Hepatitis C virus (HCV) remains a problem within hemodialysis units. Thus, we published “Manual Concerning the Standard Dialysis Procedure and Prevention of Nosocomial Infection at Dialysis Facilities (1999)”, which showed preventing measures of nosocomial and blood-borne infection(s) in dialysis facilities (1). This manual was widely distributed to dialysis facilities in Japan and was used as the standard method in preventing in-hospital infection. The prevalence of HCV infection in chronic dialysis units changed 15.5% in 1999 to 9.84% in 2007 (Fig. 1). The decrease of HCV prevalence is steady and constant, but slow. We really need eradication of HCV virus from HCV-infected dialysis patients.
Kidney Disease: Improving Global Outcomes (KDIGO) is an international initiative with a key mission of developing clinical practice guidelines in the area of CKD. KDIGO recently published evidence-based clinical practice guidelines for the prevention, diagnosis, evaluation, and treatment of hepatitis C virus infection in individuals with CKD (2).
The process of adaptation of international guidelines is an important task that, although guided by general principles, needs to be individualized for each region and country. Epidemiology, dialysis practice and reimbursement are significantly different across the world. Hepatitis C incidence and prevalence are very high in Japan. As indicated by the Dialysis Outcomes and Practice Patterns Study (DOPPS) (3), mean HCV facility prevalence was 19.6% in Japan and varied among countries from 2.7% in United Kingdom to 22.2% in Spain. HCV seroconversion was also highest in Japan (3.1% per 100 patient years) and lowest in the United Kingdom (1.1%). Seroconversion was associated with an increase in facility HCV prevalence (RR = 1.36, P < 0.0001). HCV infection is also associated with an increased prevalence of albuminuria and reduced kidney function and an increased risk of developing end-stage renal disease. Moreover, HCV infection is associated with increased mortality in patients on HD therapy (4,5) and kidney transplant recipients. A capitation system with a fixed price per dialysis is more widely present; strict protocols are required on a large scale by state or private operators, based on an optimum compromise between evidence-derived efficiency and costs. These data clearly indicate needs for the interventions to the practice pattern(s) of infection control measures to eradicate HCV infection from Japanese dialysis patients (6).
Therefore, the Scientific Committee, Japanese Society for Dialysis Therapy convened a multidisciplinary group (nephrologists and hepatologists) to comment on the application and implementation of the KDIGO guidelines for patients on dialysis therapy in Japan. There are some differences between the KDIGO guidelines and the Japanese guidelines.
Ribavirin can cause hemolytic anemia and its use might be supported with increased erythropoietin as needed. The coverage of eryrhrocyte stimulating agent (ESA) by Japanese health insurance could not support massive use of ESA and the package insert of ribavirin shows contraindication in dialysis patients. These differences suggest that ribavirin should not to be used in HD patients.
In Japanese guidelines, isolation of HCV-infected patients is recommended with strict infection-control procedures for preventing transmission of blood-borne pathogens. The use of dedicated dialysis machines for HCV-infected patients is also recommended. This is because longer dialysis duration in Japanese dialysis patients makes it difficult to sterilize the surface of dialysis machines after each session. The narrow space between dialysis beds in Japanese dialysis facilities also might increase the risk of nosocomial infection.
The purpose of this editorial is to determine the applicability of the recommendations to Japanese dialysis patients with HCV infection. We have adapted and contextualized the guidelines to the Japanese health care delivery system. Specifically, we considered the availability of diagnostic tests, therapeutic alternatives, organization of the health care system, and practices related to HD and kidney transplantation. Similar commentaries on the KDIGO guidelines can be performed for guideline adaptation to other countries or regions. The process of adaptation of international guidelines is an important task that, although guided by general principles, needs to be individualized for each region and country. The KDIGO guidelines offer an excellent framework from which to adapt specific guidelines to clinical practice and from which to develop important research questions that will strengthen the evidence base for a future update of these guidelines.