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Tuesday, March 4, 2008

What You Should Know About Infectious Diseases: A Guide for Hemodialysis Patients and Their Families

As a hemodialysis patient, you want to learn all you can about your treatment and what you can do to maintain your health at its best. One important area you should know about involves infectious diseases. These are diseases that happen when harmful germs get into your body and make you ill. Kidney failure interferes with your body’s natural immunity, making it easier for you to get some types of diseases like hepatitis or AIDS through your dialysis treatments. This booklet will give you general information about some important infectious diseases, including hepatitis B and C and HIV/AIDS, and tell you what you can do to prevent them.

Some Facts About Hepatitis B

What is hepatitis B?

Hepatitis B is a virus infection that causes liver disease. Most people fight off this infection themselves, but up to 10 percent progress to chronic liver disease and possibly liver cancer. Hepatitis B is spread by contact with the blood of an infected person.

You may have an increased chance of getting hepatitis B if you:

  • have sex with an infected person
  • inject illegal drugs
  • live with an infected person and share items such as razors and toothbrushes with the person
  • have been exposed to sharp instruments contaminated with infected blood, such as needles used for tattooing, body piercing and acupuncture (these needles should be carefully cleaned and disinfected before use, or disposable needles should be used)
  • have hemophilia
  • are a patient or work in a home for the developmentally disabled
  • your parents were born in Southeast Asia, Africa, the Amazon Basin in South America, the Pacific Islands or the Middle East.

In addition, a baby can get hepatitis B from an infected mother during childbirth.

Could I get hepatitis B through my dialysis treatment?

In the early years of dialysis, there was a danger of getting hepatitis B through exposure to the blood of an infected person at the dialysis unit. However, today the chance of getting hepatitis B through your treatment is very small because of two important advances. One of these advances is the use of strict infection control measures in dialysis units. (See Preventing Infections in Dialysis Units for more information about the infection control measures your dialysis care team should use.) The second improvement is the availability of a vaccination for hepatitis B.

Can I get hepatitis B from a transfusion?

The chances are very small. All donated blood is screened carefully for hepatitis B as well as other blood borne infections, such as hepatitis C and HIV.

How do you know if you have hepatitis B?

The only way to tell for sure is to have a blood test. Most people who get hepatitis B have no symptoms at all.

However, some people may have flu-like symptoms including:

  • loss of appetite
  • nausea or vomiting
  • fever
  • extreme tiredness
  • stomach or joint pain

In addition, you may have yellowing of the skin or eyes.

Some people may become carriers of hepatitis B, which means they have no symptoms but can still infect others with the disease. The carrier state may last for years or even for life. Some carriers may eventually develop scarring of the liver, liver failure or liver cancer.

Are there treatments for hepatitis B?

Yes. Two drugs have been approved for the treatment of chronic hepatitis B. These are interferon alpha‑2b and lamivudine. These drugs should not be given together. Overall, about 35 percent of patients treated with injections of interferon for four to six months will have a long-term response. The response to oral lamivudine, given for at least one year, may be somewhat lower. Lamivudine is very well tolerated, but viral resistance to treatment may occur. Interferon therapy often results in loss of appetite, depression and hair thinning.

How can hepatitis B be prevented?

One of the best ways to prevent hepatitis B is to be vaccinated. Hepatitis B vaccination is recommended for all children (including adolescents and teens) and hemodialysis patients and staff. The vaccine works by causing your body to make special proteins called antibodies that protect you against hepatitis B. Your response to the vaccine depends on your age, other medical conditions you may have and your general state of health, but most people will make enough antibodies to protect them against the disease. If you are vaccinated, your dialysis care team will check your blood periodically to make sure enough antibodies are present. If you have not yet been vaccinated, ask your dialysis staff about the vaccination.

You can also help to prevent hepatitis B by following safe sex guidelines and by avoiding high-risk behaviors such as injecting drugs.

Some safe sex guidelines are:

  • Use latex condoms to prevent the exchange of body fluids.
  • Have only one sexual partner.

Does Medicare cover the cost of the vaccination?

Yes. Medicare covers 80 percent of the cost of the vaccination. Check with your private insurance company about whether they will pay the balance.

Is the vaccination safe?

Yes. The vaccines are made from baker’s yeast and contain noninfectious particles called antigens. You cannot get hepatitis from the vaccination. These vaccines have undergone extensive clinical testing and have been used on millions of people worldwide with few side effects. However, people with acute illness or a known allergy to yeast should not be vaccinated.

Some Facts About Hepatitis C

What is hepatitis C?

Hepatitis C is a viral infection that can cause liver disease. Hepatitis C is spread by contact with the blood of an infected person.

You may have an increased chance of getting hepatitis C if you:

  • inject illegal drugs
  • received blood transfusions or solid organ transplants before 1992 when better testing of blood donors became available.

Less commonly, hepatitis C may be spread by:

  • passing from an infected mother to her baby during childbirth
  • having sex with an infected person
  • living with an infected person and sharing items such as razors and toothbrushes
  • exposure to sharp instruments contaminated with infected blood, such as needles used for tattooing, body piercing and acupuncture (these needles should be carefully cleaned and disinfected before use, or disposable needles should be used).

Can I get hepatitis C through my dialysis treatment? The chance of getting hepatitis C through your treatment is small because of the strict infection control measures used in dialysis units today. (See Preventing Infections in Dialysis Units for more information about these infection control measures.) However, there have been some reports that hepatitis C has been spread between patients in hemodialysis units where supplies or equipment may have been shared between patients. If you are a long term hemodialysis patient, you should be tested for hepatitis C.

Can I get hepatitis C from a blood transfusion?

The chances are small because of better testing of blood donors, which became available in 1992.

How do you know if you have hepatitis C?

Blood tests are available to check for hepatitis C. People who are at increased risk should be tested (see list in What is hepatitis C?). The doctor may do a combination of tests to make the diagnosis. Many people who have hepatitis C have no symptoms and feel well. For some, the most common symptom is extreme tiredness.

Is hepatitis C a serious illness?

Hepatitis C is serious for some persons but not for others. Most of the people who get hepatitis C carry the virus for the rest of their lives. Most of these persons have some liver damage, but many do not feel sick from the disease. Some of those with liver damage due to hepatitis C may develop scarring of the liver and liver failure, which may take many years to develop. Others have no long‑term effects.

Are treatments available for hepatitis C?

Yes. Drugs are available to treat hepatitis C. A combination of interferon alpha-2b and another drug called ribavirin has shown a better success rate than treatment with interferon alpha alone.

How can you prevent hepatitis C?

At present, no vaccine is available for hepatitis C. However, researchers are working to develop a vaccine, and it may be available in the future. In the meantime, the following steps can help to prevent hepatitis C:

  • do not inject illegal drugs
  • do not share toothbrushes, razors or other personal care articles that might have infected blood on them
  • follow safe sex guidelines
  • if you are considering getting tattoos or body piercing, make sure the tattoo artist or piercer follows good health practices such as washing hands and using disposable gloves
  • get vaccinated against hepatitis B.

Some Facts About HIV

What is HIV?

HIV is the human immunodeficiency virus. It can lead to a disease that causes progressive damage to your body’s immune system, called acquired immunodeficiency syndrome (AIDS). This disease increases your chances of getting serious infections that people normally can resist. The most common one is caused by a parasite called Pneumocystis carinii, which causes a kind of pneumonia that is hard to treat. People with AIDS are also more likely to develop certain cancers, such as Kaposi’s sarcoma. This cancer is usually limited to the skin, but may become widespread in AIDS patients, affecting the skin, lymph nodes and abdominal organs. The first sign of Kaposi’s sarcoma is red to purple bruises or sores on the body or inside of the mouth or nose. Other types of cancer may occur, including lymphoma, a cancer of the lymph nodes.

How is HIV spread?

The most common ways HIV is spread from one person to another include:

  • having sex with an infected person
  • injecting illegal drugs
  • passing from an infected mother to her baby during childbirth or breast feeding after birth.

In addition, tattooing or body piercing can be a source of HIV infection if the instruments used are contaminated with infected blood. These instruments should be used once and disposed of or cleaned and sterilized thoroughly after each use.

What are the symptoms of AIDS?

About half the people infected with HIV develop AIDS within 10 years after becoming infected. This time varies greatly from person to person. Many people who are infected with HIV do not have any symptoms for many years. The only way to tell for sure whether you are infected is to be tested for HIV infection.

The following may be warning signs of infection with HIV:

  • rapid weight loss
  • dry cough
  • continuing fever or night sweats
  • feeling very tired and run down for no reason
  • swollen lymph glands in the armpits, groin or neck
  • diarrhea that lasts for more than a week
  • white spots or unusual blemishes on the tongue, in the mouth or in the throat
  • red, brown, pink or purplish blotches on or under the skin or inside the mouth, nose or eyelids
  • memory loss, depression and other neurologic symptoms.

However, you should not assume you are infected if you have any of these symptoms. The symptoms of AIDS are similar to those of many other illnesses. AIDS is a medical diagnosis made by a doctor and based on specific criteria.

Is there a treatment for AIDS?

Today, treatments are available to fight both HIV infection and its related infections and cancers. Zidovudine, or AZT, is one of the earliest drugs used to treat HIV infection. AZT and other similar drugs can help slow the spread of HIV in the body and delay the onset of related infections. In addition, newer types of HIV drugs, such as protease inhibitors, have also proven helpful in suppressing the virus. Because HIV can become resistant to each class of drugs, combination treatment is necessary to effectively suppress the virus. Currently available drugs do not cure people of HIV infection or AIDS, however, and they all have side effects that can be serious. A number of drugs are also available to help treat the infections that occur in people with HIV. These include drugs to treat cytomegalovirus eye infections, yeast and other infections and Pneumocystis carinii pneumonia. HIV infected individuals who develop Kaposi’s sarcoma or other cancers may be treated with radiation, chemotherapy or injections of interferon.

Can I get AIDS through my dialysis treatment or a blood transfusion?

The chances are very small. The strict infection control measures used by your dialysis care team protect you against this infection. All donated blood is carefully screened for the infection before transfusions are done.

How can I prevent AIDS?

A great deal of research is being done to develop a vaccine. In the meantime, the best way to prevent the infection is to follow safe sex guidelines and avoid high-risk behaviors such as injecting illegal drugs.

Other Infectious Diseases Dialysis Patients Should Know About

MRSA (Methicillin‑Resistant Staphylococci) —Staph germs are normally found on the skin of healthy people, but occasionally they get into the body and cause an infection, which may be minor or serious, such as a blood infection. Methicillin is a drug that is commonly used to treat staph infections. Sometimes, staph can become resistant to methicillin. This may occur in dialysis units and other health care settings. Patients with chronic illness such as kidney disease may be more prone to infections by MRSA. Some patients may carry the infection without becoming ill, but they can still pass it to others.

To help prevent the spread of MRSA in the unit, your dialysis care team should follow the standard precautions recommended by the National Centers for Disease Control and Prevention (CDC) and be especially careful to:

  • wear sterile gloves for performing sterile procedures; clean, nonsterile gloves may be used for general patient care and should be changed them between patient contacts
  • wash their hands after touching a patient or any potentially contaminated articles and before taking care of another patient.

Recently, some MRSA infections have been reported to be treatment failures with vancomycin, one of the drugs most commonly used to treat these infections. These are called VISA, or vancomycin intermediate‑resistant Staph aureus. A small number of these occurred in dialysis patients with hemodialysis or peritoneal dialysis catheters. In each case, the patient was receiving vancomycin for an extended period of time to treat catheter‑related infections. To help prevent these infections, the same measures used to prevent MRSA should be used.

VRE (Vancomycin‑Resistant Enterococcus) —Enterococcus is a common germ found in the intestines. For many years, they were known to cause occasional infections. Drugs like penicillin and vancomycin would reliably cure them. However, in the 1980s, these germs developed resistance to vancomycin as well as many other antibiotic drugs. Like MRSA, VRE can often be spread in dialysis units and other health care settings. To prevent the spread of VRE from patient to patient, your dialysis care team should follow the standard precautions recommended by NCDC. In addition, they should dedicate the use of certain items, such as stethoscopes, blood pressure cuffs or rectal thermometers to a single patient or a group of patients who are infected with or carriers of VRE. If such devices are to be used on other patients, your dialysis care team should clean and disinfect them first.

Tuberculosis (TB) —The number of cases of TB has increased over the past decade. Ask your doctor or nurse whether you should be screened for TB.

Preventing Infections in Dialysis Units

What standard precautions should my dialysis care team follow to prevent the spread of infections in the dialysis unit?

The National Centers for Disease Control and Prevention (CDC) have developed a set of standard precautions, which should be followed by the dialysis care team in all units. You should be aware of these precautions, and speak to the members of your care team if you have any questions about them.

Your nurse or patient care technician should do the following:

  • Wear clean gowns, disposable gloves and face shields or masks and protective eyewear when starting your dialysis treatment and later when disconnecting you from the machine.
  • Wear disposable gloves and face shields or masks and protective eyewear when doing any procedures involving your access.
  • Change gloves after beginning a treatment, before touching any environmental surface such as dialysis machines, charts and phones, and after each patient contact.
  • Wash hands when entering patient areas, before putting on gloves and after removing them.
  • Clean and disinfect the treatment area between patient shifts.
  • Maintain separate areas for "clean" (e.g., medication prep) and "soiled" (e.g., blood samples) items.
  • Use a separate room and a dedicated dialysis machine and avoid dialyzer reuse for patients who are positive for hepatitis B.
  • Do a blood test for hepatitis B and C on all new patients and do routine follow-up testing on susceptible patients.

If you are interested in obtaining a copy of the standard precautions, you can view the web site here or download it as an Adobe Acrobat PDF file here.

Is dialyzer reuse safe?

Some units use the same dialyzer (artificial kidney) more than once on the same patient. This is generally considered safe if done properly. The dialyzer should be thoroughly cleaned and disinfected before each use. The dialyzer should be labeled carefully with the patient’s name. Check the label on your dialyzer before each treatment. Dialyzer reuse should be avoided for patients who test positive for hepatitis B.

What vaccinations should dialysis patients have?

Check the following table to make sure you are up-to-date on all recommended vaccinations. Fill in the date you received each. Speak to your doctor if you have any questions about your vaccinations.

Vaccinations Recommended for Adult Hemodialysis Patients

Vaccine Recommended Date Received
Diphtheria Tetanus (Dt) Every 10 years
Measles Mumps/Rubella (MMR) For all susceptible* patients
Hepatitis B For all susceptible* patients
Pneumococcal (pneumonia) Every 3-5 years
Meningococcal (meningitis) If needed (in case of an epidemic)
Influenza (flu) Once a year
Chicken pox (varicella) Every 10 years
* Susceptible means you have not been vaccinated and are not immune to the infection.

See also in this A-Z guide:

  • Hemodialysis
  • Hemodialysis Access
  • What Vaccinations Do You Need? A guide for adults with chronic kidney failure or a kidney transplant
  • What Vaccinations Does My Child Need? A guide for parents of children with chronic kidney failure or a kidney transplant
  • What You Should Know About Dialyzer Reuse: A Guide for Hemodialysis Patients and their Families

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