Affiliations
doi: 10.29271/jcpsppg.2025.01.103ABSTRACT
Objective: To determine the prevalence of hepatitis C virus (HCV) infection among patients with chronic kidney disease (CKD) undergoing maintenance haemodialysis, and to evaluate its association with sociodemographic variables.
Study Design: A cross-sectional study.
Place and Duration of the Study: Medical A Unit, MTI Ayub Teaching Hospital, Abbottabad, Pakistan, from September 2024 to March 2025.
Methodology: A total of 73 CKD patients undergoing maintenance haemodialysis were enrolled through non-probability consecutive sampling technique. Data were collected using a structured proforma, including age, gender, socioeconomic status, residence, education level, and duration of dialysis. HCV screening was performed using the third-generation enzyme-linked immunosorbent assay (ELISA). Quantitative variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. The Chi-square test was applied to assess associations between HCV status and categorical variables. A p-value <0.05 was considered statistically significant.
Results: The mean age of the patients was 47.53 ± 13.93 years, and the mean duration of haemodialysis was 1.60 ± 0.78 years. There were 39 (53.4%) males and 34 (46.6%) females. HCV seropositivity was found in 34 (46.6%) patients. Statistically significant associations were observed between HCV positivity and duration of dialysis (p = 0.018) and educational level (p = 0.025). No significant associations were found with gender (p = 0.938), socioeconomic status (p = 0.548), or residence (p = 0.379).
Conclusion: HCV seroprevalence is high among CKD patients on dialysis, particularly among those with longer dialysis duration and lower educational status. Targeted screening and strict infection control measures are recommended.
Key Words: Hepatitis C, Chronic kidney disease, Haemodialysis.
INTRODUCTION
Chronic kidney disease (CKD) is a major non-communicable disease and a growing global health concern. According to the Global Burden of Disease (GBD) study 2017, CKD ranked as the 12th leading cause of death worldwide, affecting approximately 9.1% of the global population—equivalent to 700 million people. This represents a 29.3% increase in prevalence since 1990.1
Hepatitis C virus (HCV) infection is a blood-borne viral disease that remains a significant public health challenge worldwide. Globally, about 58 million people are living with chronic HCV infection, and 1.5 million new infections occur annually.2
In Pakistan, the national prevalence of hepatitis C is estimated at 6.8%, with much higher rates reported in rural populations.3 Patients with CKD undergoing dialysis are at increased risk of acquiring HCV due to repeated vascular access, exposure to blood products, and immune suppression.4
The coexistence of HCV and CKD poses unique clinical challenges. HCV infection in dialysis patients is associated with poor prognosis, increased liver-related complications, and limited eligibility for renal transplantation.5 Despite this, routine screening and surveillance practices in dialysis units remain inconsistent, especially in under-resourced settings. Furthermore, HCV may contribute to glomerular pathologies such as membranoproliferative glomerulonephritis, membranous nephropathy, and cryoglobulinaemic vasculitis.6,7
Previous studies from Pakistan have reported HCV prevalence in dialysis patients ranging from 23.7 to 56.6%.8 However, many of these studies are outdated,9 region-specific, or lack analytical assessment of associated risk factors such as socioeconomic status, education level, and residential background.10 Recent national surveillance data on this population remain limited, creating a gap in effective public health interventions.11
Therefore, this study aimed to determine the current prevalence of HCV infection among CKD patients on maintenance dialysis in a tertiary care teaching hospital, and to analyse its association with specific sociodemographic factors.
METHODOLOGY
This cross-sectional study was conducted at the Medical A Unit, MTI Ayub Teaching Hospital, Abbottabad, Pakistan, from September 2024 to March 2025. Ethical approval was obtained from the hospital’s Institutional Review Board prior to data collection (Approval No. IRB/TH/NEPH/2024-042), and written informed consent was secured from all participants. A total of 73 patients with CKD undergoing maintenance haemodialysis were enrolled through non-probability consecutive sampling technique. The sample size was calculated using the WHO sample size calculator with a 95% confidence level, 9.80% margin of error, and expected prevalence of hepatitis C infection at 23.70%,6,9 resulting in a final sample of 73 patients.
Patients aged 15 to 80 years of either gender who had been on regular haemodialysis for at least three months were included in the study. Patients were excluded if they had a history of chronic liver disease unrelated to hepatitis C, had been previously treated with antiviral therapy for HCV, had received a blood transfusion within the preceding month, or had comorbid conditions such as autoimmune diseases, malignancy, or HIV infection. Individuals who declined to provide consent were also excluded.
Data were collected using a structured proforma that included demographic variables such as age, gender, education level, residential status, socioeconomic class, and duration of dialysis. Blood samples were tested for hepatitis C infection using a third-generation enzyme-linked immunosorbent assay (ELISA) to detect anti-HCV antibodies. Due to limited institutional resources, molecular confirmation through HCV RNA PCR testing was not performed.
Data were analysed using the SPSS version 25.0. Quantitative variables such as age were expressed as mean ± standard deviation (SD), while categorical variables such as gender, residence, socioeconomic status, and HCV seropositivity were summarised as frequencies and percentages. Associations between hepatitis C positivity and categorical demographic factors were evaluated using the Chi-square test, and a p-value of less than 0.05 was considered statistically significant.
RESULTS
A total of 73 patients undergoing maintenance haemodialysis were included in the study. The mean age was 47.53 ± 13.93 years, and the mean duration of dialysis was 1.60 ± 0.78 years. There were 39 (53.4%) male and 34 (46.6%) female participants. Most patients belonged to the low socioeconomic class (56, 76.7%) and resided in rural areas (55, 75.3%). Regarding educational background, 49 (67.1%) had no formal education, while only 1 (1.4%) had higher education. Anti-HCV antibodies were detected in 34 (46.6%) patients, while 39 (53.4%) were HCV negative (Table I).
Analysis of associations revealed that 18 (46.2%) of 39 male patients and 16 (47.1%) of 34 female patients were HCV positive; this difference was not statistically significant (p = 0.938). A significant association was observed between duration of haemodialysis and HCV seropositivity (p = 0.018); patients on dialysis for two years had the highest rate of HCV positivity at 13 (72.2%), followed by those on dialysis for more than two years at 7 (53.8%).
There was no statistically significant association between socioeconomic status and HCV positivity; 25 (44.6%) of 56 patients from the low socioeconomic group and 9 (52.9%) of 17 from the middle income group were HCV positive (p = 0.548). Similarly, among rural residents, 24 (43.6%) were HCV positive compared to 10 (55.6%) of urban residents (p = 0.379).
A statistically significant association was observed between the education level and HCV status (p = 0.025). Among patients with no formal education, 19 (38.8%) were HCV positive. In contrast, all 3 patients with intermediate education were HCV negative, and 1 (100.0%) patient with higher education was HCV positive (Table II).
Table I: The baseline characteristics of CKD patients on haemodialysis (n = 73).
|
Variables |
Values |
|
Age (years) |
47.53 ± 13.93 |
|
Duration of haemodialysis (years) |
1.60 ± 0.78 |
|
Gender |
- |
|
Male |
39 (53.4%) |
|
Female |
34 (46.6%) |
|
Duration of haemodialysis |
- |
|
1 year |
42 (57.5%) |
|
2 years |
18 (24.7%) |
|
More than 2 years |
13 (17.8%) |
|
Socioeconomic status |
- |
|
Low |
56 (76.7%) |
|
Middle |
17 (23.3%) |
|
Residence |
- |
|
Rural |
55 (75.3%) |
|
Urban |
18 (24.7%) |
|
Education level |
- |
|
No formal education |
49 (67.1%) |
|
Matriculation |
20 (27.4%) |
|
Intermediate |
3 (4.1%) |
|
Higher |
1 (1.4%) |
|
Hepatitis C serology |
- |
|
Positive |
34 (46.6%) |
|
Negative |
39 (53.4%) |
DISCUSSION
This study found a high prevalence (46.6%) of HCV infection among CKD patients undergoing maintenance haemodialysis. These findings are consistent with previous reports from Pakistan, where HCV prevalence in dialysis patients ranges from 23.7 to 56.6%.8-11 The persistence of high HCV burden in dialysis units despite existing guidelines points to ongoing lapses in infection control, especially in resource-limited settings.12
Table II: The association of hepatitis C seropositivity with demographic and clinical variables (n = 73).
|
Variables |
Subgroups |
HCV |
p-values |
|
|
Positive |
Negative |
|||
|
Gender |
Male |
18 (46.2%) |
21 (53.8%) |
0.938 |
|
Female |
16 (47.1%) |
18 (52.9%) |
||
|
Duration of haemodialysis |
1 year |
14 (33.3%) |
28 (66.7%) |
0.018* |
|
2 years |
13 (72.2%) |
5 (27.8%) |
||
|
>2 years |
7 (53.8%) |
6 (46.2%) |
||
|
Socioeconomic status |
Low |
25 (44.6%) |
31 (55.4%) |
0.548 |
|
Middle |
9 (52.9%) |
8 (47.1%) |
||
|
Residence |
Rural |
24 (43.6%) |
31 (56.4%) |
0.379 |
|
Urban |
10 (55.6%) |
8 (44.4%) |
||
|
Education level |
No formal education |
19 (38.8%) |
30 (61.2%) |
0.025 |
|
Matriculation |
14 (70.0%) |
6 (30.0%) |
||
|
Intermediate |
0 (0.0%) |
3 (100.0%) |
||
|
Higher |
1 (100.0%) |
0 (0.0%) |
||
A significant association was found between the duration of haemodialysis and HCV seropositivity, with the highest prevalence among patients on dialysis for two years. Prolonged vascular access, repeated blood exposure, and shared dialysis equipment increase the risk of viral transmission over time.13 This aligns with studies from Italy and India, where longer dialysis vintage was a key risk factor for HCV infection.14,15
Lower education level was also significantly associated with HCV positivity. Patients with no formal education had substantially higher rates of infection compared to those with primary or higher education. This may reflect poorer awareness of infection risks and reduced health-seeking behaviour among less educated individuals.16 Similarly, other regional studies have linked low literacy to poor compliance with hygiene and infection prevention protocols.17
No significant associations were observed between HCV positivity and gender, socioeconomic status, or place of residence in this study. This contrasts with previous literature suggesting higher HCV prevalence in rural areas and among individuals from lower socioeconomic backgrounds.18,19 The lack of significance in this study may be due to the small sample size and the homogeneity of patients in terms of healthcare exposure.
While international guidelines recommend both serologic and nucleic acid testing (NAT) for accurate HCV diagnosis in CKD patients.20 This study relied solely on ELISA due to resource limitations. This could have led to underdiagnoses or misclassification of cases, particularly in the window period of seroconversion. Additionally, data on dialysis centre infection control practices and transfusion history were not collected, limiting the ability to evaluate institutional risk factors.21
Despite these limitations, the study provides valuable insight into the current epidemiology of HCV among dialysis patients in a local tertiary care setting. The findings underscore the urgent need for comprehensive infection prevention strategies, routine HCV screening, staff training, and patient education in dialysis units.22
CONCLUSION
The prevalence of hepatitis C infection among patients with CKD undergoing maintenance haemodialysis was found to be considerably high. Significant associations were observed with duration of dialysis and lower education levels, highlighting the need for strengthened infection control practices, routine HCV screening, and targeted patient education. Early identification and preventive measures within dialysis units are critical to reducing the transmission risk and improving clinical outcomes in this vulnerable population.
ETHICAL APPROVAL:
Ethical approval was obtained from the Institutional Review Board of the MTI Ayub Teaching Hospital, Abbottabad, Pakistan (Approval No. IRB/TH/NEPH/2024-042).
PATIENTS’ CONSENT:
Written informed consent was secured from all participants included in this study.
COMPETING INTEREST:
The authors declared no conflict of interest.
AUTHORS’ CONTRIBUTION:
AU: Design of the work, acquisition, analysis, and interpretation of the data.
NA: Drafting of the work and data collection.
MUS: Analysis and interpretation of the data.
AS: Study design and data collection.
All authors approved the final version of the manuscript to be published.
REFERENCES