Hepatitis C in children with chronic kidney disease: A single-center, Egypt

Abstract

Prevalence of hepatitis C varies largely according to geographical distribution, and Egypt so far has the highest prevalence worldwide. The aim of this study was to evaluate hepatitis C infection in chronic kidney disease (CKD) children in our center with regard to its incidence and other morbidities. This is a cross-sectional study involving 50 children with CKD, not on dialysis. All patients underwent a thorough history taking including disease duration and mean duration of admission, clinical examination including blood pressure measurements, and routine laboratory examination such as hemoglobin level, serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), urea, and creatinine. The detection of anti-hepatitis C virus (HCV) antibodies was done in all patients based on the use of third-generation enzyme immunoassay (EIA) that detects antibodies directed against various HCV epitopes. Nine (18%) children were found to be hepatitis C positive and 41 were negative to hepatitis C. Infected cases were of older age group and had a longer duration of CKD, lower estimated glomerular filtration rate (eGFR), lower hemoglobin, higher ALT, higher serum urea, and creatinine. We conclude that 18% of children with CKDs have hepatitis C infection, and those with longer the duration of renal disease is more likely to be positive for HCV. Furthermore, HCV infection may predispose to higher deterioration of eGFR, lower hemoglobin level, and more days of admission. We recommend routine testing of HCV in all children with CKD.

Full text

Saudi J Kidney Dis Transpl 2017;28(1):102-106
© 2017 Saudi Center for Organ Transplantation
Brief Communication
Hepatitis C in Children with Chronic Kidney Disease:
A Single-center, Egypt
Doaa Mohammed Youssef1, Hanaa Abdo1, Ahmed Alakhras1, Tamer Adham2,3,
Abdelnasser Hussien Mohamoud4
1Department of Pediatrics, Zagazig University, Zagazig, 2Departments of Pediatrics, Ain Shams
University, Cairo, Egypt, 3Department of Pediatrics, University of Alberta, Alberta, Canada,
4Department of Pediatrics, Military Medical Academy, Cairo, Egypt
ABSTRACT. Prevalence of hepatitis C varies largely according to geographical distribution, and
Egypt so far has the highest prevalence worldwide. The aim of this study was to evaluate hepatitis
C infection in chronic kidney disease (CKD) children in our center with regard to its incidence
and other morbidities. This is a cross-sectional study involving 50 children with CKD, not on
dialysis. All patients underwent a thorough history taking including disease duration and mean
duration of admission, clinical examination including blood pressure measurements, and routine
laboratory examination such as hemoglobin level, serum aspartate aminotransferase (AST),
alanine aminotransferase (ALT), urea, and creatinine. The detection of anti-hepatitis C virus
(HCV) antibodies was done in all patients based on the use of third-generation enzyme
immunoassay (EIA) that detects antibodies directed against various HCV epitopes. Nine (18%)
children were found to be hepatitis C positive and 41 were negative to hepatitis C. Infected cases
were of older age group and had a longer duration of CKD, lower estimated glomerular filtration
rate (eGFR), lower hemoglobin, higher ALT, higher serum urea, and creatinine. We conclude that
18% of children with CKDs have hepatitis C infection, and those with longer the duration of renal
disease is more likely to be positive for HCV. Furthermore, HCV infection may predispose to
higher deterioration of eGFR, lower hemoglobin level, and more days of admission. We
recommend routine testing of HCV in all children with CKD.
Introduction
Hepatitis C virus (HCV) is a blood-borne
pathogen that appears to be endemic in many
Correspondence to:
Dr. Doaa Mohammed Youssef,
Department of Pediatrics,
Zagazig University, Zagazig, Egypt.
E-mail: Dody5176@yahoo.com
parts of the world. There are, however, subs-
tantial geographic and temporal variations in
the incidence and prevalence of HCV infec-
tion, largely due to differences in regional risk
factors for the transmission of HCV. The
highest prevalence of HCV has been found in
Egypt (17–26%).1,2
The prevalence of HCV infection is higher in
most subgroups of chronic kidney disease
(CKD) patients than in the general population.3,4
Saudi Journal
of Kidney Diseases
and Transplantation
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Prevalence of pediatric HCV infection varies
from 0.05–0.36% in the United States and
Europe; up to 1.8–5.8% in some developing
countries. The highest prevalence occurs in
Egypt, Sub-Saharan Africa, Amazon Basin,
and Mongolia.5CKD patients should be tested
for HCV as the first guideline of Kidney
Disease Improving Global Outcome (KDIGO)
2008 (weak).1
As there is very little known about HCV
infection in infants and children with CKD,
and this very limited information implies that
the current guidelines do not apply directly
and completely to this specific population, and
as the KDIGO has recommended that pediatric
nephrologists and other physicians – in charge
of caring for children with CKD should
carefully evaluate the extent to which the
current guidelines may be extrapolated to
children,1 we have tried to evaluate HCV
infection in CKD children not yet on hemo-
dialysis (HD) treated in our unit with regard to
percentage of occurrence, relation to age,
disease duration, and morbidity impact inclu-
ding effect on blood pressure, lower estimated
glomerular filtration rate (eGFR), hemoglobin
level, serum urea, and serum creatinine levels.
Patients and Methods
Study design
This was a cross-sectional study that included
50 children with CKD, not on dialysis, treated
in Nephrology Unit, Zagazig University
Children Hospital, during the period from
April to October 2014.
Patients
Patients were divided into two groups; Group
A with nine patients has CKD, not on dialysis
with hepatitis C positive and Group B with 41
patients have CKD, they were not on dialysis
with hepatitis C negative.
Our patients were 28 males and 22 females,
aged 5–15 years. Etiologies of CKD were idio-
pathic nephrotic syndrome (72%, 36 patients),
obstructive uropathy (22%, 11 patients), and
cystic kidney diseases (6%, 3 patients). Their
eGFR has ranged from 44–109 mL/min/1.73 m2
(i.e., CKD Stage 1–3).
Methods
All patients have undergone a thorough his-
tory taking including disease duration and
mean duration of admission, clinical exami-
nation including blood pressure measurements,
and routine laboratory examination as regard
hemoglobin level, serum aspartate aminotrans-
ferase (AST), alanine aminotransferase (ALT),
urea, and creatinine.
The detection of anti-HCV antibodies was
done to all patients as it was based on the use
of third-generation enzyme immunoassay
(EIA) that detects antibodies directed against
various HCV epitopes. EIA tests are repro-
ducible, inexpensive, and suitable for use in
the diagnosis of HCV infection. Given the
good performance of third-generation EIA
tests, immunoblot tests have become obsolete
in clinical practice.6
Ethical issues
Informed consent was obtained, and the re-
search was approved by the Ethical Committee
of Zagazig University of Medical Sciences.
Statistical Analysis
The data were tabulated and statistically ana-
lyzed using Statistical Package for the Social
Sciences (SPSS) software version 15.0 for
Windows (SPSS Inc., Chicago, IL, USA). Data
were expressed as a mean ± standard deviation
for numerical variables. For all tests, P<0.05
was considered statistically significant.
Results
Demographic, clinical, and laboratory data of
the studied groups
Our results have shown that hepatitis C
infection is more prevalent among those with
higher age, longer duration of CKD, and lower
eGFR. It was also seen that hepatitis C-
positive cases have lower hemoglobin, higher
ALT, and higher values of serum urea and
creatinine (Table 1).
HCV in children with CKD 103
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Correlation between serum ALT, serum AST
and demographic, clinical, and laboratory
data in Group A
Group A (HCV-positive cases) has had a
high significant positive correlation with older
age, disease duration, more number of admis-
sions, and significant negative correlation with
the level of eGFR, and no significant corre-
lation with hemoglobin level or serum crea-
tinine (Table 2).
Discussion
There are two types of tests for HCV. The
simpler enzyme-linked immunosorbent assay
(EIA) test looks for antibodies that the body
produces to fight off the virus, whereas nucleic
acid test (NAT) looks for the virus itself. NAT
is more complicated and expensive, but it is
more accurate, and it gives information about
how infectious the patient is. The KDIGO
guideline 2008 recommends that units where
there are few or no HCV-infected patients
should consider using the EIA test routinely
and only test with NAT if the EIA test is
positive.1
Approximately, 3% of the world’s population
(roughly 170–200 million people) is infected
Table 1. Demographic and laboratory data of the studied groups.
Recorded data
Group A
(HCV positive
antibody) N =9
Group B
(HCV negative
antibody) N = 41
t
P
Age in years
12.00±2
8.39±3.3
6.921
0.00**
Renal disease duration (years)
10.00±2
4.56±2.84
5.018
0.001**
No. of admissions (mean)
2.50±0.70
2.31±1.39
16.925
0.000**
Admission duration (days)
15.00±10.12
13.34±15.33
2.190
0.077
SBP
105.21±15.33
100.00±11.22
1.693
0.159
DBP
69.34±8.51
60.046±8.56
1.208
0.313
eGFR
41.30±2.17
74.08±21.47
94.153
0.000**
Hemoglobin
12.38±0.95
12.98±0.93
53.306
0.000**
ALT (mg/dL)
30.43±10
28.43±8.61
3.378
0.013*
AST (mg/dL)
29.13±8.6
25.13±9.36
1.094
0.364
Serum creatinine (mg/dL)
0.757±0.27
0.557±0.34
6.424
0.000**
Serum urea (mg/dL)
19.70±3.4
14.93±2.66
69.754
0.000**
HCV: Hepatitis C virus, ALT: Alanine aminotransferase, AST: Aspartate aminotransferase, SBP:
Systolic blood pressure, DBP: Diastolic blood pressure, eGFR: Estimated glomerular filtration rate.
*Significant, **Highly significant.
Table 2. Correlation between serum ALT, serum AST, and demographic and laboratory data in subgroup A.
ALT
AST
Recorded data
r
P
r
P
Age (years)
0.102
0.496
0.221
0.135
Renal disease duration (years)
0.225
0.128
0.603**
0.000
No. of admission (mean)
0.122
0.412
0.425**
0.003
Admission duration (days)
−0.172-
0.249
−0.112
0.455
SBP
0.075
0.615
0.034
0.822
DBP
−0.031
0.838
0.147
0.325
eGFR
−0.144
0.334
−0.105
0.484
Hemoglobin
−0.249
0.091
−0.034
0.823
Serum AST (mg/dL)
0.403**
0.005
0.403**
0.005
Serum creatinine (mg/dL)
0.219
0.139
0.229
0.121
Serum urea (mg/dL)
0.105
0.482
0.155
0.299
ALT: Alanine aminotransferase, AST: Aspartate aminotransferase, SBP: Systolic blood pressure, DBP:
Diastolic blood pressure, eGFR: Estimated glomerular filtration rate, **Highly Significant.
104 Youssef DM, Abdo H, Alakhras A, et al
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with HCV.1 In Egypt, the situation is quite
worse. Egypt has the highest prevalence of
hepatitis C in the world. Among the popu-
lation of 83 million in 2008, 14.7% was found
to be infected with this virus.7 In Egypt, only a
few studies are available regarding the exact
number of children with CKD having HCV,
despite the increase in the number of patients
undergoing HD and the increase in the number
of HCV prevalence. Therefore, the current
study was aimed to establish a simple system
to study the prevalence of HCV antibodies
among children with CKD not yet on dialysis
in Pediatric Nephrology Unit, Zagazig Univer-
sity Hospitals, and to study effects of HCV on
increasing morbidities in those patients.
Our cross-sectional study was conducted over
a period of six months from April to October
2014. A total of fifty patients were diagnosed
with CKD. Among these patients, nine (18%)
were found to be infected with HCV. The high
percentage of HCV infection in our studied
patients can be explained by the fact that CKD
patients have a higher risk for acquiring HCV
infections due to the frequent use of blood and
blood products, and multiple invasive proce-
dures performed in these patients, and also
because Egypt has a high prevalence of HCV.1,7
Our study has shown that HCV infection was
higher among those in the higher age group as
it was the most common in the age group of
13–17 years. The mean age of the HCV-
positive patients was 11.8 years. This coincides
with the results of Tsui et al8 and Moe et al9
who have stated that there that HCV infection
was high among the higher age group but
disagree with Noureddine et al10 who have
stated that no significant difference according
to age between HCV-positive and negative
cases.
Our study has also shown that the prevalence
of HCV was highly significant among those
with longer duration of disease. The mean
duration of disease for HCV-positive patients
in our study was 6.21 years.
With respect to liver enzymes, a significant
elevation of ALT (alanine transaminase) values
was found among HCV-positive patients – in
this study. This can be explained on the basis
of the destruction of hepatocytes caused by the
immune reaction of the body responding to the
hepatitis viruses leading to excessive release
of the transaminases. These findings were in
accordance with the studies conducted in
Karachi and Jenin district and Gaza strip in
Palestine (Abumwais and Idris, 2010).11 This
also agrees with Kosaraju et al12 and
Noureddine et al.13 They stated that there was a
statistically significant difference between the
cases and controls with respect to liver func-
tion tests.
With respect to renal function tests, there
were significantly high levels of urea and
creatinine in HCV-positive patients. This was
not in agreement with Kosaraju et al,12 as no
statistically significant difference was observed
between HCV-positive and negative patients
with respect to serum levels of urea and crea-
tinine. There were significantly lower levels of
estimated GFR in HCV-positive patients in
comparison with HCV-negative patients; in
agreement with our results, Noureddine et al13
who found that there were significantly lower
levels of estimated GFR in HCV-positive
patients in comparison with HCV-negative
patients.
There were significant higher levels of sys-
tolic blood pressure (SBP) and diastolic blood
pressure in HCV-positive patients (in spite of
antihypertensive drugs) versus HCV-negative
patients. However, we should put in conside-
ration that hypertension has multifactorial
causes. This coincides with Moe et al14 who
reported hypertension was more common with
HCV positive in 1999 (50.8%) versus 4274
(46.5%) in HCV negative (P <0.001).However,
Noureddine et al13 found that there was no
significant difference in levels of SBP between
HCV positive (144 ± 28) and HCV negative
(145 ± 23).
Conclusion
We have concluded that 18% of children with
CKD have hepatitis C infection and that the
longer the duration of renal disease the more
likely to be positive to HCV. We have also
concluded that HCV infection may predispose
HCV in children with CKD 105
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to faster deterioration of eGFR, lower hemo-
globin level, and a higher number of days
needing admission.
We recommend routine testing of HCV in
CKD children probably by EIA. This group of
patients requires closer monitoring of their
blood pressure, hemoglobin levels, and renal
functions to help early detection of the poten-
tial complications. Nevertheless, all efforts
should be done trying to prevent the transmis-
sion of HCV to patients.
Limitations of the study
Limitations of this study were that it is a
cross-sectional, not a prospective one, and the
number of patients involved is to some extent
small.
Conflict of interest: None declared.
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