Hepatitis B Infection during Renal Replacement Therapy

H B virus (HBV) infection in patients with end-stage renal disease (ESRD) on renal replacement therapy—hemodialysis and/or renal transplantation—usually has an unfavorable course with a tendency towards chronicity leading to increased morbidity and mortality (1). Furthermore, the patients with the infection remain a source of nosocomial infection during hemodialysis. Though the incidence of HBV infection in patients with ESRD has significantly decreased due to preventive measures like vaccination and obedience to universal precaution and isolation rules during dialysis, this infection still continues to occur during renal replacement therapy in many units in the world including India. Patients with ESRD remain at increased risk of contracting HBV because of increased exposure to blood products, shared hemodialysis equipment, frequent breaching of the skin, immunodeficiency of Chronic Kidney Disease (CKD), and continuing high prevalence rates of HBV infection among hemodialysis patients. The frequency of HBV seropositivity in renal replacement therapy in India had been reported from 4% to 44% (2-4). Higher frequencies are reported only from few units, while in most of the larger well-organized units, it is less than 5%. Patients with ESRD regularly get transplant unless they have significant histological fibrosis or clinically advanced liver disease. We had earlier reported that chronic liver disease, due to hepatitis, was the second most common cause of death in renal transplant patients in the second decade post-transplant (5). Universal precautions are the most accepted method for prevention of blood-borne infections in hemodialysis program, though it is easier said than done. Many units could not demonstrate decrease in the rate of blood-borne infection while claiming to follow universal precautions. Obviously, there is gap between knowing the principles of the precautions and implementing them in day to day practice. In various types of blood-borne infections, HBV infection has a different scenario than others like hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection. HBV prevention is possible by vaccination and abiding to universally-accepted approaches to isolation of patients as compared to no vaccine and controversy of isolation of HCV and HIV patients. In our center, the prevalence of HBV infection was 0% until 2005. The rate increased to 1.9% in 2006, 3.3% in 2007, 3% in 2008, 4.6% in 2009 and 13.7% in June 2010. The incidence rate was less than 2% per year. Therefore, in many units, patients on maintenance dialysis are still contracting new HBV infections and we need to be more careful about it.