Follow-Up of Newborns with Hepatitis B Antigenemia

INTRODUCTION

There is a need for data to evaluate hepatitis B antigenemia in newborns of mothers with hepatitis B virus (HBV) infection. This study aims to investigate this.

METHODS

Newborns with positive serum hepatitis B surface antigen (HBsAg) and/or e antigen (HBeAg) were enrolled in the study.

RESULTS

One hundred and one newborns from 98 HBV-infected mothers were included. Median maternal serum HBV DNA level was 23,200 IU/mL at delivery. Among the newborns, 48 were boys and 53 were girls. Mean birth weight was 3190.5 g. Twenty-one newborns had concurrent seropositive HBsAg and HBeAg, nine had seropositive HBsAg and seronegative HBeAg, and 71 had seronegative HBsAg and seropositive HBeAg. Eight newborns had detectable serum HBV DNA. In the follow-up, serum HBsAg and HBeAg in the newborns with undetectable HBV DNA became negative before 6 months of age. Two infants with detectable HBV DNA were diagnosed with immunoprophylaxis failure, one of whom developed active hepatitis at 3 months of age. Liver biopsy in this case showed significant interface hepatitis, fibrous septa formation, and expansion of portal areas with occasional bridging fibrosis.

CONCLUSIONS

Concurrent HBV viremia and antigenemia in newborns of HBV-infected mothers requires attention, while antigenemia without viremia is often transient.

MARCH6 promotes hepatocellular carcinoma development through up-regulation of ATF2

Background

Hepatocellular carcinoma (HCC) is a common cause of cancer mortality worldwide. Recent studies have shown that the polytopic enzyme membrane associated ring-CH-type finger 6 (MARCH6) participates in tumorigenesis, but its function in HCC development needs to be investigated. This study aimed to explore the role of MARCH6 in HCC.

Methods

Expression of MARCH6 in human HCC samples was checked by immunohistochemical staining assay. Clinical relevance of MARCH6 and activating transcription factor 2 (ATF2) was analyzed from TCGA database. CCK-8, EdU staining, colony formation and transwell were performed to assess cell proliferation, growth and migration. Xenografted tumorigenesis was used to examine in vivo role MARCH6. Immunoblotting was applied to detect protein abundance.

Results

We found that MARCH6 expression was elevated in human HCC samples. Over-expression of MARCH6 was associated with poor prognosis of HCC patients. Up-expression of MARCH6 promoted cell growth and migration of HCC cells. In contrast, the HCC cell growth and migration were suppressed by MARCH6 knockdown. Furthermore, the DNA synthesis was enhanced by MARCH6. The expression of ATF2 was potentiated by MARCH6 over-expression, while it was suppressed by MARCH6 silencing. TCGA database showed positive correlation between the expression of MARCH6 and ATF2. Importantly, ATF2 expression contributed to the oncogenic function of HCC cells.

Conclusion

Our findings suggest that MARCH6-mediated ATF2 up-regulation contributes to HCC development. MARCH6 may be a promising target for the diagnosis and treatment of HCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08540-x.

Biopsy-proven liver cirrhosis in young children: A 10-year cohort study

Young children with liver cirrhosis have a significantly high risk of mortality. However, there are few studies regarding early childhood-onset cirrhosis. This study aims to explore the causes, clinical findings and prognosis of biopsy-proven cirrhosis in infants, toddlers and preschoolers. We enroled young children with biopsy-proven cirrhosis from January 2010. Till January 2020, the study has been going on for 10 years. A total of 139 cirrhotic children were enrolled, including 87 boys and 52 girls. The median age at initially histological diagnosis of cirrhosis was 2 years old (range: 1 month-6 years). Sixty-two patients reported yellowish discoloration of sclera and/or skin as an initial symptom. Ninety-three patients had definite aetiologies while 46 had indeterminate causes. Among the confirmed cases, 31 had hepatitis B virus (HBV) infection, accounting for 33.3%. Subsequently, glycogen storage disease was diagnosed in 16 cases and Wilson disease in 14 cases. In these patients with HBV infection, nine finally achieved hepatitis B surface antigen (HBsAg) loss (29.0%) after effective antiviral therapy during the follow-up. Logistic regression revealed that baseline alanine aminotransferase (odds ratio 1.008, p = 0.028) was the independent predictor of HBsAg loss. Furthermore, one patient who underwent second biopsies showed histological reverse. HBV infection is an important cause of paediatric cirrhosis in our study. The pathogenesis of HBV-related cirrhosis in early childhood deserves further studies.

Clinical profiles and diagnostic challenges in 1158 children with rare hepatobiliary disorders

BACKGROUND

Diagnosis of rare diseases possesses a great challenge in pediatric hepatology because expert knowledge in the field is extremely insufficient. The study aims to explore new findings and collect diagnostic experience from pediatric rare liver diseases.

METHODS

The large-sample case analysis study included pediatric patients who had liver-involved rare diseases. All cases underwent liver biopsy and/or gene sequencing.

RESULTS

A total of 1158 pediatric patients were identified. Liver-based genetic diseases were most frequent (737 cases), followed by liver damages involved in extrahepatic or systemic disorders (151 cases) and cryptogenic hepatobilliary abnormalities (123 cases). Of note, diagnoses of 16 patients were re-evaluated according to genetic results combined with clinical pointers. In addition, 101 patients who underwent gene sequencing remained undiagnosed. Of them, 55 had negative genetic findings, 30 harbored mutations that failed to meet their typically pathogenic condition, and 16 had detected variants that were inconsistent with clinical pointers.

CONCLUSIONS

As a study involving known largest number of children with rare hepatobiliary disorders, it allows us to accumulate information (especially new findings) on the etiology and diagnosis of these disorders. The results can help to improve the diagnostic quality in the population.

IMPACT

Liver-based genetic diseases were most frequent in clinical profiles of pediatric rare liver diseases. Some novel variants in cases with genetic diseases (for example, two variants of c.3638G>T and c.1435G>C in a patient with progressive familial intrahepatic cholestasis type 2) were identified. As a study involving known largest number of pediatric cases with rare hepatobiliary disorders, it allows us to accumulate information on the etiology and diagnosis of these disorders. The study can help to optimize the diagnostic process and significantly improve the diagnostic quality in the field of pediatric hepatology. Given that clinical variability often exists within rare genetic disease entities and not all rare disorders are genetic, clinicians should not over-depend on the genetic results in the diagnosis.

De novo combination antiviral therapy in e antigen-negative chronic hepatitis B virus-infected paediatric patients with advanced fibrosis

To date, studies that focus on treatment of e antigen-negative chronic hepatitis B virus-infected children with advanced fibrosis are extremely limited. This puts these patients at risk of rapid disease progression. Our study aimed to investigate the efficacy of combination antiviral therapy in this population. We prospectively enrolled treatment-naı̈ve paediatric patients between 1 year and 12 years of age who had e antigen-negative chronic hepatitis B and histologically proven advanced fibrosis. All patients received de novo combination therapy with lamivudine (LAM) and interferon-α (IFN) for 12 months and then were clinically followed up. The main outcome measure was rate of serum hepatitis B surface antigen (HBsAg) loss at month 12 of treatment. A total of 14 paediatric patients were enrolled, including 9 boys and 5 girls. All patients achieved undetectable HBV DNA levels at month 9 of treatment. A total of 5 patients (35.7%) achieved HBsAg loss at month 12 and finally developed HBsAg seroconversion. Four patients who did not clear HBsAg underwent second liver biopsy, and histological evaluation revealed significant improvements in all of them. As a serum fibrosis marker, aspartate aminotransferase-to-platelet ratio index after 12-month treatment in the 14 patients showed a significant improvement compared with that at baseline (P = .0021). No serious adverse events were observed during the study. Combination antiviral therapy is beneficial to e antigen-negative chronic hepatitis B virus-infected paediatric patients with advanced fibrosis. Further studies with larger cohorts are required.

Early initiation of antiviral therapy contributes to a rapid and significant loss of serum HBsAg in infantile-onset hepatitis B

BACKGROUND & AIM

There is a paucity of data regarding antiviral therapy in hepatitis B virus (HBV)-infected infants aged <1 year who have elevated alanine aminotransferase. This study aims to assess the efficacy and safety of antiviral therapy initiated in infancy.

METHODS

A real-world cohort study was conducted from January 2010 to December 2017. HBV-infected infants under 1 year of age, with persistent elevation of alanine aminotransferase and high viral load, were recruited and divided into 2 groups. Group I included 18 infants whose parents chose to initiate antiviral therapy with lamivudine before 1 year of age. Group II included 11 infants whose parents chose to initiate antiviral therapy with interferon-α after 1 year of age and not to receive any antiviral therapies before 1 year of age. The main outcome measure was rate of serum HBV surface antigen (HBsAg) loss at month 12 of treatment.

RESULTS

There were no statistical differences between Groups I and II regarding baseline characteristics. No infants in Group II developed spontaneous HBsAg loss before 1 year of age. In Group I, the cumulative rates of HBsAg loss at month 3, 6, 9 and 12 of treatment were 39%, 67%, 78% and 83%, respectively. In Group II, the cumulative rates of HBsAg loss at month 3, 6, 9 and 12 of treatment were 18%, 27%, 27% and 36%, respectively. Statistical differences existed in the cumulative rates of HBsAg loss between the 2 groups (log-rank test, p = 0.0023). No serious adverse events occurred in the study.

CONCLUSION

Early initiation of antiviral therapy for infantile-onset hepatitis B contributes to a rapid and significant loss of HBsAg. Further trials with larger cohorts are needed to verify our results.

LAY SUMMARY

Chronicity is a serious threat to infants infected with hepatitis B. However, no treatment measure has been recommended for infantile-onset hepatitis B in current guidelines. In order to evaluate the benefit and safety of antiviral therapy in infantile-onset hepatitis B, a real-world cohort study was conducted. Long-term follow-up results showed that early initiation of antiviral therapy with lamivudine safely led to a rapid and significant loss of serum hepatitis B surface antigen in the present subset of infants with alanine aminotransferase ≥2× upper limit of normal. Further trials with larger cohorts are needed.

Antiviral therapy in hepatitis B virus-infected children with immune-tolerant characteristics: A pilot open-label randomized study

BACKGROUND & AIM

Chronic infection with hepatitis B virus (HBV) in children is a serious health problem worldwide. How to treat children with immune-tolerant chronic hepatitis B infection, commonly characterized by hepatitis B e antigen (HBeAg) positivity, high viral load, normal or mildly elevated alanine aminotransferase and no or minimal inflammation in liver histology, remains unresolved. This trial aims to study the benefits of antiviral therapy in children with these characteristics.

METHODS

This is a pilot open-label randomized controlled study. From May 2014 to April 2015, 69 treatment-naive chronically HBV-infected children, aged 1 to 16 years, who had immune-tolerant characteristics were recruited to this trial and randomly assigned, in a 2:1 ratio, to treatment group and control group. Patients in the treatment group received either interferon-α (IFN) monotherapy or consecutively received IFN monotherapy, combination therapy of IFN and lamivudine (LAM), and LAM therapy alone. All patients were observed until week 96.

RESULTS

At baseline, epidemiological, biochemical, serological, virological and histological indices were consistent across the treatment and control groups. Of the 46 patients in the treatment group, 73.91% had undetectable serum HBV DNA, 32.61% achieved HBeAg seroconversion and 21.74% lost hepatitis B surface antigen (HBsAg) at the endpoint. No LAM resistance emerged at week 96. In the control group, only one (4.35%) patient underwent spontaneous HBeAg seroconversion and had undetectable serum HBV DNA during observation, and moreover, none developed HBsAg clearance. For all patients, no serious adverse events were observed.

CONCLUSION

Antiviral treatment with a sequential combination of IFN and LAM resulted in a significant improvement in the rates of undetectable serum HBV DNA, HBeAg seroconversion and HBsAg loss in children with chronic HBV infection and immune-tolerant characteristics.

LAY SUMMARY

There is a lack of data regarding treatment of immune-tolerant chronic hepatitis B (CHB). It remains unresolved how children with immune-tolerant CHB should be treated. This paper reports the outcomes from a pilot open-label randomized controlled trial on antiviral therapy in children with immune-tolerant characteristics. It shows that a sequential combination of interferon-α and lamivudine was beneficial.

Wernicke encephalopathy in a patient with liver failure: Clinical case report

Early recognition and diagnosis of Wernicke encephalopathy is pivotal for the prognosis of this medical emergency, especially in patients with liver failure which predisposes individuals to develop hepatic encephalopathy. For these patients, distinguishing between hepatic encephalopathy and Wernicke encephalopathy is a challenge in real-world clinical practice.A male patient with 21-year medical history of liver cirrhosis presented diarrhea and ascites. One month before this visit, he was noted to have poor appetite and progressive fatigue. After admission, although several major symptoms, including diarrhea, ascites, hyponatremia, and hypoproteinemia, were greatly improved through appropriate treatments, his laboratory indicators were not changed much. His appetite was not reversed at discharge. On the 5th day after discharge, the patient suddenly became reluctant to speak and did not remember the recent happenings. Simultaneously, unsteady gait and strabismus occurred. On the basis of clinical manifestations and brain magnetic resonance imaging scan results, the patient was diagnosed as Wernicke encephalopathy and these relative symptoms were resolved after intravenous vitamin B1.To our knowledge, this is the second case report of Wernicke encephalopathy developing in a critically ill cirrhotic patient without hepatocellular carcinoma or operative intervention. Wernicke encephalopathy may be underdiagnosed in these patients and this case raises physicians' awareness of its possible onset.

Prevalence and risk factors of coronary artery disease in patients with chronic viral hepatitis

OBJECTIVES

Patients with chronic viral hepatitis usually present metabolic abnormalities and hemodynamic changes, which are known factors associated with the development of coronary artery disease (CAD). This study aims to determine the risk factors of incident CAD in these patients.

METHODS

We identified 193 patients who subsequently developed CAD amongst 37,840 cases diagnosed as chronic viral hepatitis from January 2007 through December 2013.

RESULTS

In these patients, 141 had hepatitis B virus infections and 52 had hepatitis C virus infections. There was a male preponderance (65.9%). The median age at the diagnosis of hepatitis was 51 years. In the univariate analysis, patients aged ≥ 51 years had shorter median periods from the diagnosis of hepatitis to the onset of CAD than patients aged < 51 years (50 versus 96 months, p < 0.001), and patients with hypertension had shorter median durations compared to those without hypertension (48 versus 96 months, p < 0.001). Statistical significance also existed between patients with different etiologies (p = 0.004). In the multivariate analysis by Cox regression, age at the diagnosis of hepatitis (p < 0.001; hazard ratio (HR), 1.041; 95% CI, 1.027-1.056) and hypertension (with versus without, p < 0.001; HR, 1.925; 95% CI, 1.419-2.611) were revealed.

CONCLUSIONS

Age at diagnosis of hepatitis and hypertension appeared to be independent risk factors of incident CAD in these patients. This topic deserves further studies.

Risk of incident coronary artery disease in patients with primary biliary cirrhosis

BACKGROUND

Patients with primary biliary cirrhosis (PBC) often present hyperlipidemia, which is a risk factor of incident coronary artery disease (CAD). However, few studies have examined CAD in PBC.

METHODS

We identified 41 patients who developed CAD amongst 2,675 PBC cases across seven years and selected the PBC patients without CAD as controls according to sex and age.

RESULTS

Females dominated in these patients with CAD. The median time from the diagnosis of PBC to the onset of CAD was 44 months. The patient group with CAD had higher median levels of low-density lipoprotein cholesterol (4.68 mmol/L versus 3.52 mmol/L, P=0.036) and higher proportion of cases with hypertension (63.4% versus 19.5%, P<0.001) compared to that without CAD. In the logistic regression, only hypertension (with versus without, P<0.001; OR, 1.597; 95% CI, 1.139-2.053) was selected.

CONCLUSION

PBC patients with hypertension should be monitored carefully due to the risk of incident CAD.

Acute liver failure caused by severe acute hepatitis B: a case series from a multi-center investigation

Background

Few data can be available regarding acute liver failure (ALF) caused by severe acute hepatitis B up to now. This study aims to report such cases from China.

Findings

We conducted a multi-center investigation on ALF from 7 tertiary hospitals in different areas of China. A total of 11 patients with ALF caused by severe acute hepatitis B were finally identified. In these patients, there were 10 male and 1 female patients. As a serious complication, apparent hemorrhage occurred in 9 patients. Eventually, in these 11 patients, 4 survived and 7 died. 4 died of heavy bleeding, 2 died of systemic inflammatory response syndrome and 1 died of irreversible coma. No patients received liver transplantation.

Conclusions

ALF caused by severe acute hepatitis B is worthy of formal studies based on its rarity and severity.

Acute liver failure in Chinese children: a multicenter investigation

BACKGROUND

Currently, no documentation is available regarding Chinese children with acute liver failure (ALF). This study was undertaken to investigate etiologies and outcomes of Chinese children with ALF.

METHODS

We retrospectively enrolled 32 pediatric patients with ALF admitted in five hospitals in different areas of China from January 2007 to December 2012. The coagulation indices, serum creatinine, serum lactate dehydrogenase, blood ammonia and prothrombin activity were analyzed; the relationship between these indices and mortality was evaluated by multivariate analysis.

RESULTS

The most common causes of Chinese children with ALF were indeterminate etiology (15/32), drug toxicity (8/32), and acute cytomegalovirus hepatitis (6/32). Only 1 patient (3.13%) received liver transplantation and the spontaneous mortality of Chinese children with ALF was 58.06% (18/31). Patients who eventually died had higher baseline levels of international normalized ratio (P=0.01), serum creatinine (P=0.04), serum lactate dehydrogenase (P=0.01), blood ammonia (P<0.01) and lower prothrombin activity (P=0.01) than those who survived. Multivariate analysis showed that the entry blood ammonia was the only independent factor significantly associated with mortality (odds ratio=1.069, 95% confidence interval 1.023-1.117, P<0.01) and it had a sensitivity of 94.74%, a specificity of 84.62% and an accuracy of 90.63% for predicting the death. Based on the established model, with an increase of blood ammonia level, the risk of mortality would increase by 6.9%.

CONCLUSIONS

The indeterminate causes predominated in the etiologies of ALF in Chinese children. The spontaneous mortality of pediatric patients with ALF was high, whereas the proportion of patients undergoing liver transplantation was significantly low. Entry blood ammonia was a reliable predictor for the death of pediatric patients with ALF.

Can experience from adults regarding acute liver failure fit children?

Till date, comparison of clinical characteristics in acute liver failure (ALF) between adults and children has not been performed. In this study, authors retrospectively collected data on adult acute liver failure (AALF) and pediatric acute liver failure (PALF) in seven hospitals in different areas of China from January 2007 through December 2012. A total of 177 AALF cases and 32 PALF cases were eventually included. Several vital clinical variables were significantly different between AALF and PALF, including serum alkaline phosphatase, serum creatinine, serum urea nitrogen, serum lactate dehydrogenase, platelet count, prothrombin activity, international normalized ratio and blood ammonia. It is concluded that experience from AALF could not be proper for PALF.

Causes and outcomes of acute liver failure in China

Objectives

No extensive investigation has been performed and thus no representative data are available regarding acute liver failure (ALF) in China. This study aims to investigate the causes and outcomes of ALF in China and establish a prognostic model.

Methods

Patients diagnosed as ALF in seven hospitals in different areas of China from January 2007 to December 2012 were retrospectively selected.

Results

Of the 177 patients included in this study, 112 (63.28%) eventually died. The common causes of ALF were drug toxicity (43.50%), indeterminate etiology (29.38%) and acute viral hepatitis (11.30%). Additionally, traditional Chinese herbs predominated in the causes of drug-induced ALF (30/77). No patients in this study received liver transplantation. In the established model for predicting death in ALF, four variables were finally selected out, including age (P=0.01), the entry hepatic encephalopathy grade (P=0.04), international normalized ratio (P<0.01) and arterial blood ammonia (P=0.02). Using a threshold value of 0.5683, this model had a sensitivity of 95.24% and a specificity of 91.30%.

Conclusions

Traditional Chinese medicine was a major cause of ALF in China. The spontaneous mortality of ALF was high, whereas the rate of liver transplantation was significantly low. The established prognostic model of ALF had superior sensitivity and specificity.

Comparison of rescue strategies in lamivudine-resistant patients with chronic hepatitis B

Lamivudine (LAM) resistance now poses a major problem in the management of patients with chronic hepatitis B virus (HBV) infection. We retrospectively collected clinical data on chronic HBV-infected patients who had developed LAM resistance under de novo LAM monotherapy and subsequently took nucleos(t)ide analogs as rescue strategy in our hospital. From initiation of rescue therapies to January 2012, incidence of antiviral drug resistance was 23.67%, 18%, 6.94% and 0% (P=0.007) in the group of switching to adefovir dipivoxil (ADV) monotherapy, switching to entecavir (ETV) monotherapy, adding on ADV and switching to combination of ADV and ETV. At month 12, the median levels of serum HBV DNA were respectively 9300IU/mL, 4648IU/mL, 2054IU/mL and 100IU/mL (P<0.001), and the cumulative rates of serum ALT normalization were respectively 75%, 84%, 93% and 100% (P=0.003). Additionally, the strategy of switching to ADV monotherapy induced more single rtA181T mutations. In conclusion, switching to ADV monotherapy has been widely used in real-world clinical practice in China, however, due to the high incidence of drug resistance, switching to neither ADV nor ETV monotherapy is optimal when LAM resistance occurs; combination of ADV and ETV is most effective, whereas the strategy of adding on ADV is rational for most of LAM-resistant Chinese patients with chronic hepatitis B.

Comparison of the 48-week efficacy between entecavir and adefovir in HBeAg-positive nucleos(t)ide-naïve Asian patients with chronic hepatitis B: a meta-analysis

Background

Although entacavir and adefovir were widely used in most Asian countries, there were few conclusions drawn from a meta-analysis for comparing the efficacy between entecavir and adefovir in nucleos(t)ide-naïve Asian patients with chronic hepatitis B (CHB). The aim of this study was to evaluate the 48-week efficacy between the two drugs in HBeAg-positive nucleos(t)ide-naïve Asian CHB patients with the method of Meta analysis, which was generally accepted by the international as the best evidence for evaluating the efficacy of drugs.

Methods

We searched all data documented in Pubmed, Embase, Wanfang Database and CNKI (China National Knowledge Infrastructure) before November 30, 2010. Heterogeneity was examined by Chi-square test, the relative risk calculated and forest plot drawn. Rates of undetected serum HBV DNA, serum alanine aminotransferase (ALT) normalization, HBeAg clearance and HBeAg seroconversion were analyzed. A total of 6 articles was included. Meta analysis showed that the rate of undetected serum HBV DNA (relative risk, 1.73; 95% confidence interval, 1.38-2.17; P < 0.00001) and that of serum ALT normalization (relative risk, 1.25; 95% confidence interval, 1.06-1.49; P = 0.009) in the entecavir group were higher than those in the adefovir group. However, no statistic significance existed between the two groups in the rate of HBeAg clearance (relative risk, 0.77; 95% confidence interval, 0.44-1.35; P = 0.36), or the rate of HBeAg seroconversion (relative risk, 0.74; 95% confidence interval, 0.28-1.94; P = 0.53).

Conclusions

Entecavir is superior to adefovir in decreasing serum HBV DNA and normalizing ALT but similar with adefovir in clearing HBeAg and encouraging HBeAg seroconversion for the HBeAg-positive nucleos(t)ide-naive Asian patients with chronic hepatitis B. Adefovir can be still used for first-line therapy in these patients.