1. INTRODUCTION:

The atypical liver inflammation case, caused by hepatitis viruses, characterized by the presence of inflammation in hepatic cells. Since four decades, hepatitis often strikes hemodialysis (HD) patients ¹ intravenous drug users²,

Surgical patients who have had bloodtransfusions, and poorly sterilized medical equipment³. Screening blood is an important to prevent hepatitis C strikes surgical patients who had blood transfusions⁴. The neonates may be infected from the infected mother during childbirth. It isn't spread by touching or shaking hands⁵. Diagnosis is by Anti-HCV to find out if someone has ever been infected. Testing is recommended to prevent progression of early infected⁶, no effective vaccine exists⁷. Prevention which includes screening donated blood and ‎ harm reduction efforts among individuals who utilize intravenous drugs. During the last 2 decade, the first line therapy for chronic infection consists of a combination of the interferon-alph and ribavirin, a cure rate around 50 percent, and great side effects⁸, while, the newer medications sofosbuvir or simeprevir can be cured about 90 percent, and reduced side effects⁹. Long-term infection (leading to cirrhosis, end-stage liver disease, and liver cancer), may require a liver transplant in order to live. However, the virus normally repeats after transplantation¹⁰. The levels of hepatic enzymes ɤ-glutamyl transferase (GGT) and alanine aminotransferase (ALT) are markers of inflammation hepatocytes. Thus, hepatic enzymes increased in several diseases including fatty liverdisease (alcoholic and non-alcoholic), chronic viral hepatitis and autoimmune hepatitis. Therefore, the diagnosis and treatment by follow-up these enzymes due to they reflect inflammatory action in liver parenchyma¹¹. Close to 80 percent of infections had become chronic¹². As a result of this chronic infection after several years, hepatitis patients are prone to cirrhosis or liver cancer¹³. Decrease in glomerular filtration rate (GFR) as on sign of chronic kidney disease (CKD), depending on the cause, proteinuria and hematuria might be noted. In end-stage CKD, dangerous extra fluid building up in the body (swelling body), high potassium, low calcium, high phosphate, bone disease, anemia and cardiovascular disease¹⁴^,^15,¹⁶. CKD and HCV are major health burden all over the world. HCV infection is involved in infected various organs including the kidneys. However, it is still challenging to decide if the newer Hepatitis C therapies are safe for those with severe kidney failure. There is evidence that hemodialysis for CKD patients is a major risk factor for hepatitis C infection. Despite the significant improvement in medical facility, and follow guidelines for infection control in the right way. However, the risk for HVC infection is still higher in hemodialysis patients compared to the general population. This viral infection has a negative influence on the patients on the dialysis treatment and kidney transplant patients. Using conventional or pegylated interferon with or without ribavirin in the management of hepatitis C in end-stage CKD persist a clinical issue with low response rate, high dropout rate because of poor bearableness and numerous neglected needs. The endorsement of new direct acting antiviral operators for hepatitis C may significantly change the treatment approach in hepatitis C tainted patients with gentle to direct kidney impairment. Anyway it stays to be affirmed if the more up to date Hepatitis C treatments are protected in people with extreme kidney impairment^17,¹⁸.

We aimed here to investigate of HCV infection among dialysis patients in Baghdad Teaching hospital; whether using tattooing and dental tools could contribute transmission of HCV to healthy other users in the dental or tattoo offices.

2. MATERIALS/PATIENTS AND METHODS:

2.1. Ethical Statements.:

This study was carried out after approving of Mustansiriyah University ethics committee. All volunteers provided informed consent their data were obtained from their medical records.

2.2. Subjects.

This study was carried out in the Baghdad teaching hospital department of nephrology during the period from February 2017 to December 2018 and includes 100patients. All participants had no history of any types of hepatitis viruses, HIV infections, alcoholism, and intravenous drug abuse. Their information wasobtainedfrom the database of the laboratory information system of Baghdad hospital. Individuals were 45 malesand55females. Avolume of ten ml blood sampleswas collected from each patient, and centrifuged at speed ‎‎1000-2000 RPM for 10 minutes and by using a pipette take 2ml of serum in ‎another plain tube‎. Patients were analyzed and we tested for total hepatitis B core antibody (HBcAb), surface antigen (HBsAg), and anti-HCV antibodies using by (ELISA) an enzyme-linked- immune-sorbent assay kit.Serum level of albumin, total bilirubin, alanine aminotransferase(ALT) and aspartate aminotransferase (AST) were assessed by an automated kinetic method for blood samples.

2.3. Data analysis.:

All statistical analyses were Implementation of using SPSS software Ver. 19. Data were offered as a (mean ± standard deviation), chi-square test was used to compare variables. A P values of< 0.05 was considered significant¹⁹.

3. RESULTS:

In 2017, a total of 100 patients with CKD enrolled in our study at Baghdad teaching hospital department of nephrology, the mean age of patients was 43.5 years (SD = 11.4; range 20-75). There were 55(55 %) women and45(45%)men.Non-significant increase in ALT, AST, and total bilirubin in HCV-positive hemodialysis patients group compared with HCV-negative hemodialysis patients group. Whereas, non-significant decrease in albumin in HCV-positive group compared with HCV-negative group(Table 1).

Table 1. Demographic and laboratory characteristics of the investigated groups

Characteristic	Total (n = 100)		P
Mean age, years	43.5 (SD = 11.4)
Gender
Male	45 (45%)
Female	55 (55%)
Liver function tests	HCV-ve (n=65)	HCV+ve (n=35)
ALT (U/L)	33.34± 7.10	35.23 ± 8.29	NS
AST (U/L)	22.03 ± 1.76	24.23 ± 1.57	NS
Total bilirubin (mg/dI)	0.68 ± 0.02	0.79±0.04	NS
Albumin (g/L)	40.4 ± 0.05	37.6±0.04	NS

Out of 100 patients, 5 (5%) were serologically positive for total HBcAb, zero (0%) for HBsAg, and 35 (35%) for HCVAb marker, most of these patients come to the hospital healthy and they got an infected during treatment, no co-infection was observed. Among the patients who received blood transfusion, the frequencies of seropositive individuals for HCVAb, total HBcAb, and HBsAb were 32 (59.2), 4(7.4), and zero respectively. There was high significant increase in the prevalence of HCVAb in among transfusion group comparison with non-transfusion group (p < 0.001),while no significant differences between the transfusion and non-transfusion in terms of total HBcAB and HBsAb. The results of the logit model analysis show, that the main risk factors for HCV infection in the total samples were blood transfusion ( odds ratio [OR] = 20.8, 95% cl: 5.7-75.7, p = <0.001)( table 2).

Table 2. Comparison of HBV and HCV prevalence in transfusion and non- transfusion blood patients

	transfusion (54)	Non- transfusion (46)	P Value	Risk Estimate (OR 95% cl)
Total HBcAb	4(7.4)	1(1.88)	0.236	3.6 (0.38-33.4)
HBsAg	0	0	0	0
HCVAb	32 (59.3)	3 (6.5)	< 0.001	20.8 (5.7-75.7)

We found that unsafe practices that contribute to the spread of infection in society were dental care and tattoos.The results of the logit model analysis show, that the main risk factors for HCV infection in the dental office (odds ratio [OR] = 0.89, 95% CI: 0.0725-1.315, p < 0.05), and tattoos (odds ratio [OR] = 0.75, 95% CI: 0.503-1.119, p< 0.01).(Table 3).

Table 3. Risk behavior among patients that contribute the spread infection in society

Risk factors	Groups		p	Risk Estimate
Risk factors	Groups		p	(OR 95% CI)
	HCV+ve (35)	HCV-ve (65)
DHC	24	33	< 0.05	0.98 (0.925-1.615)
tattoos	8	2	< 0.01	0.75 (0.503-1.119)

4. DISCUSSION:

During (February/2017 to December/2018) a total of 100 patients (55 % women and 45 % men)with CKD were chosen from department of dialysis in Baghdad hospital.This goes in agreement with the American study, scientists found the prevalence of impaired kidney function was greater in women rate was 15 percent compared with men rate was 12 percent, regardless of age²⁰. Anti-HCV and anti- HBV were confirmed to be positive in 25 women (25%) and 11 men (11%), we found the prevalence rates of total HBcAb, HBsAg, and HCV were 5%, 0%, and 35% respectively. Liver disease is an important cause of reduce live expectance in patients with CKD²¹. The low prevalence of HBV infection among patients on dialysis may reflect the effectiveness of vaccination for HBV in Iraq²². While,the high prevalence of anti-HCV among patients on dialysis, the rate in our study is higher than previously reported by Khattab in the same hospital, the height could be attributed to height in post transfusion HCV infection ²³. Indeed,it’samajor public health concern for several factors such as sharing tattooing and dental tools²⁴. Further, the infected patients might not be aware of their infection status²⁵.The seroprevalence rate of HCV rate differ from country to country, from <1 percent in Sweden and Hong Kong to >70 percent in Cameroon and Egypt^26,^27,²⁸.

The results obtained show a significant relationship between HCV exposure and transfusion requirement, our finding is consistent with the prevailing pattern in other studies in the worldwide²⁹^,30^,³¹.Reuse of syringes and needles, transfusion of unscreened blood, and injection drug use remain risk factors for transmission. Actually, due to transfused blood is screening and proper medical behaviors, the risk of HCV infection has significantly reduced in high incomes countries. However, transmission of hepatitis C by medical reuses of syringes and needles and blood transfusion in low incomes countries remain serious health problems^32,³³.In this decade, blood donation centers have established systems that utilize nucleic acid amplification of HCV, which will identify the nearness of infection even in recently tainted patients who are still hepatitis C antibody-negative. These techniques have been used in the U.S since 1999, and have prevented approximately 56 transfusion associated hepatitis C infections every year^34,³⁵.Results here indicateda negative (OR/RR), which means no association between tattooing and the risk of HCV transmission ³⁶.However,in the developing countries, DHC,is one of the potential transmission of HCV, infections can be transmitted through several factors including direct contact with blood or oral liquids, as well as other factors including indirect contact, such as operatory equipment, or contaminated instruments, or environmental surroundings. This requires raising awareness among dentists in order to reduce the spread of the epidemic in society³⁷^,³⁸.The risk from tattooing is elevated, with an increase seroprevalence rate HCV in society³⁹. Actually,the prevalence of tattooing increase in the world-wide in last years. In the U.S, 38 percent of individual’s ages 18 to 29 have tattoo at least one ⁴⁰. Canadian studies demonstrate that around 8 percent of secondary school understudies have in any event one tattoo, also among the individuals who didn't have a tattoo, 21 percent were eager to have one. Tattoo process, requires injection of drops pigment into the layers of skin, by tiny needle puncturing the skin about 150 times per second. Because the needle and pigment come into contact with blood, infected may be transmitted if the needle or pigment are used on more than one individual without being cleaned or without appropriate cleanliness strategies. That means tattooing may play an important role in the transmission of HCV, HBV, and HIV⁴¹^,⁴².In the U.S, an estimated (2.7-3.9) million people have chronic hepatitis C, approximately 17000 new C infections each year. However, only 25 percent of those with chronic hepatitis C ware that they are infected. Approximately (220, 697 to 245,987) people in Canada have chronic hepatitis C, only 30 percent of those aware of their infection⁴³. The current study showed, no symptoms of hepatitis C were observed in any of the 35 infected patients. However, seven were seen to have elevations in serum ALT without symptoms. It is plausible that these patients have only mild hepatitis C infection (low levels of HCV- RNA in the blood)^44,^45,⁴⁶.

5. CONCLUSION:

We observed high incidence ratesof HCV infection among hemodialysis patients in Bagdad teaching hospital in previous years, especially those who need blood transfusion. Although,the risk from prevalence of hepatitis in general population may depend on the background prevalence of HCV in the dialysis units. However, as per our data the association between DHC and tattoo artists with the risk of transmission of HCV is negative.These findings indicate, improvements the safety of blood transfusions to reduce fromhepatitis transmission.

6. ACKNOWLEDGMENTS:

This work was supported by Department of Chemistry, College of Science at Mustansiriyah Universityhttps://uomustansiriyah.edu.iq/ .

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Received on 22.01.2021 Modified on 17.07.2021

Research J. Pharm. and Tech 2023; 16(1):418-422.

DOI: 10.52711/0974-360X.2023.00071