Journal of Virology & Antiviral ResearchISSN: 2324-8955

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Research Article, J Virol Antivir Res Vol: 4 Issue: 3

Prevalence of Viral Hepatitis B and C Markers in Multitransfused Patients with Chronic Kidney DiseaseCompared with The General Population in Albania

Tatjana Nurka1*, Erika Ebranati2, Robert Çina3, Zhaneta Abazi4, Anila Kristo5, Xhensila Frasheri1, Vjollca Shpata1, Pranvera Dragusha6, Massimo Ciccozzi7, Gianguglielmo Zehender2 and Renata Shkjezi6
1Department of Medical and Technical Science, University of Medicine, Tirana, Albania
2Department of Biomedical and Clinical Sciences “L. Sacco”, University of Milan, Italy
3University of Sports of Tirana, Albania
4National Blood Transfusion Centre, Tirana, Albania
5Faculty of Medicine, University of Medicine, Tirana, Albania
6Faculty of Medicine, Catholic University “Our Lady of Good Council”, Tirana, Albania
7Department of Infectious, Parasitic and Immunomediated Diseases, Istituto Superiore di Sanità, Rome, Italy
Corresponding author : Tatjana Nurka
University of Medicine, Tirana, Faculty of Medical and Technical Science,Kongresi Manastirit 133,1005, Tirana, Albania
Tel: 00355692073253
E-mail: [email protected]
Received: August 01, 2015 Accepted: September 01, 2015 Published: September 07, 2015
Citation: Nurka T, Ebranati E, Çina R, Abazi Z, Kristo A, et al. (2015) Prevalence of Viral Hepatitis B and C Markers in Multitransfused Patients with Chronic Kidney Disease Compared with The General Population in Albania. J Virol Antivir Res 4:3. doi:10.4172/2324-8955.1000142

Abstract

Objective

Evaluation of the prevalence of viral hepatitis markers in CKD patients and comparison with the prevalence in family replacement donors as a control group of the general population in Albania.

Methods

64 patients with CKD treated with three or more blood transfusions were evaluated for Hepatitis B and C markers. They were divided in hemodialysed (HD) and non-hemodialysed (Non- HD) patients. We compared the prevalence of HBV and HCV markers founded in these patients with those of blood donors group which includes 1993 subjects divided in two categories: regular blood donors 625 subjects and family replacement donors 1368 subjects, the later being considered as control group.

Result

The prevalence of viral hepatitis B and C markers found in CKD patients were significantly higher than those of the control group (27% and 31% vs 8.5% and 2%). There are no significant differences of HBsAg prevalence in HD and Non-HD patients, but there is a significant one in the presence of anti HCV in HD patients. We also assessed the impact of age and temporal duration of hemodialysis in this prevalence. We confirm that the prevalence of HCV and HBV markers is significantly higher in CKD compared to the general Albanian population.

Conclusions

The amount of blood transfusions and the age of patients are important risk factors for the spread of these infections.

Keywords: Chronic kidney disease; Hemodialysed patients; Hepatitis B Virus; Hepatitis C Virus; Blood transfusion; Family replacement donors; Blood donors

Keywords

Chronic kidney disease; Hemodialysed patients; Hepatitis B Virus; Hepatitis C Virus; Blood transfusion; Family replacement donors; Blood donors

Introduction

Albania is an endemic country for Hepatitis B (HBV) infection with a HBsAg prevalence about 9.5% according different studies conducted from Public Health Institute and the Service of Gastrohepatology, University Hospital Centre “Mother Theresa” of Tirana [1,2]. The first epidemiological data about HBV infection in Albanian population were obtained by the screening of Albanian refugees in Italy and Greece during the year 1991 [3,4]. According to WHO recommendations, in May 1995 Albania introduced vaccination of all newborns against HBV into the National Immunization Program as the most appropriate immunization strategy to reduce the rate of HBV infection and HBV related chronic liver diseases. Infants are immunized at birth, and then after 1 and 5 months. Despite the estimated two-fold reduction of HBsAg prevalence in the general population from about 18%-19% [3,4] to 9.5% [1], Albania remains a highly endemic country yet. Viral hepatitis C (HCV) infection is distributed worldwide with approximately 130-210 million individuals chronically infected. In Western Europe, HCV prevalence ranges from 0.4% to 3%, while in Eastern Europe and the Middle East the prevalence is probably higher, but data are still lacking for the majority of countries [5]. One important route of HCV and HBV transmission is through the blood transfusion. Patients with chronic kidney disease (CKD), whether or not subject to dialysis, need to be treated with blood transfusions due to chronic anemia. Hemodialysis (HD) patients are at particular high risk for blood borne infections because of prolonged vascular access and potential exposure to contaminated equipment.
Aside from the global dimension, infection and spread of HBV have been an ongoing challenge in the very special microenvironment of dialysis units since the beginning of chronic dialysis programs in the late 1960s [6,7]. The early times were characterized by high prevalence of HBV positive HD patients and staff members and by isolated viral hepatitis epidemics too. Before 1990, important factors in HBV and HCV transmission have been the unsafe use of non – disposable medical equipments like syringes, needles, catheters and dialysis materials. Another route of transmission for these infections is the use of substances from the same vial for many patients (heparin, physiologic solution, etc.). HBV and HCV viruses can pass through the pores of the contaminated membranes of dialyses and dialysis solutions. HBV can pass through the pore diameter > 40 nm and HCV can pass the pores with diameter >35 nm. Theoretically, pores have a diameter much smaller (1.3-7 nm), but a small part of them can exceed this average as a result of small cracks membranes that come as a result of high hydrostatic pressure while allowing passage of viruses [8-11]. Throughout the past 50 years, major advances have been achieved by increasingly more sophisticated routine serological screening methods for HBV infection, guidelines for hygiene precautions, segregation of infectious and noninfectious patients in dialysis units, HBV testing of blood transfusions, introduction of erythropoietin to avoid blood transfusions, and beginning in the 1980s, introduction of routine HBV vaccination of dialysis patients and the staff [6,7,9]. Consequently, the number of HBV infections has declined, but even today HBV incidence in dialysis units is still high and far away from adequate control. It is estimated that up to 4% of HD patients are chronically infected with HBV in North America, Western Europe, and Japan [6-8,12,13]. In less developed countries, single-center reports indicate prevalence rates up to the range of 10- 20% [13]. To date, HBV in dialysis units is still a problem, despite continuous and ongoing improvements in its management.
Certainly, HBV and HCV prevalence among CKD Albanian patients are expected to be high taking also in consideration the high prevalence of HBV infection in general population and the geographic position of Albania as part of Eastern Europe with a higher prevalence for HCV infection.
Aim of the study
Evaluation of the prevalence of viral hepatitis markers in CKD patients and comparison with the prevalence in family replacement donors as a control of the general population in Albania.
Population and methods
We included 64 patients with CKD, at University Hospital Centre “Mother Theresa” of Tirana; 42 males and 22 females, 36 of them were HD and 28 had been treated only with blood transfusions (Non-HD). Only the patients with three or more transfusions were included in the study. We compared the prevalence of HBV and HCV markers founded in these patients with those of blood donors group which includes 1993 subjects divided in two categories: regular blood donors 625 subjects and family replacement donors 1368 subjects. Regular blood donor is considered the donor who has donated blood more than two times during one year.
Family replacement donors are donors who have donated blood for patients undergoing surgical procedures, despite the blood group. A family member or a friend of the recipient donates blood to replace the stored blood used in a transfusion. Generally they are first time donors. For this reason they are considered as control group. The study was conducted during the period march 2009 - march 2010.
Blood samples were tested for antibody anti HCV and HBsAg with ELISA method third generation (ABBOTT) in the Laboratory of Virology of the National Blood Transfusion Centre in Albania, as part of the screening procedure for blood donors according to the Albanian Law (blood testing is mandatory for HBV, HCV, HIV 1/2 and syphilis).
Chi-square test and Fisher test were performed using SPSS 18. The values of p ≤ 0.05 were considered statistically significiant for both tests.

Results

The mean prevalence of HBsAg in CKD patients was 27% (17/64): 25 % (9/36) among HD patients and 29% (8/28) in Non-HD patients. In regular blood donors and in control group it was respectively 0.5% and 8.5%. According to chi-square test these differences between CKD patients and control group were significant (p<0.001).
We found anti - HCV marker prevalence of 31% (20/64) in CKD patients: specifically 47% (17/36) in HD and 11% (3/28) in Non-HD patients (Figure 1). The prevalence of anti HCV marker in regular blood donors was 1% (6/625) and in control group 2% (27/1368) with significant differences between CKD patients and control group (p<0.001) (Figures 2 and 3). We also found coinfection HBV/HCV in 6% (4/64) among CDK patients.
Figure 1: The metadata (from the Pubmed) taken for this investigation was reported from different countries and the proportion of the sequences from each country is represented pictorially.
Figure 2: The prevalence of HBV and HCV markers in CKD patients according to age groups.
Figure 3: The prevalence of HBV and HCV markers in CKD patients and Blood donors.
According to age groups, we noted that the HBV prevalence is considerably higher in the patients between 20-40 years old, while the HCV prevalence is higher in age groups over 40 years (Figure 2). These findings are statistically significant (p<0.005). We also evaluated the prevalence of viral hepatitis markers in HD patients in concordance with the temporal duration of HD.
Considering only the HD patients, the mean time of HD treatment was 7.5 ± 4.42 years among the HCV positive patients, 5.1 ± 2.93 years among the HBV positive patients and 3.3 ± 2.91 years among the HCV and HBV negative patients. We found that the mean time of treatment of patients negative for both HCV and HBV markers was significantly lower than that of the HD subjects with HBV or HCV infection (p=0.03 by t test).

Discussion

We noticed high prevalences of viral HBV and HCV markers in multitransfused CKD Albanian patients compared to the general population. HBV prevalence is also high among family replacement donors that serves as control group, but it corresponds to the overall level of HBV infection in this country (data not published). Given the frequent screening (every three months) of regular blood donors, we must say that the prevalence of HBV is low in this group (0.5%). HCV markers level found in control group is within the worldwide prevalence range supported by the literature, but there are very few data published about HCV infection in Albania. We think that we must pay attention to the prevalence of 1% - 2% of anti HCV markers in blood donors (Figure 3), because it’s an alarming fact about the risk of transmission of HCV infection by mean of blood transfusion, especially in the window period when antibodies cannot be detected yet even the presence of infection [14,15]. This explains in part the high prevalence of viral hepatitis in multitransfused CDK patients. The extensive use of recombinant erythropoietin to correct renal anemia in HD patients has resulted in a significant reduction in blood transfusions.
Most epidemiological studies in HD patients have been performed using only serological testing of HCV antibodies [16-19]. In 1993, Bukh and colleagues [20] described the fact that HCV viremia can occur without detection of HCV antibodies, as in patients in advanced phase of CKD due to deficiencies in their immune system.
In recent years, HCV viremia has been routinely detected by Polymerase Chain Reaction [20-23]. In such situations, the detection of HCV RNA is the only method to confirm the diagnosis. The use of Polymerase Chain Reaction could also be of great importance for detection of both infections HBV and HCV during the “window period” and the diagnose of chronic HBV infection caused by escape mutants, where the presence of surface antigen HBsAg in serum is negative.
Although it is a persistent request from the specialists, the use of such analyze for these purposes would be very difficult to be practiced, because of limited financial resources available in medical health system. Actually, HBsAg and anti HCV serological testing are the only routine tests used for screening of blood donors and CDK patients in Albania.
In the current situation, the introduction of HBcAb testing for screening would help to exclude
“anti-HBc alone” individuals that might be in the window phase of an acute HBV infection when HBsAg disappears followed by anti- HBs a few weeks later or reflect an HBV infection which has resolved many years or decades earlier [24].
In this study, we noticed no significant difference of HBV prevalence in HD and Non-HD patients, but there’s a significant one in anti HCV prevalence. Several Authors have reported that, the prevalence of HCV infection among patients in HD varies greatly, from less than 5% to nearly 60% according to different areas of the world [6,7,25-27]. Introduction of routine screening and greater attention paid to the prevention of infection resulted in the reduction of the prevalence of HCV infection in many dialysis centres, but it remains unacceptably high yet, ranging from 8% to 10% even in the most industrialized countries [28]. Albania with its 47% of prevalence resulted from this study is included among countries with high prevalence of HCV among CKD, HD patients, and HD must be considered as a great risk for HCV transmission in our country.
As shown in different studies [7,16,21,29-39]and also as resulted in our study, HD patients are at particular high risk for blood borne infections. The prevalence of both HCV and HBV infection is consistently associated with patient age, number of transfused blood products and accuracy of laboratory tests for detection of these infections’ markers. Furthermore, some reports demonstrated that the duration of HD is a major risk factor for HCV infection in chronic HD patients [40-42].
However, previous studies have shown that de novo infections in single dialysis units may still occur in the absence of other parenteral risk factors [43-45]. Different scholars have confirmed the presence of nosocomial HBV and HCV infection caused by the staff serving at the dialysis units [22,46,47].

Conclusion

Prevalence of HBV and HCV infection is significantly higher in CKD and HD patients in Albania as compared to the general population. The duration of time in dialysis and older age of patients are important risk factors for the spread of these infections. Vaccination against HBV, donor screening and the use of recently more accurate laboratory testing of donated blood prior to transfusion, implementation of correct general preventive measures in dialysis units are of great importance for prevention of these infections in multitransfused CKD patients

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