Sir,
Human herpesvirus 8 (HHV-8) is frequently associated with Kaposi's sarcoma. It can be transmitted through organ transplantation or reactivated by immunosuppressive therapy. Chronic kidney disease (CKD) patients are at risk of this infection [1]. The present study aimed to determine the seroprevalence of HHV-8 in CKD patients in São Paulo, Brazil. The study was approved by the research ethics committees at participating institutions.
Blood samples collected from 805 CKD patients attended Hospital do Rim e Hipertensão and/or Santa Casa de Misericórdia de São Paulo (São Paulo, Brazil) were tested for latent and lytic HHV-8-specific antibodies using indirect immunofluorescence assays at Instituto Adolfo Lutz in São Paulo, Brazil, as previously described [2]. The chi-square test and/or Fisher's exact test were performed for comparing categorical variables and HHV-8 serum status, using SPSS for Windows. Of the 805 CKD patients, 61.4% were males, 61.5% white, 35.5% black/pardum and 3.0% yellow. The mean age was 58 years (18–91). Two hundred ninety-five patients were on haemodialysis (HD), 54 on peritoneal dialysis (PD) and 456 not yet on renal replacement therapy (RRT).
One hundred forty-five (18.0%) CKD patients were found HHV-8-seropositive, of whom 56 (18.9%) were on HD, 8 (14.8%) on PD and the remaining 81 (17.7%) were not on any RRT. Examination of these different groups revealed no statistical significant differences (P = 0.963). Further statistical analyses were conducted without this sub-grouping by RRT received. Table 1 discloses the comparison between HHV-8-seronegative and HHV-8-seropositive groups. Patients HHV-8-seropositive had a higher prevalence of previous transplant as well as higher prior exposure to sexually transmitted diseases. Of note, 57.0% of CKD patients who had syphilis also had HHV-8-seropositivity (P = 0.021). Other variables showed lack of association with HHV-8 serological results.
Table 1.
Comparison between HHV-8-seronegative and HHV-8-seropositive groups
| HHV-8 seronegative | HHV-8 seropositive | P-value | |
|---|---|---|---|
| Age (n = 805) | 56.6 ± 16.5 | 59.3 ± 17.8 | 0.075 |
| Gender (n = 805) | 0.574 | ||
| Male | 408 (61.8%) | 86 (59.3%) | |
| Colour/race (n = 805) | 0.798 | ||
| White | 407 (61.7%) | 88 (60.7%) | |
| Pardum | 129 (19.1%) | 30 (20.7%) | |
| Black | 106 (16.1%) | 21 (14.5%) | |
| Yellow | 18 (2.7%) | 6 (4.1%) | |
| Type of dialysis (n = 349) | 0.748 | ||
| Haemodialysis | 239 (36.2%) | 56 (38.6%) | |
| Peritoneal dialysis | 46 (7.0%) | 8 (5.5%) | |
| Immunosuppressive therapy (n = 803) | 0.952 | ||
| Yes | 31 (4.7%) | 7 (4.8%) | |
| Blood transfusion (n = 793) | 0.385 | ||
| None | 374 (57.5%) | 80 (55.9%) | |
| One | 126 (19.4%) | 23 (16.1%) | |
| Many | 150 (23.1%) | 40 (28.0%) | |
| Transplantation (n = 805) | >0.0001 | ||
| None | 629 (95.3%) | 124 (85.5%) | |
| Kidney | 27 (4.1%) | 20 (13.8%) | |
| Others | 4 (0.6%) | 1 (0.7%) | |
| Sexuality (n = 717) | 0.086 | ||
| Heterosexual | 588 (99.5%) | 123 (97.6%) | |
| Homosexual | 3 (0.5%) | 2 (1.6%) | |
| Bisexual | 0 (0.0%) | 1 (0.8%) | |
| Personal antecedents (n = 723) | 0.484 | ||
| Yes | 565 (95.0%) | 124 (96.9%) | |
| HIV (n = 723) | 0.096 | ||
| Yes | 6 (1.0%) | 4 (3.1%) | |
| STDs (n = 710) | 0.003 | ||
| Yes | 10 (1.7%) | 8 (6.4%) |
Personal antecedents: use of intravenous drugs, use of condom, cytomegalovirus and hepatitis; STDs: sexually transmitted diseases; n: number.
High HHV-8 seroprevalence was observed in CKD patients in São Paulo, Brazil [3]. Interestingly, in the present study, similar proportions of HHV-8-seropositivity were observed in pre-dialysis and dialysis patients suggesting that dialysis proceedings were not related to HHV-8 transmission/acquisition. Another result was the strong association between HHV-8-seropositivity and previous transplant presenting another route of viral transmission as previously reported [4]. The association between HHV-8-seropositivity and syphilis could suggest that the syphilis lesions facilitate the entrance of the virus during sexual intercourse.
Finally, several studies conducted worldwide have attempted to find the best immunosuppressive therapy for use with HHV-8-seropositive transplant recipients [5]. It is not yet defined, but it is certain that these patients need an appropriated attendance to avoid iatrogenic KS and organ rejection, giving them perhaps a better quality of life after transplant. Therefore, due to the high HHV-8 seroprevalence found in the present study and the seriousness of the HHV-8-associated diseases, the authors suggest that screening for HHV-8 must be performed in CKD patients, even those in pre-dialysis.
Acknowledgments
This work was supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil, fellowship to ACA (PD #304372/2006-4) and to MCM. We thank Drs Pedro Jabur, Ivoty Sens and José Ferraz Souza from Santa Casa de Misericórdia de São Paulo for data collection, and Drs Silvia R S Moreira and Silvia Manfredi from UNIFESP for samples collection.
Conflict of interest statement. None declared.
References
- 1.Farge D, Lebbé C, Marjanovic Z, et al. Human herpes virus-8 and other risk factors for Kaposi's sarcoma in kidney transplant recipients. Transplantation. 1999;67:1236–1242. doi: 10.1097/00007890-199905150-00007. [DOI] [PubMed] [Google Scholar]
- 2.Caterino-de-Araujo A, Santos-Fortuna E, Carbone PHL, et al. Human herpesvirus 8 (HHV-8) antibodies among women from São Paulo, Brazil. Association with behavioral factors and Kaposi's sarcoma. Braz J Infect Dis. 2003;7:395–401. doi: 10.1590/s1413-86702003000600007. [DOI] [PubMed] [Google Scholar]
- 3.Caterino-de-Araujo A, Magri MC, Santos-Fortuna E, et al. Human herpesvirus 8 infection in hemodialysis patients from São Paulo, Brazil: preliminary results. Transplant Proc. 2007;39:3044–3046. doi: 10.1016/j.transproceed.2007.07.087. [DOI] [PubMed] [Google Scholar]
- 4.Andreoni M, Goletti D, Pezzotti P, et al. Prevalence, incidence and correlates of HHV-8/KSHV infection and Kaposi's sarcoma in renal and liver transplant recipients. J Infect. 2001;43:195–199. doi: 10.1053/jinf.2001.0899. [DOI] [PubMed] [Google Scholar]
- 5.Stallone G, Schena A, Infante B, et al. Sirolimus for Kaposi's sarcoma in renal transplant recipients. N Engl J Med. 2005;352:1317–1323. doi: 10.1056/NEJMoa042831. [DOI] [PubMed] [Google Scholar]