HCV Prevalence, Fatality Greater Among Dialysis Patients, Especially Those on Hemodialysis

Richard Njouom, PhD

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Findings from a recent systematic review and meta-analysis are providing an overview of the global epidemiology of hepatitis C virus (HCV) infection in dialysis patients, describing its prevalence and case fatality rate in this especially-susceptible patient population.¹

The analysis of more than 600 articles revealed a 24.3% worldwide prevalence rate and a 38.7% case fatality rate among patients on dialysis, additionally calling attention to a greater prevalence among patients on hemodialysis (P = .001).¹

Although the World Health Organization (WHO) estimates there are a global 58 million people with chronic HCV infection, its prevalence varies from region to region, especially among high-risk populations such as patients on dialysis. The global epidemiology of HCV in this specific patient population remains underexplored but merits further research to aid eradication efforts and help achieve the WHO’s goal of eliminating HCV by 2030.²

“Increasing access to diagnosis and treatment is essential for reducing HCV-related mortality and morbidity in dialysis patients, according to [the World Health Organization],” wrote investigators.¹ “The lack of epidemiological data that can map the pooled prevalence of HCV in worldwide dialysis centres and target those most in need of treatment will prevent this from being possible.”

To address this gap in knowledge and determine the global prevalence of HCV in dialysis patients, Richard Njouom, PhD, research director of the International Network of Pasteur Institutes and head of the virology department at the Centre Pasteur of Cameroon, and colleagues searched Medline, Excerpta Medica Database (Embase), Global Index Medicus, and Web of Science for articles related to HCV infection among dialysis patients worldwide.¹

Eligible studies were restricted to English and French, were cross-sectional, case-control, and cohort design, described the diagnostic method used, were performed worldwide, reported HCV prevalence in hemodialysis and peritoneal units without regard to age, gender, sampling approach, ethnicity or clinical presentation, publication year, HCV detection method, or sample type, and reported the total number of deaths.¹

Investigators assessed the internal and external quality of all studies. Additionally, subgroup analyses were performed to estimate prevalence variations by HCV diagnostic technique and target, type of dialysis, WHO region, UNSD region, country income level, country, study design, and sampling method.¹

The initial search yielded 8441 articles. A total of 3044 duplicates were excluded and 4379 articles were removed based on titles and abstracts. After all exclusion criteria were applied, 634 articles were included in the qualitative and quantitative synthesis.¹

Investigators noted the majority (89.8%) of the 634 articles were cross-sectional in design. Articles were published between 1990–2022, and participants were recruited between 1968–2022.¹

Study participants ranged in mean age from 7.7 - 72.7 years, and most were recruited from hemodialysis centers (91.8%) and urban areas (57.9%). The male proportion ranged from 12% - 95.4%, the duration of dialysis was between 0.2 - 25.7 years, and the number of dialysis sessions per month was between 3 - 16. According to the WHO Region, most studies were conducted in Europe (34.4%) and in high-income countries (48.7%).¹

Investigators observed an overall HCV fatality rate of 38.7% (95% CI, 28.9–49), obtained from 490 HCV-positive dialysis participants recruited from 8 studies conducted in 8 countries. However, they pointed out a high level of heterogeneity between studies that estimated HCV fatality rates (I2 = 77.5%; 95% CI, 55.6%-88.7%]; P <.001), although no publication bias was detected (P = .221). In sensitivity analyses, studies with a low bias risk and cross-sectional designs produced similar results.¹

Based on a pooled analysis of 392,160 dialysis patients, the prevalence of HCV infection was estimated at 24.3% (95% CI, 22.6–25.9), again with considerable heterogeneity (I2 = 99.3%; 95% CI, 99.2–99.3; P <.001) but also with statistically significant publication bias (P = .001). Investigators additionally observed an anti-HCV prevalence of 24.5% (95% CI, 22.8–26.2), HCV core antigen (HCV-core Ag) of 16.7% (95% CI, 3.4–37), anti-HCV/HCV-core Ag of 22.5% (95% CI, 14.6–31.6), and viral RNA of 23% (95% CI, 17.9–28.7).¹

Subgroup analyses revealed the greatest HCV prevalence rates were observed in Indonesia (63.6%; 95% CI, 42.9–82), Romania (55.3%; 95% CI, 30.8–78.5), Egypt (55.2%; 95% CI, 47.1–63.2), Kosovo (48.2%; 95% CI, 41–55.5), and Poland (46.7%; 95% CI, 37.9–55.5) (P <.001). Investigators pointed out other significant differences based on the type of dialysis, observing an increased prevalence among patients on hemodialysis (P = .001) and HCV diagnostic method, noting an increased prevalence when using indirect ELISA (P = .003).¹

Given the novelty of these findings, investigators outlined several potential limitations to their research, including significant heterogeneity and publication bias as well as the use of a single article to determine HCV prevalence in dialysis patients for certain regions and countries.¹

“There is a high prevalence of HCV infection as well as a high case fatality rate in this study. With an increase in the number of dialysis patients requiring admission, strategies aimed at preventing and eradicating HCV in dialysis units are urgently needed,” investigators concluded.¹

References:

1. ^{Kenfack-Momo R, Nguonoue MD, Kenmoe S, et al. Global epidemiology of hepatitis C virus in dialysis patients: A systematic review and meta-analysis. Plos One. https://doi.org/10.1371/journal.pone.0284169}
2. ^{World Health Organization. Hepatitis C. Newsroom. July 18, 2023. Accessed February 15, 2024. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c}