[Hepatitis B virus and chronic progressive kidney disease]

Abstract

The prevalence and incidence of hepatitis B virus (HBV) infection in end-stage renal disease patients has significantly decreased over the past few decades. HBV infection in dialysis patients presents a distinct clinical problem in view of the immunosuppressive effect of renal failure, susceptibility to de novo infection and nosocomial transmission, long-term implications on morbidity and mortality, and change in clinical course after kidney transplantation. In order to prevent nosocomial transmission, standard precautionary measures must be rigorously followed. In addition to these standard precautions, measures specific to hemodialysis units are also important to prevent nosocomial HBV infection. Hepatitis B vaccination of patients and medical personnel is important both to prevent susceptible patients from acquiring HBV and to reduce the pool of HBV infected patients. Decisions on the treatment of chronic HBV infection are based in part upon an accurate assessment of the presence or absence of virus replication and active liver disease. Optimal therapy may involve the administration of interferon-alfa, nucleotide or nucleoside analogues, combination therapy, liver transplantation, or only observation. In patients infected with HBV that undergo kidney transplantation, the use of a preventive or preemptive approach is recommended to reduce the risk of HBV reactivation post-transplantation. The prophylactic strategy includes the administration of antiviral agents to patients at an increased risk of developing HBV reactivation either prior to or immediately after transplantation. The preemptive strategy includes periodic post-transplantation monitoring for viremia with prompt treatment upon detection and/or increase in HBV DNA levels. HBV infection may be directly associated with a variety of renal diseases, including polyarteritis nodosa, membranous glomerulonephritis and membranoproliferative glomerulonephritis. In the patient suspected of having renal disease associated with HBV, testing for HBV DNA is recommended to confirm active viral replication and kidney biopsy to confirm the presence of an underlying glomerular process, or biopsy at another tissue site to confirm polyarteritis nodosa. It is recommended to treat these patients with an antiviral agent using appropriate dose adjustment for the level of kidney function. In patients with associated vasculitis or rapidly progressive glomerulonephritis, a short course of glucocorticoids may be considered.