toxoplasma gondii is disseminated worldwide and is one of the most prevalent infectious agents in humans . toxoplasma gondii is an opportunistic parasite in which acute infection is usually asymptomatic in immunocompetent patients , and spontaneous recovery is the norm ( 1 , 2 ) . generally , toxoplasmosis is dependent on many factors , such as sanitation levels , temperature , humidity , and contact with soil and domestic animals , with a seroprevalence that varies from 0% to 95% ( 3 , 4 ) . the prevalence of toxoplasma gondii is about 22.5% , 0.27% - 12.9% , 23.1% , 80% , and 50% - 84% in the usa ( 5 ) , south korea ( 6 ) , turkey ( 7 ) , and brazil ( 8 , 9 ) , respectively . according to assmar et al . other studies have indicated that 55.7% of the population in the provinces of mazandaran , gilan , and khozestan ( 11 ) , 17.7% in fars and azarbayjan provinces ( 11 , 12 ) , and 68.4% in the southern region of tehran ( 11 , 13 ) are seropositive . acute toxoplasmosis is asymptomatic in 80% of healthy hosts and only 20% of adults and children exhibit symptomatic infection ( 14 ) . however the existence of toxoplasma tissue cysts in hosts may contribute to the maintenance of immunity against reinfection , and their presence may also cause symptomatic toxoplasmosis under certain conditions , especially in infants with congenital toxoplasmosis and immunocompromised patients ( 15 ) . studies have shown that renal failure patients , such as those on hemodialysis , are immunodeficient , and such patients are therefore at high risk for numerous infections ( 16 - 18 ) . no studies have been conducted regarding toxoplasmosis in hemodialysis patients in the northeast of iran . in the present study , we therefore aimed to determine the prevalence of anti - toxoplasma gondii igg , igm , and iga antibodies in hemodialysis patients with chronic kidney disease ( ckd ) in sari , iran . from july to september 2013 , this cross - sectional study was carried out on 73 patients with ckd undergoing regular hemodialysis in the hemodialysis unit of fatemeh zahra hospital at the mazandaran university of medical sciences in sari , iran . a total of 145 healthy volunteers with normal creatinine and bun levels and without any underlying renal disease ( control group ) who matched the ckd patients according to age , gender , and geographical area were selected . the study was approved by the local ethics committee , and informed consent was obtained from all the participants . medical records as well as data such as age , sex , and the length of time on hemodialysis treatment were obtained from all the hemodialysis patients . to determine the seroprevalence of toxoplasma infections , 10 ml of peripheral blood was taken under aseptic conditions from all the patients in the hemodialysis and control groups , and each sample was left for 30 - 60 minutes at room temperature for spontaneous clotting before being centrifuged at 1500 rpm for 10 minutes . the serum samples were stored in acid - washed polyethylene tubes and kept frozen at 20c until tested in referral laboratory of mazandaran university of medical sciences . anti - toxoplasma gondii igg , igm , and iga were determined using a conventional enzyme - linked immunosorbent assay ( elisa ) technique . elisa kits were purchased from the commercial manufacturer pishtazteb , iran , for the igg and igm tests , and ei 2410 - 9601 a ( euroimmun , germany ) was procured for the iga test . according to the manufacturers recommendations , igg absorbance levels < 9 were considered negative , 9 - 11 was considered borderline , and > 11 was positive ; igm absorbance levels < 0.9 were considered negative , 0.9 - 1.1 was assumed to be borderline , and > 1.1 was positive ; and an iga ratio < 0.8 was considered negative , a ratio  0.8 but < 1.1 was assumed to be borderline , while  11 was positive . in the event of a borderline test result , an additional blood sample was obtained 2 weeks later and retested in parallel with the first suspect sample . the data were analyzed using a chi - squared test , and p < 0.05 were considered statistically significant . of the 73 ckd patients , there were 40 males and 33 females aged between 28 and 88 years ( mean : 62.32  12.06 years ) . the length of time on hemodialysis treatment was 3 - 13 weeks ( mean : 12.05  1.97 weeks ) . in the control group comprising 145 healthy volunteers , there were 63 males and 82 females aged between 27 and 84 years ( mean : 55.52  11.43 years ) . in the present study , 59 of the 73 ( 80.8% ) cases in the patient group and 132 of the 145 ( 91% ) healthy volunteers ( control group ) were found to be positive for igg antibodies , and 23 ( 31.5% ) cases in the patient group and 46 ( 31.8% ) healthy volunteers ( control group ) were found to be positive for iga antibodies . the percentage of participants who were anti - toxoplasma 
 gondii igg - antibody positive in the control group was found to be significantly greater than in the ckd patient group , although the difference was not statistically significant for the iga antibody ( p < 0.05 ) . meanwhile , all the hemodialysis patients were negative for the anti - igm antibody , as were four ( 2.76% ) of the control group subjects , and no statistically significant difference was observed between the groups . the seroprevalence distribution of the three antibody groups and a comparison of the anti - toxoplasma antibodies present among the hemodialysis patients and healthy volunteers are shown in tables 1 and 2 , respectively . the relationship between duration of hemodialysis treatment and anti - toxoplasma 
 gondii antibody seropositivity was also verified , and we found a significant difference between these two parameters (  = 5.24 , p = 0.155 ) . abbreviations : m , male ; f , female ; ig , immunoglobulin . toxoplasmosis , which is an indexed global public health concern ( 8) , is an opportunistic infection that causes non - symptomatic infections in immunocompetent individuals ( 7 ) . almost equal percentage prevalence , namely 80.6% and 91% , of anti - toxoplasma gondii igg antibody was revealed in the hemodialysis patients and healthy volunteers in this study , respectively . the results of the patient group share a similar frequency with figures reported in turkey ( 76.5% ) ( 17 ) . however , the data in our study were higher than those reported by sahinl et al . ( 16 ) ( 59.1% ) and maraghi et al . ( 18 ) , ebrahim zadeh et al . ( 20 ) of 59.1% , 40.67% , 56.7% and 60% , respectively in iran , and aufy et al . ( 22 ) of 56.06% , 56.7% and 10% , respectively in turkey , egypt and mexico ; whereas in our results the percentage of anti - toxoplasma gondii igg antibody in the volunteer group was more than other studies ( 17 - 22 ) . furthermore , in our study , there were no positive cases of anti - toxoplasma gondii igm antibody in the patient group and only 2.76% of the healthy volunteer showed the igm antibody . ( 17 ) who studied hemodialysis patients and healthy volunteers in turkey . on the other hand , aufy et al . ( 16 ) , maraghi et al . ( 18 ) , ebrahim zadeh et al . ( 20 ) and nissaptorn et al . ( 23 ) studies determined 16.7% , 6.8% , 8.6 % , 13.5% , 3.3% and 5.7% respectively in the patient groups , which is not compatible with our results . the anti - toxoplasma gondii iga antibody was prevalent in 61.5% of the hemodialysis patients and 31.8% of the healthy volunteers in our study . the outcome in our study was different from those reported in certain studies where such differences may have been related to local environmental conditions . additionally , our study indicated that there was no significant association between anti - toxoplasma gondii due to igg antibody frequency and the duration of hemodialysis treatment in either sex , whereas such a correlation was shown in the studies of sahinl et al . we conducted a case - controlled study to determine the prevalence of anti - toxoplasma gondii igg , igm , and iga antibodies in hemodialysis patients with ckd in sari , mazandaran province , iran . nowadays clinicians should become more aware of these patients , and parasitological surveys should be carried out steadily to eliminate the risk of severe toxoplasmosis . additionally , it is recommended that this study be extended to include a large sample of ckd patients on hemodialysis from other cities in mazandaran province , iran . the epidemiological data collected in this study could serve as a reference for future studies and may be useful in developing preventive and educational strategies , and consequently reducing healthcare expenditure . we conducted a case - controlled study to determine the prevalence of anti - toxoplasma gondii igg , igm , and iga antibodies in hemodialysis patients with ckd in sari , mazandaran province , iran . nowadays clinicians should become more aware of these patients , and parasitological surveys should be carried out steadily to eliminate the risk of severe toxoplasmosis . additionally , it is recommended that this study be extended to include a large sample of ckd patients on hemodialysis from other cities in mazandaran province , iran . the epidemiological data collected in this study could serve as a reference for future studies and may be useful in developing preventive and educational strategies , and consequently reducing healthcare expenditure .
backgroundtoxoplasma gondii has worldwide distribution and is one of the most prevalent infectious agents in humans.objectivesthe aim of this study was to determine the prevalence of anti - toxoplasma gondii antibodies in hemodialysis patients with chronic kidney disease ( ckd ) in the hemodialysis unit of fatemeh zahra hospital at the mazandaran university of medical sciences in sari , iran.methodsseventy-three patients with ckd and 145 healthy volunteers were assessed for anti - toxoplasma gondii ( igg , igm , and iga ) antibodies using a conventional elisa technique.resultsthe anti - toxoplasma gondii igg antibody was detected in 80.8% of the cases in the patient group , while 31.5% of the cases in the ckd patient group and 31.8% in the control group were found to be positive for the anti - toxoplasma gondii iga antibody . 
 all the patients in the ckd group were negative for the anti - toxoplasma gondii igm antibody , although 2.76% of the healthy volunteers were found to be positive . 
 the present study suggests that there was no significant difference between the hemodialysis patient group and the healthy volunteers.conclusionsthe epidemiological data collected in this study could serve as a reference for future studies and may be useful in developing preventive and educational strategies , and consequently reducing healthcare expenditure .