Viral
hepatitis continues to be a relevant topic for haemodialysis centres, although the number of infected dialysis patients is declining in most countries.
Chronic hepatitis B and C lead to detrimental complications such as
liver cirrhosis and
hepatocellular carcinoma. These complications can be avoided by successful
antiviral treatment. In individuals with normal renal function,
drug therapy of
chronic hepatitis B is evolving quickly. Today there are several options but no agreed standard
therapy. In the absence of
renal failure, chronic hepatitis C should be treated with a combination of pegylated
interferon-alpha and
ribavirin. For both
infections, there is no general indication to treat all patients; several criteria can be used to predict benefits and downsides.
Chronic renal failure severely alters immune function, particularly activation of T lymphocytes and
cytokine production by mononuclear cells. Aging further influences the immune system with deviation of T-lymphocyte differentiation. Both effects seem to act additively, leaving the elderly haemodialysis patient with extensive immune dysfunction. While these effects do not put the patient at risk of
opportunistic infection, they do have a relevant effect on the
clinical course of viral
hepatitis. Haemodialysis patients infected with
hepatitis B manifest a subclinical, often anicteric disease, and at least 60% of the
infections become chronic. These patients usually do not fulfil the criteria for successful
antiviral treatment, since they have normal or slightly elevated liver
enzyme levels and few histological signs of liver
inflammation. In addition, the prognosis in terms of
cirrhosis and
hepatocellular carcinoma might be more favourable than in individuals with normal renal function. The former standard treatment of
chronic hepatitis B with
interferon-alpha or its derivate pegylated
interferon was badly tolerated in dialysis patients and associated with low efficacy. Indeed, prior to the advent of
nucleoside analogues there was a clear recommendation not to treat
chronic hepatitis B infection in all except a few dialysis patients. However, the newer treatment options appear to work well. In particular, there is growing evidence for the effectiveness and tolerability of
lamivudine in dialysis patients, including the elderly. Use of
adefovir and
entecavir has also been reported in a few cases. At present, while we still do not recommend treatment,
therapy with
nucleoside analogues might be an option in selected patients, for example, those planning
renal transplantation. The major effort against
hepatitis B should be directed at vaccination and hygienic precautions to prevent the
infection.Treatment of
hepatitis C in patients undergoing haemodialysis is also limited by the poor tolerability of
interferons.
Ribavirin is contraindicated because of severe
haemolytic anaemia, although a few studies have attempted to manage this with administration of high doses of erythropoetin. Those patients who complete the full course of
interferon therapy may expect sustained viral responses comparable with healthy individuals, but in most trials, 30-50% of patients were forced to interrupt treatment because of adverse effects. There is no general indication to treat
chronic hepatitis C in haemodialysis patients. Arguments in favour of treatment include elevated liver
enzymes, histological signs of relevant liver
inflammation, younger age, a virus genotype other than 1 and planned
renal transplantation.