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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 2  |  Page : 70-74

Assessment of hepatitis B and hepatitis C status in children with chronic kidney disease


Department of Pediatrics Nephrology, Dhaka Shishu (Children) Hospital, Dhaka, Bangladesh

Date of Submission20-Sep-2021
Date of Acceptance12-Dec-2021
Date of Web Publication28-Feb-2022

Correspondence Address:
Dr. Jannat Ara
Department of Pediatrics Nephrology, Dhaka Shishu (Children) Hospital, K-321, Road-15, South Banasree Project, Khilgaon, Dhaka 1219,
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pnjb.pnjb_13_21

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  Abstract 

Background: Children with chronic kidney disease (CKD) are immunocompromised and they are more prone to develop hepatitis B and hepatitis C virus infections. Objective: The aim of this study was to evaluate the status of hepatitis B and hepatitis C in children with CKD. Study Design: This was a cross-sectional study. Study Setting and Period: This study was conducted at the Department of Pediatrics Nephrology, Dhaka Shishu (Children) Hospital, from February 2019 to July 2019. Study Population: Children aged 6 months–18 years with the diagnosis of CKD participated in the study. Materials and Methods: A total of 35 purposively selected patients with CKD were enrolled. Thorough history, physical examination, and necessary investigations were done. CKD staging was done by using the revised Schwartz formula. All 35 patients were in CKD stages 3–5. They were divided into three groups: CKD stage 3–4; CKD stage 5 pre-hemodialysis (pre-HD); and CKD stage 5 maintenance HD. Then hepatitis B surface antigen (HBsAg), anti-hepatitis C virus (anti-HCV), and hepatitis B surface antibody (anti-HBs) titer were assessed in all patients and compared between the groups. Analysis was done by the analysis of variance (ANOVA) and t test. A value of P < 0.05 was considered statistically significant. Results: The study revealed that all 35 patients were negative for HBsAg and anti-HCV. Anti-HBs antibody titer in 25.7% patients were 00 mIU/mL, in 40% patients <10 mIU/mL, in 20% patients 10–100 mIU/mL, and in 14.3% patients >100 mIU/mL. Majority (65.7%) of the patients had no protection (titer 0–<10 mIU/mL) against hepatitis B virus (HBV) infection and seen declining of anti-HBs antibody titer with increase of age in the study population. No significant difference of antibody titer was found in between gender, cause of CKD, different stages of CKD, and duration of the disease. Conclusion: In this study, all patients with CKD were negative for HBsAg and anti-HCV. Patients were negative for HBsAg. However, majority (65.7%) of patients show no protection against HBV infection.

Keywords: Children, CKD, hepatitis B, hepatitis C


How to cite this article:
Ara J. Assessment of hepatitis B and hepatitis C status in children with chronic kidney disease. Paediatr Nephrol J Bangladesh 2021;6:70-4

How to cite this URL:
Ara J. Assessment of hepatitis B and hepatitis C status in children with chronic kidney disease. Paediatr Nephrol J Bangladesh [serial online] 2021 [cited 2022 Oct 5];6:70-4. Available from: http://www.pnjb-online.org/text.asp?2021/6/2/70/338564




  Background Top


Chronic kidney disease (CKD) is an emerging serious public health issue, which means functional or structural damage of kidney or decrease in glomerular filtration rate (GFR) to <60 mL/min per 1.73 m² for more than 3 months.[1],[2] The incidence of CKD in children has steadily increased.[3] CKD has a prevalence of 1.5 to 3.0 per 1,000,000 among children younger than the age of 16 years.[4] In pediatric nephrology centers of Dhaka city among the current pattern of renal disease in children is CKD 6%.[5] In patients with CKD, infection is a major cause of morbidity and mortality. They are prone to infections due to the disease process and its complications such as anemia, metabolic acidosis, hypertension, uremia-associated immune deficiency also due to frequent blood transfusion and erythropoietin therapy. Hepatitis B and C are the most frequent among viral infections,[6] which complicate the life of CKD patients more and more. The prevalence of the hepatitis B virus (HBV) and its modes of transmission vary geographically.[7],[8],[9] Every year millions of people are infected with HBV in Bangladesh and most of them are children.[10] Although there is a scarcity of information regarding a nationwide survey about HBV prevalence in Bangladesh, the data published show that approximately 5%–6% of apparently healthy individuals are HBV carriers in Bangladesh[11],[12],[13] and the prevalence of children is 0.8%.[14] From the Dialysis Outcomes and Practice Patterns Study, data analysis showed an HBV prevalence across dialysis facilities in Western Europe, Japan, and in the USA is 0 to 6.6%.[15] In contrast, a study of Asia-Pacific countries found the prevalence of hepatitis B surface antigen (HBsAg) positivity ranged and varies between 1.3% and 14.6%,[16] 13.3% in Turkey and 2.4%–10% in Brazil.[17],[18]

Prevalence of hepatitis C virus (HCV) viral markers among patients with hemodialysis (HD) has been reported to range from 2.6% to 54% worldwide.[19],[20],[21],[22],[23],[24] The seroprevalence of HCV is 0.88% in Bangladesh which is very low and found positive for anti-HCV in a study[25] Parenteral exposure is an effective route of HCV transmission in persons who share needles and syringes, receive transfusions of blood or blood product, or have catheters inserted for long-term vascular access, especially in the hospital setting. Over decades, blood and blood product transfusion, volume transfused, and duration of HD have been considered as the principal risk factors for HCV infection in patients undergoing HD for more than 6 months.[22],[26] Patients with HD are prone to HCV infection because the risk for exposure to HCV is associated with the dialysis procedure. Unlike the HBV infection, no vaccine is available for HCV. Patients infected with HCV often have little clinical evidence of disease. HCV infection in end-stage renal disease (ESRD) patients has been associated with greater morbidity and mortality.[27],[28] Very little is known about the hepatitis B and C status of Bangladeshi children with CKD. Therefore, this study aimed to find out the present hepatitis B and C status of Bangladeshi CKD children.


  Materials and Methods Top


The cross-sectional study was conducted at the Department of Pediatrics Nephrology, Dhaka Shishu (Children) Hospital from February 2019 to July 2019. Sample size of 35 (CI = 95%, Z = 1.96, P = 0.06[5], q = 0.94, and d = 0.05) was purposively selected among all children suffering from CKD aged 6 months to 18 years admitted in Dhaka Shishu Hospital. Different stages of CKD were categorized by using revised Schwartz formula. All patients were in CKD stages 3–5. They were divided into three groups: CKD stage 3–4; CKD stage 5 pre-HD; and CKD stage 5 maintenance HD and completed primary vaccination for hepatitis B within the period. Patients who were previously HBsAg and anti-HCV positive and who were on vaccination schedule were excluded from the study.

Blood samples were collected immediately after inclusion. Venous blood (5 mL) was collected for the quantification of biochemical parameters.Serum was then tested for the presence of HBsAg, antibody to Hepatitis B surface antigen and antibody to Hepatitis B core antigen (Ig G and Ig M) using enzyme-linked immunosorbent assay by using Dimension EXL 200 Integrated Chemistry System. Detection of HBV DNA, by polymerase chain reaction (PCR) in-house method with 200 IU/mL detection limit. Anti-HCV was also detected by enzyme-linked immunosorbent assay by using Dimension EXL 200 Integrated Chemistry System.

After the collection of all information, these data were checked, verified for consistency, and edited for finalized results. After editing and coding, the coded data were directly entered into the computer by using the Statistical Package for the Social Sciences (SPSS) software program, version 25.0. Data cleaning validation and analysis were performed using the SPSS. Statistical analyses were done by using appropriate statistical tools like analysis of variance (ANOVA) and t test. Statistical significance was set as P < 0.05 and confidence interval at 95% level.

Operational definition

CKD

CKD is a functional or structural damage of the kidney or decrease in GFR to <60 mL/min per 1.73 m² for more than 3 months.[1] CKD can be divided in five stages, based on GFR which is estimated in children from the level of serum creatinine and height, using the Schwartz formula: Stage 1––GFR > 90 (mL/min/1.73 m²), Stage 2––60–89 (mL/min/1.73 m²), Stage 3––GFR 30–59 (mL/min/1.73 m²), Stage 4––GFR 15–29 (mL/min/1.73 m²), and Stage 5––GFR< 15 (mL/min/1.73 m²).[2]

Socioeconomic status

Socioeconomic status of study population was classified according to World Bank calculation, July 2017 per capita Gross National Income (GNI).

  • Low income: BDT ≤ 6827.00 tk/month


  • Lower middle income: BDT 6828.00–26852.00 tk/month


  • Upper middle income: BDT 26853.00–83018.00 tk/month


  • High income: BDT ≥ 83019.00 tk/month


  • Ethical implication

    The protocol was approved by the Ethical Review Committee of Bangladesh Institute of Child Health and every procedure was discussed with the patients’ parents regarding the study without any delay in treatment or harm to the patient maintaining full confidentiality.


      Result Top


    [Table 1] shows frequency distribution of the studied population (n = 35). Most of the participants were male, mean age of study population was 8.56 ± 3.71 years, and age range was 0.58-14 years. [Table 1] also shows that maximum study population belonged to lower middle-income group. Among them, most were suffering from stage 5 pre-HD (34.3%). Maximum population (54.3%) were suffering for less than 1 year. All of them were negative for HBsAg, Anti-HCV. Anti HBs titer of maximum population (65.7%) were within (0≤10 mIU/mL) and only 14.3% had seroprotection (>100 mIU/mL). [Table 2] shows most common cause of CKD was obstructive uropathy due to posterior urethral valve which was found all stages of CKD and responsible for CKD stage 4 and stage 5 pre-HD. Glomerulonephritis was second most common cause and responsible for stage 5 MHD CKD. [Table 3] shows mean anti-HBs titer of studied population according to gender, age, and CKD stages. Maximum titer found in female (30 mIU/mL), age group 3–5 years (178.9 mIU/mL) and in CKD stage 4 (72.99 mIU/mL). Minimum titer found in male (28 mIU/mL), age group 12–14 years (3.2 mIU/mL), and stage 3 CKD (7.40 mIU/mL). [Table 4] shows statistically significant difference between age groups determined by one way ANOVA (F = 7.35, P = 0.00).
    Table 1: Frequency distribution of the studied population (n = 35)

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    Table 2: Causes for different stages of CKD

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    Table 3: Mean anti-HBs titer of studied population according to gender, age, and CKD stages (n = 35)

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    Table 4: Statistically significant difference between groups determined by one-way ANOVA (F = 7.35 and P = 0.00)

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      Discussion Top


    Mass vaccination against HBV was introduced in the expanded program of immunization (EPI) schedule for newborns in Bangladesh in 2003 with coverage of more than 97%.[13] This has yielded positive outcome as the prevalence had declined from 8% in 1984 to 5.4% in 2007 in this country.[13] In this study, all patients with CKD were negative for HBsAg and anti-HCV. Though all patients were primarily vaccinated against hepatitis B but due to disease process of CKD and its complications, the patients had not achieved adequate seroprotection. Approximately 65.7% of patients showed titer within 0–<10 mIU/mL, which gives no protection against HBV infection. Patients with CKD who had anti-HBs between 10 and 99 IU/mL were less protected than who had anti-HBs ≥ 100 IU/mL. No similar study was found in Bangladesh but another study showed seroconversion followed by rapid immunization only in 72% of the population with CKD where 95% seroconversion was seen in normal population.[29] Another study showed that the prevalence of hepatitis B and C in Iranian children with CKD was 2.5% and 1.4%, respectively,[30] but there was no such type of study in CKD children in Bangladesh. Adult patients with CKD who were on dialysis found 21.3% of patients on maintenance HD, infected with HBV, and/or HCV. Approximately 3.56% of them were positive for HBsAg, 15.6% were positive for anti-HCV, and other 2.1% were found positive for both HBsAg and anti-HCV.[25] The seroprevalence of HCV in Bangladesh is only 0.88%.[25] Prevalence of HBsAg had been found 1.1% and anti-HCV 13.4% of patients in three pediatric hemodialysis centers in Baghdad.[31]

    In this study, the most common cause of CKD was obstructive uropathy due to posterior urethral valve, which is responsible for Stage 4 CKD and Stage 5 pre-HD CKD. Glomerulonephritis was the second most common cause, responsible for Stage 5 MHD CKD. Another study found that congenital kidney diseases are the most common cause of CKD in pediatrics age group. Nephropathies were found as the most common cause of CKD in several other studies carried out with different populations, both pediatric and adult patients. In this study, 62.9% patients were male which is similar with other studies.[32]

    No significant difference was found between gender and anti-HBs titer but other studies have reported male gender having decreased immunogenicity than female following vaccination.[25] In this study, maximum patients were within 9–11 years age group; similar data were found in another study.[32] There is a significant difference between age and titer, which is inversely proportional with increase in age (P = 0.00). Mean titer of anti-HBsAg is decreasing with advanced stages of CKD but not statistically significant. No similar study was found.


      Conclusion Top


    In this study, all patients with CKD were negative for HBsAg and anti-HCV. However, all of them received Hepatitis B Vaccine, majority (65.7%) of patients show no protection against HBV infection.

    Limitation of this study

    This was a single-center time-constrained study. Therefore, calculated sample size could not be taken.

    Recommendation

    All CKD children should measure anti-HBs titer at disease diagnosis and at a 6 months interval, even after achieving seroprotection and immunized with recombinant hepatitis B DNA vaccine according to anti-HBs antibody titer.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
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