Một đề tài fulltext về tình trạng nhiễm viêm gan ở bệnh nhân chạy thận nhân tạo. Đề tài có trích dẫn tài liệu tham khảo đầy đủ tiện làm tổng quan y văn cho các bạn học viên cao học chuyên ngành y dược. Kết quả đề tài cho thấy: có 11,44% bệnh nhân chạy thận nhân tạo bị nhiễm viêm gan B. Tỷ lệ bệnh nhân có dương tính HBSAb là 51,46%. Tỷ lệ bệnh nhân nhiễm HCV là 21,24%. Tỷ lệ nhân viên y tế dương tính HBsAg là 8%. Tỷ lệ nhiễm viêm gan tỷ lệ thuận với thời gian bệnh nhân chạy thận, Bệnh nhân chạy thận có truyền máu sẽ có nguy cơ nhiễm viêm gan cao hơn bệnh nhân không truyền máu.
SURVEY ON THE HEPATITIS VIRUS INFECTION IN HEMODIALYSIS PATIENTS AT CHO RAY HOSPITAL IN VIET NAM Graduate student: Supervisor: Nguyen Tran Duc Professor Neoh, Choo - Aun SURVEY ON THE HEPATITIS VIRUS INFECTION IN HEMODIALYSIS PATIENTS AT CHO RAY HOSPITAL IN VIET NAM Graduate student: Nguyen Tran Duc Supervisor: Professor Neoh, Choo - Aun Meiho University Graduate Institute of Health Care Thesis A thesis submitted to the Graduate Institute of health Care of Meiho Institute of Technology In partial fulfillment of the requirement for the degree of Master of Health Care July 2014 Abstract Hemodialysis patients are at the more higher risk group for Hepatitis B virus ( HBV) and Hepatitis C virus ( HCV) infection than the general population The two this diseases are the main cause increased morbidity and mortality in hemodialysis patient The aim of this study was carried out to determine the rate of HBV and HCV among hemodialysis patients and medical staff , as well as understanding risk factors for infection Also to identify the relationship between dialysis duration with hepatitis prevalence in this groups Because of the HEV testing not makes in my hospital and a lot of hospitals in the south of Viet nam, so I can't collect HEV data This cross-sectional description study was conducted at the hemodialysis department in Cho Ray Hospital A convenience sample was 311 patients, who was treating by hemodialysis and 50 medical staff are working at this department Blood samples were taken immediately before start of dialysis Data analysis was done by using the Statistical Package for Social sciences SPSS 16.0 for Window Result: The mean age of patients was 49.55 ± 16.47 with a range from 19-92 years of age The percentage of patients with positive hepatitis B were 35 patients (11.44% ) There are 159 patients ( 51,46% ) with Positive Anti-HBs The mean HBsAg of 311 patients was 168.85 ± 710.23 with the range varies from 0.065610.22) The percentage of patients with hepatitis C were 65 patients (21.24%) The duration of hemodialysis had a statistical significant association with HCV infection in which the more patients had dialysis the more risk of HCV infection they got (p = 0.002) The percentage of medical staff with positive hepatitis B were (8% ) The result of our study show the need for regular screening of HBV and HCV among patients and medical staff in our hemodialysis unit, the strict observance of communicable disease precautions by thorough staff and patients education and monitoring Keywords: Hemodialysis (HD), hepatitis B virus (HBV), hepatitis C virus (HCV) Acknowledgement During the perform this thesis, I have received the enthusiastic support of everyone I would like to express my gratitude to all those who helped me complete this thesis First of all, I would like to thank Meiho University in Taiwan and Nguyen Tat Thanh University in Viet Nam has created conditions for me to join this course I would like to send sincere thanks to the teachers of the Meiho University and Medicine and Pharmacy University in Ho Chi Minh City has to offer expertise and knowledge base that can be write a research topic I am honored to express my deepest gratitude to my dedicated supervisor, Professor Neoh, Choo-Aun , who has direct instructions, repair and help me to complete my thesis I would like to thank friends and colleagues in Hemodialysis Unit, Cho Ray hospital who helped me in collecting data and providing documentation to complete this thesis Contents Certification……………………………………………………………………… ii Abstract………………………………………………………………… ……….iii Acknowledgement ……………………………………………………………… iv List of figures…………………………………………………………………… ix List of tables……………………………………………………………………… x Chapter INTRODUCTION 1.1 Statement of this research: 1.2 Significance of this research: .3 1.3 Aim of this research: 2.2 States of chronic kidney disease ( CKD ) Table 2.1 Kidney disease outcomes quality initiative suggested stage of chronic kidney disease 2.3 WHAT IS HEMODIALYSIS ? * What are the risks and potential complications of dialysis? 19 2.4 Hepatitis B and C .22 2.6 Chapter summary .44 Chapter Research methodology 45 3.1 Introduction: .45 3.2 Research design: 45 3.3 The research framework 45 3.4 Sampling issues: 46 3.5 Data management and data analysis strategy: 47 3.6 Ethic issue: 47 3.7 Summary 48 CHAPTER RESULTS 49 4.1 Introduction 49 Table 4.1 Demographic characteristics of patients (n=311) 49 Table 4.2 Health conditions of patients prior to dialysis (n=311) 50 Table 4.3 Subclinical characteristics of patients prior to dialysis (n=311) 50 Table 4.4 Factors related to dialysis and treatment of patients (n=311) 51 4.4 Laboratory findings of patients with dialysis .52 Table 4.6 HBV infection results 52 Table 4.7 HCV infection results 53 Table 4.9 Liver fuction results .54 Table 4.10 The characteristics of patients with HBV infection 56 Table 4.13 The number of cases summary of HBV infection, HCV infection and HCV + HBV infection (if classified by private group) 62 Table 4.14 The relationship between HBV infection and other factors (n=311) 62 Table 4.15 The relationship between HCV infection and other factors .64 Table 4.16 Characteristics of medical staff (n=50) 66 4.6 Chapter summary 67 CHAPTER Discussion and conclusion .68 5.1 Introduction 68 5.2 Discussing the significance results of findings 68 Figures 5.1 HBsAg prevalence in Asia- Pacific countries 70 Figures 5.2 HCV prevalence in Asia- Pacific countries .73 5.3 Viral hepatitis among health-care staff 79 5.4 Contributions and Implications 79 5.5 Limitations 81 5.6 Recommendation for further research .82 5.7 Conclusion 82 5.8 Summary 83 References 85 Chapter INTRODUCTION 1.1 Statement of this research: 1.2 Significance of this research: .3 1.3 Aim of this research: 2.2 States of chronic kidney disease ( CKD ) Table 2.1 Kidney disease outcomes quality initiative suggested stage of chronic kidney disease 2.3 WHAT IS HEMODIALYSIS ? * What are the risks and potential complications of dialysis? 19 2.4 Hepatitis B and C .22 2.6 Chapter summary .44 Chapter Research methodology 45 3.1 Introduction: .45 3.2 Research design: 45 3.3 The research framework 45 3.4 Sampling issues: 46 3.5 Data management and data analysis strategy: 47 3.6 Ethic issue: 47 3.7 Summary 48 CHAPTER RESULTS 49 4.1 Introduction 49 Table 4.1 Demographic characteristics of patients (n=311) 49 Table 4.2 Health conditions of patients prior to dialysis (n=311) 50 Table 4.3 Subclinical characteristics of patients prior to dialysis (n=311) 50 Table 4.4 Factors related to dialysis and treatment of patients (n=311) 51 4.4 Laboratory findings of patients with dialysis .52 Table 4.6 HBV infection results 52 Table 4.7 HCV infection results 53 Table 4.9 Liver fuction results .54 Table 4.10 The characteristics of patients with HBV infection 56 Table 4.13 The number of cases summary of HBV infection, HCV infection and HCV + HBV infection (if classified by private group) 62 Table 4.14 The relationship between HBV infection and other factors (n=311) 62 Table 4.15 The relationship between HCV infection and other factors .64 Table 4.16 Characteristics of medical staff (n=50) 66 4.6 Chapter summary 67 CHAPTER Discussion and conclusion .68 5.1 Introduction 68 5.2 Discussing the significance results of findings 68 Figures 5.1 HBsAg prevalence in Asia- Pacific countries 70 Figures 5.2 HCV prevalence in Asia- Pacific countries .73 5.3 Viral hepatitis among health-care staff 79 5.4 Contributions and Implications 79 5.5 Limitations 81 5.6 Recommendation for further research .82 5.7 Conclusion 82 5.8 Summary 83 References 85 Chapter INTRODUCTION 1.1 Statement of this research: 1.2 Significance of this research: .3 1.3 Aim of this research: 2.2 States of chronic kidney disease ( CKD ) Table 2.1 Kidney disease outcomes quality initiative suggested stage of chronic kidney disease 2.3 WHAT IS HEMODIALYSIS ? * What are the risks and potential complications of dialysis? 19 2.4 Hepatitis B and C .22 2.6 Chapter summary .44 Chapter Research methodology 45 3.1 Introduction: .45 3.2 Research design: 45 3.3 The research framework 45 3.4 Sampling issues: 46 3.5 Data management and data analysis strategy: 47 3.6 Ethic issue: 47 3.7 Summary 48 CHAPTER RESULTS 49 4.1 Introduction 49 Table 4.1 Demographic characteristics of patients (n=311) 49 Table 4.2 Health conditions of patients prior to dialysis (n=311) 50 Table 4.3 Subclinical characteristics of patients prior to dialysis (n=311) 50 countries In fact, our finding was higher than those found in several Asia-Pacific countries and lower than that in a study conducted in Shanghai, China That difference may be due to Vietnam is on the ring of endemic of hepatitis virus and preventive immunization was still insufficient b The proportion of HBsAb In our study, the proportion of positive antiHBs was 51.46% (159/306) The figure was much higher than proportion of positive HBsAg (almost five-fold) This may result from earlier HBV infection among hemodialysis patients without HBV immunization The proportion was higher than those in previous studies A study of Ferreira showed a lower proportion of positive antiHBs (24.8%), while that proportion in a study of Phanichphant was 36.8% The percentage of negative antiHbs in our study was 48.54% (150/366) This group of patients could have a high risk of HBV infection, so they need to be administered preventive immunization for hepatitis B 71 c The proportion of HCV Among 306 patients, the proportion of positive anti-HCV was 21.24% (65/306) Compared with the prevalence of anti-HCV in the general community, the proportion in the present study was much higher (4.3%) However, it was lower than that found in a 2008 study carried out in Bach Mai Hospital (49.2%) Our result was similar to findings of many studies in artificial kidney centers in several countries around the world The prevalence of positive anti-HCV in periodically dialysis patients was significantly higher than that in healthy communities The global proportion of positive HCV among dialysis patients ranged from 6.1% in Germany to nearly 70% in Casablanca Generally, North Africa and Middle East are regions having higher proportion of patients infected with HCV compared to other areas Previous studies in different region had reported the following proportions of positive anti-HCV in patients treated at several dialysis centers: - 80,7% in Indonesia - 50% in Saudi Arabia - 43% in Kosova - 31.1 % in Libya - 22,5 – 32,1 % in Italy 72 - 20,2% in Turkey - 21% in Jordan - 16,3% in France - 7% - 23,3% in United State - 6,7% in Mexico - 6,1% in German - 6.1% in China - 4% in UK In the study conducted at Asia-Pacific countries the proportion of positive anti-HCV ranged from 0,7% to 18,1% (HD: hemodialysis) Figures 5.2 HCV prevalence in Asia- Pacific countries 73 Through the result in our study, we concluded that the proportion of positive anti-HCV among our study population was higher than those found in other countries in the region This may be due to the prevalence of hepatitis in the population was high and that resulted in high proportion of positive anti-HCV at hospital admission (8.05%) Moreover, lack of machines and poor infrastructure resulted in sharing utilization of dialysis machine among healthy patients and patients with HCV infection, changes in ward where patients had dialysis, longterm duration of dialysis, and overuse of dialyzer may be the key factors that contribute to that high proportion Finally, blood transfusion for some patients at the beginning of the dialysis also leads to that high rate Our data suggested that a small part of patients (13.46%) with positive antiHCV aged from 33 to 49 years and 11.41% were in the age group of over 50 This observation was consistent with previous studies In general, the high proportions of HBV (+) and HCV (+) in hemodialysis patients reflects widespread infection of hepatitis virus in the general population, the limited quality of health care services, and poor control of nosocomial infections at dialysis unit The importance of preventing infection should be further enhanced to reduce mortality in hemodialysis patients 74 d HBC and HCV infection and the duration of dialysis Many studies have concluded that patients with long-term hemodialysis had higher risk of infecting of hepatitis virus In the present study, we found that: • Among patients with positive HBV infection: - The proportion of patients with less than years of dialysis was 12.28% (21/171) - The proportion of patients with 5-10 years of dialysis was 9.19% (10/109) - The proportion of patients with over 10 years of dialysis was 15.38% (4/26) • Among patients with positive HCV infection: - The proportion of patients with less than years of dialysis was 15,20% (26/171) - The proportion of patients with 5-10 years of dialysis was 22.94 % ( 25/109) - The proportion of patients with over 10 years of dialysis was 53.85% (4/26) From those results, we suggested that the more duration of dialysis patients had the more risk of hepatitis virus they infected, especially with HCV (p < 0.001) A study of Nguyen Dang Manh investigating on the risk of HCV infection among hemodialysis patients also confirmed that patients with multiple times of dialysis were at higher risk of hepatitis virus infection Namely, the prevalence of positive HCV infection after months of dialysis was 22.77 %, whereas the 75 prevalence after 12 months of dialysis increased sharply up to 42.57 % None of studied patients had a history of positive anti-HCV at the time of admission To explain the relationship between hepatitis virus infection and duration of dialysis, many authors suggested that long-term dialysis patients could had blood transfusion during their dialysis that could result in higher risk of hepatitis infection However, some other studies showed strong evidence that about 5-25.7% of dialysis patients who did not have blood transfusion were infected with hepatitis virus due to several risk factors including nosocomial cross-sectional infection, sharing dialysis machine, dialysis within the same rooms with infected patients, operative procedures, and multiple reuse of dialyzer e Hepatitis infection and blood transfusion For years, it is believed that blood tranfusion has strong association with HCV infection and other communicable diseases Moreover, blood donors who had anti-HCV during their incubational period have not been diagnosed with high accuracy Those may be the reservoir of infection to blood recipients In the last few decades, in spite of breakthrough progresses in preventing hepatitis transmission during blood transfusions, HBV or HCV infection are still occurring, especially among patients with immunosupression or long-term dialysis 76 Since HCV immunization is not available now, preventions of HCV infection are mostly done by non-specific measures of reduction of risk factors To investigate the risk of hepatitis virus infection among dialysis patients, we conducted the present study at Artificial Kidneys ward in Cho Ray hospital Data related to blood transfusion was provided by a colleague carrying out a study on anemia treatment In our study, 65 patients (20.9%) had blood transfusions Of those, 15.63% had positive HBsAg compared to 10.33% in patients without blood transfusion and 30.77% had positive HCV compared to 18.67% in patients without blood transfusion The resulted showed that a small amount of patients with HBV and HCV infection were due to blood transfusion during their dialysis A study conducted in Uruguay the prevalence of HCV and HBV infection in dialysis patients with blood transfusion was 6.2% and 1.2%, respectively Dussol et al reported that only 7% dialysis patients without blood transfusion were diagnosed with positive anti-HCV, this figure was 73% among dialysis patients with blood transfusion The risk of infection can be reduced by more effective management of anemia with iron supplements and erythropoietin administration f Hepatitis virus infection and renal transplantation Renal transplantation is also a factor that could increase the rate of hepatitis as the graft source is not well controlled In our study, there were 15 patients with a history of renal transplantation; of those, patient had positive HBsAg (6.67%) 77 and patients had positive HCV (20%) That data was comparable with those from other studies g AST and ALT enzyme levels in dialysis patients The serum level of transaminase enzyme closely relates to the extent of inflammation and necrosis of hepatocytes in hepatitis patients However, the serum concentration of transaminase in patients with renal failure was lower than that in patients with other health conditions The study results showed that among 311 patients the mean AST was 29.85 ± 19:42 (6-190) and the mean ALT was 22.98 ± 23.75 (5-198) Therefore, the concentration of transaminase in the study was higher than that in the study of Yasuda in which the mean AST was 9,2 ± 2,4 and the mean ALT was 7.4 ± 1.7 UI/L , but was comparable with that in the study of Wong Ping in which the mean AST was 24 UI/L and the mean ALT was 17 UI/L The proportion of patients with the AST concentration that was higher than normal level was 8.36% (26/311) Among those, got positive HBsAg accounting for 11.54% and 11 patients with positive anti-HCV accounting for 42.31% The proportion of patients with ALT concentration that was higher than normal level was 8.04% (25/311) Of those, had positive HBsAg accounted for 12% and 11 patients had positive HCV accounting for 44% rate The result showed that patients with positive HCV had the levels of AST and ALT 78 higher than those in patients with positive HBsAg and patients without hepatitis infection In addition, we also found a statistically significant difference in AST and ALT levels between patients with and without viral hepatitis (p = 0.008) 5.3 Viral hepatitis among health-care staff In our study, there were 50 health staff working in the ward There were five employees (10%) had positive HBsAg at the beginning of work Other studies had prevalence of positive HBsAg among health-care staff approximately 3% There were only staff (18%) had HBV immunization The results showed that there were staff with positive HBsAg (8%), staff with positive HBsAg at the beginning but negative after treatment There were 26 employees had positive HBsAb accounting for 52% and 24 employees had negative HBsAb constituting for 46% Those were persons who did not have anti-HBV, so preventive measures should be carried out on those to prevent the widespread of the disease among health staff 5.4 Contributions and Implications The results of our study showed the need for regular testing of HBV and HCV among patients with long-term hemodialysis and medical staff in the renal unit of Cho Ray hospital to detect and prevent promptly and properly crosssectional infection It is necessary to comply with the preventive measures of cross-sectional 79 infection of HBV and HCV recommended by international organization (CDC, WHO ) among dialysis patients and medical staff It is necessary to improve and enhance the standard procedure of nursing toward patients In addition, overcoming the limitations and shortcomings in practicing nursing is also vital task for the hospital There is a need for separately isolated dialysis rooms for patients infected with HBV and HCV Limiting blood transfusions and implementing safety measures in blood transfusion including alternation of blood with drugs such as Erythropoietin and application of modern techniques in dialysis to ensure the quality of transfused blood Diagnosing and treating of HBV infection in general communities and then application proper treatment methods for dialysis patients based on their background profile HBV immunization should be performed for communities, dialysis patients and medical staff to prevent the widespread of the disease Developing a training program in which patients and medical staff will be trained about the importance of hepatitis prevention and the enormous impacts caused by cross-contamination 80 5.5 Limitations Some limitations of this study had been found Medical records usually did not provided sufficient information on clinical characteristics and laboratory findings of patients, particularly new records in the last year because of changes of formats Consequently, several added information must be collected during the examination of doctors in the ward Diagnosis indications from doctors were not followed routine procedure and that resulted in lacking of information during data collection process The identification of prevalence of patients with incubated HBV infection was not sufficient, so identification of overall proportion of HBV infection was impossible The number of dialysis patients in each ward was not well documented In addition, the collection of data on blood transfusion encountered difficulties since patients had blood transfusion from a variety of wards prior to transferred to the renal unit The solution for that problem was utilization of data collected from an implementing study conducted by another doctors in the ward There were several difficulties those we had to face during the collection of data on history of hepatitis infection The data on history of HBV or HCV infection was collected based on medical recorded and patients’ recall as they firstly presented to the hospital Unfortunately, due to long-term dialysis, medical records of several patients 81 were not well documented and patients could not remember exactly their history of hepatitis infection Another problem was that a small portion of patients was not diagnosed as positive viral hepatitis at the admission due to their incubation of the disease and then was onset of the disease during their dialysis All of mentioned problems resulted in limitations of identifying the incidence of viral hepatitis among studied population With limited time of studying, a cross-sectional study design was reasonable However, the investigation of relationships between viral hepatitis infection and epidemiological characteristics of patients could not have causal conclusions 5.6 Recommendation for further research No studies on the same topic have been conducted in the ward in previous years, so the data collection was engaged lots of difficulties From the findings of the study, it is advisable to conduct a consecutive study in which identifying the incidence of viral hepatitis infection and exploring the causal relationships of hepatitis infection and other risk factors will be the main aims of the study A secondary objective of the study will be identification of factors that had impacts on quality of life of long-term dialysis patients and from the findings we could advocate a training program on improving patient’s quality of life 5.7 Conclusion The study on current status of hepatitis infection in hemodialysis patients at 82 Cho Ray Hospital had obtained following conclusion: The prevalence of HBV infection - The proportion of positive HBsAg was 11.44% (35/306) This proportion was at average level compared to those in developing countries but higher compared to developed countries -The proportion of positive HBsAb was 51.46% (159/306) The prevalence of HCV infection: - The proportion of positive HCV was 21.24% (65/305) This proportion was higher than those in Asia-Pacific countries The prevalence of HBV among medical staff - The proportion of positive HBsAg was 8% ( 4/50) - The proportion of positive HBsAb was 52% ( 26/50) The prevalence of viral hepatitis in dialysis patients increases proportionally with the duration of dialysis The longer duration of dialysis patients had the higher risk of infection they encountered The risk of viral hepatitis infection among patients with blood transfusion was higher than that among patient without 5.8 Summary This chapter has outlined the main findings of the study on the prevalence of viral hepatitis and discussions with comparison to the results of other studies worldwide From these findings, some recommendations were established to 83 reduce the transmission of disease among patients with dialysis In addition, based on the findings of the study, the authors are going to carry further studies to explore more knowledge on that topic Finally, the limitations of the study also mentioned 84 References 85 ... References 85 Chapter INTRODUCTION 1.1 Statement of this research: According to the World Health Organization , chronic viral hepatitis are very popular across the globe An estimated 350 million... Then it is softened Next the water is run through a tank containing activated charcoal to adsorb organic contaminants Primary purification is then done by forcing water through a membrane with very... its next use The newer method of automated reuse is achieved by means of a medical device which began in the early 1980s These devices are beneficial to dialysis clinics that practice reuse- especially