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Treatment Of Hepatitis B In Dialysis Patients

Surveillance For Infections And Other Adverse Events

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Develop and maintain a separate centralized record-keeping system to record the results of patients’ vaccination status, serologic testing results for viral hepatitis , episodes of bacteremia or loss of the vascular access caused by infection ,* and adverse events . Designate a staff person to promptly review the results of routine testing each time such testing is performed and periodically review recorded episodes of bacteremia or vascular access infections. Specify a procedure for actions required when changes occur in test results or in the frequency of episodes of bacteremias or vascular access loss because of infection. Maintain records for each patient that include the location of the dialysis station and machine number used for each dialysis session and the names of staff members who connect and disconnect the patient to and from a machine.

Prevention Of Bbv Infection In The Renal Unit

Guideline 1.1- BBV prevention: infection control procedures

The single most important method of prevention of transmission of blood borne viruses is the rigorous application of universal infection control precautions. We recommend that infection control procedures must include hygienic precautions that effectively prevent the transfer of blood or fluids contaminated with blood between patients either directly or via contaminated equipment or surfaces .

Guideline 1.2 BBV prevention: use of parenteral medicines

We recommend that medicine vials should be discarded after single use and multi-use vials should be avoided. If medicine vials are used for more than one patient, we recommend they are divided into multiple doses and distributed from a central area. Intravenous medication vials labelled for single use should not be punctured more than once, as the sterility of the product cannot be guaranteed once a needle has entered a vial labelled for single use .

Antiviral Therapy In Ckd And Hemodialyzed Patients

The current recommendations for the initiation of antiviral therapy in CKD and dialysis patients are based upon similar factors as they are for the general population. The most important parameter in this regard seems to be the viral replication level . The critical level for therapy initiation has been proven to be 2,000 IU/ml. In some cases, the therapeutic decision should not be based on the HBV-DNA level alone. Additionally, the severity of liver disease should be considered, and the antiviral therapy should only be initiated if significant fibrosis or necroinflammatory activity is present . Therefore, antiviral therapy should be initiated in HBeAg-positive as well as in HBeAg-negative disease only if HBV-DNA 2,000 IU/ml therefore, HBV-DNA should be tested annually or in case of any unexplained ALT elevation . In HBeAg-negative disease, the replication may be present due to mutations in the BCP or pre-C regions of the HBV genome . These mutations block the secretion of HBeAg into the serum of the infected individuals.

The ideal objective of the treatment is the seroconversion to anti-HBs. This status is called closest to cure as at the molecular level, HBV infection is an incurable disease because cccDNA persists in the hepatocytes of every HBV-exposed person for their entire lives. The real aim of the treatment, which is achievable by the current treatment options, is the long-term suppression of HBV replication .

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Are There Treatments For Hepatitis B

Yes. Your healthcare provider will choose the right combination of available medicines to help treat your symptoms and hepatitis b infection. During this time, you will be closely watched by your healthcare provider to make sure treatments are working. Treatments include:

  • Interferon injection

There are also medicines you can take by mouth. These are:

These drugs do not always provide a complete cure for hepatitis B, but they do help decrease the risk of damage to your liver from a hepatitis b infection. In more serious cases, and if treatment does not work, a liver transplant may be needed.

Immunisation Of Patients Against Hepatitis B Virus

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Guideline 5.1 BBV infection: indications for immunisation of patients against hepatitis B virus

We recommend that all patients who require renal replacement therapy for CKD should be assessed for current or past infection with Hepatitis B and offered vaccination against HBV if indicated. .

Guideline 5.2 BBV infection: timing of initiating immunisation schedule against HBV

We recommend that patients who are likely to require RRT, who are deemed susceptible to HBV infection, should be offered vaccination prior to the development of Stage V CKD . A kidney failure risk calculator could be used to facilitate this prediction.

Guideline 5.3 BBV infection: identification of patients for whom immunisation against HBV is not indicated

Hepatitis B vaccine is not indicated in patients who have current positive or HBV DNA positive) or confirmed past HBV infection. Presence of the anti HBc antibody in isolation should not be taken as confirmation of previous HBV infection. Patients identified to be core antibody positive who are at risk of reactivation of HBV may need to be vaccinated and the case should be discussed with a local virologist. .

Guideline 5.4 BBV infection: immunisation schedule for vaccination against Hepatitis B virus

We recommend that the initial HBV immunisation schedule should involve high doses, frequent doses or both of the available preparation .

Table 1 Available vaccines, doses and immunisations schedules

We would suggest the following strategies:

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World Health Organization Recommendations

The 2015 WHO guidelines for the prevention, care, and treatment of persons with chronic hepatitis B infection indicates treatment priority for individuals of all ages who have chronic hepatitis B infection and clinical evidence of compensated/decompensated cirrhosis , regardless of their levels of ALT or HBV DNA, or their HBeAg status.

Treatment is recommended for adults with chronic hepatitis B infection without clinical evidence of cirrhosis , but who have all of the following features , and regardless of HBeAg status :

  • Are older than 30 years
  • Have persistently abnormal ALT levels
  • Have evidence of high-level HBV replication .

In individuals with HBV/human immunodeficiency virus coinfection, the AASLD recommends initiating ART in all those with evidence of severe chronic liver disease, regardless of CD4 count, as well as those with a CD4 count of 500 cells/mm3 or below, regardless of their liver disease stage.

However, the AASLD does not recommend antiviral therapy, indicating it can be deferred, in individuals with all of the following , regardless of HBeAg status or age :

  • No clinical evidence of cirrhosis
  • Persistently normal ALT levels
  • Low levels of HBV DNA replication . ]

Hepatitis And Dialysis: What Patients Can Do To Prevent Infection

In recognition of Hepatitis Awareness Month APIC presents information on these infections, why patients undergoing dialysis are more susceptible and what dialysis patients can do to protect themselves from hepatitis and other infections.

What is Hepatitis?

Hepatitis is inflammation of the liver that may be caused by viruses, drugs, alcohol, or some hereditary or immune problems. The most common types of hepatitis are A, B, and C. Those who undergo dialysis are at increased risk of getting hepatitis B and C. The virus can be transmitted from the use of multidose drug vials and contamination of medical equipment. Hepatitis B and C may cause liver infections that can lead to serious complications, including liver cancer, liver failure or death. While there is no vaccine for hepatitis C, you can get vaccinated for hepatitis B. The Centers for Disease Control and Prevention recommends that patients receive the hepatitis B vaccine before they become dialysis dependent.

What is hemodialysis?

Infections during hemodialysis

Infections can also be linked to the type of blood stream access the dialysis patient has. There are two main types of blood stream access. One is a plastic tube which is capped off, and remains in one of the blood vessels . The second is a vein which has been surgically enhanced to make it stronger . Studies show that patients with catheters are more likely to acquire an infection than patients who have fistulas.

What patients can do:

Additional resources

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Management Of Chronic Hbv Infection

Current treatment options for patients with CHB are interferons or antiviral therapy with nucleoside analogs that target the viral polymerase. The treatment of CHB in patients with CKD is based on nucleoside or nucleotide analogues . Entecavir and tenofovir represent the currently recommended first-line NAs for NA-naive CHB patients, while tenofovir is the NA of choice for CHB patients with resistance to nucleosides.Table 1 and Figure 1 show the dose adjustment and the algorithm of use of NAs in CKD patients.

Mechanisms of action for direct-acting antivirals, currently in development. NNPI, nonnucleoside polymerase inhibitor

American Association For The Study Of Liver Diseases Recommendations

Hepatitis B and Liver Disease in Asians

The 2016 AASLD guidelines for the treatment of chronic hepatitis B as well as select recommendations from the 2018 AASLD guidance update on the prevention, diagnosis, and treatment of chronic hepatitis B are outlined below and in the Guidelines section.

Adults with immune-active chronic hepatitis B infection

Administer antiviral therapy to lower the risk of morbidity and mortality associated with chronic hepatitis B infection.

The recommended initial agent for adults is PEG-IFN, entecavir, or tenofovir.

Adults with immune-tolerant chronic hepatitis B infection

Antiviral therapy is not recommended.

The AASLD suggests obtaining ALT levels at least every 6 months to monitor for potential transition to immune-active or -inactive chronic hepatitis B.

For select patients older than 40 years, the AASLD suggests antiviral therapy in the setting of normal ALT levels, elevated HBV DNA , and significant necroinflammation or fibrosis on liver biopsy specimens.

Adults with HBeAg-positive immune-active chronic hepatitis B who seroconvert to anti-HBe on nucleoside analog therapy

After a period of treatment consolidation , consider discontinuing NA therapy in noncirrhotic HBeAg-positive adults who seroconvert to anti-HBe while on NA treatment. If antiviral therapy is stopped, monitor the patient every 3 months for a minimum of 1 year for recurrent viremia, ALT flares, seroreversion, and clinical decompensation.

Adults with HBeAg-negative immune-active chronic HBV infection

Inpatient care

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Is The Vaccination Safe

Yes. The vaccines are made from baker’s yeast and contain noninfectious particles called antigens. You cannot get hepatitis from the vaccination. These vaccines have undergone extensive clinical testing and have been used on millions of people worldwide with few side effects. However, people with acute illness or a known allergy to yeast should not be vaccinated.

How Can Hepatitis B Be Prevented

One of the best ways to prevent hepatitis B is to be vaccinated. Hepatitis B vaccination is recommended for all children and hemodialysis patients and staff. The vaccine works by causing your body to make special proteins called antibodies that protect you against hepatitis B. Your response to the vaccine depends on your age, other medical conditions you may have and your general state of health, but most people will make enough antibodies to protect them against the disease. If you are vaccinated, your dialysis care team will check your blood to make sure enough antibodies are present. If you have not yet been vaccinated, ask your dialysis staff about the vaccination.

You can also help to prevent hepatitis B by following safe sex guidelines and by avoiding high-risk behaviors such as injecting drugs.

Some safe sex guidelines are:

  • Use latex condoms to prevent the exchange of body fluids.
  • Have only one sexual partner.

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Measures To Prevent Hbv Spread In Hemodialysis Units

There are three stages of preventive measures of HBV spread within hemodialysis units:

The standard precautions against the transmission of any blood-borne infection represent the basis of all preventive methods. Each of these precautions should be very strictly applied. A separate hemodialysis room, exclusively designated for HBV-positive patients, seems to be a controversial issue however, this has been recommended by the Centers for Disease Control and Prevention since 2001 . HBV particles are usually found in high titers in the blood of patients on hemodialysis, and as HBV has been proven potentially infectious for > 1 week, there is the real risk of transmission from small amounts of blood, or even from infected surfaces that may appear to be clean. In comparison, the HCV and HIV viruses are less infectious: HCV survives in the environment for a shorter time, and HIV cannot survive in the environment . The risk of HBV transmission after a needle stick injury is obviously given by the serological status of the source, specifically of its HBV-DNA level/viral load. Repeatedly, it has been found that the risk of HBV transmission is 6% if the source is HBeAg negative and > 30% if the source is HBeAg positive .

What Are The Symptoms Of Hiv

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Many people who are infected with HIV do not have any symptoms for many years. The only way to tell for sure whether you are infected is to be tested for HIV infection. About half the people infected with HIV develop AIDS within 10 years after becoming infected. This time period is different for everyone.

The following may be warning signs of infection with HIV:

  • Rapid weight loss
  • Continuing fever or night sweats
  • Feeling very tired and run down for no reason
  • Swollen lymph glands in the armpits, groin or neck
  • Diarrhea that lasts for more than a week
  • White spots or unusual blemishes on the tongue, in the mouth or in the throat
  • Red, brown, pink or purplish blotches on or under the skin or inside the mouth, nose or eyelids
  • Memory loss, depression and other neurologic symptoms.

However, you should not assume you are infected if you have any of these symptoms. The symptoms of AIDS are similar to those of many other illnesses. AIDS is a medical diagnosis made by a doctor and based on specific results from physical examination and test results.

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Preventing And Treating Viral Hepatitis In End

Due to innate and adaptive immune alterations and the risk fornosocomial infection from exposure to potentially infected blood-borne sources,patients with end-stage renal disease have an elevated risk ofcontracting viral infections such as hepatitis B virus and hepatitis Cvirus . An estimated 8% to 10% of ESRD patients in the United States haveHCV infection compared with 1.6% of the general population, and HBV prevalencerates as high as 6.6% have been noted in dialysis centers across severalcountries.1

HBV and HCV infection are associated with significant morbidity,mortality, and substantial treatment challenges in this patient group,including complications arising from concurrent hepatic and renal disease.Cirrhosis can develop in untreated individuals and compound the alreadyimmense burden of disease in patients with ESRD, manifesting as encephalopathy,refractory ascites, coagulopathy, and variceal bleeding, wrote nephrologistVivek Soi, MD, and colleagues at Henry Ford Health System in Detroit, Michigan,in a 2019 review published in Advances in Chronic Kidney Disease.1

What are the recommended screening andprevention strategies for HBV and HCV in patients with end-stage renal disease?

Prevention strategies include standard precautions , as well as hemodialysis-specific measures .

What are the optimal treatment approachesfor patients with HBV or HCV and concurrent ESRD?

How Could I Get Hepatitis C

Anyone can get infected with the hepatitis C virus. However, you may have an increased chance of getting hepatitis C if you:

  • Were born between 1945-1965
  • Received blood transfusions or solid organ transplants before 1992

Less commonly, hepatitis C may be spread by:

  • Passing from an infected mother to her baby during childbirth
  • Having sex with an infected person
  • Living with an infected person and sharing items such as razors and toothbrushes
  • Exposure to sharp instruments that came into contact with infected blood, such as:
  • Needles used for tattooing
  • Needles used for body piercing
  • Needles used for acupuncture

If you have to come into contact with needles, it is important that these needles be carefully cleaned and disinfected before use, or disposable needles should be used. You should always ask anyone using a needle on you if it was properly sterilized and, if possible, to use a new needle on you.

While it is important to know how you can get hepatitis C, you should also know that you cannot get hepatitis C from:

  • Shaking hands or holding hands with someone infected with hepatitis C
  • Being coughed or sneezed on
  • Hugging an infected person
  • Sitting next to an infected person
  • Sharing spoons, forks, and other eating utensils
  • Drinking water or eating food

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Natural Course Of Hcv In Hemodialysis And Rtr Patients

HCV infection in dialysis patients is usually asymptomatic in both the acute and chronic phases. HCV is a slowly progressive disease, with a course typically extending for several decades, but dialysis patients have a much shorter life expectancy. This makes it very difficult to establish the long-term consequences of HCV infection for patients on dialysis as well as for RTRs.

Patients under regular hemodialysis were found to have lower ALT/aspartate transaminase elevations, lower grading and staging in histology, and lower viral load than non-dialyzed individuals in both acute and chronic HCV infection . A number of factors have been suggested to explain these findings. Likely, immunosuppression, uremia, and dialysis itself may play a role in this controversial issue .

To summarize, it has been calculated that HCV increases mortality among dialysis patients with an RR of 1.251.57 .

In a certain portion of HCV-positive recipients, HCV-related glomerulonephritis may lead to graft injury and may decrease its function. Berthoux found significantly higher anti-HCV positivity in RTRs with membranous glomerulonephritis and MPGN than in the entire recipient group . HCV infection has also been linked to chronic allograft nephropathy and diabetes mellitus after RT .

Preventive Measures Of Hcv Spread In Hemodialysis Units

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There is only one preventive measure against HCV spread within hemodialysis units, and that is the strict adhesion to the general precautions for blood-borne infections. As mentioned above, there is no universal recommendation to provide a hemodialysis procedure for HCV-positive patients in exclusively dedicated rooms or on dialysis machines . The risk of transmission after needlestick injury from an HCV-positive source is rather low . Also, there are no recommended measures after exposure. Active vaccination against HCV is still not available despite very intensive research in this field.

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