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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 44  |  Issue : 2  |  Page : 33-38

Prevalence and significance of hepatitis-B core antibodies among hepatitis B surface antigen-negative Egyptian patients on hemodialysis in Al-Gharbia governorate


1 Department of Internal Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission31-Jan-2016
Date of Acceptance16-Feb-2016
Date of Web Publication29-Aug-2016

Correspondence Address:
Tamer A Elbedewy
Department of Internal Medicine, Faculty of Medicine, Tanta University, 51719 Tanta
Egypt
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DOI: 10.4103/1110-1415.189348

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  Abstract 

Background/aims
Hepatitis B virus (HBV) infection in hemodialysis (HD) patients represents a serious problem due to the immunosuppressive effect of renal failure and the susceptibility for de-novo HBV infection during HD with high morbidity and mortality. Occult hepatitis B virus infection (OBI) is defined as the presence of HBV-DNA in the serum and/or the liver in the absence of hepatitis B surface antigen (HBsAg). The strategy of combined screening for HBsAg and hepatitis B core antibody (anti-HBc) can virtually eradicate blood-transmitted HBV. The aim of this study was to evaluate the presence of anti-HBc among Egyptian regular HD adult patients and to determine the presence or absence of HBV-DNA in the serum samples from HBsAg-negative, anti-HBc-positive regular HD adult patients using the polymerase chain reaction (PCR) method to assess the magnitude of OBI in these patients.
Patients and methods
This cross-sectional study included 90 regular HD patients negative for HBsAg and anti-hepatitis C virus. Patients were investigated for anti-HBc, and samples of anti-HBc-positive patients were tested for HBV-DNA using real-time PCR.
Results
Among the 90 HBsAg-negative sera, anti-HBc was detected in 17 sera (18.9%). Eleven anti-HBc-positive patients were anti-HBs-positive. HBV-DNA was detected in seven of those 17 anti-HBc-positive patients (41.2%) (7.8% of all patients).
Conclusion
The overall prevalence of OBI in adult Egyptian regular HD patients is 7.8% in Al-Gharbia Governorate.

Keywords: anti-HBc, HBsAg, HBV-DNA, hemodialysis (HD), occult HBV (OBI)


How to cite this article:
Elbedewy TA, Elshweikh SA, Baiomy N. Prevalence and significance of hepatitis-B core antibodies among hepatitis B surface antigen-negative Egyptian patients on hemodialysis in Al-Gharbia governorate. Tanta Med J 2016;44:33-8

How to cite this URL:
Elbedewy TA, Elshweikh SA, Baiomy N. Prevalence and significance of hepatitis-B core antibodies among hepatitis B surface antigen-negative Egyptian patients on hemodialysis in Al-Gharbia governorate. Tanta Med J [serial online] 2016 [cited 2019 Nov 17];44:33-8. Available from: http://www.tdj.eg.net/text.asp?2016/44/2/33/189348


  Introduction Top


Hepatitis B virus (HBV) is a partially double stranded DNA, highly contagious, and is the most commonly transmitted blood-borne virus in the healthcare setting. Transmission generally occurs through contaminated instruments or accidental needle-stick or sharps injuries [1].

HBV infection in hemodialysis (HD) patients represents a serious problem due to the immunosuppressive effect of renal failure and the susceptibility for de-novo HBV infection during HD with high morbidity and mortality. HBV infection in dialysis patients may also vary according to the timing of infection, genotype, and ethnicity. Dialysis patients are more prone to become chronic carriers, compared with patients without renal failure, due to their immunosuppressed state [2]. The majority of newly HBV-infected dialysis patients have a relatively mild clinical course, or are asymptomatic with normal or slightly elevated serum transaminases [3]. The risk for severe life-threatening complications is highest when de-novo HBV infection occurs shortly after transplantation, but hepatitis flares and liver-related complications can occur at any time after kidney transplantation, including those who have been asymptomatic HBV carriers during dialysis [4].

Occult hepatitis B virus infection (OBI) is defined as the presence of HBV-DNA in serum and/or liver tissue in the absence of hepatitis B surface antigen (HBsAg) [5]. OBI can cause the transmission of the infection through organ transplantation or blood transfusion with reactivation of HBV when an immunosuppressive status occurs [6]. OBI is related to a low level of HBV infection, and may also be due to infection with HBV variants or mutants [7]. OBI can aggravate chronic liver damage and fibrosis, can cause progression of cirrhosis, can lead to the development of hepatocellular carcinoma, and can also lower the virology response in hepatitis C virus (HCV) infection [8],[9],[10].

Hepatitis B core antibody (anti-HBc) is the most sensitive marker of a previous HBV infection [11]. Blood that is free of HBsAg but has a high-titer of anti-HBc in the absence of antibodies against HBsAg (anti-HBs) can also transmit HBV infection [12]. A strategy of combined HBsAg and anti-HBc screening can virtually eliminate blood-transmitted HBV, with the rare exception of donations in the early phase of the window period when all serological markers are still negative [13].

The aim of this study was to evaluate the presence of anti-HBc among the Egyptian adult patients on maintenance HD and to determine the presence or absence of HBV-DNA in the serum samples of HBsAg-negative, anti-HBc-positive adult patients on HD using the PCR method to assess the magnitude of OBI in these patients.


  Patients and methods Top


This cross-sectional study included 90 patients on regular HD for more than 6 months. Patients of this study were selected from the Hemodialysis Unit, Internal Medicine Department, Faculty of Medicine, Tanta University, and other centers of dialysis in Al-Gharbia Governorate from January 2015 to June 2015. All participants included were negative for HBsAg and hepatitis C (anti-HCV). This study was conducted in accordance with the guidelines of the declaration of Helsinki and its subsequent amendments. Participation in the study was voluntary and informed written consent was obtained from the patients before the study.

Full history taking was carried out and included frequency of HD, past surgical procedures, intravenous drug abuse, jaundice, fever-related hospitalization, schistosomiasis, and HBV vaccination. Careful clinical examination was carried out for all patients before enrollment into the study.

Intravenous drug abusers, those with a history of promiscuous sexual relationships, homosexuals, patients with recent jaundice, those with recent hospitalization at fever hospitals, pregnant women, those who underwent recent delivery less than 12 weeks, or in close contact with a patient suffering from hepatitis in the last 6 months were excluded from the study. Patients with acute or chronic HBV infection as marked by positive HBsAg, patients with AIDS or receiving immunosuppressive medications (for any chronic disease), and patients with other causes of liver dysfunction (e.g. primary biliary cirrhosis, autoimmune hepatitis, continued alcohol abuse, and autoimmune hepatitis) were also excluded. None of the patients included had undergone a kidney transplant.

Serological assays

Ten milliliters of blood was collected from each patient in a sterile, capped tube. Thereafter, the blood was centrifuged and stored at –80°C until it was needed for testing. All serum samples were tested for serum alanine transaminase (upper normal limit=42 IU/l) and aspartate transaminase (upper normal limit=37 IU/l) using chemistry autoanalyzer (Synchron CX5; Beckman Instrument Inc., Scientific Instrument Division, Fullerton, California, USA). Hepatitis B markers (anti-HBc, HBsAg, and HBsAb) were detected using electrochemiluminescence immunoassay (Elecsys) (Roche Diagnostics Limited, Rotkreuz, Switzerland, www.cobas.com). Anti-HCV were detected using a standard third-generation ELISA test (Murex anti-HCV, version 4.0) (Murex Biotech S.A. (PTY) Ltd, Kyalami, Republic of South Africa). All procedures were performed according to the manufacturers’ instructions.

Detection of HBV-DNA and HCV-RNA [14]

Following serological tests, DNA was extracted from patients with anti-HBc-positive serum. Samples from each patient were tested for HBV-DNA using a highly sensitive and specific real-time PCR. HBV-DNA was extracted from 850 μl of plasma using the Cobas AmpliPrep instrument (Roche Diagnostics Limited, Rotkreuz Switzerland, www.cobas.com). The Cobas TaqMan 48 analyzer (Roche Diagnostics Limited, Rotkreuz Switzerland, www.cobas.com) was used for automated real-time PCR amplification and detection of PCR products. HBV-DNA levels were expressed in IU/ml. The HBV detection limit was 12 IU/ml.

For patients with anti-HBc, HCV-RNA was tested using real-time PCR. The HCV detection limit was 15 IU/ml.

Statistical analysis

The collected data were tabulated and analyzed using SPSS, version 17 software (SPSS Inc., Chicago, Illinois, USA). Categorical data were presented as number and percentages, and quantitative data were expressed as mean and SD. Comparison of continuous data between two groups was made using the unpaired t-test and the Mann–Whitney test for parametric and nonparametric data, respectively. Fisher's exact test was used for comparison between categorical data. The accepted level of significance in this work was 0.05 (P < 0.05 was considered significant).


  Results Top


This study included 90 patients on regular HD for more than 6 months. Their ages ranged from 24 to 67 years (mean 49.7 ± 9.2 years) [49 male (54.4%) and 41 female (45.6%)]. All patients did not receive HBV vaccination before. All patients (100%) had undergone surgery before. A total of 27 patients (30%) had a history of schistosomiasis with oral treatment only. Among the 90 HBsAg-negative patients, anti-HBc was detected in 17 patients (18.9%). Eleven anti-HBc-positive patients were anti-HBs-positive. HBV-DNA was detected in seven of those 17 anti-HBc-positive patients (41.2%) (7.8% of all patients) [Table 1]. None of the patients with OBI had anti-HCV or HCV-RNA.
Table 1 Frequencies of HBV viral markers in the studied group

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Comparison between patients with positive anti-HBc and patients with negative anti-HBc is shown in [Table 2], and comparison between patients with positive HBV-DNA and patients with negative HBV-DNA in anti-HBc-positive patients is shown in [Table 3].
Table 2 Comparison between patients with anti-HBc (+) and patients with anti-HBc (–) as regards different variables

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Table 3 Comparison between patients with HBV-DNA (+) and patients with HBV-DNA (–) in anti-HBc (+) as regards different variables

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  Discussion Top


HBV infection is a major health problem. Currently, about two billion people are infected despite the effective vaccination. There are 350 million carriers of HBV worldwide, and about one million die annually from HBV-related liver disease [15]. The prevalence of HBV infection varies in different parts of the world, ranging from less than 1–15%. In the Middle East, the carrier rate is 2–8% [16]. Anti-HBc is the first antibody produced after HBV infection, and it is the only detectable marker in the window period. Isolated anti-HBc refers to the presence of anti-HBc in serum without HBsAg or HBsAb. Isolated anti-HBc may be due to resolved HBV infection in which HBsAb had declined to an undetectable level, testing during the window period or chronic infection when HBsAg cannot be detected due to protein mutation makes it undetectable using certain diagnostic assays [17],[18]. Recent studies cannot judge the HBV infection based only on the presence or absence of HBsAg and HBsAb [19]. It is possible that, donors with OBI, who lack detectable HBsAg, might have HBV infection that is only indicated by anti-HBc and HBV-DNA [20]. Such individuals are a potential source of HBV transmission [21].

In Egypt, testing for the presence of HBsAg is the initial diagnostic examination used to determine HBV infection. Anti-HBc is not used as a screening test to determine previous exposure to the HBV. In our study, among the 90 HBsAg-negative patients, anti-HBc was detected in 17 patients (18.9%). Eleven patients with anti-HBc-positive were anti-HBs-positive. HBV-DNA was detected in seven of those 17 anti-HBc-positive patients (41.2%) (7.8% of all patients). The prevalence rate of OBI in HD patients in endemic and nonendemic countries is as follows: Brazil, 1.5%; Iran, 1–4%; Italy, 26.6%; Korea, 1.3%; and Sudan, 0–3.3% [22],[23],[24],[25],[26],[27],[28],[29]. These differences in the OBI prevalence may also be attributed to race and ethnicity, geographical area, the HBV subtypes, and differences in the storage and age of serum samples used in studies. Moreover, the infection control guidelines for HBV, which include checking the levels of viral markers before HD, performing regular tests for HBV and liver enzyme levels after HD, double-dose vaccinations, the use of separate dialysis machines for HBV-infected patients, and patient education with regard to hygiene (e.g. hand washing) may differ from country to country.

OBI incidence in HD patients in Egypt had many different figures, varying from 1.8 to 32% in many studies [30],[31],[32],[33],[34].

In Menoufiya governorate, Ismail et al. (2010) [30] found in HD patients without HCV that only six of 52 patients (11.5%) were anti-HBc-positive and two of them (3.8%) had OBI.

In Minia and Assuit governorates, Abu El Makarem et al. (2012) [31] found in HD patients without HCV that only nine of 66 patients (7.5%) were anti-HBc-positive and two of them (3.03%) had OBI. Only five of 66 (13.6%) patients in the HD without HCV group were anti-HBs-positive and all of them were anti-HBc-positive.

In Mansoura, in the study by Zaki et al. (2014) [32], anti-HBc-IgG, anti-HBc-IgM, and HBV-DNA was detected in 19/96 (19.8%), 4/96 (4.2%), and 18/96 (18.8%) patients, respectively. The majority of patients under HD had positive HBV-DNA in the absence of any serological markers (72.2%). Anti-HCV antibodies were detected in 41/96 (42%) patients.

In Suez Canal region, Mandour et al. (2015) [33] found that HD patients (169 patients) were negative for HBsAg. An overall 49.1% of the patients in the HD groups were anti-HBc-positive. In addition, 52.1% of anti-HBs-positive patients were detected in the HD group. Three cases (1.8) were positive for HBV-DNA in the HD group. Two of the three HBV-DNA-positive patients in the HD group were seropositive for anti-HBc alone, and the third patient was seronegative.

In Alexandria governorate, Helaly et al. (2015) [34] found that anti-HBc was detected in 48% of patients. HBV-DNA was detected in 32% of the HD patients. An overall 34% of the patients were anti-HCV and 70.6% of anti-HCV positive patients were also positive for anti-HBc.

The discrepancy in the reported incidence of OBI in Egypt between several studies, including our study, could be due to several factors. One could be the differences in the sensitivity of the methods used for the detection of the virus genome (nested PCR vs. quantitative real-time PCR) [35]. Another factor may also be attributed to the number of the studied groups. Two of these studies examined the OBI in HD patients in patients with or without HCV without separation and it is well known that OBI is more common in HCV-infected patients because of sharing same infection route [32],[34].

Our results showed that patients with positive anti-HBc or HBV-DNA had a significantly longer HD duration when compared with negative anti-HBc or HBV-DNA, respectively. Our results coincided with the study by Ismail et al. (2010) [30], who found that longer HD duration could distinguish patients with OBI from those with HBV-DNA-negative infection in HD patients. Moreover, Zaki et al. (2014) [32] revealed a significant association between duration of HD and OBI.

Liver enzyme abnormalities are uncommon in patients with OBI [36]. We also did not find any relationship between biochemical liver tests and OBI in our study population. Serum transaminases values tend to be attenuated in dialysis patients [37] regardless of whether or not they are dialysis-dependent; this makes the recognition of liver damage on the basis of liver biochemical tests very difficult [38],[39].

Our study is not without limitation. First, our study lacked examination of liver biopsy to certify that patients with anti-HBc and negative HBV-DNA had no OBI. Indeed, we found it unethical to expose the patient to this aggressive technique without direct benefit to them, but this may be overcome by using peripheral blood mononuclear cells instead of liver tissue. Moreover, our study was cross-sectional study and did not follow-up the patients with OBI. A longitudinal follow-up study is needed to examine the clinical implications of OBI. Third, the study population was small. A large-scale epidemiologic study is needed to confirm the findings reported.


  Conclusion Top


The overall prevalence of occult HBV on regular HD patients is 7.8% in Al-Gharbia Governorate. For all patients on regular HD, hepatitis B core antibody positivity should be screened for probable OBI. Routine anti-HBc screening is recommended in all HD patients.

Acknowledgements

The authors thank Tanta hemodialysis centers for allowing them to collect the sample from patients.

Tamer A. Elbedewy: Concept, design, definition of intellectual content, and statistical analysis; Tamer A. Elbedewy, Samah A. Elshweikh, Nivin Baiomy: Literature search, manuscript preparation, manuscript review, manuscript editing, data acquisition, and data analysis; Tamer A. Elbedewy, Samah A. Elshweikh: Clinical studies; Nivin Baiomy: Experimental studies. All authors have read and approved the final version of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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