NDT Advance Access originally published online on March 25, 2008
Nephrology Dialysis Transplantation 2008 23(6):2104-2105; doi:10.1093/ndt/gfn113
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Reply
Correspondence and offprint requests to: E-mail: a.geretti{at}medsch.ucl.ac.ukWe would like to thank Dr Woywodt and colleagues for highlighting important issues related to the risk of acquisition of hepatitis C in patients receiving haemodialysis [1]. There exists significant variability in screening protocols for hepatitis C in UK dialysis centres. This persists despite guidance issued by the Department of Health in 2002 that re-admitted patients who have been dialysed outside the UK should be tested and found negative for hepatitis C antibody and RNA before being dialysed in the main unit [2]. While lack of awareness of the risk may be to blame in some cases, the cost of introducing hepatitis C RNA testing is not negligible and is likely to be affecting best practice. One consequence of financial pressures is that hepatitis C RNA testing may be limited to patients at the highest risk of infection because of travel to resource-limited countries, where infection control procedures are known or predicted to be suboptimal. Selective testing may indeed evoke emotions of discrimination. However, in the absence of cost-effectiveness analyses to guide a decision about routine versus selective testing, it has proved difficult to persuade financial authorities to support generalized testing. In these circumstances, we believe that travel to resource-limited countries should not be necessarily discouraged, but patients should be made aware of the risks and implications through sympathetic counselling.
We share Dr Woywodt's concern about the lack of formal guidance for patients on the cadaveric renal transplant waiting list and would like to join the call for specific guidelines to be issued both at the National and European level. Our own local policy is currently not to suspend patients returning from holiday haemodialysis abroad. However, we are fortunate to work in a large teaching hospital with both major centres for viral hepatitis and HIV and a large liver transplant programme and have experience transplanting patients with hepatitis B, hepatitis C and HIV. Serving an ethnically diverse population, we have numerous patients who regularly dialyse abroad, and suspending all such patients for 3 months, as suggested, would not only increase the transplant assessment workload, but in practice would lead to otherwise healthy patients remaining suspended for >3 months. As such, we would advocate an intensive surveillance programme post-transplantation for patients deemed at risk. Importantly, the diagnostic window period for the detection of hepatitis C can be reduced upon return to the unit, to 
20 days, by hepatitis C RNA testing [3], thus allowing more rapid reinstatement on the transplant list for those units who currently suspend their holiday dialysis patients.
Conflict of interest statement. None declared.
Royal Free Hospital and Royal Free University College Medical School
References
- Ghafur A, Raza M, Labett 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] - Good Practice Guidelines for Renal Dialysis. /Transplantation Units. Prevention and Control of Blood-borne Virus Infection; 95 Department of Health (UK): Recommendations of a working group convened by the Public Health Laboratory Service (PHLS) on behalf of the Department of Health, 2002.
- Muller-Breitkreutz K, Baylis SA, Allain JP. Nucleic acid amplification tests for the detection of blood-borne viruses. Vox Sang (1999) 76:194–199.[CrossRef][Medline]
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