelines,^[10] the prevalence of HCV infection among dialysis patients in different parts of the world varies from 1% to 90%.^[11] but still the seroepidemiological studies on HCV prevalence in patients undergoing hemodialysis remain inadequate worldwide.

Prevalence

The incidence and prevalence of HCV among dialysis patients varies markedly from country to country and among dialysis centers within a single country. Many Indian studies had a prevalence rate between 2% and 14%.^[12],[13]

Our study shows a prevalence of 13.2% among patients on maintenance dialysis which is lower than the studies done by^{[11],[12],[13],[14],[15]} and concordant with a study done by another author.^[16] In our study, the median age was 45 years which is similar to study done by Agarwal et al. It was mostly seen in males.^[17]

Risk factors

Among the predisposing factors, the main cause of dialysis was hypertension followed by idiopathic causes, diabetes mellitus and usage of native medicines. Many studies have concluded that history of jaundice and number of blood transfusion were significantly higher in HCV-positive patients as compared to HCV-negative cases.^[18] In our study, we did not find blood transfusion as an important source of HCV infection. Our study is similar to the work done by another author.^[17] Many studies^{[13],[19],[20],[21],[22],[23]} have concluded that the longer duration of dialysis was associated with an increased seroprevalence of HCV which is similar to our study. Nosocomial transmission, prolonged vascular access, potential for exposure to infected patients and contaminated equipment, and sharing of multi-dose heparin vials are some factors responsible for the high risk in HD patients.

Biochemical parameters

The serum levels of the liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST), and GGT are considered as markers of aggression against hepatocytes.^[24],[25] In our study AST and ALT were increased in 35% and 41% respectively but GGT was significantly increased in 73.5% of the patients. We found that GGT serum levels appear to be a useful marker in the identification of viral hepatitis during the follow-up of CKD patients on HD. A study done by authors^{[24],[25],[26]} recommends GGT levels to be measured monthly for HD patients, as is performed for ALT and can be useful as a low-cost marker in the diagnosis of chronic HCV infection.

In our study, there was no significant difference in the levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) between anti-HCV positive and negative patients. In a study done by Jasuja et al.^[13] reported a significant correlation of HCV RNA positivity with elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST). A study done by Hegde and Boloor^[27] also reported raised ALT levels in 33.3% of patients and Chigurupati et al.^[15] in 41.6% patients. Hypocalcemia was seen in 21 (62%) and hyperphosphatemia in 5 (15%).

Hematology parameters

Anemia was found in all the patients on hemodialysis, but a history of blood transfusions was given to 20% of the patients. Extensive use of recombinant erythropoietin to correct renal anemia along with iron supplementations in HD patients resulted in a significant reduction in a number of blood transfusions.

Serology

In the present study, the prevalence of HCV antibodies was found to be positive in 34 (13.2%) patients by immunochromatographic method (79.4% in males and 20.6% in females) which is similar to the study done by other authors.^{[11],[12],[13],[14],[15]} HCV RNA by RT-PCR was detected in 38 (14.72%) patients. The most standard policy for diagnosis of HCV infection consists of initial screening with a simple, inexpensive, cost-effective, and reliable serological assay for early case detection and improving treatment outcome and, if the assay is positive, subsequent nucleic acid testing (NAT). As anti-HCV tests are unable to differentiate between resolved HCV infection and current HCV infection. Detection of HCV viremia relies on NAT technologies. During the initial phase, if the serum conversion has not yet occurred, this may lead to difficulty in diagnosis. This may be a reason for lack of detection of HCV antibodies in the individuals who have tested positive for HCV by RT-PCR. In our study, 4 patients were RT-PCR positive. Several studies have corroborated that the patient may be seronegative but PCR positive.^[6] Patient attending more than one hemodialysis center and those who underwent HD for longer durations were found to be likely contract HCV infection. In our study, 79.4% were male and 20.6% were female. This statistics is similar to a study done by Malhotra et al.^[11] The majority of patients were found to be positive, between 41 and 60 age, 24 (70.5%), followed by above 60 years 8 (23.5%) and 21–40 age Group 2 (6%). This is similar to the study done by Malhotra et al.^[11]

Hospital infection control practices

HCV nosocomial transmission can be prevented to a large extent by implementing stringent infection control practices in the dialysis units, providing separate dialysis machines for infected patients and regular screening of the patients for HBV and HCV, training for healthcare workers and regular observational audits of infection control procedures in HD units.

Conclusions

Our study concludes that regular screening of patients for HCV is an absolute necessity for early detection of HCV infection that could result in better management of patients and also stresses the importance of HCV RNA detection by PCR in screening for HCV infection in these patients. Strict adherence to universal precautions, use of dedicated machines along with regular surveillance for HCV in HD units will dramatically decrease the risk of transmission of HCV.

Limitation of study

No limitation in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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