Malnutrition inflammation index in chronic haemodialysis patients with or without hepatitis C virus infection

Hepatitis C virus infection is one of the main causes of chronic liver disease worldwide. Both chronic hepatitis C and chronic kidney disease are common and serious diseases; this work aimed to determine the clinical impact of HCV infection on malnutrition inflammation index score in chronic kidney disease patients. This study was conducted on 96 patients on haemodialysis. They were divided into two groups. The first group was composed of 46 patients who were on maintenance haemodialysis and had chronic hepatitis C. The second group was composed of 50 patients on haemodialysis who were negative for hepatitis C. HCV-infected patients were associated with higher malnutrition inflammation score values (10% had MIS 16–20) compared to non-infected patients (2% only had MIS 16–20). The prevalence of malnutrition was higher in the HCV-positive than the HCV-negative group.


Background
HCV infection is one of the main causes of chronic liver disease worldwide [1]. The number of infected persons may be about 160 million, but most are unaware of their infection [2]. The long-term impact of HCV infection is highly variable from minimal changes to extensive fibrosis and cirrhosis with or without hepatocellular carcinoma [1]. Both HCV and chronic renal disease are common and potentially serious diseases [3]. Patients undergoing maintenance haemodialysis have a significantly higher prevalence of HCV infection and malnutrition inflammation complex syndrome (MICS) [4]. Malnutrition causes cardiovascular mortality in dialysis patients [5] and decreases the quality of life of haemodialysis patients [6].
This work aimed to determine the clinical impact of HCV infection on malnutrition inflammation index score in chronic kidney disease patients.

Design of the study
Our patients in this study were selected from those who attended Sherbeen Central Hospital (Dakahlia), Haemodialysis Unit.

Sample size and selection of the patients
This study was conducted on 96 patients (61 males and 35 females) on haemodialysis from April 2016 to December 2016, and they were divided into two groups: the first is 46 haemodialysis patients with positive HCV infection; the second is 50 haemodialysis patients with negative HCV infection. Patient ages range between 20 and 60 years.

Inclusion criteria
The inclusion criteria are as follows: chronic kidney disease patients on haemodialysis and patients aged from 20 to 60 years.

Exclusion criteria
The exclusion criteria are as follows: patients who had clinical or laboratory evidence of active infectious disease 1 month before the study onset and patients with history of tumours.

Methods of the study
They were evaluated by Malnutrition-Inflammation Score, and clinical examination with special stress on some items (Fig. 1).

Laboratory investigations
These are as follows: serum calcium, potassium, and sodium; complete blood count (CBC); blood urea; serum creatinine; C-reactive protein (CRP); ELISA for HCV antibody; PCR for hepatitis C-positive ELISA patients; total iron-binding capacity (TIBC); and serum transferrin.  (2), and <140 mg/dL [7] Statistical analysis All statistical analyses were performed by using the Statistical Package for the Social Sciences (SPSS) software version 15.0 (SPSS Inc., Chicago, IL) and Graph-Pad Prism package v.5.0 (GraphPad Software, San Diego, CA). Continuous variables were expressed as mean ± standard deviation (SD). ANOVA or Student's t test for continuous variables and chi-square (χ 2 ) for categorical variables were used to determine differences between groups. A P value of < 0.05 was considered statistically significant. The correlation coefficients (r) were assessed by Pearson's correlation coefficient or Spearman's correlation coefficient as appropriate.
Results (Table 1) Independent sample t test showed that there was no significant difference (P > 0.05) between the two groups of subjects in the count of red blood cells, white blood cells, and platelets. In addition, there was no significant difference (P > 0.05) in haemoglobin levels between the two groups (Tables 1 and 2).
Independent sample t test revealed that there were no significant differences (P > 0.05) between the two groups as regards serum iron markers (TIBC and serum transferrin) and CRP levels, while there were highly significant differences between two the groups in the albumin level (P = 0.0001) (Tables 3 and 4).
In the present study, we found that total MIS score was significantly higher in the HCV-infected group than the non-HCV group (Table 5).

Discussion
In the current study, the male to female ratio was 32/14 in infected HCV on haemodialysis that reflected increased incidence of HCV infection among males.
Our findings agreed with those recorded in Sudan among haemodialysis patients [8]. In both groups, there was decreased haemoglobin level which was below normal as it was 8.8 ± 0.2 g/dL in the non-HCV infection group and 8.4 ± 0.2 g/dL in the HCV infection group. That was in accordance with the findings of Boubaker et al. [9].
Platelet count was less in the HCV group than in the negative HCV group although this difference was still non-significant [10].
We found that serum albumin was significantly decreased in the HCV infection group when compared with the non-HCV infection group. These findings agreed with the findings of Barakat et al. [11]. No number of patients, SD standard deviation, BMI body mass index. P value: P > 0.05 is non-significant and P < 0.05 is significant. The basic demographics of the two groups were similar, and there was no significant difference between the two groups of subjects; P > 0.05 in height, body weight, and BMI Table 2 Comparison of haematology parameters between HCVnon-infected and HCV-infected haemodialysis patients   In our study, we found that there was no significant difference in the level of transferrin in the HCV-infected group HD and HCV-non-infected group HD; however, the values in both groups were more than the normal range. These findings were matched with a previous study carried out by Bharadwaj et al. [12].
In maintenance haemodialysis patients (MHD), inflammation was also a well-known feature; we found that serum CRP in both groups showed increased level than the known normal level of CRP. That was in accordance with the findings of Al-Amir et al. [13]. The MIS is a comprehensive scoring system that considered prospective shortterm hospitalisation, mortality, nutrition, inflammation, and anaemia in maintenance haemodialysis patients [14].
A previous study of HD patients reported that the presence of active HCV infection, detected by molecularbased testing, is associated with certain clinical features that are suggestive of MICS [4].
We found that HCV infection was associated with a higher MIS score values (Table 6) which was in accordance with the findings of Tsai et al. [15].

Limitations
Not all patients agree to be in a research easily in addition, high price of elastography so could not be done.

Conclusion
The prevalence of malnutrition is higher in patients with positive hepatitis C virus than non-hepatitis C virus haemodialysis patients.

Recommendations
Routine nutritional screening and assessment at diagnosis of chronic kidney disease patients.   BMI body mass index, MIS Malnutrition-Inflammation Score, r correlation coefficient; P value: P > 0.05 is non-significant and P < 0.05 is significant