Hepatitis C infection in renal transplant recipients in Israel

Hepatitis C Infection in Renal Transplant T. Weinstein,

D. Zevin, Y. Ori, A. Korzets, A. Chagnac,

H

Recipients

in Israel

M. Herman, FL Tur-Kaspa,

and U. Gafter

EPATITIS C virus (HCV) is the causative agent for most cases of what had been previously considered as non-A, non-B hepatitis.’ The prevalence of HCV antibodies in renal allograft recipients is high and has been reported to range from 10% to 48S.l.’ Chronic hepatitis occurs in 10% to lS% of kidney transplant recipients and contributes signiticantly to mortality and morbidity:’ Although HCV infection is often subclinical, the disease may become chronic in at least half of the patients, and may result in significant liver discase or hepatocellular carcinoma.’ The contribution of HCV infection to long-term patient outcome has become an important issue. The aims of this study were (a) to define the prevalence of HCVRNA in 7.7 renal allograft recipients in the Nephrology Dcpartmcnt at the Rabin Medical Center, Golda Campus, Israel, and (b) to define the distribution of HCL gcnotypcs in this patient population.

PCR was performed in a reaction mixture volume of SO ~1. containing Taq polymcrase hutfer (Promega). 2 mmol/L dNTP. 1.5 mmol/L MgCI,, 20 ng of sense primer SI, and 2.5 units TX! Polymerasc (Promcga). The reaction was carried out hy 35 cycles of PCRa at Y4”C for 1.S minutes, SK’ fur 1.5 minute,. and 72°C for 3 minutes. The second PCR reaction was performed as hcfore. using the same conditions, with 5 PL of the first PCR reaction mixture and the nested set of primers SII (senbc) and AS11 (anti-scnsc). The primers wc’rc from the highly conserved S’ untranslated region (5’ UTR). The primers were: Sl 7-26: S’-CACTCC-ACC-ATA-GAT-CAT<‘CCC-~‘; AS11 248.222: S’-AAC-AC’TACT-CGG-CTA-C;C’A-G1‘-.i’: SII lh-hS: S’-‘M‘C-ACG-C’AGAAA-GCG-TCT-AG-3’; AS11 IYII-171: 5’.(;TT-GAT-(‘CA-A(;AAAG-GAC-(‘C-3’. PCR products wcrc detected by 2% agarosc gel clcctrophorcsis using the appropriate nucleic acid markers. The

PATIENTS

IICV genotyping was performed with a hybridization assay, a line-probe assay (INNO-LiPA, Innogenetica, Brussels. Belgium) hascd on the revcrsc-hybridization principle. It employs hiotinyl-

studied

HCV AND

METHODS

Patients All

73

renal

transplant

rccipienls

treated

at the Nephroloby

Dcp;irtmcnt of Rabin Medical Center. Golda Campus. during IYYS wcrc enrolled in the study. The patients wcrc transplanted at ditfcrcnt ccntcrs. Aa of 1905, WC conduct annual routine HCVRNA testing. Information was obtained by chart rcvicws and by questionnaires that sddresscd the mode of dialysis pcrformcd prior to tr~~naplantation. numhcr of years of dialysis treatment and renal transplantation, numhcr of blood transfusions. results of serological testing for HCV, HBV. IIIV, and results of liver-function tats. Serology

samples

wcrc

tcsted

FIT-PCR

RNA was extracted from 50 PL of serum by using RNAzol ““B (Biotccx Lahoratorics, Houston, TX). RNA was dissolved in IO m1. RNAse-free water; cDNA was synthesized using SO ng of the anti-sense primer AS1 in a reaction mixture containing I X Taq polymcrasc huffcr (Promcga Corp. Madison. WI), 0.5 mmol/I. dNTP, 20 units RNAsin (Promega), IO mmol/L DTT. and 30 units avimn myclohlastosis virus (AMV) rcvcrse transcriptaac (Life Scicnccs. Bcthcsda. MD) for 60 min at 42°C.

0041-l

run with

positive

and negative

controls.

and the

al Icast 1wicc.

Genotyping

ated. universal

primers;

to _rcnotypc-specific

simultaneous subtypes. Liver

amplification

probes.

determination

products

arc then hyhridircd

INNO-LiPA bzchnology allowed the of the tivc major serotypes and six

Biopsies

Pcrcutancous significantly

liver

hiopsics

were

pcrformcd

clcvatcd

liver

cnLymcs.

after

I ICV infection

sent: one had acquired

Assays

for anti-HO’ antibodies using ii third-generation microparticlc enzyme immunoassay (IMx MEIA, Orthc> Diagnostics Systems and Chiron Corp. NJ) designed to detect antibodies to four recombinant IICV proteins: c?OO. c21-3, HC-34, and HC-31. Hepatitis B surface antigen (HBsAg). antihodits to hepatitis B surface antigen (HBsAb), and antibodies to IIIV were measured hy commercially available kits.’ Strum

sc~it wcrc

wcrc contirmcd

results

t;ltion.

and

kidney

from

one

wiis

a hemodialysis

in two patients

obtaining following

patient

informed renal

about

with con-

transplan-

to receive

;I

his mother.

RESULTS Patients

Nine of 73 patients were HCV-RNA positive (1X3%,). Table I summarizes the data on this group, which included five men and four women. Their mean age was 40 years (range 26 to 60 years). and the mean duration of transplanFrom and

the

Rabin

Department

Medical

School,

Address Nephrology, Kayemet

Medical

Center,

of Medicine Tel-Aviv

reprint Rabin

University,

requests Medical

St, Petach-Tikva,

345/97/$17.00

Department

D and the to

Liver

Sackler

Israel.

Uzi Gafter,

Center,

of Nephrology, Institute,

MD,

Golda

Head,

Campus,

Dept

of

7 Keren

Israel.

0 1997 by Elsevier Science Inc. of the Americas, New York, NY 10910

PII SO041 -1345(97)00560-5

655 Avenue

2696

Transplantation

Proceedings,

29, 2696-2698

(1997)

2697

HEPATITIS C INFECTION IN ISRAEL Table 1. Summary of Data on HCV-RVA-Positive

_ Age/Sex

215 l/l2 2/4 l/3 l/4 l/l I/%

40/M

26/M 26/M 60/F 46/M 59/F 4%/F 42/F 54/M Tr, transplantation;

Dialysis/years

TX No/years

Renal Transplant Recipients Transfusions

anti-HCV

HD/2

0

+

HD/I

0

+

0

+

14

+

HI3 HDl3

0

+

4

0

+

lb

0

+

H/l

4

+

l/3

HD/lO

0

+

chronic

3

HD/1 HD/l

CAPD.

lb

HDl2, CAPDll

l/18

HD, hemodialysis;

Genotpye

ambulatory

peritoneal

tation was 4.6 years (range 1 to 18 years). Transfusion records indicated that two transplant recipients (20%) had received blood transfusions in the past. No patient had a history of intravenous drug abuse or HBsAg or HIV infection.

Z;erology and HCV-RNA Serum samples from patients were evaluated by thirdgeneration anti-HCV enzyme immunoassay and by HCVRNA PCR. Serologic and virologic data for the positive HCV-RNA patients are summarized in Table 1. All patients had anti-HCV antibodies. Ten of the HCV-RNA-negative patients were found to have anti-HCV antibodies. When HCV-RNA PCR is taken as the gold standard for the diagnosis of HCV infection, the third-generation microparticle enzyme immunoassay proved to be a highly reliable test. The sensitivity of the antibody immunoassay was 94% and the specificity was 91%. The positive predictive value of lhc test was 76%. Results of the HCV genotyping were: subtype lb, 3 patients; subtype 3, 1 patient; subtype 4, 1 patient. In the remaining patients, genotyping was unavailable.

Liver Biopsies ‘Two patients underwent a liver biopsy owing to persistent elevated liver enzymes; they both had histological characteristics of chronic hepatitis with varying degrees of activity. ‘The hemodialysis patient received interferon treatment prior to transplantation, and the transplanted patient received ribavarin therapy, both having only a partial responsc.

DISCUSSION

HCV has become the leading cause of dialysis- and transplant-associated hepatitis.‘,’ The risk of acquiring HCV has decreased with the use of recombinant erythropoietin, thereby reducing transfusions and the selective use of organs from anti-HCV-positive donors. Yet the prevalence of HCV infection in renal transplant patients has remained high, reported in the range of 10% to 48%,‘,2 while HCV

lb

dialysis.

positivity in the general population is between 0.3% and 1.6%.’ Nine transplanted patients (12.3%) were found to be HCV-RNA positive. Today, in most centers, renal transplantation from HCV-RNA-positive donors is restricted to positive recipients. Therefore, the risk of acquiring the infection is minimized, although the possibility of being co-infected with different serotypes cannot be overlooked. Chronic liver disease is a major cause of mortality and morbidity in these patients? Two patients with clcvated liver enzymes underwent liver biopsy, having histological characteristics of chronic hepatitis with varying degrees of activity, and they received appropriate therapy, with a partial response. Positive HCV-RNA and abnormalities of liver-function tests have no diagnostic value unless accompanied by liver histology.” The exact impact of chronic HCV infection on the survival of kidney recipients and the influence of transplantation on the evolution of HCV hepatitis are still controversial. In one study, it was found that these patients are at an increased risk for infection, rejection, and posttransplant liver disease, yet no difference was found in patient and graft survival after 5 years.” During a mean follow-up of 5.7 years, yet another group showed significant progression to hepatic failure in 35% of patients with early active chronic hepatitis and in 60% of patients with advanced chronic active hepatitis.’ A liver biopsy should be obtained from every HCV-RNA-positive transplant candidate to histologically stage the patient’s liver disease, rcgardless of the serum transaminase levels. Although the HCV-positive patient may be at increased risk, this should not be considered a contraindication to renal transplantation. Further long-term studies are warranted to answer the question whether HCV-positive patients with biopsyproven chronic active hepatitis on dialysis should be offered renal transplantation as opposed to continuing dialysis.

ACKNOWLEDGMENTS We express our gratitude to Dr. Jerry Orlin for performing the anti-HCV and anti-HBV antihody assays, and to H. Madar and V. Alpert for assisting in collection of the data.

2698

WEINSTEIN,

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