臺灣血液透析病人的常見病毒感染

Common Viral Infections in Hemodialysis Patients in Taiwan

尿毒症病人包含長期也液透析病人之防禦機轉，因有欠陷而容易得到細菌感染或惡性腫瘤之事，已是醫界大家共認的。關於長期血液透析病人的細菌感染已有多的研究報告。至於病毒感染如B型及C型肝炎病毒感染在各國也有不少研究發表。大多研究成績顯示血液透析病人B型肝炎感染率和一般正常人相似。但C型肝炎感染率在血液透析病人都明顯的高，雖其感染路經尚不明瞭，這顯示血液透析治療過程，如打針、輸血，各種儀器操作及藥品等接觸因素不能勿視。關於長期血液透析病人常見病毒感染研究報告稀少：如帶狀泡疹病毒、後天免疫機能不全症候群及巨噬細胞病毒感染等，已有少數報告外，其他尚無較多種和較詳細病毒感染研究發表。在台灣尚無此類研究報告。台灣是人口密度非常高的國家，更容易得到空氣及互相密切接觸而被傳染該病毒疾病。我們在台灣之血液透析病人，做6種常見病毒感染做較廣曠研究。首先就血液透析病人175位及398位正常人為對象，檢驗各種病毒血清中之抗體濃度，結果血清中CMV,HSV,VZV,Inf A及B抗體陽性率都比正常人明顯高，又糖尿病血液透析患者VZV抗體陽性率比非糖尿病人更高(P<0.001)。透析病人血清中常見病毒抗體陽性率與輸血量或次數，透析期間長短和年齡大小都無關，我們推測與尿毒症本身之防禦機轉欠陷有關係。如上記述長期血液透析病人的常見病毒感染異常高。尚無有關和這些病人，因職業上日常接觸之醫護人員的常見病毒感染率研究報告。我們在53位血液透析工作人員及正常人205位研究6種常見病毒，各血清中抗體陽性率做比較。未見兩者間血清中之各常見病毒抗體陽性率差異，又和工作人員之工作期間長短也無關係，此結果顯示，血液透析醫護人員未因工作上容易得到這些病毒感染。關於血液透析病人常見病毒感染的長期季節性變化追蹤研究，也尚未見有發表。我們於長期血液透析病人18人和正常人21人，6種常見病毒追蹤2年間觀察。由此2年追蹤檢驗結果，除Inf A外5種常見病毒血清中抗體陽性率，在病人組無論在那一個季節，特別在9月及12月都比其正常人明顯高，尤其是EBV及CMD更明顯。4位血液析病人在2年透析期間B型和C型肝炎檢驗都陰性，但EBV或CMV抗體濃度昇高而有6次臨床上都顯示肝炎症狀，此肝炎可能和EBV或CMV感染有關。

Uremic patients as well as patients receiving maintenance hemodialysis (HD) are susceptible to various infections owing to impaired host defense mechanisms. The associations of hepatitis B virus (HBV) and hepatitis C virus (HCV) with HD patients have been studied. The majority of papers reported that the prevalence of HBV infection markers in HD patients was similar to that found in normal control groups, but a higher prevalence of anti-HCV in HD patients is well recognized. There have been very few investigations of the prevalence of common viral infections in HD patients, especially in Taiwan, up to now. Taiwan is an area of very high population density. Because the inhabitants live more closely and come into contact with each other more frequently, common viral infections from direct or indirect person-to-person contacts may be more casily transmitted. Six common virus infections, including Epstein-Barr Virus (EBV), Cytomegalovirus (CMV), Herpes Simplex Virus (HSV), Varicella-Zoster Virus (VZV), Influenza A virus and Influenza B virus were studied in 175 HD patients and 398 normal controls. The EBV titers were tested by immunofluorescence, while the antibodyytiters, of the others were tested with complement fixations. Serum samples showed significantly higher frequencies of positive antibody titers to CMV, HSV, VZV, Influenza A and B viruses in HD patients. Meanwhile, 100% of subjects of both groups had positive antibody titers to EBV. Furthermore, diabetic HD patients had a significantly higher seropositive rate than that of nondiabetics (93.3% vs 71.9%, p<0.01). No significant association was found between the seropositive rate and the volume or frequency of blood transfusion in HD patients. There was also no significant correlation between the seropositivity rate and the duration of HD or the increment of age. These findings suggest that high seropositivities to common viral infections of HD patients may be related to the uremic status. The frequency of infection with the six viruses in HD nursing personnel was determined to investigate the occupational hazards of frequent contract with HD patients. Subjects were of 53 HD nursing personnel and 205 age-matched normal controls. Antibody titers in those subjects indicated that the frequency of scropositivy was not significantly different between HD nursing personnel and controls and there was no relation with the duration of working in an HD unit. These results may suggest that HD nursing personnel do not carry a higher occupational risk for these six common viral infections than the general population. While the high susceptibility of HD patients to infections is well documented, there have been no reports on seasonal variation of common virus infection in HD patients. From June 1992 to March 1994. 18 regular HD patients and 21 normal volunteers were enrolled a prospective study to determine. Serum samples from the patients and controls were collected every 3 months for 2 years. The results showed: l) The number of patients with persistently high antibody titers of the six common viruses, especially EMB and CMV, were significantly higher in the patient group, which suggested HD patients are more susceptive to these viruses. 2)Most of the peak antibody titers of paired sera were obtained in September and December, and correlated with clinical manifestations. This might refrect that most of those common viral infections are more common in autumn and winter in Taiwan; and 3) EBV and CMV may have been the pathogen in non-B and non-C hepatitis in some HD patients. In conclusin, HD patients have significantly higher prevalence rates of the six common virus infections tested owing to the defective host defence mechanisms of uremics. HD nursing personal do not carry a higher occupational risk for these six common viral infections than the general population. The peak seasons for infection with these six common viruses are the autumn and winter in Taiwan, when more caution is needed to prevent such infections.