Management of Hepatitis B Patients Undergoing Dialysis
HBsAg-positive dialysis patients who require treatment should receive entecavir (ETV) or tenofovir alafenamide fumarate (TAF) as first-line antiviral therapy, with appropriate dose adjustments based on renal function. 1
Screening and Diagnosis
- All dialysis patients should be screened for HBV markers (HBsAg, anti-HBs, and anti-HBc) before admission to a dialysis unit 1, 2
- Monthly HBsAg screening is recommended for susceptible patients to identify seroconversion early 2
- Annual monitoring of anti-HBs antibody levels is necessary, with revaccination if levels fall below 10 IU/L 2
Infection Control Measures
- Standard precautions to avoid nosocomial transmission are essential for preventing HBV transmission in dialysis units 1, 2
- Key infection control practices include proper hand hygiene, glove changes between patient contacts, aseptic medication preparation, and thorough cleaning of dialysis stations 2
- Regular observational audits of infection control procedures should be conducted to ensure compliance 2
Vaccination
- Vaccination is necessary for all dialysis patients without anti-HBs protection 1, 2
- Vaccine efficacy is higher when administered earlier, as antibody production rates are lower in dialysis patients (50-60%) compared to the general population (90%) 1
- Antibody response decreases as residual renal function declines, emphasizing the importance of early vaccination 1
Antiviral Treatment
- Oral antiviral agents are strongly recommended over interferon-alpha for HBV-infected dialysis patients due to increased adverse events with interferon in this population 1
- Entecavir (ETV) is the preferred first-line agent for nucleos(t)ide analog (NA)-naïve patients 1
- For patients on hemodialysis with creatinine clearance <10 mL/min, entecavir dose should be adjusted to 0.5 mg every 7 days (or 1 mg every 7 days for lamivudine-refractory patients) 3
- TAF is another preferred option when available, particularly for patients with risk factors for bone disease 1
- Tenofovir disoproxil fumarate (TDF) should be avoided due to renal safety concerns 1
- Lamivudine is not recommended due to high resistance rates (up to 39% at 16.5 months) 1
Monitoring During Treatment
- Regular monitoring of HBV DNA levels is essential during and after antiviral therapy 1
- Renal function should be carefully monitored during treatment with NAs 1
- Unexpected deterioration of renal function during NA therapy may necessitate a change of treatment or dose adaptation 1
- Liver function tests may be unreliable in dialysis patients as they can progress with modest hepatic inflammation despite significant fibrosis 4
Special Considerations
HBV/HCV Co-infection
- Determine which virus is dominant through serologic or virologic tests 1
- For patients with detectable HCV RNA, appropriate HCV treatment should be initiated 1
- Monitor for HBV reactivation during or after HCV treatment 1
Renal Transplant Candidates
- All HBsAg-positive renal transplant recipients should receive ETV or TAF as prophylaxis or treatment 1
- Long-term NA therapy has been shown to reduce liver complications and improve survival in transplant recipients 1, 5
- PegIFN-α is contraindicated in transplant recipients due to the risk of rejection 1
Pitfalls and Caveats
- Aminotransferase levels are an unreliable parameter for assessing HBV activity in dialysis patients; levels may remain normal despite active disease 1, 4
- The conventional cut-off level for serum ALT may be too high for dialysis patients; consider liver disease activity with ALT levels >30 IU/L 4
- Lamivudine resistance develops rapidly in dialysis patients, similar to the general population, making it a poor long-term option 1, 4
- HBsAg-negative, anti-HBc positive patients should be monitored for HBV reactivation, especially after transplantation 1
- When a new case of HBV is identified in a dialysis unit, aggressive measures must be taken to improve infection control practices 2