Which hepatitis tests are required before initiating dialysis?

Hepatitis Testing Required Prior to Dialysis

All patients initiating dialysis must be screened for both hepatitis B and hepatitis C, with specific testing panels that include HBsAg, anti-HBs, and anti-HBc for hepatitis B, plus HCV antibody testing (or nucleic acid testing) for hepatitis C. 1

Hepatitis B Testing Panel

The CDC and CMS mandate a comprehensive three-test panel for hepatitis B screening before dialysis admission 1:

• Hepatitis B surface antigen (HBsAg) - identifies active infection or carrier state 1
• Antibody to hepatitis B surface antigen (anti-HBs) - indicates immunity from vaccination or prior cleared infection 1
• Antibody to hepatitis B core antigen (anti-HBc) - detects prior or ongoing infection, crucial for identifying acute infection in the window period 1

This three-test approach is essential because testing only HBsAg and anti-HBs can miss acute infections during the window period when HBsAg has cleared but anti-HBs has not yet developed. 1 Testing only HBsAg and anti-HBc fails to identify susceptible patients who need vaccination. 1

Hepatitis C Testing

For hepatitis C screening at dialysis initiation 2, 1:

• Initial screening with HCV antibody (anti-HCV) testing is the standard approach 1
• Nucleic acid testing (NAT) alone or anti-HCV followed by NAT if positive is recommended for in-center hemodialysis patients (KDIGO 1A recommendation) 2
• In high-prevalence dialysis settings, immediate NAT should be considered rather than antibody testing first 2

Samples for HCV NAT should be drawn before the dialysis session, as hemodialysis reduces viremia levels. 2

Dialysis Modality-Specific Recommendations

In-Center Hemodialysis

• Mandatory screening for both HBV and HCV upon initiation (KDIGO 1A) 2, 1
• Repeat screening upon transfer from another dialysis facility or modality (KDIGO 1A) 2
• Monthly HBsAg screening for susceptible patients (negative HBsAg and anti-HBs) 1
• Annual anti-HBs screening for immune patients, with revaccination if levels fall below 10 IU/L 1

Peritoneal Dialysis and Home Hemodialysis

• Screening is suggested upon initiation (KDIGO 2D), though the evidence is weaker than for in-center hemodialysis 2
• If these patients require temporary in-center hemodialysis, they should be screened as per in-center protocols, with continued screening until 6 months after returning to their original modality 2

Additional Considerations

HIV Screening

CDC recommends HIV antibody testing for all dialysis patients aged 13-64 years, performed voluntarily after informed consent 1

Transplant Evaluation

All patients being evaluated for kidney transplantation must be screened for HCV infection (KDIGO 1A) 2

Common Pitfalls to Avoid

• Do not rely on HBsAg testing alone - this misses approximately 40% of hepatitis B events acquired in dialysis units 3
• Do not skip anti-HBc testing - it is essential for detecting acute infections during the window period 1
• Do not draw HCV NAT samples after dialysis - hemodialysis sessions reduce viremia levels and may yield false-negative results 2
• Do not assume peritoneal dialysis patients are at low risk - many will require in-center hemodialysis at some point and need baseline documentation 2