Hepatitis Screening for First-Time Dialysis Patients
For patients initiating in-center hemodialysis, order a comprehensive hepatitis panel consisting of: HBsAg, anti-HBs, anti-HBc for hepatitis B, and anti-HCV antibody (or NAT) for hepatitis C before admission to the dialysis facility. 1, 2
Hepatitis B Screening Requirements
The CDC and Centers for Medicare & Medicaid Services mandate a three-test hepatitis B panel before admission to any outpatient dialysis facility 1, 2:
- HBsAg (Hepatitis B surface antigen): Identifies active infection (acute or chronic) or carrier state 1
- Anti-HBs (Antibody to HBsAg): Indicates immunity from vaccination or resolved infection 1
- Anti-HBc (Antibody to hepatitis B core antigen): Distinguishes natural infection (past or present) from vaccine-induced immunity 1
Why all three tests matter: Testing only HBsAg and anti-HBs misses acute infections during the window period when HBsAg has cleared but anti-HBs hasn't yet developed 1. Testing only HBsAg and anti-HBc fails to identify susceptible patients who need vaccination 1.
Hepatitis C Screening Requirements
The KDIGO 2022 guidelines provide a Grade 1A recommendation to screen all patients upon initiation of in-center hemodialysis using either 1, 2:
- Anti-HCV antibody immunoassay followed by NAT if positive, OR
- NAT (nucleic acid testing) alone in high-prevalence dialysis units 1
Critical consideration: In immunocompromised patients or high-prevalence settings, NAT alone as first-line testing avoids false-negatives during the antibody window period 1, 2. Approximately 10% of anti-HCV-negative hemodialysis patients may be HCV RNA-positive due to this window period 1.
Important technical detail: Draw NAT samples before the dialysis session, as hemodialysis reduces viremia levels 1.
Additional Baseline Testing
Establish a baseline ALT level at dialysis initiation for ongoing HCV surveillance, as newly elevated ALT has 83% sensitivity and 90% specificity for acute HCV infection in hemodialysis patients 1.
Common Pitfalls to Avoid
- Don't skip anti-HBc testing: Economic constraints have led some facilities to screen only HBsAg, but this misses occult HBV infection and fails to distinguish vaccine immunity from natural immunity 3
- Don't assume resolved HCV provides immunity: Patients with resolved HCV remain at risk for reinfection and require ongoing NAT surveillance every 6 months 2, 4
- Don't delay testing until after dialysis initiation: All screening must be completed before admission to the outpatient dialysis facility to implement appropriate infection control measures immediately 1, 2
Post-Admission Surveillance Requirements
Once baseline screening is complete, implement ongoing surveillance 1, 2: