Due to the nature of haemodialysis treatment and the likelihood of receiving multiple blood transfusions, long term haemodialysis patients have a higher risk of acquiring Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infection compared to the normal population.
In the past, HBV was the major cause of viral hepatitis in end-stage renal disease. The introduction of rigorous infection-control strategies has led to a decline in the spread of HBV infection in the dialysis units. 1, 2
Hepatitis C infection is now a major problem in the Malaysian haemodialysis scene. In 2000, 29% of patients in the government centres were positive for anti-HCV antibody. The chronically infected person is central to the epidemiology of HCV transmission.
3,5 Studies have indicated that HCV transmission most likely occurs because of breakdown in standard infection control practices. 6, 7 Nosocomial transmission within the dialysis centre is the principal route of HCV dissemination in the dialysis population. 4,8,9 HCV transmission within the dialysis environment can be prevented by strict adherence to infection control precautions. 10
7.1 Measures to reduce risk of transmission of virus or other infectious agents include:
7.1.1 Universal precaution for the care of all haemodialysis patients:
a. Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station; remove gloves and wash hands between each patient or station
b. All machines should be cleaned after each use
c. Sharing of ancillary supplies such as tray, BP cuffs, clamps, scissors and other nondisposable items among patients should be discouraged
d. Nondisposable items should be cleaned or disinfected appropriately between uses
e. Medication and supplies should not be shared among patients and medication carts should not be used
f. Medication should be prepared and distributed from a centralised area
g. There should be separate clean and contaminated areas (e.g.
handling and storage of medication). Hand washing should not be done in or near an area where used equipment or blood samples are handled.
7.1.2 Serological testing
a. HbsAg and anti-HCV antibody should be checked 3 monthly and anti-HIV antibody yearly
b. For those with negative HbsAg, negative anti-HCV antibody, repeat serologic tests every 3 months
c. In newly infected HBV patient, repeat HbsAg testing and test for anti-HBs six months later to determine clinical outcome
d. Patients with chronic HBV infection require annual HBsAg testing to detect the small percentage of those who might lose their HbsAg
e. In HbsAg negative patient, vaccination should be given for those with negative anti-HBs antibody status
f. Confirmed positive anti-HCV patients do not require repeated serologic test
7.2 Hepatitis B vaccine
Larger vaccine doses, an increased number of doses or both may be required to produce protective anti-HBs concentrations in adult haemodialysis patients. For children with progressive chronic renal failure, hepatitis B vaccine is recommended early in the disease course to provide protection and potentially decrease the need for larger doses once dialysis is initiated.
Table 7.1 Recommended dosages of hepatitis B vaccines
Target Group Recombivax HB
Dose, ug (ml) Engerix-B Dose ug, (ml) Infants, children and
adolescents < 20 yrs of age 5 (0.5) 10 (0.5) Adults 20 yrs of age or older 10 (1.0) 20 (1.0) Patients undergoing dialysis
and other
immunocompromised adults
20 (1.0ml-special formulation for dialysis patients )
40 (2.0)
7.2.1 Schedule
Dosing schedule for dialysis patients:
4 dose schedule at 0, 1, 2, and 6 to 12 months 7.2.2 Repeat serologic testing
Serum anti-HBs-antibody should be checked 1-2 months after completing the vaccination course
Formatted: Ge
7.2.3 Management of non-responders
a. Vaccine recipients who do not develop a serum anti-HBs-antibody response (> 10 mIU/ml) after a primary vaccine series should be re-immunised (unless they are confirmed to be HbsAg-positive)
b. Re-immunisation consists of 1 to 3 doses. Those who remain anti-HBs-negative after a re-immunisation series of 3 doses are unlikely to respond to additional doses of vaccine.
7.2.4 Booster doses
a. For haemodialysis patients, the need for booster doses should be assessed by annual anti-HBs testing
b. A booster dose should be given if the anti-HBs concentration is less than 10 mIU/ml
7.2.5 Staff of haemodialysis units should be routinely immunised 7.3 Isolation
Patients positive for HbsAg or anti-HCV antibody should be dialysed on separate machines not shared by seronegative patients.
A separate area is recommended. 11,12
7.4 Management of patients with hepatitis B/C infection
• Patients positive for HbsAg and/or anti-HCV should be monitored for evidence of chronic liver disease and its complications; 3 monthly LFT, yearly α-fetoprotein and liver ultrasound
• Hepatology referrral for possible interferon (IFN) therapy may be considered in patients who are positive for anti-HCV, persistent ALT elevation and HCV RNA-positive
7.5 Management of patients with HIV infection
• For anti-HIV positive patients, disposables should not be reused.
The disposal of bloodlines and dialysers should be made according to the recommendations of the Ministry of Health.
• For anti-HIV positive patients who acquire the virus whilst on regular haemodialysis or newly accepted patients for haemodialysis who are asymptomatic, the decision to continue the treatment will be based on similar grounds as those for non-HIV infected patients.
References
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