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BANGLADESH JOURNAL OF MEDICAL SCIENCE Volume-8 No. 1-2; January-March 2009 

Original Article 
 

Evaluation of the antibody response against Hepatitis B Virus infection in 
patients on maintenance hemodialysis: A Pilot Study 

S Shahin1, Khoybar A2, A Farhana3, K Matira4 
 

Abstract 
Objective: This study was undertaken to evaluate the antibody response of hepatitis B virus infection in 
patients on maintenance hemodialysis (MHD) by detecting different viral markers. Method: Study 
subjects comprised a total of 88 chronic kidney disease (CKD) patients from Bangladesh Institute of 
Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) and 
Bangabandhu Sheikh Mujib Medical University (BSMMU). Of them 63 patients on MHD and 25 
predialysis patients served as cases and controls respectively. Clinical history was taken and serological 
markers for HBV (HBsAg, Anti-HBs, and Anti-HBc) were determined by using ELISA. Results: 
Hepatitis B virus was positive in 1.6% of maintenance hemodialysis (MHD) patients and in 16% of 
controls (p<0.02). Anti-HBc antibody was positive in 62% of dialysis patients and 72% of controls 
(p=NS) and the positivity was significantly associated in dialysis subjects with longer duration of dialysis 
(18 ± 22 vs. 10 ± 7, months, p<0.04), multiple units of blood transfusions (22 ± 29 vs. 10 ± 12, units, 
p<0.04) and more reuse of dialyzer (3 ± 1 vs. 2 ± 1, times, p<0.03) than the negative ones. Among MHD 
patients 84% were vaccinated against HBV with a schedule of 3 (79%) and 4 (21%) doses and protective 
antibody titer (>10 IU/L) was found in 57%. None of the controls were vaccinated but 66% had protective 
titer indicating post exposure natural immunity. Conclusions: Hepatitis B virus positivity was 
significantly higher among the predialysis subjects compared to dialysis group. 
 
Key words: Hepatitis B virus, Antibody response, Hemodialysis  
______________________________________________________________________________ 
 
Introduction 
End-stage renal disease (ESRD) subjects on 
maintenance hemodialysis are at high risk 
for hepatitis B virus infection1. Parenteral 
route is the major route for HBV 
transmission2. The process of hemodialysis 
requires vascular access for prolonged 
period3. Furthermore, hemodialysis patients 
are immunosuppressed4 that increases their 
susceptibility to infection requiring frequent 
hospitalization and surgery, which again 
increases    their    risk    for    exposure     to  

 
nosocomial infections3. Although 
vaccination is routinely recommended in 
ESRD patients, antibody response to 
vaccination is suppressed and its level 
rapidly declines among patients on chronic 
dialysis due to the decreased immunological 
responses5. The prevalence of chronic 
hepatitis B virus (HBV) infection is high 
(>8%) in sub-Saharan Africa, most of Asia 
and the Pacific Islands, intermediate 
prevalence (2 to 7%) regions include the 

________________________________________________________________________
______ 

1. Assistant Professor, Department of Microbiology, Shahabuddin Medical College, Dhaka 
2. Assistant Professor, Department of Paediatrics, Ibn Sina Medical College, Dhaka 
3. Assistant Professor, Department of Biochemistry, Uttara Adhunic Medical College, Dhaka 
4. Assistant Professor, Department of Pharmacology & Therapeutics, Shahabuddin Medical College, 

Dhaka 
Corresponds to:                                                                      

 15



Dr Md Khoybar Ali FCPS. Assistant Professor, Department of Paediatrics, Ibn Sina Medical College, 1/1B 
Kalyanpur, Mirpur Road, Dhaka-1216, Bangladesh. 

 16



Shahin S. et al. 

Amazon, southern parts of Eastern and 
central Europe, the Middle East and the 
Indian sub-continent, low prevalence (<2%) 
regions include most of Western Europe and 
North America6. In India, HBV prevalence 
was 8.8% and 14.2% in predialysis and 
hemodialysis group respectively7,8. In 
Turkey, prevalence of HBV was 10.5% and 
13.3% in predialysis and hemodialysis 
patient’s respectively9,10. In Bangladesh, 
around 12% of all patients on MHD were 
serologically positive for hepatitis B virus 
infection, has been shown in a recent 
study11. So far no study has been conducted 
to see the seroprevalence of HBV in CKD 
(predialysis) patients in Bangladesh. 
Therefore, this study was undertaken to 
evaluate the antibody status of HBV in 
predialysis and dialysis patients follow-
upped in two selected tertiary renal care 
center  

Subjects and methods 
Study design 
This cross sectional study was carried out in 
the Department of Immunology, BIRDEM, 
Dhaka and Nephrology Department of 
BSMMU during the period of June 2006 to 
June 2007. 
 
Study subjects  
Eighty-eight patients were finally included 
in this study. Of them 63 end stage renal 
disease (ESRD) patients who were on 
maintenance hemodialysis for at least 3  
months and getting dialysis through  
 
 
 

 
arteriovenous (AV) fistula considered as 
cases and 25 chronic renal failure (CRF) 
patients attending Nephrology Out-patients 
departments of BIRDEM and BSMMU and 
‘CRF patients follow-up project’ who were 
not on dialysis (predialysis) considered as 
control group. 
 
Sample collection and preservation 
Five milliliter blood was taken from the 
arterial channel immediately after pricking 
the fistula during dialysis session in MHD 
patients and labeled with a known serial 
number for each patient. In controls fasting 
samples were taken. Serum sample were 
preserved at -20°C and assayed within 
fifteen days of collection.        

 

Laboratory analysis  

Serological markers for hepatitis B (HBsAg, 
Anti-HBc, Anti-HBs) were assessed using 
commercial third generation enzyme-linked 
immunosorbent assay kit (Diasorin, Italy). 
Serum creatinine and alanine 
aminotransferase were assessed by standard 
laboratory method (Kinetic method). 

 

Statistical analysis of data  
All the relevant data were entered and then 
analyzed using the statistical package for 
social science (SPSS) version 13. Results 
were expressed as mean ± SD or percentage 
as appropriate. Level of significance was 
expressed as ‘P’ value and p<0.05 was  
considered as significant.

 
 
 
 
 

 17



Antibody response against HBV infection in patients on maintenance hemodialysis 

Results 
Table I- Baseline Parameters of Study Subjects 

 

Parameters 

 

Cases (n=63) 

 

Controls (n=25) 

 

P Value 

Age (yrs) 54±11 57±10 0.28 

M/F 36/27 15/10 0.80 

DM Duration(yrs) 12±6 5±2 0.92 

CKD Duration(yrs) 6±4 4±3 0.53 

S Cr (mg %) 9±2.5 4±2 0.001 

ALT (U/L) 25±17 20±16 0.30 

DM = Diabetes mellitus, results are expressed in mean ± SD on percentage where 
suitable, M/F = Male/Female, CKD = Chronic Kidney Disease, S Cr = Serum Creatinine, 
ALT = Alanine Aminotransferase 
 
Table II - Distribution of patients by hepatitis B virus infection    

HBsAg 
Cases 

n (%) 

Controls 

n (%) 
P Value 

Positive 1 (1.6%) 4 (16%) 

Negative 62 (98.4%) 21 (84%) 

 

0.022 

HBsAg – Hepatitis B surface antigen 
P value reached from chi square test; p<0.05 considered significant  
 
Figure 1- Distribution of patients by anti-HBc total 

                                      

61.9

38.1

72.0

28.0

0

10

20

30

40

50

60

70

80

%

Case Control

Study patients 

Positive Negative

                 
Note: Figure 2 above indicated that among cases and controls, anti-HBc positive was 61.9% 
(n=39) vs. 72% (n=18) (P=NS) and this was not significantly different between the two groups    

 18



Shahin S. et al. 

 
Table III- Distribution of Cases (MHD patients) by anti-HBc total  
 

 Parameters Positive (n=39) 
Negative 
(n=24) P Value 

Age (yrs) 52±10 58±11 0.03 
CKD Duration(yrs) 6±4 5±2 0.41 
DM Duration(yrs) 14±7 13±7 0.28 
Dialysis Duration (m) 18± 22 10±7 0.03 
BT (total units) 22± 29 10±12 0.03 
BT (units/month) 1.4± 1.2 1.1±1.3 0.07 
Dialyzer Reuse 3±1 2±1 0.02 
CKD- Chronic Kidney Disease, DM – Diabetes mellitus, BT- Blood transfusion, m - months 
Results are shown in mean ± SD 
 
Table IV - Level of immunity against hepatitis B virus in cases (MHD) 
 
   

Vaccinated 
n=53, (84%) 

 
Non-vaccinated 

n=10, (16%) 

 
P 

Value 
 
Protective 
(>100IU/l) 

 
11 (19%) 

 
4 (57%) 

Low protective 
(10-100IU/L) 

20 (39%) - 

Non protective 
(<10IU/L) 

22 (42%) 3 (43%) 

 
 

0.74 

P value reached from chi square test; p<0.05 considered significant 
 
Different laboratory parameters were similar 
between cases (MHD patients) and controls 
(predialysis patients). The only difference 
was in serum creatinine (S. Cr) level and 
this was higher in MHD patients (p<0.001) 
(Table I). 
The proportion of positive hepatitis B virus 
infection was found to be higher among the 
control (16%) compared to case (1.6%) and 
the difference was statistically significant 
(p<0.02) (Table II).   
Results showed no significant association 
between positivity of anti-HBc with duration 
of chronic renal failure and duration of 
diabetes mellitus (Table III). However, data 
shows higher preponderance of positive 
anti-HBc among the patients with prolonged 

duration of maintenance haemodialysis 
(p<0.03) and number of total units of blood 
transfusion (p<0.03). A statistically 
significant association was also found 
between anti-HBc status and number of 
reuse of dialyser (p<0.02) indicating the 
positivity of anti-HBc was high among the 
patients with more reuse of dialyser. Data 
analysis also indicated that the mean age of 
the positive anti-HBc total was found to be 
low (52.21±10.2 years) compared to 
negative anti-HBc total (57.96±10.8 years) 
and the difference was significant (p<0.05).  
Result showed that 84% of the cases 
(dialysis patients) were vaccinated and 16% 
of them non-vaccinated (P<0.001). No 
significant difference was seen in proportion 

 19



Antibody response against HBV infection in patients on maintenance hemodialysis 

of the patients with protective and non-
protective titers among the vaccinated and 
non-vaccinated subjects. Vaccination 
schedule was 3 doses in 79% and 4 doses in 
21% of cases (Table IV). 
 
Discussion 
Bangladesh has an intermediate prevalence 
of hepatitis B virus infection with a 4% 
HBsAg positive population12. In a previous 
study 3.5% prevalence rate of hepatitis B 
virus infection in pregnant woman of 
Bangladesh was seen13. It was observed in 
the present study that HBsAg was positive 
in hemodialysis patients in lower frequency 
(1.6%). Lower prevalence of HBsAg in 
MHD patients probably due to routine 
screening for HBsAg before selection of 
patients for MHD. Furthermore, we selected 
patients from two hemodialysis units where 
HBsAg positive patients were not accepted 
for hemodialysis to minimize the risk of 
spreading of HBV infection. This notion 
was similar to14. Moreover, 84% of our 
dialysis patients were vaccinated which 
might also contribute to low number of 
HBsAg positive cases in MHD group. On 
the other hand, HBsAg was found in higher 
frequencies in our predialysis diabetic CKD 
patients (16%). In diabetic patients HBV 
infection has been shown about 14% in a 
study15 and in predialysis patients it ranged 
from 8-10% in studies from India and 
Turkey7,9. Higher prevalence of HbsAg in 
our predialysis patients may be attributed to 
the fact that these patients had not been 
undergone routine screening for HBsAg and 
vaccination. Although, other factors like, 
frequent hospitalization, history of injections 
(including insulin), poor nutritional status 
(metabolic derangement) leading to 
suppressed immune response etc. remain 
common for both groups. Therefore, HBV 
vaccination alone seems to make the 
difference of HBsAg status observed in both 
groups.  

We found 62% of the dialysis patients and 
72% controls are anti-HBc positive, which is 
higher than some other reports showing 
around 40%16 but similar to one showing 
76%17. Positive anti-HBc total always 
indicate a remote HBV infection and is the 
most valuable single serologic marker in 
diagnosis of HBV infection even when 
HBsAg remains negative. We found 
positivity of anti-HBc total higher among 
the patients with more reuse of dialyzer18, 
Qadi et al. reported reuse of dialyzer is one 
of the risk factors for viral transmissions. 
Similarly increased duration of dialysis and 
higher number of blood transfusion has been 
shown to be associated with increased 
frequency of HCV infection19, which was 
seen in our patients too. It is possible that 
our patients became more anti-HBc positive 
due to higher blood transfusion and longer 
duration of dialysis.  
 
Majority of our MHD patients had 
vaccination (84%) but analysis found that 
only 19% have protective immunity, 39% 
low protective immunity and 42% have non 
protective immunity indicating that 
approximately half of the dialysis patients 
had no protection despite vaccination which 
is probably due to immunosuppression. In 
present study in all immunity groups, 
majority of the patients were more than 50 
years ages. It has been suggested that 
advanced age reduces the response against 
HBV vaccine in hemodialysis patients20. In 
our study response against hepatitis B 
vaccine to attain a protective titer was in 
58% subjects. This relatively low response 
may be due to higher age, presence of 
diabetes and lower doses of vaccination 
schedule as majority (79%) took three-dose 
regimen. Some studies showed that vaccine 
response is 64% with 3 doses whereas 86% 
with 4 doses21.  
 

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Shahin S. et al.

We can conclude that Hepatitis B virus 
positivity was significantly higher among 
the predialysis subjects compared to dialysis 
group. Anti-HBc antibody was positive in 
two-third of the study subjects. With a three-
dose vaccine schedule only half of the 
dialysis patients could attain protective 
antibody titer. According to standard 
statistical formula, a large sample size 
should have been taken to reflect the picture  
 

of whole population. However, as this is a 
Pilot study sample size was confined at 88 
subjects. 
 
Acknowledgement 
The authors sincerely acknowledge the help 
and cooperation of the Immunology 
department and Chronic Renal Failure 
(CRF) project of BIRDEM. 

________________________________________________________________________

______ 

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__________________________________________________________________________ 
“Allah has not sent down a disease except that He also sent down its cure: whoever knows 
it (the cure), knows it, and whoever is unaware of it (the cure), he is unaware of it.” (the 
medicine) while those who are ignorant of it are unaware of it.” [An-Nasai’, Ibn Mãjah, 
Al-Hakim and Ibn Hibban]

Antibody response against HBV infection in patients on maintenance hemodialysis 

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