| Summary: | 碩士 === 國立臺灣大學 === 職業醫學與工業衛生研究所 === 96 === Background: High prevalence of hepatitis C virus (HCV) infection and end-stage renal disease is noticed in Yunlin, Chiayi area in Taiwan. Patients with maintenance hemodialysis (MHD) in this area have the highest risk for HCV infection and cardiovascular disease. Understanding the natural history of HCV and its association with inflammation, nutrition and outcomes in dialysis patients may provide more information for anti-HCV management strategies in dialysis and other patient populations.
Objective: We hypothesize that HCV infected MHD patients have distinct metabolic and inflammatory characteristics that can be linked to malnutrition-inflammation complex syndrome (MICS) and leads to higher clinical complications.
Design: A prospective longitudinal study was conducted in one regional teaching hospital during Sept. 2007 to March 2008. A cohort of 171 MHD patients including 76 HCV subjects was recruited. Basic data and dialysis characteristics were collected. Anti-HCV antibody was detected with a third-generation enzyme immunoassay while HCV genotype and viral load were analyzed by polymerase chain reaction twice in the first and last month. Insulin resistance was defined by HOMA-IR index. Nutritional and appetite status were evaluated by appetite and diet assessment tool and anthropometric evaluation. Inflammatory status was measured by high sensitivity C-reactive protein. Outcome evaluation was based on malnutrition-inflammation score to rate the severity of MICS in first month and followed prospectively at the seventh month.
Results: Of 171 enrolled patients, 58 having anti-HCV positive with at least one positive HCV-RNA titer (HCV RNA > 50 IU/mL) were categorized as active HCV group, 18 anti-HCV positive with two negative HCV-RNA titers as inactive HCV group, 95 negative anti-HCV titers as non-HCV group. Active HCV group had 51 (87.9%) persistent and 7 (12.1%) intermittent HCV viremia patients with 44.8% genotype 1b and 31% genotype 2a. Active and inactive HCV group experienced longer dialysis vintage then non-HCV group (64.0±54.1 month vs. 67.9±54.0 vs. 42.3±36.0 month, P <0.05). Serum triglyceride level was lowest and GPT level was highest in active HCV group during the first and seventh month. After 7 months follow-up, Active HCV group had significant difference from non-HCV group in MIS component as co-morbidity (1.6±0.8 vs. 1.7±0.7, P <0.05), albumin index (1.1±0.8 vs. 0.7±0.7, P <0.05), muscle wasting (1.6±0.8 vs. 1.3±0.8, P<0.05), decreased fat stores (0.5±0.7 vs. 0.3±0.6, P<0.05) and higher total MIS score (6.9±4.0 vs. 5.3±3.3, P<0.05). After adjustment of HCV activity, sex, centered age and body mass index, posthemodialysis weight, appetite status, normalized protein catabolic rate, severe cerebrovascular accident, marginal regression analysis by GEE model denoted HCV infection as a significant independent predictor of MICS (β= 0.82, P <0.05, CI= 0.16-1.49).
Conclusions: This study proves active HCV infection as an independent predictor of MICS in Taiwanese MHD patients. MIS can be used as an assessment tool to evaluate the short-term clinical outcome in HCV-MHD patients.
Key words: Hepatitis C, virus activity, malnutrition-inflammation complex syndrome (MICS), hemodialysis, uremia-associated anorexia
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