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Liver disease in patients undergoing hemodialysis and kidney transplantation
Insights
Liver dysfunction affects 33% of patients undergoing hemodialysis and kidney transplantation. Cytomegalovirus (CMV) reactivation is a significant factor, potentially leading to chronic hepatitis and cirrhosis in these vulnerable patients.
Area of Science:
- Nephrology and Hepatology
- Infectious Diseases
- Transplantation Immunology
Background:
- Liver dysfunction (LD) is a significant complication in patients undergoing renal replacement therapy.
- Hepatitis B virus (HBV) infection, indicated by HBs antigenemia, is a known risk factor for LD in this population.
- The role of other infectious agents and factors in LD development requires further investigation.
Purpose of the Study:
- To investigate the causes and incidence of liver dysfunction in patients treated with hemodialysis and kidney transplantation.
- To assess the contribution of HBs antigenemia and cytomegalovirus (CMV) infection to liver dysfunction.
- To identify potential etiological agents for LD in HBsAg-negative and anti-CMV-negative patients.
Main Methods:
- Retrospective analysis of a cohort of 267 patients undergoing hemodialysis and kidney transplantation between 1969 and 1976.
- Monitoring of HBs antigenemia and serological markers for cytomegalovirus (CMV).
- Clinical and pathological evaluation of liver dysfunction, including drug toxicity and granulomatous disease.
Main Results:
- 33% of patients experienced liver dysfunction; 58% of these had HBs antigenemia, and 77% of HBsAg-positive patients showed LD.
- Despite a decrease in HBs antigenemia prevalence, LD incidence did not decline.
- Cytomegalovirus (CMV) infection was implicated in LD, particularly in HBsAg-negative patients, potentially leading to chronic hepatitis and cirrhosis.
Conclusions:
- Hepatitis B virus remains a significant cause of liver dysfunction in kidney patients, but its impact may be decreasing.
- Cytomegalovirus (CMV) reactivation is a critical factor in liver dysfunction and chronic hepatitis development in kidney recipients.
- Other viral agents, including hepatitis C virus and Epstein-Barr virus, should be investigated as potential causes of liver disease in this patient group.
Abstract:
Liver dysfunction was observed in 33% of patients treated by hemodialysis and kidney transplantation. Fifty-eight percent of these cases of hepatitis occurred in patients with past or present HBs antigenemia, and 77% of HBsAg-positive patients showed evidence of LD. However, during the course of a program conducted from 1969 to 1976 and involving 267 patients, the decrease in the prevalence of HBs antigenemia observed during the last two years did not lead to any reduction in LD incidence. In a small number of patients, potentially hepatotoxic drugs could be incriminated, but in our experience azathioprine never appeared to be involved. In a few patients, LD was due to granulomatous disease of the liver, such as tuberculosis and schistosomiasis. Twenty-one (7%) of the 267 patients at risk developed chronic hepatitis, which contributed to death in nine patients. In 12 cases (three deaths), this form of hepatitis occurred in HBsAg-positive patients, and in nine cases (six deaths), in HBsAg-negative patients. In three of these latter individuals, cytomegalovirus could be incriminated. Routine monthly screening for CMV in kidney recipients confirmed the high incidence of this viral infection in such patients. Studies on murine CMV infection have demonstrated that this infection can be enhanced by histoincompatible graft or by cyclophosphamide in a model that is very close to the kidney recipient. As in mice, CMV infection in kidney recipients apparently results from reactivation of a latent infection. It seems to play a major role in the LD observed and could apparently lead to chronic hepatitis and even to cirrhosis of the liver. Finally, the occurrence of LD in HBsAg-, anti-HBs- and antiCMV-negative patients would suggest the responsibility of other viruses for the pathogenesis of liver disease in patients treated by hemodialysis and kidney transplantation. Besides Epstein-Barr virus, other viruses, such as hepatitis C virus, should be thoroughly scrutinized.