Preventing Hepatitis B and Hepatitis C Virus Infections in End-Stage Renal Disease Patients: Back To Basics

In this issue of HEPATOLOGY, Mathurin et al. report the results of a 10-year retrospective study of kidney transplant recipients that compared rates of patient and graft survival among patients with and without chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection.1 Following this cohort of patients at intervals of 5 and 10 years, the investigators found a statistically significant decrease in survival in the HBV-infected group at both 5 and 10 years and a similar decrease at 10 years in the HCV-infected group. The findings of this study underscore the importance of preventing these infections in end-stage renal disease patients. End-stage renal disease patients on chronic hemodialysis are at risk for both HBV and HCV infection.2,3 HBV is the most efficiently transmitted blood-borne virus in the hemodialysis setting. Outbreak investigations and other studies have consistently shown that risk factors associated with HBV transmission among hemodialysis patients include the presence of a chronically infected patient; failure to separate that patient by room, machine, and staff; and failure to vaccinate patients against hepatitis B.4-6 After the 1977 publication of specific infection control practices for controlling HBV infection in chronic hemodialysis units (i.e., hemodialysis unit precautions),7 the incidence of HBV infections in these patients decreased dramatically.4,5 These practices included (1) monthly serological testing for hepatitis B surface antigen (HBsAg) of all susceptible patients and prompt review of results; (2) glove use whenever patients or hemodialysis equipment are touched; (3) the assignment of specific nondisposable items to individual patients so that no sharing of instruments, medications, and supplies between any patients occurred, regardless of serological status; and (4) separation of clean and contaminated areas, such that handling and storage of medications and hand washing are not done in the same or an adjacent area to that where blood samples or used equipment are handled. Other routine precautions recommended for all hemodialysis patients included the assignment of patients to specific dialysis stations and cleaning or disinfecting nondisposable items and environmental surfaces between uses. In addition, the recommended precautions for HBsAg-positive patients required the physical separation of these patients from susceptible patients and the cohorting of separate dialysis machines, instruments, supplies, and staff to HBsAg-positive patients. In 1982, hepatitis B vaccination was recommended for all susceptible patients and staff in hemodialysis units.2 Although hepatitis B vaccination produces lower immunogenicity rates in hemodialysis patients than in healthy persons, half or more of hemodialysis patients can be protected from hepatitis B by vaccination, and maintaining immunity among these patients reduces the frequency and costs of serological screening.2,8 Higher rates of protection can be achieved by vaccinating end-stage renal disease patients before they begin dialysis.