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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:

  1. 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).

  2. 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.

  3. 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).

  4. 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

  1. Curran JW, Evatt BL, Lawrence DN. Acquired immune deficiency syndrome: the past as prologue. Ann Intern Med 1983;98:401-2.

  2. Favero MS. Recommended precautions for patients undergoing hemodialysis who have AIDS or non-A, non-B hepatitis. Infect Control 1985;6:301-5.

  3. Peterman TA, Lang GR, Mikos NJ, et al. HTLV-III/LAV infection in hemodialysis patients. JAMA 1986;255:2324-6.

  4. 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.

  5. 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.

  6. 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).

  7. CDC. Hepatitis surveillance report no. 49. Issued January 1985:3-4.

  8. Garner JS, Simmons BP. CDC guideline for isolation precautions in hospitals. Infect Control 1983;5:245-325.

  9. 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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