This document discusses hepatitis C virus (HCV) and its relationship to chronic kidney disease. It covers HCV diagnosis in chronic kidney disease patients, HCV-related glomerulonephritis, HCV in dialysis patients, and HCV and kidney transplantation. Key points include that HCV prevalence is higher in dialysis populations, HCV increases the risk of death in dialysis patients, and universal precautions can prevent HCV transmission in hemodialysis units. Cryoglobulinemia is also discussed as it relates to HCV infection and kidney involvement.
Hepatitis C virus infection is associated with many renal diseases.
Renal disease caused by
• Virus itself
• Drugs used for treatment of hepatitis c
• Associated condition with hepatitisadvanced liver cell failure.
A. The renal disease associated with hepatitis c due to advanced liver cell failure:
• Prerenal (Hypovolemia , shock and hepatorenal syndrome )
• ATN ( sepsis or shock)
B. Drugs used for treatment of hepatitis c:
• Interstitial nephritis secondary to Interferon
C. Hepatitis c itself
o Hepatitis c is RNA flavivirus( single strand)
o Has extrahepatic manifestation like arthritis, DM, cryglobulinemia and glomerulonephritis
o Renal diseases associated with hepatitis C
1. The most common types is MPGN with cryoglobulinemia
2. Others are
MPGN without cryoglobulinemia
Membranous nephropathy (MN)
Focal segmental glomerulosclerosis
IgA nephropathy
Fibrillary glomerulopathy
Immunotactoid glomerulopathy
Thrombotic microangiopathy
Amyloid
Vasculitis
Interstitial nephritis secondary to virus
HCV-associated PAN
Hepatitis C virus infection is associated with many renal diseases. Renal disease caused by :•Virus itself •Drugs used for treatment of hepatitis c •Associated condition with hepatitis → advanced liver cell failure.
Hepatitis C virus infection is associated with many renal diseases.
Renal disease caused by
• Virus itself
• Drugs used for treatment of hepatitis c
• Associated condition with hepatitisadvanced liver cell failure.
A. The renal disease associated with hepatitis c due to advanced liver cell failure:
• Prerenal (Hypovolemia , shock and hepatorenal syndrome )
• ATN ( sepsis or shock)
B. Drugs used for treatment of hepatitis c:
• Interstitial nephritis secondary to Interferon
C. Hepatitis c itself
o Hepatitis c is RNA flavivirus( single strand)
o Has extrahepatic manifestation like arthritis, DM, cryglobulinemia and glomerulonephritis
o Renal diseases associated with hepatitis C
1. The most common types is MPGN with cryoglobulinemia
2. Others are
MPGN without cryoglobulinemia
Membranous nephropathy (MN)
Focal segmental glomerulosclerosis
IgA nephropathy
Fibrillary glomerulopathy
Immunotactoid glomerulopathy
Thrombotic microangiopathy
Amyloid
Vasculitis
Interstitial nephritis secondary to virus
HCV-associated PAN
Hepatitis C virus infection is associated with many renal diseases. Renal disease caused by :•Virus itself •Drugs used for treatment of hepatitis c •Associated condition with hepatitis → advanced liver cell failure.
Infectious diseases are the second most common cause of death in end-stage renal disease (ESRD) patients. Patients with ESRD are at high risk for several infections, due to exposure to blood products and frequent dialysis. The increased susceptibility to infections among these patients is indicative of a complex and varied state of immunodeficiency manifested by abnormal phagocytosis, T and B lymphocytes abnormalities and impaired response to T cell dependent pathogens such as hepatitis B and influenza viruses. These immunologic abnormalities are complicated by the use of immunosuppressive drugs used to treat and control underlying disease and exacerbated by nutritional deficiency and the dialysis procedure. Though many of these infections can be prevented by appropriate vaccination, the usual schedules of vaccination may be less effective.
The aim of this paper is to review the studies on the use of vaccines in ESRD patients
and summarize the vaccines required in this population.
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/AtiaKPIdzAQ
Arabic Language version of this lecture is available at:
https://youtu.be/2cwyPcRDGEY
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Infectious diseases are the second most common cause of death in end-stage renal disease (ESRD) patients. Patients with ESRD are at high risk for several infections, due to exposure to blood products and frequent dialysis. The increased susceptibility to infections among these patients is indicative of a complex and varied state of immunodeficiency manifested by abnormal phagocytosis, T and B lymphocytes abnormalities and impaired response to T cell dependent pathogens such as hepatitis B and influenza viruses. These immunologic abnormalities are complicated by the use of immunosuppressive drugs used to treat and control underlying disease and exacerbated by nutritional deficiency and the dialysis procedure. Though many of these infections can be prevented by appropriate vaccination, the usual schedules of vaccination may be less effective.
The aim of this paper is to review the studies on the use of vaccines in ESRD patients
and summarize the vaccines required in this population.
- Recorded videos of this lecture:
English Language version of this lecture is available at:
https://youtu.be/AtiaKPIdzAQ
Arabic Language version of this lecture is available at:
https://youtu.be/2cwyPcRDGEY
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
This is a part of the first study done on BK virus among renal transplant recipients in Sri Lanka, presented at the Annual Scientific Sessions of Sri Lanka Medical Association, 2016
This lecture is about Spectrum of HCV infection presented by Dr. Muhammad Mostafa Abdel Ghaffar, Head of Tropical Medicine Department, Ahmed Maher Teaching Hospital.
The lecture was presented in the scientific meeting of Internal and Tropical Medicine departments, Ahmed Maher Teaching Hospital titled (Towards Eradication of HCV in Egypt) in celebration of World Hepatitis Day on July 28, 2016.
https://www.facebook.com/AMTH.IM
https://www.facebook.com/events/1072758396145209/
http://www.no4c.com
HIV Transplant Case Report, Transplant Outcomes in Clinical Trials, and Organ Availability in High Risk Donors
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UCSD HIV & Global Health Rounds
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Hepatitis C virus & chronic kidney diseases
1. HCV & chronic renal diseases
Samir Haffar M.D.
Associate Professor of Gastroenetrology
Faculty of Medicine – Damascus – Syria
24th Congress of the SSGE – May 25-28, 2010
Dedeman Hotel – Lattakia – Syria.
2. HCV & chronic kidney diseases
• HCV diagnosis in CKD Patients
• HCV-related glomerulonephritis
• HCV in dialysis patients
• HCV and kidney transplantation
3. Testing of chronic hepatitis C
• anti-HCV (EIA*-3) Initially
• HCV RNA (RT-PCR**) Document viremia
• HCV genotyping Before treatment
* ELISA: Enzyme-Linked Immuno-Assay
** RT-PCR: Real time Polymerase Chain Reaction
4. HCV diagnosis in dialysis patients
2,653 patients
2 108 HD – 545 CAPD
39 of 49 dialysis centers in the Netherlands
Anti-HCV (EIA-3)
79 patients +
HCV RNA +
57 patients +
2574 patients –
HCV RNA
in pools of five
6 patients +
False negative 0.23%
Schneeberger PM et al. J Clin Microbiol 1998;36:1711–1715.
5. HCV-RNA test should be obtained prior to HD
• Heparin used during dialysis can interfere with the
PCR technique
• HD can lower HCV RNA by adsorption of HCV RNA
onto inner surface of dialyzers & destruction of viral
particles by hydraulic pressure exerted by blood
Okuda K et al. Lancet 1999;347:909–910.
6. Percutaneous liver biopsy in CHC with ESRD
Pawa S et al. Clin Gastroenterol Hepatol 2007;5:1316–20.
319 patients with CHC
Platelet, PT & PTT
No bleeding time
No arginine vasopressin
241 control patients
CHC without renal failure
5 complications
3 severe
2.1%
78 patients
CHC & ESRD
1 complication
Moderate
1.3%
7. Accuracy of fibrotest* in HD patients with CHC
*Noninvasive method to assess liver fibrosis in HCV on scale from 0 to 1
Varaut A et al. Transplantation 2005 Dec 15;80:1550–5 .
110 CHC
60 renal transplant recipients
50 hemodialysis patients
METAVIR score
Fibrotest
50 patients had fibrosis F2
AUROC for significant fibrosis
Global population: 0.66
Hemodialysis patients: 0.47
Renal transplant patients: 0.71
8. Liver stiffness for each Metavir stage in CHC
Box-and-whiskers plot
Vertical axis in logarithmic scale (wide range of F4 values)
Ziol M et al. Hepatology 2005 ; 41 : 48 – 54.
Prospective multicenter study
327 patients
Castera L et al. Gastroenterology 2005;128:343–350.
Prospective study
183 patients
9. HCV & chronic kidney diseases
• HCV diagnosis in CKD Patients
• HCV-related glomerulonephritis
• HCV in dialysis patients
• HCV and kidney transplantation
10. HCV-related glomerulonephritis
• Membranoproliferative glomerulonephritis (MPGN)
• IgA nephropathy
• Postinfectious glomerulonephritis
• Membranous nephropathy
• Thrombotic microangiopathies
• Focal & segmental glomerulosclerosis
• Fibrillary glomerulopathy
Perico N et al. Clin J Am Soc Nephrol 2009;4:207–220.
11. Cryoglobulinemia
Systemic vasculitis of small-calibre arteries & veins
Type Frequency Associated disease
Type I
Single
10 – 15 % Monoclonal Lymphoproliferative disorder
Indistinguishable from MM,
Waldenström, or CLL
Type II
Mixed
50 – 60% Mixed
Monoclonal & polyclonal
HCV
Type III
Mixed
30 – 40% Mixed
Monoclonal & polyclonal
Connective tissue disease
Autoimmune diseases
Chronic bacterial infections
Chronic viral infections
Incidence of CHC in Mixed Cryoglobulinemia 40 – 100%
90% in Mediterranean basin
Sansonno D et al. Lancet Infect Dis 2005; 5: 227–36
12. Prevalence of cryoglobulinemia in CHC
Meta-analysis
• No of studies 19 studies between 1994 & 2001
• No of patients 2 323 patients
• Cryoprecipitate 1 022 patients prevalence 44%
• Cirrhosis 40% of patients with cryoprecipitate
17% of patients without cryoprecipitate
OR for cirrhosis in CP*+: 4.87 (3.3-7.1)
* CP: Cryoprecipitates
Kayali Zeid et al. Hepatology 2002;36:978-985.
13. Signs & symptoms in mixed cryoglobulinemia
• Skin Palpable purpura 90%
Leg ulcers 15%
Raynaud’s phenomenon 30%
Cold urticaria 10%
• Liver Hepatomegaly 70%
Hypertransaminasaemia 50%
• Kidney Microscopic hematuria 30%
Proteinuria 15%
Arterial hypertension 40%
• MS system Arthralgia 70%
Asthenia 80%
• NS Peripheral: Motor-sensory axonopathy 60%
Acute mononeuritis 5%
Central Neurocognitive impairment 25%
Sansonno D et al. Lancet Infect Dis 2005;5:227–36.
14. Palpable purpura
Sansonno D et al. Lancet Infect Dis 2005;5:227–36.
Most frequent sign of MC: 90%
Usually the first sign of MC
Raise immediate suspicion of MC
15. Chronic leg ulcers
Relatively frequent
Above the malleoli
Always associated with purpura
Absence of severe stasis dermatitis
Sansonno D et al. Lancet Infect Dis 2005;5:227–36.
16. Mixed Cryoglubulinemia in CHC
Majority of patients have no or nonspecific symptoms
• Meltzer's triad (30%): purpura, asthenia, arthralgia
• Most frequent affected tissues: skin, nerves, & kidney
• Renal involvement (1/3 of patients)
Signs Proteinuria – microhematuria – RI – HTN
Diagnosis Positive anti-HCV & HCV RNA
Biopsy MPGN with immune complex deposition
17. Renal biopsy of cryoglobulinaemic patient
Immunohistochemical detection of HCV core
protein in glomerular vascular structures
Sansonno D et al. Lancet Infect Dis 2005;5:227–36.
18. Association between HCV & ESRD
Retrospective cohort study
Medicare, Department of Veterans Affairs, & US Renal Data System
Creatinine measured between Oct 2000 & Sept 2001
2 352 584 patients
3 years follow-up – ESRD
Tsui JI et al.Arch Intern Med. 2007;167:1271-1276.
Anti-HCV –
421 495patients (89%)
3.05/ 1000 person-years
95% CI: 2.96 – 3.14
Anti-HCV +
52 874 patients (11%)
4.26 /1000 person-years
95% CI: 3.97 – 4.57
anti-HCV test within 1 year of creatinine testing
474 369 patients
19. HCV & chronic kidney diseases
• HCV diagnosis in CKD Patients
• HCV-related glomerulonephritis
• HCV in dialysis patients
• HCV and kidney transplantation
20. Prevalence of HCV in long-term dialysis patients
Developing countries
Country Anti-HCV positives Reference year
Brazil 16.4% (180/1095) 2007
Turkey 19% (83/437) 2005
Tunisia 20% (79/395) 2006
Sudan 23.7% (56/236) 2007
Iran 24.8% (74/298) 2005
Saudi Arabia 43.4% (86/198) 2004
Moldavia 75% (111/148) 1999
Morocco 76% (141/186) 2005
Egypt 80% (169/210) 2000
Martin P et al. J Hepatol 2008;49:613–624.
21. DOPPS
Prospective observational study – Based on anti-HCV
• Facilities 308 representative dialysis facilities
• Patients 8615 hemodialysis patients
• Countries 7 countries from 3 continents
France, Germany, Italy, Japan, Spain, US
• Time 1997-98 to 2001
• Prevalence Mean 13.5% (2.6 – 22.9%)
• Seroconversion 56% of facilities: no seroconversion
44% of facilities: > 0 – 20%
DOPPS: Dialysis Outcomes & Practice Patterns Study
Fissell RB et al. Kidney Int 2004;65:2335–2342.
22. HCV prevalence & time on dialysis
Fissell RB et al. Kidney Int 2004;65:2335–2342.
23. Impact of HCV on survival in dialysis patients
Meta-analysis
• No of studies 7 studies (5 cohorts – 2 case-controls)
• No of patients 11 589 patients on maintenance dialysis
• RR for death 1.34 (95% CI: 1.13-1.59)
Heterogeneity statistics, R(i) = 0.48
P-value by Q-test = 0.13
• Cause of death Liver cirrhosis & HCC more frequent
Fabrizi F et al J Viral Hepat 2007;14:697–703.
24. HCV & death risk in hemodialysis patients
82 933 patients on MHD for at least 45 days
3 year period: 2001 – 2004
580 outpatient dialysis facilities of DaVita Inc*
* DaVita Inc: Large dialysis organization
Kalantar-Zadeh K et al. J Am Soc Nephrol 2007;18:584–1593.
anti-HCV EIA at least once
13 664 patients
1590 patients (12%)
anti-HCV +
Mortality Hazard Ratio: 1.25
95% CI: 1.12 – 1.39 (P < 0.001)
Higher all-cause & CV mortality
25. Preventing HCV transmission in HD units
• Wear disposable gloves when caring for patient
Remove gloves & wash hands between each patient
• Use disposable items
Nondisposable items dedicated for use on single patient
Unused medications dedicated for use on single patient
• Separation of clean & contaminated areas
• Clean & disinfect dialysis station between patients
e.g., chairs, beds, tables, machines
Centers for Disease Control & Prevention MMWR Recomm Rep 2001;50:1-43.
26. Practice of hand hygiene in HD units
One person observed the staff in 9 dialysis units during 1 month
495 randomly distributed 30 min observation periods
Covered all steps of hemodialysis session
Dolores Arenas M et al. Nephrol Dial Transplant 2005;20:1164–1171.
977 opportunities to wear gloves
& wash hands following activity
Gloves used in 93%
Hands washed in 36%
1902 opportunities to wash hands
before activity
Hands washed in 148%
Higher patient-to-nurse ratio influenced
hand washing before& after patient contact
27. Universal precautions prevent HCV transmission
963 patients – 15 Belgian units
No isolation of anti-HCV patients
Anti-HCV (EIA 2 or 3) every 18 m for 54 m
Jadoul M et al. Kidney Int 1998;53:1022-1025.
488 patients available
Drop-up from death or RT
1st 18 month (May 91 – Nov 92): 1.41 %
HCV seroconversion
2nd 18 month (Nov 92 – May 94): 0.56 %
Reinforced precautions
3rd 18 month (May 94 – Nov 95): 0 %
P=0.04
28. HCV & chronic kidney diseases
• HCV diagnosis in CKD Patients
• HCV-related glomerulonephritis
• HCV in dialysis patients
• HCV and kidney transplantation
29. Kidney transplantation for HD patients with CHC
Anti-HCV positive patient on dialysis0
HCV RNA –
Waiting list
for KT
Normal LFTs
30. Kidney transplantation for HD patients with CHC
Anti-HCV positive patient on dialysis0
Liver failure
Liver & kidney
transplantation
31. Kidney transplantation for HD patients with CHC
Chronic hepatitis
IFN
HCV RNA – HCV RNA +
Anti-HCV positive patient on dialysis0
Cirrhosis
Liver & kidney
transplantation
HCV RNA +
Liver biopsy
Waiting list
for KT
Normal
37. Serological tests of chronic HCV infection
Rodés J et all. Textbook of hepatology: from basic science to clinical practice.
Blackwell Publishing, Oxford, UK, 3rd edition, 2007
38.
39. Cryoglobulinemia
Type Frequency Associated disease
Type I
Single
10 – 15 % Monoclonal Lymphoproliferative disorder
Indistinguishable from MM,
Waldenström, or CLL
Type II
Mixed
50 – 60% Mixed
Monoclonal & polyclonal
HCV
Type III
Mixed
30 – 40% Mixed
Polyclonal & monoclonal
Connective tissue disease
Autoimmune diseases
Chronic bacterial infections
Chronic viral infections
Incidence of HCV infection in EMC 40–100%
90% in Mediterranean basin
40. Mixed Cryoglobulinemia
Josephsen G. N Engl J Med 2005;352:2627.
38-year-old woman
CHC treated with IFN- several years ago
Palpable lesions on legs & feet
HBsAg – & anti-HCV +
Acute renal failure & pancytopenia
Improvement with plasmapheresis
41.
42. Kidney transplantation for HD patients with CHC
CirrhosisChronic hepatitis
IFN
HCV RNA – HCV RNA +
Anti-HCV positive patient on dialysis0
HCV RNA –
Waiting list
for KT
Normal LFTs
Liver failure
Liver & kidney
transplantation
HCV RNA +
Liver biopsy
Normal
43. Increased risk of HCV in HD patients
• Longer time on dialysis
• Male gender
• Black race
• Diabetes
• HBV infection
• Prior renal transplantation
• Alcohol or substance abuse in previous 12 month
Fissell RB et al. Kidney Int 2004;65:2335–2342.
44. Proposed model of cryoprecipitating immune
complex in HCV-related cryoglobulinemia
Sansonno D et al. Lancet Infect Dis 2005;5:227–36.
45. Practice of hand hygiene in hemodialysis units
• One person observed health care staff in 9 dialysis units
495 randomly distributed 30 min observation periods
Covered all steps of hemodialysis session
Dolores Arenas M et al. Nephrol Dial Transplant 2005;20:1164–1171.
46. Tests no longer needed
• RIBA: Recombinant Immuno-Blot Assay
• Qualitative HCV RNA by PCR
47. Practice of hand hygiene in hemodialysis units
• One person observed health care staff in 9 dialysis units
495 randomly distributed 30 min observation periods
Covered all steps of hemodialysis session
• 1902 opportunities to wash hands before patient contact
• 977 opportunities to wear gloves
•
Dolores Arenas M et al. Nephrol Dial Transplant 2005;20:1164–1171.
48. HCV & death risk in hemodialysis patients
Kalantar-Zadeh K et al. J Am Soc Nephrol 2007;18:584–1593.
Editor's Notes
Hepatitis C Virus Infections in Dialysis Centers in The Netherlands: a National Survey by Serological and Molecular Methods. Schneeberger PM et al. J ClinMicrobiol June 1998, p. 1711–1715.Abstract: A national survey of hepatitis C virus (HCV) infections among dialysis patients in The Netherlands was performed. The study involved 2,653 patients (2,108 hemodialysis patients and 545 chronic ambulatory peritoneal dialysis [CAPD] patients) from 39 of the 49 dialysis centers in the country. Patient sera were analyzed by both serological and molecular methods. Screening by a third-generation enzyme immunoassay (EIA) yielded 79 reactive sera. The presence of anti-HCV antibodies was confirmed in 70 patients by a line immunoassay. All seropositive samples were tested by reverse transcriptase PCR, and 57 samples were found to contain HCV RNA. Of the nine EIA-positive and line immunoassay-negative or indeterminate samples, four were HCV RNA positive. All seronegative samples were screened for the presence of HCV RNA in pools of five sera. Of 2,576 antibody-negative samples, 6 contained HCV RNA. All antibody-positive and RNA-positive samples were also tested by a second serological assay. The prevalence of HCV infections among Dutch dialysis patients as determined by serology or the presence of HCV RNA was 3% (80 of 2,653), i.e., 3.5% (73 of 2,108) in patients treated on hemodialysis and 1.3% (7 of 545) in patients on CAPD. Of these 80 HCV-infected dialysis patients, 67 (84%) were HCV RNA positive. Serological screening alone would have diagnosed only 70 infected patients. Therefore, antibody screening combined with detection of HCV RNA should be considered as the “gold standard” for diagnosing HCV infection in dialysis patients. The prevalence of HCV-infected patients inDutch dialysis centers ranged from 0 to 8%, suggesting the existence of local risk factors for acquiring HCV infection. Genotyping analysis by reverse hybridization line probe assay revealed the presence of genotypes 1a (23%), 1b (46%), 2 (3%), 2a (13%), 2b (1%), 3a (7%), and 4a (4%). In four (6%) samples multiple genotypes were detected. The genotype distribution of HCV isolates among Dutch dialysis patients was similar to the distribution among nondialysis patients from the Benelux, except for subtype 1a, which was significantly moreprevalent among dialysis patients. In only one center, a high prevalence of an uncommon genotype was suggestive of infection from a common source.
Liver biopsy provides key information on the extent of HCVassociated hepatic disease, but requires caution in CKD because of the potential low risk of bleeding complications, especially in patients with chronic kidney diseases. Transjugular biopsy seems safer.Percutaneous liver biopsy is safe in chronic hepatitis C patients with end-stage renal disease.Pawa S et al. ClinGastroenterolHepatol2007 Nov;5(11):1316-20.AbstractBackground & Aims: Liver biopsy is useful for staging fibrosis in chronic hepatitis C (CHC) patients with end-stage renal disease (ESRD) to determine renal transplant eligibility and to make CHC treatment decisions. There is concern about an increased risk associated with percutaneous liver biopsy (PCNB) in ESRD patients. We compared the safety of PCNB in CHC patients with and without ESRD. Methods: We reviewed PCNBs performed between 1996 and 2004 for technique, histology, and complications in 78 ESRD patients with CHC and in 241 control patients with CHC and no renal failure, randomly matched for age, sex, and race. Platelet counts, prothrombin, and partial thromboplastin times, but not bleeding times, were checked before biopsy. Deamino-8-D-arginine vasopressin was not given before the biopsy. Results: The mean age of the patients was 50 years; 72% were male, 97% were African American, and 3% were Caucasian. The control group had a significantly higher proportion of patients with advanced fibrosis (P < .04). Only 1 patient with ESRD (1.3%) developed a moderate complication. Five controls (2.1%) developed complications, 3 of which were severe. Conclusions: Severe complications after PCNB are uncommon, and patients with ESRD and CHC are at no increased risk. Testing for bleeding time and the routine use of deamino-8-D-arginine vasopressin are not necessary before PCNB in patients with ESRD.
Fibrotest:Algorithm combining the results of serum tests of 2-macroglobulin, haptoglobin, apolipoprotein A1, total bilirubin, GGT, & ALT to assess the level of fibrosis and necroinflammatory activity. Imbert-Bismut F, Ratziu V, Pieroni L, Charlotte F, Benhamou Y, Poynard T: MULTIVIRC Group: Biochemical markers of liver fibrosis in patients with hepatitis C virus infection: A prospective study. Lancet 357: 1069–1075, 2001.SummaryBackground: Liver biopsy is thought mandatory for management of patients with hepatitis C virus (HCV) infection, especially for staging fibrosis. We aimed, in our prospective study, to assess the predictive value of a combination of basic serum biochemical markers for diagnosis of clinically significant fibrosis (including early stages). Methods: We assessed liver-biopsy patients with detectable HCV by PCR, for eligibility, and took a blood sample on the day of the procedure. The analysis was done in a first-year period for 205 patients and then tested in a second period on 134 patients. We devised a fibrosis index that included the most informative markers (combined with age and sex) for the first-year group. 11 serum markers were assessed as well as fibrosis stage: FO=no fibrosis and F1=portal fibrosis; and for clinically significant fibrosis, F2=few septa, F3=many septa, and F4=cirrhosis. Statistical analysis was by logistic regression, neural connection, and receiver-operating characteristic (ROC) curves. Findings: First-year and second-year patient-group characteristics and biochemical markers did not differ. The overall frequency of clinically significant fibrosis was 40% (138 patients). The most informative markers were: α2 macroglobulin, α2 globulin (or haptoglobin), γ globulin, apolipoprotein A1, γ glutamyltranspeptidase, and total bilirubin. The areas (SD) under the ROC curves for the first-year (0·836 [0·430]) and second-year groups (0·870 [0·340]) did not differ (p=0·44). With the best index, a high negative predictive value (100% certainty of absence of F2, F3, or F4) was obtained for scores ranging from zero to 0·10 (12% [41] of all patients), and high positive predictive value (>90% certainty of presence of F2, F3, or F4) for scores ranging from 0·60 to 1·00 (34% of all patients). Interpretation: A combination of basic serum markers could be used to substantially reduce the number of liver biopsies done in patients with chronic HCV infection.Diagnostic accuracy of the fibrotest in hemodialysis and renal transplant patients with chronic hepatitis C virus.Varaut A et al. Transplantation 2005 Dec 15;80(11):1550-5.AbstractBackground: An accurate diagnosis of hepatitis C virus (HCV)-related liver lesions is mandatory in dialysis patients and kidney recipients to better define the treatment of and contraindications to kidney transplantation. The aim of this study was to assess the diagnostic accuracy of the fibrotest (a noninvasive method to assess liver fibrosis in HCV on a scale from 0 to 1) in hemodialysis & renal transplant patients infected by chronic HCV. Methods: In all, 110 patients with biopsy-proven HCV (60 renal transplant recipients and 50 hemodialysis patients), determined using the METAVIR scoring system, were studied. Results: Forty-six percent of patients had fibrosis > or =F2. A positive predictive value of a score >0.6 for the presence of significant fibrosis by comparison with liver biopsy was 71%, and an negative predictive value of < 0.2 for excluding significant fibrosis was 77%, respectively. The areas under the ROC curves for the diagnosis of significant fibrosis were 0.66, 0.47, and 0.71 in the global population, hemodialysis patients, and renal transplant patients, respectively. In all, 75% of patients were correctly classified using the fibrotest. If biopsy was restricted to scores in the intermediate range (< 0.6 and >0.2), the index could reduce the indication for biopsy by 47%. The results did not differ significantly in hemodialysis and renal transplant patients. Conclusion: The fibrotest has a diagnostic value in hemodialysis and renal transplant patients which is similar to that reported in the general population (75%) and its use could avoid 32% of liver biopsies if it were interpreted in detail in nephrology patients.
Castera L et al. Prospective comparison of transient elastography, Fibrotest, APRI, and liver biopsy for the assessment of fibrosis in chronic hepatitis C. Gastroenterology 2005;128:343–350.Background & Aims:Transient elastography (FibroScan; Echosens, Paris, France) is a novel, noninvasive, and rapid bedside method to assess liver fibrosis by measuring liver stiffness. We prospectively assessed the performance of FibroScan in patients with chronic hepatitis C, in comparison with and combined with currently available biochemical markers (Fibrotest; Biopredictive; and the aspartatetransaminase to platelets ratio index [APRI]); a liver biopsy examination performed the same day served as the reference. Methods:We studied 183 consecutive patients with chronic hepatitis C (METAVIR fibrosis stage F1, n = 47; F2, n = 53; F3, n = 37; F4, n = 46). Results:FibroScan values ranged from 2.4 to 75.4 kilopascals (median, 7.4 kilopascals). Cut-off values were 7.1 kPa for F ≥ 2, 9.5 kPa for F ≥ 3, and 12.5 kPa for F = 4. The areas under the receiver operating characteristic (ROC) curve of FibroScan, FibroTest, and APRI values were of the same order (.83, .85, and .78, respectively, for F ≥ 2; .90, .90, and .84, respectively, for F ≥ 3; and .95, .87, and .83, respectively, for F = 4). The best performance was obtained by combining the FibroScan and FibroTest, with areas under the ROC curve of .88 for F ≥ 2, .95 for F ≥ 3, and .95 for F = 4. When the FibroScan and FibroTest results agreed, liver biopsy examination confirmed them in 84% of cases for F ≥ 2, in 95% for F ≥ 3, and in 94% for F = 4. Conclusions:FibroScan is a simple and effective method for assessing liver fibrosis, with similar performance to FibroTest and APRI. The combined use of FibroScan and FibroTest to evaluate liver fibrosis could avoid a biopsy procedure in most patients with chronic hepatitis C.
The most common HCV-related nephropathy is MPGN, usually in the context of cryoglobulinemia.
Cryoglobulins are single or mixed immunoglobulins that reversibly precipitate at low temperatures.Before the discovery of HCV and the establishment of serological tests for the detection of specific circulating anti-HCV antibodies, patients without identifiable underlying disease were considered to have “essential” mixed cryoglobulinaemia. In hindsight, it is now clearthat most of these patients were chronically infected with HCV.The incidence of HCV infection in “essential” mixed cryoglobulinaemia varies geographically, generally falling in the range of 40–100% (90% in the Mediterranean basin).
KayaliZeid et al. Hepatitis C, Cryoglobulinemia, and Cirrhosis: A Meta-analysis. Hepatology 2002;36:978-985.Approximately 40% of patients with chronic hepatitis C virus (HCV) infection develop detectable serum cryoglobulins or cryoprecipitates (CP), although most do not show clinical or physical signs of syndromiccryoglobulinemia. Although association of HCV with theextrahepatic complications of cryoglobulinemia is widely recognized, the relationship of cryoglobulinemia with liver disease is unclear. We wished to study the relationship between CP and cirrhosis and to determine whether the development of CP is a true covariate forprogressive liver disease or a confounding variable that impacts cirrhosis because of patient age, duration of disease, or differences in gender. We undertook ameta-analysis of 19 studies published between 1994 and 2001. The incidence of cirrhosis was compared in patients with and without CP after logistic regression adjustments for accepted risk factors for progressive liver disease, including age, gender, and estimated duration of disease (EDD). A total of 2,323 patients with chronic hepatitis C were identified, with 1,022 (44%) having detectable CP. Cirrhosis was present in 40% of patients with CP but only 17% of patients without CP (total x2 141.69, P < .001). After adjusting for age, gender, and estimated duration of disease by logistic regression, the combined odds ratio for incidence of cirrhosis in patients CP positive versus CP negative was 4.87, (95% CI: 3.32, 7.15), indicating a highly significant association between cirrhosis and cryoglobulinemia. In conclusion, cryoglobulins may be a useful prognostic indicator for increased risk of cirrhosis with chronic hepatitis C.
Any organ may be affectedPalpable purpura is evident in more than 90% of mixed cryoglobulinaemia patients, and is usually the first sign of cryoglobulinaemia, raising an immediate suspicion of cryoglobulinaemicvasculitis and foreshadowing systemic complications. Triad: purpura, asthenia, arthralgia & oserved in 30% of cases
PatientsThe study cohort was selected from the larger population of patients who underwent at least 1 serum creatinine measurementwithin the VA between October 1, 2000, and September 30, 2001 (n=2 352 584). The date of the first serum creatinine measurement during this period served as the point of cohortentry. We excluded patients who were already undergoing dialysis or who had undergone kidney transplantation (n=11 125). Among the remaining patients, 474 369 were tested for HCV within 1 year before or 1 year after cohort entry and comprised the analytic cohort for this study.Veterans AffairsIn 1988, the VA launched a major initiative to test all veterans at risk for HCV; the VA has the largest program for screening HCV in the United States. Screening is recommended among the following: Vietnam-era veterans, recipients of blood transfusions prior to 1992, individuals with a history of intravenous drug use, unequivocal blood exposure of skin or mucous membranes, multiple sexual partners (10 lifetime), hemodialysis, tattoo or repeated body piercings, intranasal cocaine use, unexplained liver disease, abnormal alanineaminotransferase levels, or heavy alcohol use, and individuals who express a desire to be screened.This is the first study, to our knowledge, that demonstrates an association between HCV and ESRD in a national cohort of health care users.Limitations: 1- This study was restricted to veteran health care users who had received HCV testing; therefore, results may not be generalizable to nonveteran populations. 2- Also did not have information on proteinuria or albuminuria in our cohort, as it was infrequently ordered by physicians; therefore, we could not determine whether proteinuria was a risk factor for ESRD risk among patients with HCV.3- Our follow-up time was short given the natural history of most types of kidney disease: it is possible that the strength and magnitude of the associations described herein might differ during a longer follow-up period.Conclusion:In this large national cohort of adult veterans, patients younger than 70 years with HCV seropositivity were at increased risk for developing ESRD treated with dialysis or transplantation.
It has been estimated that, among patients on hemodialysis, the prevalence of HCV infection varies greatly, from less than 5% to nearly 60% according to different areas of the world. The prevalence is consistently associated with patient age and the number of transfused blood products. The prevalence of HCV infection has declined in many dialysis centers, and yet it remains unacceptably high, ranging from 8% to 10% even in the most industrialized countries.Spontaneous disappearance of HCV RNA has been reported in 1% of untreated dialysis patients.
Increasing years on dialysis has been the risk factor most consistently reported as being independently associated with higher rates of HCV infection. As the number of years patients were on dialysis increased, their prevalence of HCV infection increased from an averageof 12% to an average of 37%. This relationship was found even for patients with no history of blood transfusion or injecting drug use, suggesting that HCV might be transmitted between patients in the hemodialysis setting.Kellerman S et al. Hepatology 1999;29:291-293.
Fabrizi F et al. The impact of hepatitis C virus infection on survival in dialysis patients: meta-analysis of observational studies. J Viral Hepat2007 Oct;14(10):697-703.Abstract:The impact of hepatitis C virus (HCV) infection on mortality of patients receiving regular dialysis remains unclear. The assessment of the natural history of HCV in dialysis population is difficult because of the low progression of HCV-related liver disease over time and the reduced life expectancy in patients with end-stage renal disease. The aim of the study was to conduct a systematic review of the published medical literature concerning the impact of HCV infection on the survival of patients undergoing maintenance dialysis. The relative risk of mortality was regarded as the most reliable outcome end-point. Study-specific relative risks were weighted by the inverse of their variance to obtain fixed- and random-effects pooled estimates for mortality with HCV across the published studies. We identified seven studies involving 11 589 unique patients on maintenance dialysis; two (29%) were case-control studies. Pooling of study results demonstrated that presence of anti-HCV antibody was an independent and significant risk factor for death in patients on maintenance dialysis. The summary estimate for adjusted relative risk (aRR) (all-cause mortality) was 1.34 with a 95% confidence interval (CI) of 1.13-1.59. Heterogeneity statistics, R(i) = 0.48 (P-value by Q-test = 0.13). In a sensitivity analysis including only (n = 5) cohort studies, the pooled aRR was 1.38 (95% CI, 1.20-1.59); heterogeneity statistics R(i) = 0.46. As a cause of death, hepatocellular carcinoma and liver cirrhosis were significantly more frequent among anti-HCV-positive than -negative dialysis patients. Our meta-analysis indicates that anti-HCV-positive patients on dialysis have an increased risk of mortality compared with HCV-negative patients. The excess risk of death in HCV-positive patients may be at least partially attributed to chronic liver disease with its attendant complications.
Dolores Arenas M et al. A multicentric survey of the practice of hand hygiene in haemodialysis units: factors affecting compliance. Nephrol Dial Transplant (2005) 20: 1164–1171. SpainBackground: This study intended to investigate the degree of compliance with hand hygiene and use of gloves by health workers in haemodialysis (HD) units, and the factors that influenced adherence to hand hygiene protocols.Methods: During the month of November 2003, one person observed the health care staff in each of nine different dialysis units, during 495 randomly distributed 30 min observation periods that covered all steps of a haemodialysis session (connection, dialysis anddisconnection). The observers noted the number of potential opportunities to implement standard precautions and the number of occasions on which the precautions were actually taken. Adherence to standard precautions was evaluated, analysing the influenceof the following variables: the patient-to-nurse ratio, the number of HD shifts scheduled per day, acute HD units vs chronic, whether or not infectious patients were isolated and in-house vs contract cleaning personnel.Results: There were a total of 977 opportunities to wear gloves for, and to wash the hands following, a patient-oriented activity, and 1902 opportunities to wash hands before such an activity. Gloves were actually used on 92.9% of these occasions. Hands werewashed only 35.6% of the time after patient contact, and only 13.8% of the time before patient contact. Poor adherence to hand washing was associated with the number of shifts per HD unit per day and with higher patient-to-nurse ratios. In the acute HD units, there was greater adherence to standard precautions than in the chronic units, although there too it was substandard. The personnel’s knowledge of patients’ infectious status did not modify their adherence to hand hygiene practices. A higher patient-to-nurse ratio independently influenced hand washing both before and after patient contact.Conclusions: The overall adherence of health care workers to recommended hand washing practices is low. Whether or not programmes promoting higher hand hygiene standards and the potential use of alcohol-based hand cleansers will improve hand hygiene practices in HD units requires further investigation.
Cryoglobulins are single or mixed immunoglobulins that reversibly precipitate at low temperatures.Before the discovery of HCV and the establishment of serological tests for the detection of specific circulating anti-HCV antibodies, patients without identifiable underlying disease were considered to have “essential” mixed cryoglobulinaemia. In hindsight, it is now clearthat most of these patients were chronically infected with HCV.The incidence of HCV infection in “essential” mixed cryoglobulinaemia varies geographically, generally falling in the range of 40–100% (90% in the Mediterranean basin).
HCV core protein is linked to IgG molecules with specific anticore reactivity, which in turn are bound to IgM molecules with rheumatoid factor activity. Multimolecular complexes are good acceptors of C1q protein, and this results in specific binding to endothelial cells via the C1q receptor (C1qR). In boxes, the relative proportions of IgG, IgM, and complement proteins in relation to cryoprecipitate and supernatant phases are depicted.
Dolores Arenas M et al. A multicentric survey of the practice of hand hygiene in haemodialysis units: factors affecting compliance. Nephrol Dial Transplant (2005) 20: 1164–1171. SpainBackground: This study intended to investigate the degree of compliance with hand hygiene and use of gloves by health workers in haemodialysis (HD) units, and the factors that influenced adherence to hand hygiene protocols.Methods: During the month of November 2003, one person observed the health care staff in each of nine different dialysis units, during 495 randomly distributed 30 min observation periods that covered all steps of a haemodialysis session (connection, dialysis anddisconnection). The observers noted the number of potential opportunities to implement standard precautions and the number of occasions on which the precautions were actually taken. Adherence to standard precautions was evaluated, analysing the influenceof the following variables: the patient-to-nurse ratio, the number of HD shifts scheduled per day, acute HD units vs chronic, whether or not infectious patients were isolated and in-house vs contract cleaning personnel.Results: There were a total of 977 opportunities to wear gloves for, and to wash the hands following, a patient-oriented activity, and 1902 opportunities to wash hands before such an activity. Gloves were actually used on 92.9% of these occasions. Hands werewashed only 35.6% of the time after patient contact, and only 13.8% of the time before patient contact. Poor adherence to hand washing was associated with the number of shifts per HD unit per day and with higher patient-to-nurse ratios. In the acute HD units, there was greater adherence to standard precautions than in the chronic units, although there too it was substandard. The personnel’s knowledge of patients’ infectious status did not modify their adherence to hand hygiene practices. A higher patient-to-nurse ratio independently influenced hand washing both before and after patient contact.Conclusions: The overall adherence of health care workers to recommended hand washing practices is low. Whether or not programmes promoting higher hand hygiene standards and the potential use of alcohol-based hand cleansers will improve hand hygiene practices in HD units requires further investigation.
Dolores Arenas M et al. A multicentric survey of the practice of hand hygiene in haemodialysis units: factors affecting compliance. Nephrol Dial Transplant (2005) 20: 1164–1171. SpainBackground: This study intended to investigate the degree of compliance with hand hygiene and use of gloves by health workers in haemodialysis (HD) units, and the factors that influenced adherence to hand hygiene protocols.Methods: During the month of November 2003, one person observed the health care staff in each of nine different dialysis units, during 495 randomly distributed 30 min observation periods that covered all steps of a haemodialysis session (connection, dialysis anddisconnection). The observers noted the number of potential opportunities to implement standard precautions and the number of occasions on which the precautions were actually taken. Adherence to standard precautions was evaluated, analysing the influenceof the following variables: the patient-to-nurse ratio, the number of HD shifts scheduled per day, acute HD units vs chronic, whether or not infectious patients were isolated and in-house vs contract cleaning personnel.Results: There were a total of 977 opportunities to wear gloves for, and to wash the hands following, a patient-oriented activity, and 1902 opportunities to wash hands before such an activity. Gloves were actually used on 92.9% of these occasions. Hands werewashed only 35.6% of the time after patient contact, and only 13.8% of the time before patient contact. Poor adherence to hand washing was associated with the number of shifts per HD unit per day and with higher patient-to-nurse ratios. In the acute HD units, there was greater adherence to standard precautions than in the chronic units, although there too it was substandard. The personnel’s knowledge of patients’ infectious status did not modify their adherence to hand hygiene practices. A higher patient-to-nurse ratio independently influenced hand washing both before and after patient contact.Conclusions: The overall adherence of health care workers to recommended hand washing practices is low. Whether or not programmes promoting higher hand hygiene standards and the potential use of alcohol-based hand cleansers will improve hand hygiene practices in HD units requires further investigation.