Current Trends Recommendations for Providing Dialysis
Treatment to Patients Infected with Human T-Lymphotropic Virus
Type III/Lymphadenopathy-Associated Virus
Patients with end-stage renal disease who are undergoing
maintenance dialysis and who have manifestations of human
T-lymphotropic virus type III/lymphadenopathy-associated virus
(HTLV-III/LAV)* infection, including acquired immunodeficiency
syndrome (AIDS), or who are positive for antibody to HTLV-III/LAV
can
be dialyzed in hospital-based or free-standing dialysis units using
conventional infection-control precautions. Standard blood and
body
fluid precautions and disinfection and sterilization strategies
routinely practiced in dialysis centers are adequate to prevent
transmission of HTLV-III/LAV.
Soon after AIDS was recognized in the United States, it became
apparent that risk factors for persons with AIDS were similar to
risk
factors for persons with hepatitis B virus (HBV) infection (1).
Prevention measures applied to control HBV infection in health-care
institutions were used as a model to develop infection-control
guidelines for patients with AIDS before the identification of the
etiologic agent and the development of serologic tests for antibody
to
HTLV-III/LAV (anti-HTLV-III). Isolation of infected patients and
nonreuse of a dialyzer by the same patient were initially
recommended
for patients receiving dialysis in dialysis centers (2). These
strategies are not currently believed necessary for preventing
HTLV-III/LAV transmission.
No transmission of HTLV-III/LAV infection in the
dialysis-center
environment has been reported (3), and the possibility of such
transmission appears extremely unlikely when routine
infection-control
precautions are followed (4). The routine infection-control
precautions used in all dialysis centers when dialyzing all
patients
are considered adequate to prevent HTLV-III/LAV transmission.
These
would include: blood precautions; routine cleaning and disinfection
of
dialysis equipment and surfaces that are frequently touched; and
restriction of nondisposable supplies to individual patients unless
such supplies are sterilized between uses (2).
The following recommendations take into consideration recent
knowledge about HTLV-III/LAV and update infection-control
strategies
for dialyzing patients infected with HTLV-III/LAV:
Procedures for environmental control and for disinfection
and
sterilization of hemodialysis machines have been described
(5). The hemodialysis machine pumps dialysis fluid into
the
dialyzer (artificial kidney) where circulating blood from
the
patient is separated from the dialysis fluid by a
membrane.
The dialyzer, along with the associated blood lines, is
disposable. Strategies for disinfecting the dialysis
fluid
pathways of the hemodialysis machine are targeted to
control
bacterial contamination and generally consist of using
about
500-750 ppm of sodium hypochlorite for 30-40 minutes or
1.5%-2.0% formaldehyde overnight. In addition, several
chemical germicides formulated to disinfect dialysis
machines
are commercially available. None of these protocols or
procedures need to be altered after dialyzing patients
infected with HTLV-III/LAV. Chemical germicides used for
disinfection and sterilization of devices in the dialysis
center are effective against HTLV-III/LAV (4).
Patients infected with HTLV-III/LAV can be dialyzed by
either
hemodialysis or peritoneal dialysis and do not need to be
isolated from other patients. The type of dialysis
treatment
(i.e., hemodialysis or peritoneal dialysis) should be
based
on the needs of the patient. The dialyzer may be
discarded
after each use. Alternatively, centers that have
dialyzer-reuse programs, in which a specific dialyzer is
issued to a specific patient, removed, cleaned,
disinfected,
and reused several times on the same patient only, may
include HTLV-III/LAV-infected patients in the
dialyzer-reuse
program. An individual dialyzer must never be used on
more
than one patient.
Standard infection-control strategies that are used
routinely
in dialysis units for all dialysis patients and personnel
should be used to prevent HTLV-III/LAV transmission.
Specifically, these strategies include blood precautions
and
barrier techniques, such as the use of gloves, gowns, and
handwashing techniques, that have been described elsewhere
(4-8).
Precautions against needlestick injuries, as well as the
appropriate use of barrier precautions, such as wearing
gloves when handling items contaminated with blood or
serum,
should be practiced by all personnel caring for all
dialysis
patients. Such injuries constitute the major potential
risk
for HTLV-III/LAV transmission to personnel. Extraordinary
care should be taken to prevent injuries to hands caused
by
needles, scalpels, and other sharp instruments or devices
during procedures; when cleaning used instruments; during
disposal of used needles; and when handling sharp
instruments
following procedures. After use, disposable syringes and
needles, scalpel blades, and other sharp items must be
placed
in puncture-resistant containers for disposal. To prevent
needlestick injuries, needles should not be recapped;
purposefully bent or broken; removed from disposable
syringes; or otherwise manipulated by hand. No data are
currently available from controlled studies examining the
effect, if any, of the use of needle-cutting devices on
the
incidence of needlestick injuries.
Reported by Hospital Infections Program, AIDS Program, Center for
Infectious Diseases, CDC.
Editorial Note
Editorial Note: In a study of 520 dialysis patients, 25 were
reactive
for anti-HTLV-III/LAV by enzyme immunoassay (EIA), but only four
were
confirmed by the Western blot technique (3). The rate of falsely
reactive EIA tests among these dialysis patients was 4%, much
higher
than the falsely reactive rate for blood donors (0.17%). The rate
of
truly reactive tests was 0.8%, much lower than in high-risk groups
but
higher than in blood donors. The higher rate of falsely reactive
tests is probably due to the exposure of dialysis patients to
H9-cell-associated antigens during blood transfusions that are
common
among these patients. These antigens are also present in cell
lines
used to grow HTLV-III/LAV for use as reagents in serologic tests
for
anti-HTLV-III/LAV (9). Identification of antibody to H9 lymphoid
cell
lines in the absence of isolation of HTLV-III/LAV in dialysis
patients
with reactive EIA and nonreactive Western blot tests supports the
conclusion that these test results are falsely reactive. The
higher
rate of truly reactive tests most likely reflects the frequency of
blood transfusion in this patient population before initiation of
blood donor screening for anti-HTLV-III/LAV. None of the four
infected persons identified in that study were dialyzed in the same
dialysis center.
CDC is initiating a cooperative study to further assess the
prevalence of anti-HTLV-III/LAV among patients undergoing chronic
hemodialysis. Representatives of dialysis centers who are
interested
in participating in such a study and who regularly have more than
60
patients on dialysis should contact the Hospital Infections
Program,
Center for Infectious Diseases, CDC, Building 1, Room 5065,
Atlanta,
Georgia 30333 (telephone (404) 329-3406).
References
Curran JW, Evatt BL, Lawrence DN. Acquired immune deficiency
syndrome: the past as prologue. Ann Intern Med 1983;98:401-2.
Favero MS. Recommended precautions for patients undergoing
hemodialysis who have AIDS or non-A, non-B hepatitis. Infect
Control 1985;6:301-5.
Peterman TA, Lang GR, Mikos NJ, et al. HTLV-III/LAV infection
in
hemodialysis patients. JAMA 1986;255:2324-6.
CDC. Summary: recommendations for preventing transmission of
infection with human T-lymphotropic virus type
III/lymphadenopathy-associated virus in the workplace. MMWR
1985;34:681.
Favero MS. Dialysis-associated diseases and their control.
In:
Bennett JV, Brachman PS, eds. Hospital infections. Boston:
Little, Brown and Company, Inc., 1985:267-84.
CDC. Hepatitis--control measures for hepatitis B in dialysis
centers. Viral hepatitis: Atlanta, Georgia: Center for
Disease
Control, 1977: HEW publication no. (CDC)78-8358 (Investigation
and control series, November 1977).
CDC. Hepatitis surveillance report no. 49. Issued January
1985:3-4.
Garner JS, Simmons BP. CDC guideline for isolation precautions
in
hospitals. Infect Control 1983;5:245-325.
CDC. Update: Public Health Service workshop on human
T-lymphotropic virus type III antibody testing--United States.
MMWR 1985;34:477-8.
*An international committee on taxonomy has proposed the name human
immunodeficiency virus (HIV).
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