Ibrahim M. N, Alhadi M. S, Elbadawy W. Y. Serodetection of Cytomegalovirus and Epstein - Barr virus Antibodies Among Hemodialysis Patients. Biomed Pharmacol J 2022;15(1).

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Manuscript received on :31-10-2021
Manuscript accepted on :04-02-2022
Published online on: 16-03-2022

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Plagiarism Check: Yes
Reviewed by: Dr. Hany Akeel
Second Review by: Dr. Chandrabose Selvaraj, Dr. Subhasis Chakraborty
Final Approval by: Dr. H Fai Poon

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Mohamed N. Ibrahim¹ Mohamed S. Alhadi ^{2, 3}, and Waleed Y. Elbadawy ³,

¹Clinical Laboratories department, College of Applied Medical Sciences, Jouf University, Qurayat, Saudi Arabia

²Biochemistry department, Faculty of Science, Ain Shams University, Egypt

³Hematology department, Wadii El-Nile Hospital, Cairo, Egypt

Corresponding Author E-mail: mnabil@ju.edu.sa

DOI : https://dx.doi.org/10.13005/bpj/2360

Abstract

The infection with herpesviruses as Human herpes virus-5 (cytomegalovirus-CMV) and Human herpes virus-4 (Epstein – Barr virus -EBV) is one of the main causes of morbidity and mortality in hemodialysis patients. This study aims to investigate the serostatus of CMV and EBV in patients with renal failure who underwent hemodialysis. The study included 134 cases (55 females and 79 males) with an age range of 35-68 years (mean age 37.43±13.42 years). HCMV-IgG, IgM and EBV-IgG, EBV-IgM were determined in subjects' sera. 87 of 134 (65%) were underwent hemodialysis, while 47 (35%) had normal kidney functions without HCV infection. 68 (78.2%) and 31 (35.6%) cases out 87 hemodialysis patients were positive for CMV-IgG and IgM antibodies, respectively. On the other hand, 56.3% and 20.7% of the 87 hemodialysis patients were positive for EBV-IgG and IgM antibodies, respectively. There is no significant differences were observed between females and males in terms of seroprevelance rates. The rate of positive CMV-IgG among 48-64 years hemodialysis patients was high, Whereas, EBV-IgG were detected among 39-67 years. Our data suggest that seroprevalence of CMV and EBV antibodies among hemodialysis cases is a high and cause complications for these patients.

Keywords

CMV-IgG, CMV-IgM, EBV-IgG and IgM for Hemodialysis Patients

Introduction

Cytomegalovirus (CMV) is a worldwide virus which can cause severe morbidity and mortality in immunocompromised patients, such as AIDS patients, allograft recipients and patients with renal failure [1]. HCMV (HHV-5) is the prototype of subfamily betaherpesvirinae, like all herpes viruses in latency and persistence for lifetime of the individuals ^{2, 5}. CMV infection is almost asymptomatic or is followed by mild symptoms ³. Reactivation of the virus occurs in immunosuppressed patients such as HIV cases, elderly patients, hemodialysis patients and subjects subjected to chemotherapy and ionized radiation treatment, and pregnant women, due to suppression of the immune system ^{1, 4}.

The most common human infection in immunosuppressed patients is Epstein–Barr virus (EBV) infection and can lead to life-threatening lymphoproliferative diseases. The Epstein – Barr Virus has been implicated in several diseases, including infectious mononucleosis, African Burkitt lymphomas (BL), Hodgkin lymphoma, B-cell lymphomas of immunosuppressed cases, nasopharyngeal carcinomas (NPC) ^{6, 8}.

Primary HCMV infection (first time) occurs when an individual without defense against cytomegalovirus. Afterwards, the second type of CMV infection creates latency from which it may reactivate ^{7, 9}. The third type of HCMV infection is called reinfection when contact with an infectious person who has already been infected, despite their possession of natural immunity ^{9, 13}.

The transmission of human cytomegalovirus and EBV in patients with renal failure may occur through hemodialysis or transplantation ^{5, 11}. Among hemodialysis patients, the probability of direct contact with human cytomegalovirus is high ¹⁴.

Reactivation of the latent virus in patients with renal failure undergoing hemodialysis can result in severe systemic disease, with high fever, multiple organ dysfunction with leukopenia, and CMV in the blood ^{10, 16}.

Many procedures for CMV and EBV detection are available, including serology techniques, conventional virus culture, shell-vial, and molecular techniques ¹⁵. Among the highly sensitive and specific immunological technique used for the detection of specific human anti-cytomegalovirus, EBV antibody (IgM and IgG) is the microparticle enzyme-linked immunosorbent assay (ELISA) ¹⁷. This study was proposed to evaluate the prevalence of CMV and EBV antibodies (IgM and IgG) using serological tests as ELISA in patients with renal failure undergoing hemodialysis.

Subjects and Methods

Ethical approval

The Review Board of Ain Shams University approved this research protocol.

Study population

One hundred and thirty four cases were listed in this study. The 134 individuals included 55 women and 79 men, with an age range 35-68 means of (37.43±13.42) years. All blood samples were collected from different hospitals (Waddi El-Nile, Dar El-Fouaad, General Daqahlya, and Qena hospitals). The cases were divided into two types; hemodialysis cases that had a failure and underwent hemodialysis (n= 87) and control cases (n=47) that had normal kidney functions and negative for HCV antibodies. Infected samples (n=87) were selected from patients treated at nephrology departments of previous hospitals. The consent forms that include (name, age, sex, history of blood transfusion) were obtained from each individual before sampling. All sera samples were separated after centrifugation at 1000 rpm for 10 min. Antibodies against HCMV and EBV (IgG, IgM) were assessed and recorded for all samples.

Serological analysis of HCMV

HCMV-IgM and HCMV-IgG antibodies were determined by enzyme-linked immunosorbent assay (ELISA) technique using commercially available HCMV-IgM and IgG kits (BioCheck, Foster City, CA, USA). Procedures were done according to the manufacturer instructions and results of CMV-IgM and IgG were expressed as optical density (O.D) units.

Serological analysis of EBV

EBV-IgG antibodies were detected using commercially available kits (ATLAS Medical EBV-IgG Kit, UK) according to the manufacturer’s instructions. Human EBV-IgM antibodies were detected in all samples by qualitative ELISA test using commercially available EBV kits (Diagnostic Automation, USA). The data from the EBV IgG and IgM measurements were expressed as optical density units.

Statistical analysis

The SPSS software package was used for data analysis and data management. Statistical significance was considered when p < 0.05.

Results

Total responses of HCMV-IgG antibodies

68 out of 87 patient cases (78.2%) were positive for CMV-IgG antibodies, while 21.8% were negative for HCMV-IgG. Among the control cases, 24 out of 47 (51%) had detectable HCMV-IgG antibodies, while 49% of the cases were negative for HCMV-IgG. (table.1)

Table 1: HCMV-IgG rates in hemodialysis and control cases.

Responses of total HCMV-IgM antibodies:

Among hemodialysis cases, 31 out of 87 patient cases (35.6%) were positive for HCMV-IgM antibodies, while 64.4% were negative for HCMV- IgG. Ten out of 47 control cases (21.3%) had detectable HCMV-IgM antibodies, while 78.7% of the cases were negative for HCMV-IgM. (Table 2).

Table 2. HCMV-IgM antibodies rates in hemodialysis and control cases.

Total EBV-IgG antibody responses

47 out of 87 patient cases (56.3%) were positive for EBV-IgG antibodies, while 43.7% were negative for EBV-IgG. Among the control cases, 19 out of 47 (40.4%) had detectable EBV-IgG antibodies, while 59.6% of the cases were negative for EBV-IgG. (table.3)

Table 3: EBV-IgG rates in hemodialysis and control cases.

Responses to total EBV-IgM antibodies

Among hemodialysis cases, 18 out of 87 patient cases (20.7%) were positive for EBV-IgM antibodies, while 79.3% were negative for EBV-IgG. Eight out of 47 control cases (17%) had detectable antibodies to EBV-IgM, while 83% of the cases were negative for EBV-IgM. (Table 4).

Table 4: EBV-IgM antibodies rates in hemodialysis and control cases.

Discussion

Human Herpes Virus-5 (HHV-5, also known HCMV) is one of β-herpes viruses which cause infection for 75-90% of the world population. HCMV infections are regulated by the effective immune system, but without the virus’ ultimate clearance ^{17, 22}.

During periods of down-regulation of the immune system, such as treatment with pharmaceutical products and stress associated with illness, or viral co-infection, CMV and EBV can be reactivated ¹⁸.

CMV was first identified as a one of mortality in elderly, organ allograft recipients, and hemodialysis patients [19].  Another study shows the presence of infection due to activated HCMV in the population presenting alterations of the immune system ^{20, 27}.

In this investigation, we study the seroprevalence of HCMV in Egyptian patients with renal failure who underwent hemodialysis. The results showed that the percentage of seropositive CMV-IgG was significantly higher (P<0.01) in hemodialysis cases than in control cases (normal kidney function without HCV infection). Similarly, CMV-IgM was detected in 35.6% of hemodialysis patients (69% of them had positive IgG antibodies) compared to 12% of the control group to negative CMV-IgG. The results of this study showed that the seropositivity of CMV-IgG, and IgM was higher in elderly hemodialysis patients. Our results were in agreement with other studies concluded on, the correlation between CMV seropositivity and prevalent frailty in older people ²¹.

Other studies illustrated that, the source of infection in the majority of allograft recipients (60–75%) during kidney transplantation is a kidney from a seropositive donor ²⁴. The remaining infections (25–40%) are due to transfusion of leukocyte-containing blood products from CMV-positive donors ^{20, 28, 30}. CMV infection is a frequent complication and the main cause of death, of end-stage renal failure disease ^{25, 30}. Acquired immunity is suppressed in uremic cases ^{26, 27}.

Other studies suggested that, the number of circulating T cells was reduced and suppressor cells increased, where hemodialysis does not recover the weakness of the immune response in patients with renal failure ^{12, 28}. These factors contribute to the suppression of the adaptive immune response and increase the incidence of CMV infection among hemodialysis patients ^{16, 29}. Likewise, our results displayed insignificant difference between female and male hemodialysis cases with seropositive HCMV antibodies. These results are resemble to other data concluded that, there is no significant variation in CMV seroprevalence by gender ²³.

Sagedal et al.,¹⁷ reported a highly significant prevalence of CMV antibodies in chronic hemodialysis patients compared to healthy individuals.

In the current study, the rate of positivity for anti-IgG antibody was 49/87 (43.7%). Also, EBV-IgM was detected in 18/87 (20.7%). No significant variation was observed in EBV IgG antibody in male and female hemodialysis cases. These results are in agreement with Vilibić-Čavlek et al. (2017) who observed a seroprevalence of EBV-IgG antibodies among hemodialysis patients ³¹.    In another study carried out in Cyprus, the seroprevalence of EBV IgG antibodies between hemodialysis patients was very high ³². Saghafi et al. reported that the prevalence of EBV IgG and IgM antibody is 100% among adult potential donors and recipients ³³.

In our findings, the percentage of hemodialysis patients positive for anti-CMV IgG was found to be significantly higher than in the healthy volunteers. The risk of CMV infection increases with increasing the time for dialysis treatment. In addition, seroprevalence of EBV antibodies among hemodialysis is high.

Conclusion

Based on our results, 78.2%, 56.3% of seropositivity was found for HCMV-IgG and EBV-IgG, respectively. On the other hand, 35.6% for HCMV-IgM and 17% for EBV-IgM in hemodialysis patients, showing a high morbidity rate by cytomegalovirus in these individuals. Therefore, it is important to estimate the route of transmission of the CMV and EBV and verify the risk of the transmission through hemodialysis to seropositive and seronegative cases and define strategies of selection. Therfore, we recommended that patients with renal failure who undergo hemodialysis should be tested for HCMV and Human EBV before dialysis and a viral survey should be performed periodically to avoid the transmission of viral infection through the dialysis procedure.

Acknowledgment

To the managers of the hospitals reported in this paper, for their permission to collect blood samples.

Conflict of interest

All the authors declare no conflict of interest in this work.

Funding Sources

There is no funding sources

References

1. Krishna, BA., Wills, MR., and Sinclair, JH. Advances in the treatment of cytomegalovirus British Medical Bulletin, 2018; 131:5–17 doi: 10.1093/bmb/ldz031
   CrossRef
2. Forbes BA. Acquisition of Cytomegalovirus infections: an update. Clin Microbiol ev. 1989;2(2):204–216
   CrossRef
3. Roso CC, Beuter M, Bruinsma JL, Silva JH, Timm AMB, Pauletto MR. Clinical aspects of people with chronic renal failure in conservative treatment. Rev Rene., 2013; 14(6):1201-8
4. Riou, R., Bressollette-Bodin, C., and Boutoille, D. Severe symptomatic primary HCMV infection despite effective innate and adaptive immune responses. J Virol.2016; e02245–16.
   CrossRef
5. Griffiths, P., Emery, VC. Cytomegalovirus. In: Clinical virology. New York: Churchill Livingstone, 1997; p. 445–70.
6. Schooley RT. Epstein–Barr virus (infectious mononucleosis). In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 4^th Churchill-Livingston, New York, NY, 1995; 1354–1377.
7. Giral M, Nguyen JM, Daguin P. Mycophenolate mofetil does not modify the incidence of cytomegalovirus (CMV) disease after kidney transplantation but prevents CMV-induced chronic graft dysfunction. J Am Soc Nephrol., 2001; 12: 1758–1763.
   CrossRef
8. Randhawa PS, Magnone M, Jordan M, Shapiro R, Demetris AJ, Nalesnik M. Renal allograft involvement by Epstein–Barr virus associated post-transplant lymphoproliferative disease. Am J Surg Pathol 1996; 20: 563–571
   CrossRef
9. Celina, G., Ana, C., Fábio V. S., Miguel A., Josefina, M., and Rui, S. Cytomegalovirus acute infection with pulmonary involvement in an immunocompetent patient IDCases 14; e00445.
   CrossRef
10. Matos SB, Meyer R, Lima FWM. Seroprevalence of cytomegalovirus infection among healthy blood donors in Bahia State, Brazil. Rev Bras Hematol 2010; 32(1):45-9.
    CrossRef
11. Roberts, ET., Haan, MN., Dowd, JB., and Aiello, AE. Cytomegalovirus antibody levels, inflammation, and mortality among elderly latinos over 9 years of follow-up. Am J Epidemiol. 2010;172:363-371
    CrossRef
12. Wikby, A., Johansson, B., Olsson, J., Löfgren, S., Nilsson, BO., Ferguson, F. Expansions of peripheral blood CD8 T-lymphocyte subpopulations and an association with cytomegalovirus seropositivity in the elderly: the Swedish NONA immune study. Exp Gerontol. 2002; 37:445-453
    CrossRef
13. Rafailidis PI, Mourtzoukou EG, Varbobitis IC, Falagas ME. Severe cytomegalovirus infection in apparently immunocompetent patients: a systematicreview. Virol J. 2008; 27(5):47
    CrossRef
14. Reeves M, and Sinclair J. Aspects of human cytomegalovirus latency and reactivation. Curr Top Microbiol Immunol., 2008; 325: 297–313.
    CrossRef
15. Griffiths, P., Baraniak, I., and Matt Reeves, M. The pathogenesis of human cytomegalovirus. J Pathol. 2015; 235: 288–297
    CrossRef
16. Lindau, P., Mukherjee, R., Gutschow, M. Cytomegalovirus Exposure in the Elderly Does Not Reduce CD8 T Cell Repertoire Diversity. The Journal of Immunology, 2019; 202(2) 476-483
    CrossRef
17. Sagedal S, Nordal KP, Hartmann A et al. The impact of cytomegalovirus infection and disease on rejection episodes in renal allograft recipients. Am J Transplant, 2002; 2:850–856
    CrossRef
18. Hjelmesaeth J, Sagedal S, Hartmann A et al. Asymptomatic cytomegalovirus infection is associated with increased risk of new-onset diabetes mellitus and impaired insulin release after renal transplantation. Diabetologia, 2004; 47: 1550–1556
    CrossRef
19. Cordero E, Casasola C, Ecarma R. Cytomegalovirus disease in kidney transplant recipients: Incidence, clinical profile, and risk factors. Transplant Proc. 2012; 44:694-700
    CrossRef
20. Chiche, L., Forel, J-M., Roch, A., Guervilly, C., Pauly, V., and Allardet-Servent, J. Active cytomegalovirus infection is common in mechanically ventilated medical intensive care unit patients. Crit Care Med. 2009; 37(6):1850
    CrossRef
21. Ahmed, M., Al-Hakami, P., Ayed, A., Shati, C., and Ali, M. Seroprevalence of human cytomegalovirus antibodies among children with type I diabetes mellitus in the Aseer Region, Southwest KSA. Journal of Taibah University Medical Sciences, 2016; 11(4), 388e394
    CrossRef
22. Limaye, AP., Kirby, KA., and Rubenfeld, GD. Cytomegalovirus reactivation in critically ill immunocompetent patients. JAMA. 2008; 300:2367.
    CrossRef
23. Limaye, AP., Stapleton, RD., Peng, L. Effect of ganciclovir on IL-6 levels among cytomegalovirus-seropositive adults with critical illness: a randomized clinical trial. JAMA. 2017; 318:731-740.
    CrossRef
24. Brennan DC, Garlock KA, Lippmann BA et al. Control of cytomegalovirus-associated morbidity in renal transplant patients using intensive monitoring and either preemptive or deferred therapy. J Am Soc Nephrol., 1997; 8: 118–125.
    CrossRef
25. Zhu, N., Zhang, D., Wang, W., Li, X., Yang, B., Song, J. China novel coronavirus investigating and research team. A novel coronavirus from patients with pneumonia in China. N Engl J Med. 2019; 382(8):727–33.
    CrossRef
26. Osawa, R., and Singh, N. Cytomegalovirus infection in critically ill patients: a systematic review. Crit Care. 2009; 13:R68
    CrossRef
27. Boyce NW, Hayes K, Gee D. Cytomegalovirus infection complicating renal transplantation and its relationship to acute transplant glomerulopathy. Transplantation, 1988; 45: 706–709.
    CrossRef
28. Wang, G. C., Kao, W. H., Murakami, P., Xue, Q. L., Chiou, R. B., Detrick, B., McDyer, J. F., Semba,  D., Casolaro, V., Walston, J. D., and Fried, L. P. Cytomegalovirus infection and the risk of mortality and frailty in older women: a prospective observational cohort study. Am. J. Epidemiol. 2010; 171: 1144–1152.
    CrossRef
29. Nett PC, Heisey DM, Fernandez LA, Sollinger HW, Pirsch JD. Association of cytomegalovirus disease and acute rejection with graft loss in kidney transplantation. Transplantation, 2004; 78: 1036–1041.
    CrossRef
30. Shaver MJ, Bonsib SM, Abul-Ezz S, Barri YM. Renal allograft dysfunction associated with cytomegalovirus infection. Am J Kidney Dis., 1999; 34: 942–946.
    CrossRef
31. Vilibić-Čavlek T, Kolarić B, Bogdanić M, Tabain I, Beader N. Herpes group viruses: a seroprevalence study in hemodialysis patients. Acta Clin Croat, 2017; 56:255-261.
    CrossRef
32. Elie D, Dana K, Efthychia G, Astero C, Anastasia L, Marios P, et al. Evaluation of Epstein-Barr virus-specific antibodies in Cypriot multiple sclerosis patients Immunol 2019 ;105:270-275
    CrossRef
33. Saghafi H, Qorashi M, Heidari A. Is screening for IgG antibody to cytomegalovirus and Epstein-Barr virus infections mandatory in potential renal transplant recipients and donors in Iran? Transplant Proc., 2009;41:2761-2763.
    CrossRef