Hepatitis C virus (HCV) infection remains a significant global health challenge, particularly among patients undergoing dialysis. Chronic kidney disease (CKD) is associated with an increased risk of HCV transmission due to frequent exposure to blood and invasive medical procedures (1). Despite advancements in infection control measures and antiviral therapies, the prevalence of HCV in dialysis patients remains a major concern, with substantial implications for morbidity, mortality, and healthcare costs (2).

Understanding the risk factors associated with HCV infection in dialysis patients is crucial for developing effective preventive strategies, improving patient outcomes, and reducing transmission within healthcare settings (3,4).

HCV is a blood borne pathogen that primarily affects the liver, leading to chronic liver disease, cirrhosis, and hepatocellular carcinoma if left untreated (5).

In dialysis patients, HCV infection can accelerate the progression of liver disease, increase the risk of cardiovascular complications (6), and contribute to higher mortality rates (7).

The unique characteristics of dialysis patients, including repeated vascular access, prolonged hospital stays, and impaired immune function, place them at heightened risk for acquiring HCV (8).

Furthermore, hemodialysis units, where multiple patients receive treatment in close proximity, present a potential environment for nosocomial transmission if strict infection control measures are not enforced (9,10).

Several risk factors contribute to the increased susceptibility of dialysis patients to HCV infection. Blood transfusions, which were historically a major source of HCV transmission, continue to pose a risk in some regions with limited access to nucleic acid testing for blood screening (11-13). Contaminated dialysis equipment, lapses in infection control protocols, and inadequate sterilization techniques have also been implicated in HCV outbreaks within dialysis centers (14). Moreover, the reuse of dialysis filters and other equipment in resource-limited settings can significantly elevate the risk of transmission. Additionally, patient-to-patient transmission through healthcare workers’ hands or improperly disinfected surfaces remains a concern, highlighting the need for stringent adherence to hygiene protocols (15).

The mode of dialysis itself may influence the risk of HCV infection. Hemodialysis patients are generally at a higher risk compared to peritoneal dialysis patients due to the direct blood exposure associated with extracorporeal circulation. Several studies have reported a higher prevalence of HCV infection among hemodialysis patients, emphasizing the role of hemodialysis centers as potential sites for virus transmission (16). While peritoneal dialysis reduces the likelihood of direct blood exposure, other factors such as prolonged catheter use and peritonitis episodes may still contribute to an increased risk of infection (17).

Patient-related factors, including age, duration of dialysis, and comorbid conditions, also play a role in HCV transmission. Longer dialysis duration has been consistently associated with an increased risk of HCV infection, likely due to cumulative exposure to contaminated environments or repeated medical interventions (18). Older patients and those with compromised immune systems may have a reduced ability to clear the virus, leading to persistent infection and increased transmission risk. Additionally, co-infections with hepatitis B virus (HBV) or human immunodeficiency virus (HIV) may further complicate the clinical course and management of HCV in dialysis patients (19).

The advent of direct-acting antiviral (DAA) therapies has revolutionized the treatment of HCV, offering high cure rates with minimal side effects. However, access to these therapies remains limited in many parts of the world due to high costs, lack of healthcare infrastructure, and limited awareness among healthcare providers (20). The successful elimination of HCV in dialysis patients requires a multifaceted approach, including routine screening, early diagnosis, implementation of strict infection control measures, and expansion of treatment availability. Regular HCV screening in dialysis centers using sensitive diagnostic methods, such as polymerase chain reaction (PCR) testing, is essential for early detection and prevention of further transmission (21).

Infection control practices remain the cornerstone of HCV prevention in dialysis settings. The implementation of strict hand hygiene protocols, the use of dedicated dialysis machines for HCV-positive patients, and the proper sterilization of medical equipment are critical measures to minimize transmission (22). Additionally, adherence to universal precautions, including the use of gloves and protective barriers, can significantly reduce the risk of cross-contamination. Healthcare workers should undergo regular training on infection prevention strategies to ensure compliance with best practices and reduce the likelihood of human errors that could contribute to HCV spread (19).

In conclusion, HCV infection remains a persistent challenge in dialysis patients, with multiple risk factors contributing to its transmission. Understanding these risk factors is essential for developing effective prevention strategies, optimizing patient care, and reducing the burden of HCV in dialysis populations. While advances in antiviral therapy have improved treatment outcomes, addressing the underlying causes of HCV transmission through enhanced infection control measures, routine screening, and improved healthcare infrastructure is crucial. A comprehensive approach involving healthcare providers, policymakers, and patients is needed to achieve long-term success in reducing HCV prevalence among dialysis patients.

Materials and Methods

Study Design: This study is a systematic review aimed at evaluating the risk factors for Hepatitis C Virus (HCV) infection in dialysis patients. The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure methodological rigor and transparency. Studies included in this review were assessed for their methodological quality, relevance, and contribution to understanding the risk factors associated with HCV transmission in dialysis settings.

Inclusion and Exclusion Criteria: To ensure the inclusion of relevant and high-quality studies, specific eligibility criteria were established. Studies were included if they investigated risk factors for hepatitis C virus (HCV) infection in adult dialysis patients (aged≥18 years), employed observational designs such as cross-sectional, case-control, or cohort studies, were published in peer-reviewed journals, and provided clearly defined diagnostic criteria for HCV infection. Studies were excluded if they were case reports, editorials, commentaries, or conference abstracts; if they lacked sufficient data on risk factors; if they focused on pediatric dialysis populations; or if they were published in non-English languages without an accessible translation.

Sampling Methodology: A systematic search was conducted across major electronic databases, including PubMed, Scopus, Web of Science, and Embase. Studies published up to the present were reviewed without time restrictions to provide a comprehensive analysis. The search strategy involved a combination of Medical Subject Headings (MeSH) terms and keywords related to HCV, dialysis, risk factors, and infection control. Additional articles were identified through reference lists of relevant studies and reviews.

 Data Extraction and Study Selection

Two independent reviewers systematically screened the titles and abstracts of retrieved articles to identify studies that met the eligibility criteria. Full-text versions of studies deemed potentially relevant were obtained and thoroughly assessed based on the predefined inclusion and exclusion criteria. To ensure accuracy and consistency in study selection, any disagreements between the two reviewers were discussed and resolved collaboratively. If consensus could not be reached, a third reviewer was consulted to make the final decision. From the studies that met the inclusion criteria, key data were extracted, including details about the study itself (such as the author’s name, year of publication, country of origin, and study design), characteristics of the patient population (sample size, age distribution, and type of dialysis performed), prevalence rates of HCV infection, and the diagnostic tools used to confirm infection. Additionally, reported risk factors associated with HCV transmission were carefully documented, alongside any information related to preventive measures or infection control strategies applied within the dialysis setting.

 Methodology of Data Analysis

The extracted data were synthesized using a narrative approach, with emphasis on identifying common and significant risk factors. For quantitative synthesis, statistical analyses were performed where applicable. Pooled prevalence rates and odds ratios (OR) were calculated for key risk factors using meta-analysis techniques when sufficient data were available. Heterogeneity among studies was assessed using the I² statistic, and a random-effects model was applied in cases of high heterogeneity. Publication bias was evaluated using funnel plot analysis and Egger’s test.

Ethical Considerations

As this study is a systematic review, no direct patient involvement or new data collection was conducted. Ethical approval was not required; however, all included studies were reviewed to ensure compliance with ethical standards, including approval by institutional review boards and adherence to ethical guidelines for human research. In cases where patient consent was necessary in the original studies, compliance with informed consent protocols was verified. This systematic review adheres to principles of scientific integrity and transparency, ensuring that findings contribute to the ongoing efforts to reduce HCV transmission in dialysis settings while maintaining the highest ethical research standards.

Results

The results of this systematic review are presented in three tables, each summarizing key findings from the included studies. The first table illustrates the characteristics of the selected studies, the second table highlights the prevalence of HCV in dialysis patients, and the third table presents the identified risk factors along with their statistical associations.

The studies included in this review were conducted across different regions, with varying sample sizes and study designs. The majority of patients in these studies were undergoing hemodialysis, with a smaller proportion receiving peritoneal dialysis. Cohort, case-control, and cross-sectional methodologies were used to investigate the prevalence and risk factors of HCV infection in dialysis patients (table 1).

Table 1: Characteristics of Included Studies

The prevalence of HCV infection in dialysis patients varied across studies, ranging from 9.38% to 15.04%. The highest prevalence was reported in the study conducted in Egypt, where endemicity and resource limitations may contribute to increased transmission. Despite improvements in infection control, a considerable proportion of dialysis patients remain at risk for HCV, underscoring the need for enhanced preventive strategies (table 2).

Table 2: Prevalence of HCV in Dialysis Patients

Multiple risk factors were significantly associated with HCV infection in dialysis patients. Longer dialysis duration (>5 years) was the strongest predictor of infection, followed by inadequate infection control measures. Blood transfusion history and reuse of dialysis filters were also significantly associated with increased risk. Additionally, hemodialysis patients had a higher likelihood of acquiring HCV compared to those undergoing peritoneal dialysis, emphasizing the need for stringent infection control in hemodialysis units. These findings highlight the critical importance of reinforcing infection prevention measures, optimizing dialysis protocols, and implementing routine HCV screening in dialysis centers to mitigate transmission risks (Table 3).

Table 3: Identified Risk Factors for HCV in Dialysis Patients

Discussion

Hepatitis C Virus (HCV) infection remains a major health concern among dialysis patients worldwide, despite advances in infection control and antiviral therapies. The findings of this systematic review highlight the significant burden of HCV in dialysis settings and emphasize the critical role of multiple risk factors in its transmission. The prevalence of HCV among dialysis patients, as observed in the included studies, ranged from 9.38% to 15.04%, with variations attributable to differences in geographical regions, infection control measures, and dialysis practices. Understanding these risk factors is essential for developing targeted preventive strategies and improving patient outcomes (23-25).

One of the most significant risk factors identified in this review is the duration of dialysis treatment. Patients who had undergone dialysis for more than five years exhibited a significantly higher risk of acquiring HCV infection (OR: 3.45, 95% CI: 2.18–5.11, p<0.001). This finding aligns with previous studies indicating that prolonged exposure to dialysis environments increases cumulative risks, particularly due to repeated vascular access, frequent blood handling, and potential breaches in infection control. Long-term dialysis patients have higher chances of undergoing multiple invasive procedures, which may further contribute to their susceptibility to blood borne infections. This underscores the importance of routine HCV screening, particularly in patients with extended dialysis durations, to facilitate early detection and intervention (26-28).

Another major risk factor observed in this study is a history of blood transfusions, which was associated with an increased likelihood of HCV infection (OR: 2.87, 95% CI: 1.95–4.02, p<0.001). Although blood screening protocols have significantly improved over the past decades, transfusion-related HCV transmission remains a concern, particularly in regions with limited access to nucleic acid testing (NAT) for blood donors. Patients with chronic kidney disease (CKD) often require transfusions due to anemia, further increasing their exposure risk. Strategies such as optimizing erythropoiesis-stimulating agents (ESAs) to reduce the need for transfusions and ensuring rigorous blood donor screening can help mitigate this risk (29,30).

The reuse of dialysis filters was another identified factor contributing to HCV transmission (OR: 2.42, 95% CI: 1.72–3.51, p<0.001). In some resource-limited settings, dialyzers and other equipment are reused to reduce costs, which can inadvertently lead to cross-contamination if proper sterilization protocols are not strictly followed. While single-use dialyzers are the standard in many high-income countries, the continued practice of reuse in lower-income regions poses a persistent challenge. Strengthening guidelines on single-use policies, ensuring strict sterilization procedures, and investing in disposable dialysis equipment where feasible can significantly lower transmission risks (31).

Inadequate infection control measures were strongly associated with increased HCV transmission risk (OR: 4.12, 95% CI: 2.85–5.94, p<0.001), highlighting the critical role of hygiene and safety protocols in preventing nosocomial infections. Hemodialysis centers, where multiple patients receive treatment in close proximity, present an environment conducive to viral transmission if standard precautions are not followed. Poor hand hygiene, improper disinfection of dialysis stations, and shared use of medical instruments between patients can facilitate viral spread. Reinforcing strict infection control protocols, such as proper hand hygiene, dedicated dialysis machines for HCV-positive patients, and adherence to universal precautions, remains a cornerstone in preventing transmission.

The comparison between hemodialysis and peritoneal dialysis revealed that patients undergoing hemodialysis had a higher risk of HCV infection (OR: 1.89, 95% CI: 1.31–2.74, p=0.003). This is likely due to the nature of hemodialysis, which involves frequent vascular access and greater exposure to blood borne pathogens. In contrast, peritoneal dialysis is performed at home with less exposure to medical equipment and healthcare personnel, thereby reducing the risk of nosocomial transmission. While peritoneal dialysis may not be suitable for all CKD patients, increasing awareness of its potential benefits in reducing infection risks should be considered in clinical decision-making.

The geographical variation in HCV prevalence observed across studies suggests disparities in healthcare infrastructure, infection control practices, and access to antiviral therapies. In regions with higher prevalence rates, healthcare policies should focus on improving HCV screening in dialysis patients, enhancing staff training on infection prevention, and ensuring accessibility to direct-acting antiviral (DAA) therapies.

Another crucial aspect of HCV management in dialysis patients is the implementation of routine screening programs. Many infections remain undiagnosed due to the asymptomatic nature of chronic HCV, leading to delayed treatment and prolonged risk of transmission. Regular screening using sensitive diagnostic tools, such as nucleic acid testing (NAT) and polymerase chain reaction (PCR) assays, should be an integral part of dialysis protocols. Current guidelines recommend testing all dialysis patients at the initiation of treatment and periodically thereafter, depending on the prevalence and risk factors in specific healthcare settings. Early detection not only improves patient outcomes but also prevents further spread within dialysis units  (32).

Conclusion

In conclusion, HCV infection remains a significant challenge in dialysis patients, driven by multiple risk factors, including prolonged dialysis duration, blood transfusions, equipment reuse, inadequate infection control, and hemodialysis modality. Addressing these risks requires a multifaceted approach, encompassing strict infection prevention measures, routine HCV screening, improved dialysis protocols, and expanded access to antiviral treatments. Healthcare providers, policymakers, and dialysis center administrators must collaborate to implement effective strategies that minimize HCV transmission and improve the quality of care for dialysis patients.

Disclosure Statement

No potential conflict of interest reported by the authors.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' Contributions

All authors contributed to data analysis, drafting, and revising of the paper and agreed to be responsible for all the aspects of this work.