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ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 1  |  Page : 37-43

Study of epidemiological features of hepatitis D virus infection in HBsAg-positive chronic hemodialysis patients


1 Department of Internal Medicine, Nephrology Unit, Faculty of Medicine, Menoufiya University, Egypt
2 Shebin El-Kom Fever Hospital, Shebin El-Kom, Menoufiya Governorate, Egypt

Date of Submission30-Nov-2014
Date of Acceptance02-Mar-2015
Date of Web Publication18-Mar-2016

Correspondence Address:
Mohamed K Dewedar
MBBCh, Shebin El-Kom Fever Hospital, 5 Taiseer Street, Shebin El-Kom, 32511 Menoufiya Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.178945

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  Abstract 

Objective
Study the prevalence, clinical, and laboratory features of hepatitis D virus (HDV) infection in hepatitis B surface antigen positive chronic hemodialysis (HD) patients.
Background
Delta virus or HDV is a small RNA-containing virus requiring the concomitant presence of hepatitis B virus (HBV) for its survival and pathogenicity. Worldwide, 20 million of chronic HBV patients are thought to be infected with HDV. It is important to know that HDV infection is present in a HD patient with HBV infection, because it allows a more accurate determination of prognosis, and the response of HDV patients to antiviral therapy and needed dosage therapeutic regimens are different from those with chronic hepatitis B alone.
Materials and methods
The study included 50 chronic HBV-infected renal patients and 25 chronic HBV nonrenal patients collected from Shebin El-Kom Fever Hospital and Menoufiya University Hospital, Menoufiya, Egypt. The study was conducted from January 2013 to May 2014. Enzyme-linked immunosorbent an assay was used to detect hepatitis B surface antigen and HDV antibodies (total antibody).
Results
HDV antibody (total) was positive in 58% of the HBV renal patients and in 24% of the HBV nonrenal patients, with high significant statistical difference. Laboratory data showed significant statistical differences between the two groups regarding platelet concentration (higher in HBV renal patients), albumin and prothrombin (higher in HBV nonrenal patients), bilirubin levels, and renal functions (higher in HBV renal patients). Furthermore, the infection with hepatitis delta is more common in HBV renal patients in the HD group IA (72%) than HBV renal patients on conservative treatment group IB (44%), with significant statistical differences of laboratory data between the two groups regarding hemoglobin (higher in group IB) and platelet concentration (higher in group IA), albumin and prothrombin (higher in group IA), bilirubin levels (higher in group IB), and renal functions (higher in group IA).
Conclusion
It is concluded that HD may have a major role in widening the prevalence of delta infection among the studied HBV renal patients (72%).

Keywords: Hemodialysis, hepatitis B virus, hepatitis D virus


How to cite this article:
El Hady HA, Yassein YS, Tawfek AR, Elsayed AF, Dewedar MK. Study of epidemiological features of hepatitis D virus infection in HBsAg-positive chronic hemodialysis patients. Menoufia Med J 2016;29:37-43

How to cite this URL:
El Hady HA, Yassein YS, Tawfek AR, Elsayed AF, Dewedar MK. Study of epidemiological features of hepatitis D virus infection in HBsAg-positive chronic hemodialysis patients. Menoufia Med J [serial online] 2016 [cited 2019 Sep 21];29:37-43. Available from: http://www.mmj.eg.net/text.asp?2016/29/1/37/178945


  Introduction Top


Delta virus or hepatitis D virus (HDV) is a small RNA-containing virus requiring the concomitant presence of hepatitis B virus (HBV) for its survival and pathogenicity [1]. Within a few years of its discovery, it was linked to cases of progressive chronic hepatitis B. Approximately, 5% of the patients with chronic hepatitis B infection worldwide are infected with HDV [2].

Development of chronic kidney disease (CKD) has become a serious problem worldwide. CKD is characterized by a slow and progressive decline in the kidney function. Some of the manifestations of CKD include atherosclerosis, increased hemolysis, platelet dysfunction, and neuropathy [3].

HBV is a blood-borne and sexually transmitted virus. Each year, 600 000 HBV-related deaths occur worldwide [4]. Studies in the Middle East showed that the prevalence of hepatitis B surface antigen (HBsAg) ranged from 3 to 11% in Egypt. These groups of chronic carriers include apparently healthy adults, school children, infants, pregnant women, blood donors, and healthcare staff [5]. Carriers of HBV are at increased risk of developing cirrhosis, hepatic decompensation, and hepatocellular carcinoma.

Delta virus is of particular potential concern in hemodialysis (HD) units where segregation of HBsAg-positive patients to minimize hepatitis B transmission to susceptible patients may facilitate the transmission of delta agent [6].The high risk of HDV/HBV transmission in HD patients, the high mortality and morbidity rate of hepatitis D, the problems of diagnosis of HDV in HD patients, the irreversible complications of its infection, and the difficult and controversial treatments have made HDV infection a major concern in HD patients [7].

The current study aimed to evaluate the prevalence, clinical, and laboratory features of HDV infection in HBsAg-positive chronic HD patients.


  Materials and methods Top


The study was carried out at Shebin El-Kom Fever Hospital and Menoufiya University Hospital, Menoufiya, Egypt. It was conducted from January 2013 to May 2014. It is a case - control study that included 75 HBV-infected patients divided into two groups:

  1. Group I included 50 chronic HBV-infected renal patients; they were subclassified into: group IA: included 25 HBV-infected renal patients on regular HD for more than 11-month 4 h session at least three sessions per week; and group IB: included 25 HBV-infected CKD patients on conservative treatment.
  2. Group II included 25 chronic HBV nonrenal patients as a control.


Exclusion criteria

Patients positive for hepatitis C virus antibody (Ab) and HIV infection.

Ethical consideration

Consent was taken from patients or their relatives before the samples were taken and they had the right to refuse at any time. The study was approved by ethical committee of Faculty of Medicine, Menoufia University and Shebin El-Kom Fever Hospital, Egypt.

All patients were subjected to:

  1. History taking including age, sex, duration of disease, history of any previous renal disease, history of surgical operation, blood transfusion, injections, instrumental, tattooing, history of HBV vaccination, and dialysis history.
  2. Physical examination.
  3. Investigations including:

    1. Complete blood count by Swelab's fully automatic auto counters.
    2. Renal function tests: serum urea by urea/blood urea nitrogen - color, urease/salicylate, and creatinine colorimetric method.
    3. Liver function tests.
    4. Prothrombin time and activity by calcium/thrompoplastin reagent from DiaMed AG, Switzerland.
    5. Lipid profile and blood glucose levels.
  4. Radiological investigation: Abdominal ultrasonography using Siemens - Sienna apparatus with probe No. 3.5 convex linear array, for examination of liver status, portal vein diameter, and both kidneys.
  5. Enzyme immunoassays to detect hepatitis C virus Ab, HBsAg, and HDV Abs (total Ab).


Determination of serum hepatitis D antibodies concentration

Measurement of HDV total Ab was taken by enzyme-linked immunosorbent assay technique using (ETI-AB-DELTAK-2 kit manufactured by DiaSorin S.p.A., Saluggia, Vercelli, Italy) intended for determination of HDV total Ab in serum

Principle of the assay

The method for qualitative anti-HD determination is a simultaneous competitive assay, based on the enzyme-linked immunosorbent assay technique. Anti-HD present in the sample and labeled anti-HD Abs compete for a fixed quantity of HDAg bound to the solid phase. The quantity of enzyme tracer bound to the solid phase and consequently the enzyme activity are inversely proportional to the anti-HD concentration present in samples or controls. Enzyme activity is measured by adding a colorless chromogen/substrate solution. The enzyme action on chromogen/substrate produces a color which is measured with a photometer [8].

Assay steps

Reagents were brought to room temperature (20°-25°C) before assaying. Sufficient number of strips to run three negative controls, two positive controls, and the unknowns were chosen. Samples and controls were subjected to the same process and incubation time. Blank prepared well and containing chromogen/substrate only. A disposable tip used for dispensing each sample and control:

  1. Fifty microliters negative control, positive control, and samples dispensed into their respective wells.
  2. Hundred microliters diluted enzyme tracer (4.2) dispensed into all wells, except for the blank well.
  3. A cardboard sealer applied to prevent evaporation.
  4. Incubation for 3 h ± 15 min at 37° ± 1°C.
  5. Chromogen/substrate prepared just before the end of the incubation.
  6. When incubation has been completed, the cardboard sealer discarded and strips rinsed. A semiautomatic washer was used for washing strips. After rinsing, the strips mouth turned down onto blotting paper and gently taped to remove any liquid residue.
  7. Hundred microliters chromogen/substrate solution dispensed into all wells.
  8. Incubation for 30 ± 2 min at room temperature, away from intense light.
  9. Hundred microliters blocking reagent dispensed into all wells in the same order and at the same rate as for chromogen/substrate.
  10. The absorbance of specimens measured with a photometer at 450/630 nm within 1 h of adding the blocking reagent, absorbance values are provided automatically after selecting the suitable protocol, and then blank the instrument with the blank, the absorbance recorded at 450/630 nm for each specimen and the 630 nm absorbance value were subtracted from the 450 nm absorbance value.
  11. The cutoff value is determined by adding the mean absorbance for the negative control values multiplied by 0.5 to the mean absorbance for the positive control values multiplied by 0.5.
  12. Interpretation of results: The presence or absence of anti-HD is determined by comparing the absorbance of the unknown samples with that of the cutoff value.


The unknown samples with absorbance values less than or equal to the cutoff value were considered reactive for anti-HD. The unknown samples with absorbance values greater than the cutoff value were considered nonreactive.

Statistical methods

The data collected were tabulated and analyzed by statistical package for social science, on IBM-compatible computer (version 22; SPSS Inc., Chicago, Illinois, USA). Two types of statistics performed are as follows:

  1. Descriptive statistics: percentage, range, mean (x) and SD.
  2. Analytical statistics:
    1. t-test, for comparison of two groups of normally distributed variables.
    2. ν2 , used to study association between two qualitative variables.
    3. Analysis of variance (f) test, test of significance used for comparison between three or more groups having parametric quantitative variables.


Data were considered statistically significant when P-value was less than 0.05.


  Results Top


  1. Comparing group I (HBV renal patients) and group II (HBV nonrenal patients):
    1. HDV Ab (total) was positive in 58% of the HBV renal patients and in 24% of the HBV nonrenal patients, with high significant statistical difference between the two groups (P < 0.01) [Table 1].
    2. Laboratory data showed that regarding hemoglobin and platelets, the lowest level was reported in control patients with no statistical significant difference in hemoglobin but with statistical highly significant difference in the platelets. Regarding liver function tests, the highest levels of alanine transaminase and aspartate transaminase (AST) were reported in control patients, with no statistical significant difference between the two groups. Albumin and prothrombin concentration showed the lowest levels in the patient group (HBV renal patients), with a very highly significant statistical difference. On the other hand, the bilirubin levels (total and direct) were high in the patient group (HBV renal patients), with a significant statistical difference. Renal functions (urea and creatinine) showed the highest levels in the patient group, with a very highly significant statistical difference.
  2. On comparing group IA (HBV renal patients on HD) and group IB (HBV renal patients on conservative treatment):
    1. HDV Ab (total) was positive in 72% of the patients in group IA and 44% of the patients in group IB, with a significant statistical difference between the two studied groups (P < 0.05) [Table 1].
  3. Regarding HDV Ab-positive and HDV Ab-negative subgroups of group IA (HBV renal patients on HD):
    1. Demographic data showed no significant differences between both subgroups regarding age (P > 0.05). For sex and risk factors, there was a very highly significant difference in all risk factors (P<0.001) [Table 2].
    2. All studied laboratory data showed no significant statistical differences between the two studied subgroups (P > 0.05) [Table 3].
  4. Comparing HDV Ab-positive and HDV Ab-negative subgroups of group IB (HBV renal patients on conservative treatment):
    1. Demographic data showed highly significant differences between both subgroups (P < 0.01) regarding age, and very highly significant differences between studied groups (P < 0.001) in sex and all risk factors [Table 4].
    2. All studied laboratory data showed no significant statistical differences between the two studied subgroups (P > 0.05) [Table 5] and [Figure 1] and [Figure 2].
Figure 1: Comparison between HBV renal patients and HBV nonrenal patients with regard to hepatitis markers. Ab, antibody; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; HCV, hepatitis C virus; HDV, hepatitis D virus .

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Figure 2: Comparison between group IA and group IB with regard to hepatitis D antibody (total) .

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Table 1: Distribution of HDV infection among the studied HBV-infected patient groups

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Table 2: Clinical characterestics of HDV coinfection in HBV-infected renal patients on HD (group IA)

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Table 3: Laboratory characterestics of HDV coinfection in HBV-infected renal patients on HD (group IA)

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Table 4: Clinical characterestics of HDV coinfection in HBV-infected nonrenal patients on conservative therapy (group IB)

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Table 5: Laboratory characterestics of HDV coinfection in HBV-infected nonrenal patients on conservative therapy (group IB)

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  Discussion Top


HDV infection is significant because, although it suppresses HBV replication, it can cause severe liver disease that may include fulminant liver failure and rapid progression to cirrhosis and hepatic decompensation, as well as an increased risk of liver cancer [9].

HDV infection is a major concern among HD patients, particularly the HBsAg-positive patients. In HBsAg-positive patients, HDV can be transmitted at very high-serum dilutions; HBsAg-positive HD patients therefore stand a very high risk of becoming infected with HDV through blood contamination of the HD machinery or through transfusions [7].

Considering that HDV can lead to chronic liver disease and no efficient treatment has been identified for HDV infection, prevention and early detection seems to be the best solution for limiting the rate of transmission. On this basis, designing an integrative protocol appears to play a vital role in lowering the morbidity and mortality among HBsAg-positive HD patients [7].

The aim of this study was to study the prevalence, clinical, and laboratory features of HDV infection in HBsAg-positive chronic HD patients.

All patients in current study were HBV patients: 50 of them were renal and 25 were nonrenal patients; HDV Ab (total) was positive in 58% of HBV renal patients and in 24% of HBV nonrenal patients. Moreover, HDV Ab (total) was positive in 72% of HBV renal patients on HD and in 44% of renal patients on conservative treatment.

Rezvan et al. [10] reported that the rate of anti-HDV seropositivity in asymptomatic HBV carriers was 2.5%, whereas in dialysis patients who were HBsAg-positive this rate reaches 44.5%. This shows that these people are in greater risk of getting the infection than the rest of HBs-positive patients. In a survey in Taiwan, 22.2% of the patients infected with HIV with chronic HBV coinfection had positive findings for anti-HDV [11]. A published study in Iran has shown a high HDV prevalence of 31.57% in individuals with HIV/HBV coinfection in Kermanshah, Western Iran [12]. Recent study by Aghasadeghi et al. [13] showed that 1.5% of the cases with HIV infection had HBV infection. It can be owing to increased knowledge about HBV transmission routes, national vaccination program, and HBV vaccination of high-risk patients. Of the patients infected with HIV, 0.8% are coinfected with both HBV and HDV. All of the patients coinfected with HIV/HBV/HDV were intravenous drug users. On the other hand, higher frequency of HDV infection (55.5%) was found among patients with HBV/HIV coinfection than that in the general population of Iranian HBsAg carriers (2.4-5.8%).

Laboratory data of the present study between HBV renal patients and HBV nonrenal patients showed that regarding hemoglobin and platelets, the lowest level were reported in control patients, with no statistical significant difference in hemoglobin but with statistical highly significant difference in platelets. Regarding liver function tests, the highest levels of alanine transaminase and AST were reported in control patients, with no statistical significant difference between the two groups. Albumin and prothrombin concentration showed that the lowest levels in the patient group (HBV renal patients) with very highly significant statistical difference. On the other hand, the bilirubin levels (total and direct) were high in the patient group (HBV renal patients), with significant statistical difference. Renal functions (urea and creatinine) showed the highest levels in the patient group, with very highly significant statistical difference. Tahaei et al. [14] in their study observed that the AST level was higher in HDV-seropositive patients than HDV-seronegative patients.

On the other hand, comparing all HDV-positive and HDV-negative patients in this study, there were no significant statistical differences between both groups regarding any laboratory parameters.

The prevalence of HDV infection in patients with chronic HD is not clear. In studies by Ramia et al. [15], anti-HDV was not found in patients undergoing HD. Abraham et al. [16] reported that 2.9% of renal transplant recipients were infected with HDV. In an investigation in Iran, 44.5% of patients undergoing HD with HBV infection were infected with HDV [9]. Whereas other studies in this country found that 25.2% of patients undergoing HD and positive results for HBsAg were found to be anti-HDV-positive.


  Conclusion Top


It is concluded that hepatitis delta infection is much more frequent in HBV renal patients (58%) than HBV nonrenal patients (24%). Furthermore, the infection with hepatitis delta is more common in HBV renal patients on HD (72%) than HBV renal patients on conservative treatment (44%), denoting the major role of HD in widening the prevalence of delta infection among HBV renal patients.

Recommendations

It is advised to vaccinate all susceptible patients, staff, and avoidance of dialyzer reuse and use of dedicated dialysis rooms and machines. As a mean of limiting HBV transmission within dialysis units.

Additional studies are required to clarify that coinfection with HDV leads to more aggressive liver disease, a severe clinical presentation, and an infrequent response to interferon alpha treatment in HD patients. In addition, the confirmation of ongoing HDV infection by PCR testing of HDV RNA is recommended to be carried out in further studies.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Aghasadeghi MR, Mohraz M, Bahramali G, Aghakhani A, Banifazl M, Foroughi M, et al. Frequency and genotype of hepatitis D virus infection in patients infected with HIV and those undergoing hemodialysis. Hepat Mon 2013; 13 :e7481.  Back to cited text no. 13
    
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Tahaei SM, Mohebbi SR, Azimzadeh P, Behelgardi A, Sanati A, Mohammadi P, et al. Prevalence of hepatitis D virus in hepatitis B virus infected patients referred to Taleghani hospital, Tehran, Iran. Gastroenterol Hepatol Bed Bench 2014; 7 :144-150.  Back to cited text no. 14
    
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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