NDT Advance Access originally published online on March 28, 2008
Nephrology Dialysis Transplantation 2008 23(6):2104; doi:10.1093/ndt/gfn037
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Travel-associated acquisition of hepatitis C— implications for the renal transplant waiting list
Correspondence and offprint requests to: E-mail: Alex.Woywodt{at}lthtr.nhs.ukWe read with interest the article by Ghafur and co-workers on travel-associated acquisition of hepatitis C in dialysis patients [1]. We would like to highlight an issue that was not discussed, namely the implications of their findings for the transplant waiting list.
The data presented by Ghafur and co-workers are in line with previous reports [2] and confirm that the risk of acquiring hepatitis C through holiday dialysis is not confined to visiting the Indian sub-continent. An increasing number of cases have now been reported after dialysis in other countries, such as France, Tenerife, Saudi Arabia [2] as well as Singapore and Slovakia [1]. Current recommendations indicate that returning dialysis travellers can only be declared free of infection after 3 months of repeated testing [3].
There are considerable implications for patients on the transplant waiting list but guidelines are lacking. We currently suspend patients for 3 months after haemodialysis abroad. There is, we believe, sufficient evidence to support this policy, since subsequent renal transplantation in the presence of patients having contracted HCV may result in catastrophic hepatitis, acute liver failure and death [4]. Suspending patients is often difficult in the absence of formal guidelines, as patients may perceive suspension after travel as discriminatory. Discussions about ‘safe’ and ‘unsafe’ travel destinations may evoke similar emotions of discrimination, particularly if the destination is the home country. Finally, we do not want to discourage travel since we believe that holidays are important for the quality of life of our patients.
Furthermore, suspending all patients for 3 months after return from holidays abroad will inevitably increase the workload of those who look after renal transplant waiting lists: dialysis units have to be made aware of the policy, patients have to be suspended, virology results have to be scrutinized and patients have to be re-activated. A survey within our unit revealed that 7 haemodialysis patients out of 172 patients on our waiting list (4%) had dialysed abroad in 2007. In 2006, 6384 patients were on the UK renal transplant waiting list. We calculate that a policy of 3 months’ suspension after haemodialysis abroad would lead to an extra 766 patient-months of suspension per year in the UK. It is likely that some patients could have received a transplant during that time. The extra months of suspension may therefore lead to an even longer waiting time or a less compatible transplant.
In summary, we believe that formal guidance on this issue would be helpful, both at National and European level. Such guidelines would obviate the need for lengthy and difficult discussions. We are not aware of an upcoming revision of the European Best Practice Guidelines [5] but we suggest to incorporate this issue in their revised form.
Conflict of interest statement. None declared.
Renal Unit, Lancashire Teaching Hospitals NHS Foundation Trust Royal Preston Hospital, Sharoe Green Lane, Preston PR2 9HT, UK
References
- Ghafur A, Raza M, Labbett W, et al. Travel-associated acquisition of hepatitis C virus infection in patients receiving haemodialysis. Nephrol Dial Transplant (2007) 22:2640–2644.
[Abstract/Free Full Text] - Coward RA, Garrues M, Solomon LR, et al. Hepatitis C and holiday dialysis. A postal survey of UK renal units. Nephrol Dial Transplant (2000) 15:1715.
[Free Full Text] - Lorenz R, Endres S. Diagnosis and treatment of acute hepatitis C in adults. www.uptodate.com (10 Dec. 2007).
- Terrault NA, Adey DB. The kidney transplant recipient with hepatitis C infection: pre- and posttransplantation treatment. Clin J Am Soc Nephrol (2007) 2:563–575.
[Abstract/Free Full Text] - European Best Practice Guidelines for Renal Transplantation (part 1). Nephrol Dial Transplant (2000) 15(Suppl_7):1–85.
[Free Full Text]
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