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Dialysis and hepatitis

From about 1964, there was increasing excitement that dialysis might become a major life-saving treatment for chronic renal failure, not just for acute renal failure. Transplantation was also in its infancy, but despite some promise, overall success rates at this time were very poor. A major frustration was the lack of resources to give dialysis to all who could benefit. Some remarkably bold approaches included self-dialysis and home dialysis, as much due to space and economy as patient independence.

A notorious anonymous editorial in the Lancet in November 1965 railed against the expansion of dialysis, complaining that it was consuming resources and diverting the attention of nephrologists who ought to be spending time on developing transplantation and blood pressure treatments. In the following three weeks, five pages of letters of protest were published from the renal units at Charing Cross, Edinburgh, Exeter, Leeds, Newcastle and the Royal Free, and from patient and medical student Robin Eady from Guy’s Hospital.

One paragraph of the gloomy editorial mentioned a recent serious outbreak of hepatitis at Manchester Royal Infirmary which had already affected over 50 people, and killed a nurse and a hospital porter. It later extended to 14 members of staff, with a further death. “Clearly the risk of similar outbreaks in other dialysis centres cannot be discounted” – this turned out to be the article’s only accurate premonition.

This Manchester outbreak turned out to be just the beginning of similar outbreaks affecting multiple units in the UK and worldwide. Edinburgh had one of the worst experiences with a particularly high mortality. The outbreak began when a patient was given a blood transfusion from a donor who turned out to be incubating hepatitis. In just over a year, from June 1969, 26 dialysis patients were affected and 7 died. Twelve members of staff developed hepatitis, of whom four died: two were transplant surgeons and two were technicians. Renal units now caused fear above and beyond the complexity of their diseases and treatments.

HBsAG (Hepatitis B virus surface antigen. Transmission electron Micrograph) by GrahamColm. CC BY 3.0 via Wikimedia Commons.

The Australia antigen was linked to serum hepatitis in 1966, leading to the identification of hepatitis B, and testing became widely available in 1969. It became apparent how extraordinarily easy it was to transmit hepatitis B. The Rosenheim Report in 1972 made recommendations about prevention, and coincided with a decline in new cases and the end of outbreaks. However, in the same year, the European Renal Registry recorded that 499 members of staff contracted hepatitis across 568 reporting renal units in Europe, with 12 deaths (2.4%).

Further expansion of dialysis slowed markedly, and in some units no new patients were taken on for a prolonged period. In many centres, and notably in the UK, there was a strong move towards home treatments delivered by patients. Vaccination against hepatitis B only became available from 1979 and was widely implemented in the 1980s. Newcomers sometimes wonder why current protocols for hepatitis testing remain so strict given the availability of vaccination, but history makes this clear.

In Edinburgh, the experience was so powerful that the full story was not presented at an internal meeting for 35 years. The memories of carrying out exchange transfusions on a dying surgical colleague in one’s own unit are indelibly imprinted on the minds of those involved. At the time, it was not clear who would develop the disease next, or when the epidemic would end.

A version of this blog post first appeared in the History of Nephrology blog.

Featured image credit: HBsAG (Hepatitis B virus surface antigen. Transmission electron Micrograph) by GrahamColm. CC BY 3.0 via Wikimedia Commons.

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