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Coppola N, Sagnelli C, Pisaturo M, Minichini C, Messina V, Alessio L, Starace M, Signoriello G, Gentile I, Filippini P, Sagnelli E. Clinical and virological characteristics associated with severe acute hepatitis B. Clin Microbiol Infect 2014; 20:O991-7. [PMID: 24930916 DOI: 10.1111/1469-0691.12720] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 06/08/2014] [Accepted: 06/10/2014] [Indexed: 12/16/2022]
Abstract
To identify early predictors of a severe or fulminant course in patients with acute viral hepatitis B (AVH-B). One hundred and thirty-eight patients with symptomatic acute hepatitis B observed from 1999 to 2012 were enrolled. For each patient, the demographics, risk factors for the acquisition of hepatitis B virus (HBV) infection, clinical, biochemical and virological data (HBV DNA, HBV DNA sequences) were recorded and analysed. The HBV mutants in the polymerase region were sought in 110 (87%) patients by direct sequencing, and the rtM204V/I mutations also by an allele-specific PCR. AVH-B was severe in 13 (9.4%) of the 138 patients enrolled, fulminant in 6 (4.3%) and with a normal clinical course in 119. The 19 patients with severe or fulminant AVH-B more frequently than the 119 with a normal course stated intravenous drug use (63.2% versus 36.1%, p 0.04) and were HBV-DNA negative (31.6% versus 11.8%, p 0.03) and anti-hepatitis C virus (HCV) positive (57.9% versus 19.3%, p 0.0008); the prevalences of different HBV genotypes and of the rtM204V/I mutant were similar in these three forms of AVH-B. A multivariate logistic regression analysis identified a pre-existing HCV chronic infection as the only factor independently associated with a severe or fulminant clinical course of AVH-B (OR 4.89, 95% CI 1.5-15.94, p 0.01). A pre-existing HCV chronic infection was identified as the only factor independently associated with a severe clinical presentation of acute hepatitis B, an association most probably due to the combination of the liver lesions caused by acute hepatitis B and the pre-existing histological abnormalities related to HCV chronic infection.
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Affiliation(s)
- N Coppola
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, Naples, Italy
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Abstract
OBJECTIVE Viral infections are often suspected to cause pediatric acute liver failure (PALF), but large-scale studies have not been performed. We analyzed the results of viral testing among nonacetaminophen PALF study participants. METHODS Participants were enrolled in the PALF registry. Diagnostic evaluation and final diagnosis were determined by the site investigator and methods for viral testing by local standard of care. Viruses were classified as either causative viruses (CVs) or associated viruses (AVs). Supplemental testing for CV was performed if not done clinically and serum was available. Final diagnoses included "viral," "indeterminate," and "other." RESULTS Of 860 participants, 820 had at least 1 test result for a CV or AV. A positive viral test was found in 166/820 (20.2%) participants and distributed among "viral" (66/80 [82.5%]), "indeterminate" (52/420 [12.4%]), and "other" (48/320 [15.0%]) diagnoses. CVs accounted for 81/166 (48.8%) positive tests. Herpes simplex virus (HSV) was positive in 39/335 (11.6%) who were tested 26/103 (25.2%) and 13/232 (5.6%) among infants 0 to 6 and >6 months, respectively. HSV was not tested in 61.0% and 53% of the overall cohort and those 0 to 6 months, respectively. Supplemental testing yielded 17 positive, including 5 HSV. CONCLUSIONS Viral testing in PALF occurs frequently but is often incomplete. The evidence for acute viral infection was found in 20.2% of those tested for viruses. HSV is an important viral cause for PALF in all age groups. The etiopathogenic role of CV and AV in PALF requires further investigation.
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Pourkarim MR, Amini-Bavil-Olyaee S, Kurbanov F, Van Ranst M, Tacke F. Molecular identification of hepatitis B virus genotypes/subgenotypes: revised classification hurdles and updated resolutions. World J Gastroenterol 2014; 20:7152-68. [PMID: 24966586 PMCID: PMC4064061 DOI: 10.3748/wjg.v20.i23.7152] [Citation(s) in RCA: 144] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 11/28/2013] [Accepted: 01/02/2014] [Indexed: 02/06/2023] Open
Abstract
The clinical course of infections with the hepatitis B virus (HBV) substantially varies between individuals, as a consequence of a complex interplay between viral, host, environmental and other factors. Due to the high genetic variability of HBV, the virus can be categorized into different HBV genotypes and subgenotypes, which considerably differ with respect to geographical distribution, transmission routes, disease progression, responses to antiviral therapy or vaccination, and clinical outcome measures such as cirrhosis or hepatocellular carcinoma. However, HBV (sub)genotyping has caused some controversies in the past due to misclassifications and incorrect interpretations of different genotyping methods. Thus, an accurate, holistic and dynamic classification system is essential. In this review article, we aimed at highlighting potential pitfalls in genetic and phylogenetic analyses of HBV and suggest novel terms for HBV classification. Analyzing full-length genome sequences when classifying genotypes and subgenotypes is the foremost prerequisite of this classification system. Careful attention must be paid to all aspects of phylogenetic analysis, such as bootstrapping values and meeting the necessary thresholds for (sub)genotyping. Quasi-subgenotype refers to subgenotypes that were incorrectly suggested to be novel. As many of these strains were misclassified due to genetic differences resulting from recombination, we propose the term "recombino-subgenotype". Moreover, immigration is an important confounding facet of global HBV distribution and substantially changes the geographic pattern of HBV (sub)genotypes. We therefore suggest the term "immigro-subgenotype" to distinguish exotic (sub)genotypes from native ones. We are strongly convinced that applying these two proposed terms in HBV classification will help harmonize this rapidly progressing field and allow for improved prophylaxis, diagnosis and treatment.
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Oketani M, Uto H, Ido A, Tsubouchi H. Management of hepatitis B virus-related acute liver failure. Clin J Gastroenterol 2014; 7:19-26. [PMID: 26183504 DOI: 10.1007/s12328-013-0447-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 12/15/2013] [Indexed: 12/17/2022]
Abstract
Hepatitis B virus (HBV) is the most important cause of acute liver failure (ALF) in Eastern countries. HBV-related ALF may occur after acute HBV infection (A-ALF) or during acute exacerbation (flare) of chronic HBV infection (C-ALF). C-ALF may occur spontaneously or as a result of the effect of immunosuppression due to chemotherapeutic or immunosuppressive agents. The definition of HBV-related ALF is uncertain, because different diagnostic criteria are used in C-ALF, which may present as acute-on-chronic liver failure. Although the pathogenesis differs in the two subgroups of ALF, the symptoms and biochemical parameters can be similar. High titers of immunoglobulin M hepatitis B core antibody and lower viral loads are frequent in A-ALF as compared with C-ALF. The prognosis of C-ALF is significantly poor as compared with that of A-ALF. In C-ALF, most immunosuppression-mediated reactivation of hepatitis B results in fatality. Many case series or case-control studies have not demonstrated the survival benefit of nucleos(t)ide treatment. This treatment failure is probably related to delayed initiation of nucleos(t)ide treatment and viral suppression. Treatment with nucleos(t)ide analogs should be started immediately and should be continued regardless of subgroups of HBV-related ALF. Liver transplantation is the only treatment option that improves the prognosis of HBV-related ALF. Patients under consideration for transplantation should be given nucleos(t)ide analogs as prophylaxis to reduce the likelihood of post-transplant HBV recurrence.
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Affiliation(s)
- Makoto Oketani
- Digestive and Lifestyle Diseases, Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan,
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55
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Abstract
Acute liver failure (ALF) is characterized by the sudden onset of liver failure in a patient without evidence of chronic liver disease. This definition is important, as it differentiates patients with ALF from patients who suffer from liver failure owing to end-stage chronic liver disease [1].
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Affiliation(s)
- M. Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California School of Medicine, Davis, California USA
| | - John M. Vierling
- Medicine and Surgery, Baylor College of Medicine, Houston, Texas USA
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School of Hannover, Germany
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Emergence of hepatitis B virus genotype f in aligarh region of north India. Adv Virol 2013; 2013:846849. [PMID: 24381592 PMCID: PMC3870090 DOI: 10.1155/2013/846849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/07/2013] [Accepted: 10/11/2013] [Indexed: 12/18/2022] Open
Abstract
Introduction. HBV genotypes and subtypes are useful clinical and epidemiological markers. In this study prevalent HBV genotypes were assessed in relation to serological profile and clinical status. Material & Methods. 107 cases of HBV were genotyped. Detailed clinical history was elicited from them. HBsAg, HBeAg, anti-HBs, anti-HBe, and anti-HBc-IgM were assessed. HBV genotyping was performed using Kirschberg's type specific primers (TSP-PCR), heminested PCR, and Naito's monoplex PCR. Nucleotide sequencing was performed. Results. A total of 97 (91%) were genotyped following the methods of Kirschberg et al./Naito et al. Genotype D was by far the most prevalent genotype 91 (85.04%) in this region. A surprising finding was the detection of genotype F in 5 (4.67%) of our patients. Genotype A strangely was observed only in one case. In 85.7% genotype D was associated with moderate to severe liver disease, 43.9% HBeAg, and 18.7% anti-HBc-IgM positivity. Majority of genotype F (80%) was seen in mild to moderate liver disease. It was strongly associated with HBeAg 60% and 20% anti-HBc-IgM positivity. Conclusion. Emergence of genotype F in India merits further study regarding its clinical implications and treatment modalities. Knowledge about HBV genotypes can direct a clinician towards more informed management of HBV patients.
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A Rationalized Approach to the Treatment of Patients Infected with Hepatitis B. Mol Diagn Ther 2013; 18:203-12. [DOI: 10.1007/s40291-013-0072-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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58
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Jindal A, Kumar M, Sarin SK. Management of acute hepatitis B and reactivation of hepatitis B. Liver Int 2013; 33 Suppl 1:164-75. [PMID: 23286861 DOI: 10.1111/liv.12081] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
The natural course of hepatitis B virus infection and the resulting hepatic injury is determined by the degree of virus replication and the intensity of host immune response. Upon exposure to hepatitis B virus (HBV), individuals with a vigorous and broad immune response develop acute self-limited infection, which may result in acute hepatitis. However, with stringent testing for HBV and universal precautions, acute HBV is rather rare. Reactivation of HBV most often presents as acute hepatitis B (AVH-B) and clinically, it is difficult to differentiate AVH-B from reactivation of chronic hepatitis B (CHB) and it requires a high index of suspicion. In the presence of high HBV DNA (>2 × 10(4) IU/ml) underlying liver disease should be investigated by liver biopsy, endoscopy and/or imaging. The degree of liver failure often depends on the severity of acute insult and the stage of underlying chronic liver disease. Mutations in the HBV genome, immunosuppressive therapy and viral or drug induced injury are common causes of reactivation. As most patients with AVH-B resolve the infection spontaneously, antiviral therapy is not indicated in them. However, the use of a potent oral nucleoside(tide) analogue is necessary as soon as possible in patients with CHB reactivation. Liver transplantation should be considered in patients who develop liver failure secondary to severe acute exacerbation. If this is not feasible, supportive therapy with the addition of granulocyte colony stimulating factor (GCSF) therapy could be beneficial.
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Affiliation(s)
- Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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59
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High frequency of genotype D and spontaneous hepatitis B virus genomic mutations among Haitians in a multiethnic North American population. J Clin Gastroenterol 2013; 47:83-8. [PMID: 23059410 DOI: 10.1097/mcg.0b013e318268003b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
GOALS/BACKGROUND The importance of hepatitis B virus (HBV) genotype and mutations has been increasingly recognized. We aimed to determine HBV genotype, precore (PC), and basal core promoter region (BCP) mutations in a HBV multiethnic South Florida population. STUDY Samples from 213 patients were tested for HBV-DNA using Abbott RealTime HBV IUO assay, and for mutations using INNO-LiPA assay. RESULTS Patients were predominantly male (67%); 61 (31%) were African American, 60 (28%) Hispanic, 37 (17%) Haitian, 27 (19%) white non-Hispanic, and 14 (6.6%) Asian. Genotype A was found in 101 (69%), D in 25 (17%), F in 9 (6%), G in 7 (5%), C and E in 6 (4%) each, B in 4 (3%), and H in 2 (1%) patients. Mixed genotypes were detected in 11 patients. Genotype A was more prevalent in all ethnicities except for Asian. Among hepatitis B e antigen (HBeAg)-negative patients (59%), BCP, PC, and combined BCP/PC mutations were found in 30 (37.5%), 13 (16.3%), and 14 (17.5%), respectively. Genotype D was associated with higher frequency of HBeAg-negative status [18/24 (75%) vs. 62/121 (51%) P=0.03] and mutations [16/19 (84%) vs. 40/67 (60%) P=0.04] compared with others. Genotype A was negatively associated with mutations [26/31 (84%) vs. 30/55 (55%), P=0.009]. PC mutations were more common in genotype D (14/19, 73%) compared with genotype A (7/54, 13%, P<0.0001). One-hundred percent and 79% of Asians and Haitians had spontaneous mutations, respectively. All Haitians with genotype D had PC mutations and 3 (50%) had BCP/PC. CONCLUSIONS The present study shows that HBeAg-negative status and spontaneous mutations were more common with genotype D; the presence of genotype D in Haitians was always associated with spontaneous mutations.
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60
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Dao DY, Seremba E, Ajmera V, Sanders C, Hynan LS, Lee WM. Use of nucleoside (tide) analogues in patients with hepatitis B-related acute liver failure. Dig Dis Sci 2012; 57:1349-57. [PMID: 22198704 PMCID: PMC3565239 DOI: 10.1007/s10620-011-2013-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 12/01/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The efficacy of nucleoside(tide) analogues (NA) in the treatment of acute liver failure due to hepatitis B virus (HBV-ALF) remains controversial. We determined retrospectively the impact of NAs in a large cohort of patients with HBV-ALF. METHODS The US Acute Liver Failure Study Group, a 23-site registry, prospectively enrolled 1,413 patients with ALF with different etiologies between 1998 and 2008. Of those, 105 patients were identified as HBV-ALF patients, of whom we excluded those without data on NA use or with co-infection with hepatitis C, leaving 85 patients, 43 of whom had received NA treatment. HBV-DNA on admission was quantified by real time polymerase chain reaction. RESULTS The treated and untreated groups were similar in most respects but differed significantly in regard to higher aminotransferase and bilirubin levels and hepatic coma grades, all being observed in the untreated group. Median duration of NA treatment was 6 days (range, 1-21 days). Overall survival in the NA treated and untreated groups were 61 and 64%, respectively (P = 0.72). Rates of transplant-free survival were 21 and 36% in the treated and untreated groups, respectively (P = 0.42). Multivariate analysis revealed that not using a NA [odds ratio (OR) 4.4, 95% CI 1.1-18.1, P = 0.041], hepatic coma grade I or II [OR 14.4, 95% CI 3.3-62.8, P < 0.001] and prothrombin time (PT) [OR 0.59, 95% CI 0.39-0.89, P = 0.012] were predictors of improved transplant-free survival. CONCLUSIONS Patients who are admitted with established HBV-ALF do not appear to benefit from viral suppression using nucleoside(tide) analogues presumably because of rapid disease evolution and short treatment duration. Despite the lack of benefit, NAs should still be given to transplantation candidates since viral suppression prevents recurrence after grafting.
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Affiliation(s)
- Doan Y Dao
- Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas
| | | | - Veeral Ajmera
- Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas
| | - Corron Sanders
- Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas
| | - Linda S. Hynan
- Departments of Clinical Sciences (Biostatistics), Psychiatry, University of Texas Southwestern Medical Center at Dallas
| | - William M. Lee
- Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas
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61
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Tillmann HL, Zachou K, Dalekos GN. Management of severe acute to fulminant hepatitis B: to treat or not to treat or when to treat? Liver Int 2012; 32:544-53. [PMID: 22099371 DOI: 10.1111/j.1478-3231.2011.02682.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 09/20/2011] [Indexed: 12/24/2022]
Abstract
Despite a decline in cases of acute hepatitis B and the low hepatitis B virus (HBV) chronicity rates in adults, still some patients progress to HBV-related fulminant liver failure. In this review, we discuss treatment options that may prevent the progression of severe acute hepatitis B to fulminant liver failure and death. In severe acute HBV with prolonged prothrombin time and increased bilirubin, interferon failed to be effective while antiviral treatment, particularly with lamivudine, appears to improve survival (mean survival almost 80%). Outcome without antiviral therapy has remained considerably poor, whereas there is no convincing evidence of amelioration of HBV-targeted immunity. Of note, most patients who died or required transplantation despite lamivudine therapy, were started on lamivudine at advanced stages compared with those survived. This suggests that prompt and timely antiviral therapy is crucial. Owing to the abovementioned results the design of randomized placebo-control trials in the setting of severe acute hepatitis B seems unethical. On the contrary, the design of multicentre double-blind randomized trials to compare the efficacy between lamivudine and entecavir or even tenofovir in acute severe HBV cases is ideally needed, but these studies appear to be very difficult to perform considering that these cases are not frequent and therefore, it is almost impossible to have two arms adequately numerous and homogenous for statistical evaluation. Thus, in the absence of solid evidence based data, the hepatologists could treat their patients with severe acute hepatitis B with lamivudine or the most potent antivirals entecavir or tenofovir.
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Affiliation(s)
- Hans L Tillmann
- Division of Gastroenterology, GI/Hepatology Research Program, Duke Clinical Research Institute, Durham, NC, USA
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62
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Shi W, Carr MJ, Dunford L, Zhu C, Hall WW, Higgins DG. Identification of novel inter-genotypic recombinants of human hepatitis B viruses by large-scale phylogenetic analysis. Virology 2012; 427:51-9. [PMID: 22374235 DOI: 10.1016/j.virol.2012.01.030] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 01/14/2012] [Accepted: 01/26/2012] [Indexed: 02/08/2023]
Abstract
Recombination plays an important role in the evolutionary history of Hepatitis B virus (HBV). We performed a phylogenetic analysis of 3403 full-length HBV genome sequences isolated from humans to define the genotype. The genome sequences were divided into 13 sub-datasets, each approximately 250 bp in length. Genotype designations obtained from the sub-datasets that differed from the genotype defined by the whole genome were assigned as putative recombinants. Our results showed that 3379 out of 3403 sequences belonged to the previously described and putative genotypes A to J respectively, with 315 sequences defined in this analysis. The remaining 24 viruses had sequence divergence of less than 8% with both genotypes B and C and were provisionally assigned genotype "BC". 1047 out of 3403 sequences were identified to be putative recombinants, of which 72 were identified to be novel recombinants. Notably, all viruses of the herein described genotype "BC" were identified to be B/C recombinants.
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Affiliation(s)
- Weifeng Shi
- The Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin 4, Ireland.
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63
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Association of hepatitis B virus mutations in basal core promoter and precore regions with severity of liver disease: an investigation of 793 Chinese patients with mild and severe chronic hepatitis B and acute-on-chronic liver failure. J Gastroenterol 2011; 46:391-400. [PMID: 20848146 PMCID: PMC7088102 DOI: 10.1007/s00535-010-0315-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Accepted: 08/15/2010] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate the features of hepatitis B virus (HBV) basal core promoter/precore (BCP/PC) mutations and genotypes in a large number of mild/severe chronic hepatitis B (CHB-M/CHB-S), and acute-on-chronic liver failure (ACLF) patients and analyze the clinical implications of the virologic features. PATIENTS AND METHODS Sera of 793 (325 CHB-M, 170 CHB-S, and 298 ACLF) patients admitted to or who had visited Beijing 302 Hospital from January 2005 to December 2008 were collected and successfully amplified for the HBV BCP/PC and a 1225-bp-long S/Pol (nt 54-1278) gene regions. Biochemical and serological parameters and HBV DNA level were routinely performed. Viral DNA was extracted and subjected to a nested PCR. Genotypes/subgenotypes were determined based on complete genomic sequence or on analysis of the 1225-bp-long S/Pol-gene sequence. HBV genotyping was performed by direct PCR sequencing followed by molecular evolutionary analysis of the viral sequences. A P value of <0.05 (two-sided) was considered to be statistically significant. CONCLUSIONS Our findings suggest that CHB patients infected with BCP/PC mutant viruses are more susceptible to severe hepatitis and ACLF than those with the BCP/PC wild-type virus and that ACLF patients with PC mutant viruses have an increased risk of death. As such, the HBV PC mutation is a potential predictive indicator of ACLF outcome.
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64
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Abstract
Outcomes of chronic hepatitis B virus (HBV) infection are heterogeneous. Estimates of annual incidence of cirrhosis and hepatocellular carcinoma (HCC) are 2-10% and 1-3%, respectively. Several viral factors, including HBV genotype, viral load and specific viral mutations, have been associated with disease progression. Among these, HBV genotype is not only predictive of clinical outcomes but has also been associated with response to interferon treatment. Currently, at least 10 HBV genotypes and several subtypes have been identified; they have distinct geographic distribution. Acute infection with genotypes A and D results in higher rates of chronicity than genotypes B and C. Compared to genotype A and B cases, patients with genotypes C and D have lower rates of spontaneous hepatitis B e antigen (HBeAg) seroconversion; when this occurs, it tends to be delayed. HBV genotype C has a higher frequency of basal core promoter (BCP) A1762T/G1764A mutation, pre-S deletion and is associated with higher viral load than genotype B. Similarly, genotype D has a higher prevalence of BCP A1762T/G1764A mutation than genotype A. These observations suggest important pathogenic differences between HBV genotypes. These may contribute to more severe liver disease, including cirrhosis and HCC with genotypes C and D HBV infection. In addition, genotype A and B patients have better responses to interferon-based therapy than genotypes C and D, but there are few consistent differences for direct HBV antivirals. In conclusion, genotyping of chronic HBV infections can help practicing physicians identify those at risk of disease progression and determine optimal anti-viral therapy.
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Affiliation(s)
- Chih-Lin Lin
- Department of Gastroenterology, Taipei City Hospital, Taiwan
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65
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Khaled IAEA, Mahmoud OM, Saleh AF, Bioumie EE. Prevalence of HBV genotypes among Egyptian hepatitis patients. Mol Biol Rep 2010; 38:4353-7. [PMID: 21181276 DOI: 10.1007/s11033-010-0562-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 11/17/2010] [Indexed: 12/15/2022]
Abstract
Phylogenetic analysis has led to the classification of hepatitis B virus into eight genotypes, designated A to H. The genotypes have differences in biological properties and show heterogeneity in their global distribution. These attributes of the genotypes may account not only for differences in the prevalence of hepatitis B virus mutants in various geographic regions, but also makes them responsible for differences in the clinical outcome and response to antiviral treatment in different population groups. Africa is one of the highly endemic regions of HBV with five genotypes (A-E) identified. Almost all patients in the Mediterranean area are infected with genotype D. However, there is little information of genotype distribution in Egypt. A total of 140 Egyptian patients with hepatitis B surface antigen (HBsAg) positive were enrolled in this study. Of the 140 patients, only 100 patients were HBV DNA positive and only these were included in the study. They were classified into 20 patients with acute hepatitis (AH), 75 patients with chronic active hepatitis (CAH) and 5 patients with hepatocellular carcinoma (HCC). HBV genotypes were determined using INNO-LiPA methodology which is based on the reversed hybridization principle. This study showed that genotype D constituted 87% of the total infections (75 CAH cases, 7 AH cases and 5 HCC cases). The other 13% showed mixed infections of D/F. These findings show that the most prevalent genotype in Egypt is genotype D especially in CAH and HCC patients while the mixed type D/F is only encountered in AH.
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Affiliation(s)
- Iman A El Aziz Khaled
- Haematology & Blood Bank, Haematology & Blood Bank Theodor Bilharz Research Institute (TBRI), Cairo, Egypt.
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66
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Ren X, Xu Z, Liu Y, Li X, Bai S, Ding N, Zhong Y, Wang L, Mao P, Zoulim F, Xu D. Hepatitis B virus genotype and basal core promoter/precore mutations are associated with hepatitis B-related acute-on-chronic liver failure without pre-existing liver cirrhosis. J Viral Hepat 2010; 17:887-95. [PMID: 20070500 PMCID: PMC2998700 DOI: 10.1111/j.1365-2893.2009.01254.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The study was undertaken to investigate the features and clinical implications of hepatitis B virus (HBV) genotypes, basal core promoter (BCP) and precore (PC) mutations in hepatitis B-related acute-on-chronic liver failure (HB-ACLF). Samples from 75 patients with HB-ACLF and without pre-existing liver cirrhosis and 328 age-matched patients with chronic hepatitis B (CHB) were analyzed. HBV genotype and BCP/PC mutations were determined by direct sequencing. Mutations at 8 sites of the BCP/PC region were compared between the two groups of patients. A significantly higher ratio of genotype B to C was found in patients with HB-ACLF than in patients with CHB (30.7-69.3% vs 16.5-82.6%, P < 0.01). Single mutations including T1753V (C/A/G), A1762T, G1764A, G1896A and G1899A and triple mutations T1753V/A1762T/G1764A and A1762T/G1764A/C1766T (or T1768A) were more frequently detected in patients with HB-ACLF than in patients with CHB. Correspondingly, BCP/PC wild-type sequences were absent in patients with HB-ACLF in contrast to 27.1% in patients with CHB. The BCP/PC mutations were found to be associated with increased HBeAg negativity, higher alanine aminotransferase level and lower viral load. Patients with HB-ACLF infected with the PC mutant virus had a higher mortality. The findings suggest that patients with CHB infected with genotype B with BCP/PC mutations were more likely to develop HB-ACLF than those with genotype C with wild-type BCP/PC regions, and patients with HB-ACLF with the PC mutation had increased risk of a fatal outcome.
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Affiliation(s)
- X Ren
- Viral Hepatitis Research Laboratory, Institute of Infectious DiseasesBeijing 302 Hospital, Beijing, China
| | - Z Xu
- Viral Hepatitis Research Laboratory, Institute of Infectious DiseasesBeijing 302 Hospital, Beijing, China
| | - Y Liu
- Viral Hepatitis Research Laboratory, Institute of Infectious DiseasesBeijing 302 Hospital, Beijing, China
| | - X Li
- Viral Hepatitis Research Laboratory, Institute of Infectious DiseasesBeijing 302 Hospital, Beijing, China
| | - S Bai
- Viral Hepatitis Research Laboratory, Institute of Infectious DiseasesBeijing 302 Hospital, Beijing, China
| | - N Ding
- Viral Hepatitis Research Laboratory, Institute of Infectious DiseasesBeijing 302 Hospital, Beijing, China
| | - Y Zhong
- Viral Hepatitis Research Laboratory, Institute of Infectious DiseasesBeijing 302 Hospital, Beijing, China
| | - L Wang
- Viral Hepatitis Research Laboratory, Institute of Infectious DiseasesBeijing 302 Hospital, Beijing, China
| | - P Mao
- Viral Hepatitis Research Laboratory, Institute of Infectious DiseasesBeijing 302 Hospital, Beijing, China
| | - F Zoulim
- INSERM, U871 and Department of Hepatology and Gastroenterology, Hospices Civils de LyonHôtel Dieu, Lyon, France
| | - D Xu
- Viral Hepatitis Research Laboratory, Institute of Infectious DiseasesBeijing 302 Hospital, Beijing, China,*Correspondence: Dongping Xu, Viral Hepatitis Research Laboratory, Institute of Infectious Diseases, Beijing 302 Hospital, Beijing, China. E-mail:
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67
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Guirgis BS, Abbas RO, Azzazy HM. Hepatitis B virus genotyping: current methods and clinical implications. Int J Infect Dis 2010; 14:e941-53. [DOI: 10.1016/j.ijid.2010.03.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2008] [Revised: 03/10/2010] [Accepted: 03/11/2010] [Indexed: 02/06/2023] Open
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68
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Abstract
Hepatitis B virus is a common cause of acute liver failure. It can be especially problematic in patients coinfected with hepatitis C, hepatitis D or human immunodeficiency virus. In addition, immunosuppression-associated hepatitis B reactivation is being increasingly recognized following chemotherapy, biologic therapy, and organ transplantation. This article highlights treatment options in these special populations.
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69
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Abstract
Acute liver failure is a rare disorder with high mortality and resource cost. In the developing world, viral causes predominate, with hepatitis E infection recognised as a common cause in many countries. In the USA and much of western Europe, the incidence of virally induced disease has declined substantially in the past few years, with most cases now arising from drug-induced liver injury, often from paracetamol. However, a large proportion of cases are of unknown origin. Acute liver failure can be associated with rapidly progressive multiorgan failure and devastating complications; however, outcomes have been improved by use of emergency liver transplantation. An evidence base for practice is emerging for supportive care, and a better understanding of the pathophysiology of the disorder, especially in relation to hepatic encephalopathy, will probably soon lead to further improvements in survival rates.
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MESH Headings
- Acetaminophen/adverse effects
- Ammonia/metabolism
- Analgesics, Non-Narcotic/adverse effects
- Chemical and Drug Induced Liver Injury/epidemiology
- Chemical and Drug Induced Liver Injury/etiology
- Emergency Treatment/methods
- Europe/epidemiology
- Global Health
- Hepatic Encephalopathy/epidemiology
- Hepatic Encephalopathy/etiology
- Hepatitis, Viral, Human/complications
- Hepatocytes/transplantation
- Humans
- Liver Failure, Acute/chemically induced
- Liver Failure, Acute/classification
- Liver Failure, Acute/epidemiology
- Liver Failure, Acute/etiology
- Liver Failure, Acute/mortality
- Liver Failure, Acute/physiopathology
- Liver Failure, Acute/surgery
- Liver Failure, Acute/virology
- Liver Transplantation
- Patient Selection
- Prognosis
- Severity of Illness Index
- Survival Rate
- Time Factors
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Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital, London, UK.
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70
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B cell gene signature with massive intrahepatic production of antibodies to hepatitis B core antigen in hepatitis B virus-associated acute liver failure. Proc Natl Acad Sci U S A 2010; 107:8766-71. [PMID: 20421498 DOI: 10.1073/pnas.1003854107] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hepatitis B virus (HBV)-associated acute liver failure (ALF) is a dramatic clinical syndrome due to a sudden loss of hepatic cells leading to multiorgan failure. The mechanisms whereby HBV induces ALF are unknown. Here, we show that liver tissue collected at the time of liver transplantation in two patients with HBV-associated ALF is characterized by an overwhelming B cell response apparently centered in the liver with massive accumulation of plasma cells secreting IgG and IgM, accompanied by complement deposition. We demonstrate that the molecular target of these antibodies is the hepatitis B core antigen (HBcAg); that these anti-bodies display a restricted variable heavy chain (V(H)) repertoire and lack somatic mutations; and that these two unrelated individuals with ALF use an identical predominant V(H) gene with unmutated variable domain (IGHV1-3) for both IgG and IgM anti-HBc antibodies, indicating that HBcAg is the target of a germline human V(H) gene. These data suggest that humoral immunity may exert a primary role in the pathogenesis of HBV-associated ALF.
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71
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Abstract
Acute hepatitis B virus (HBV) is a common cause of acute icteric hepatitis in adults. The vast majority of these patients resolve this acute infection and develop long-lasting immunity. In contrast, the vast majority of patients who develop chronic HBV have minimal symptoms and do not develop jaundice after becoming infected with HBV. These patients will frequently remain undiagnosed for years or decades. Approximately 1% of persons with acute HBV develop acute liver failure. Preventing acute HBV with vaccination is the best treatment. Although universal vaccination is now administered to newborns in many countries, the majority of adults have not been vaccinated and remain at risk. Because the majority of patients with acute HBV resolve this infection spontaneously, treatment with an oral anti-HBV agent is not necessary. However, the use of an oral anti-HBV agent is not unreasonable to use in a patient who is developing acute liver failure from severe acute HBV.
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72
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High prevalence of HBV genotype D in Syria and the clinical characteristics of hepatitis B e antigen-negative chronic hepatitis B. Epidemiol Infect 2010; 138:40-4. [PMID: 19538827 DOI: 10.1017/s0950268809990288] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Hepatitis B virus (HBV) genotype D and hepatitis B e antigen (HBeAg) negative chronic hepatitis are the most prevalent in Mediterranean countries. No data have ever been published on their prevalence in Syria, a country of intermediate endemicity for HBV. The aims of the current study were to determine the HBV genotype distribution in Syria, the prevalence of HBeAg-positive and HBeAg-negative chronic hepatitis and to analyse the clinical characteristics of each group. A total of 220 patients were included. Ninety-seven percent of the patients were of genotype D, and 72% were HBeAg negative. The HBeAg-negative patients were older, had a lower viral load, had more cirrhosis and the mode of contamination was known less than for HBeAg-positive patients. These findings have major implications in understanding the natural history of the infection and are of great relevance in the choice of therapy.
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73
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Rajekar H, Wai CT, Majeed TA, Lee KH, Wong SY, Leong SO, Singh R, Tay KH, Soosaynathan C, Tan KC. Prognostic factors in patients with acute liver failure undergoing live donor liver transplantation. Transplant Proc 2008; 40:2492-3. [PMID: 18929776 DOI: 10.1016/j.transproceed.2008.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Mortality from acute liver failure (ALF) is high. Live donor liver transplantation (LDLT) is the treatment of choice for ALF in Asia, because cadaveric donors are rare. We sought to review our results in ALF patients with undergoing LDLT at our center. One hundred two LDLTs were performed at our center from April 2002 to November 2007, 15 (14%) because of ALF. Mean (SEM; median, range) follow-up was 1,065 (189; 1400; 3-2046) days. Nine patients (60%) had acute exacerbation of chronic hepatitis B; and 6 (40%) had drug-induced liver injury. Age was 47 (3; 50; 27-65) years. Ten patients (67%) were men. At transplantation, laboratory values were included bilirubin, 449 (35) micromol/L; creatinine concentration, 182 (32) mmol/L. The international normalized ratio was 2.4 (0.2). The Model for End-Stage Liver Disease (MELD) score was 34 (2). Both inpatient and long-term mortality was 20% 3 of 15 patients died. The 5-year survival was 80%. Compared with survivors, patients who died had a significantly higher creatinine concentration 289 vs 155 micromol/L, international normalized ratio (3.4 vs 2.1), MELD score (47 vs 32). We conclude that despite being sick with median and mean MELD scores of 32 and 34, 80% of patients with ALF can achieve good long-term survival after LDLT.
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Affiliation(s)
- H Rajekar
- Asian Center for Liver Diseases and Transplantation, Singapore
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74
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McMahon BJ. The influence of hepatitis B virus genotype and subgenotype on the natural history of chronic hepatitis B. Hepatol Int 2008; 3:334-42. [PMID: 19669359 DOI: 10.1007/s12072-008-9112-z] [Citation(s) in RCA: 181] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 10/30/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic infection with hepatitis B virus (HBV) is associated with a high lifetime risk of developing hepatocellular carcinoma (HCC) and cirrhosis of the liver. PURPOSE To review the studies published to date regarding the association of HBV genotypes and subgenotypes in the development of adverse sequelae from HBV. METHODS Review of the literature for articles describing studies of HBV genotype/subgenotypes and development of HCC, cirrhosis, and liver-related death. RESULTS Eight genotypes of HBV (A through H), which differ from each other in viral genome sequence by more than 8%, and multiple subgenotypes, which differ from each other by 4-8% have been identified. Recently, studies investigating the association between the risks of developing HCC and cirrhosis by specific HBV genotypes and subgenotypes have reported marked differences in outcome. Certain HBV genotypes and subgenotypes, including genotype C, B2-5, and F1, appear to be associated with a higher risk of developing HCC, and others, including genotypes B1, B6, and A2, appear to be associated with a lower risk of complications of HBV. Our understanding of the role of HBV genotypes and subgenotypes on the outcome of HBV infection is limited, as few population-based prospective studies have been performed and most studies compare only the outcome in areas where two genotypes predominate whereas others have not examined subgenotypes. CONCLUSIONS Studies to date suggest that HBV genotypes/subgenotypes have important influences on the outcome of chronic HBV infection, but more population-based prospective studies examining multiple genotypes are needed.
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Affiliation(s)
- Brian J McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium; and Arctic Investigations Program, Centers for Disease Control and Prevention, 4315 Diplomacy Drive, Anchorage, AK, 99508, USA,
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75
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Abstract
Hepatitis B virus (HBV) is an important cause of acute liver failure (ALF) worldwide. Two clinical entities are responsible for HBV-related ALF: acute hepatitis B and acute exacerbation of chronic HBV infection. Differentiation between these clinical entities is sometimes difficult, especially when past status of hepatitis B surface antigen (HBsAg) is unknown. A quantitative analysis of serum immunoglobulin M (IgM) antibody to the hepatitis core antigen (anti-HBc) may be helpful in the differential diagnosis. The recent definition of ALF in chronic HBV infection is somewhat problematic, because clinical, laboratory and radiological findings cannot reliably predict the presence of underlying liver cirrhosis in patients with acute exacerbation of chronic HBV infection. Explant liver shows underlying liver cirrhosis in >50% of these cases, even when there is no clinical evidence of liver cirrhosis. Therefore, it is advisable to exclude these patients in clinical trials because of the high incidence of underlying liver cirrhosis. The clinical course, however, is not different and neurologic complications are responsible for about half of the deaths, so a priority for liver transplantation should be maintained in these patients. The prognosis of HBV-related ALF is quite grim without liver transplantation with transplant-free survival rates ranging from 26% to 53%. To date, there is not enough evidence that antiviral therapy or artificial liver support devices can enhance the patient's survival, therefore, liver transplantation is still the only effective treatment option that can alter the grave prognosis of HBV-related ALF.
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Affiliation(s)
- Han Chu Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
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76
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Sorber K, Chiu C, Webster D, Dimon M, Ruby JG, Hekele A, DeRisi JL. The long march: a sample preparation technique that enhances contig length and coverage by high-throughput short-read sequencing. PLoS One 2008; 3:e3495. [PMID: 18941527 PMCID: PMC2566813 DOI: 10.1371/journal.pone.0003495] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 09/30/2008] [Indexed: 11/20/2022] Open
Abstract
High-throughput short-read technologies have revolutionized DNA sequencing by drastically reducing the cost per base of sequencing information. Despite producing gigabases of sequence per run, these technologies still present obstacles in resequencing and de novo assembly applications due to biased or insufficient target sequence coverage. We present here a simple sample preparation method termed the “long march” that increases both contig lengths and target sequence coverage using high-throughput short-read technologies. By incorporating a Type IIS restriction enzyme recognition motif into the sequencing primer adapter, successive rounds of restriction enzyme cleavage and adapter ligation produce a set of nested sub-libraries from the initial amplicon library. Sequence reads from these sub-libraries are offset from each other with enough overlap to aid assembly and contig extension. We demonstrate the utility of the long march in resequencing of the Plasmodium falciparum transcriptome, where the number of genomic bases covered was increased by 39%, as well as in metagenomic analysis of a serum sample from a patient with hepatitis B virus (HBV)-related acute liver failure, where the number of HBV bases covered was increased by 42%. We also offer a theoretical optimization of the long march for de novo sequence assembly.
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Affiliation(s)
- Katherine Sorber
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, California, United States of America
| | - Charles Chiu
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, California, United States of America
- Division of Infectious Diseases, Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Dale Webster
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, California, United States of America
- Biological and Medical Informatics Program, University of California San Francisco, San Francisco, California, United States of America
| | - Michelle Dimon
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, California, United States of America
- Biological and Medical Informatics Program, University of California San Francisco, San Francisco, California, United States of America
| | - J. Graham Ruby
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, California, United States of America
| | - Armin Hekele
- Department of Microbiology and Immunology, University of California San Francisco, San Francisco, California, United States of America
| | - Joseph L. DeRisi
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, California, United States of America
- Howard Hughes Medical Institute, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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77
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Gaglio P, Singh S, Degertekin B, Ishitani M, Hussain M, Perrillo R, Lok AS. Impact of the hepatitis B virus genotype on pre- and post-liver transplantation outcomes. Liver Transpl 2008; 14:1420-7. [PMID: 18825703 DOI: 10.1002/lt.21563] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Emerging data suggest that the hepatitis B virus (HBV) genotype and the precore and core promoter variants impact the outcome of orthotopic liver transplantation (OLT) for hepatitis B. The aim of this study was to determine if there is a correlation between HBV genotype, precore and core promoter variants, and pre- and post-OLT outcomes. Serum samples from patients participating in the National Institutes of Health HBV-OLT study were tested for HBV genotype and precore and core promoter variants. A total of 123 patients were studied: 43% were Asians, 46% were Caucasians, and 8% were African Americans. HBV genotypes A (35%) and C (35%) were the most prevalent, followed by genotypes D and B. Precore and core promoter variants were detectable in 44% and 90% of patients. Patients with genotype C were more likely to have hepatocellular carcinoma (HCC) at listing (P < 0.001). Waitlist mortality was highest among patients with genotype D, while posttransplant mortality was highest among patients with genotype C. Precore or core promoter variants did not correlate with pre- or post-OLT survival. In conclusion, in this US patient population, patients with genotype C were more likely to have HCC at the time of transplant listing and to die after transplant than patients with non-C genotypes. Patients with genotype D had the highest posttransplant survival, but this was offset by higher waitlist mortality. Our study suggests that HBV genotypes but not precore or core promoter variants may have an impact on pre- and post-OLT outcomes of hepatitis B patients.
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Affiliation(s)
- Paul Gaglio
- Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York, NY, USA
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78
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Ananthakrishnan AN, McGinley EL, Saeian K. Effect of hospital volume and teaching status on outcomes of acute liver failure. Liver Transpl 2008; 14:1347-56. [PMID: 18756487 DOI: 10.1002/lt.21519] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute liver failure (ALF) often requires multidisciplinary support. Higher hospital volumes have been associated with better outcomes for surgical procedures, but whether such a relationship exists for ALF has not been explored previously. In this study, our aim was to examine if hospital volume affects mortality from ALF. Using data from the Nationwide Inpatient Sample for the years 2001 to 2004, we identified cases by the presence of a primary discharge diagnosis of ALF (International Classification of Diseases, 9th revision, Clinical Modification code 570.x). Hospitals were divided into low-, medium-, and high-volume hospitals on the basis of 1 to 5, 6 to 20, and more than 20 annual ALF discharges. There were 17,361, 6756, and 1790 discharges with ALF from low-, medium-, and high-volume hospitals, respectively. There was no difference in adjusted mortality between low- and high-volume hospitals (odds ratio 0.94, 95% confidence interval 0.68-1.28). Teaching hospitals had a trend toward lower mortality among patients with hepatic encephalopathy (odds ratio 0.69, 95% confidence interval 0.47-1.01). High-volume centers had a higher rate of orthotopic liver transplantation (OLT) primarily because they were transplant centers, had better in-hospital post-OLT survival, and showed a trend toward a shorter time to OLT. In conclusion, patients with ALF receiving care at teaching hospitals and high-volume centers tend to be sicker. However, teaching hospitals and high-volume centers have equivalent in-hospital survival despite caring for this more severely ill cohort.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Department of Population Health, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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79
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Abstract
Acute liver failure (ALF) is a dramatic, highly unpredictable clinical syndrome defined by the sudden onset of coagulopathy and encephalopathy. Acetaminophen overdose, the leading cause of ALF in the United States, has a 66% chance of recovery with early N-acetylcysteine treatment and supportive care. Cerebral edema and infectious complications are difficult to detect and treat in these patients and may cause irreversible brain damage and multiorgan failure. One-year survival after emergency liver transplantation is 70%, but 20% of listed patients die, highlighting the importance of early referral of patients who have ALF with a poor prognosis to a transplant center.
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Affiliation(s)
- Robert J Fontana
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, University of Michigan Medical Center, Ann Arbor, MI 48109-0362, USA.
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80
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Abstract
Acute liver failure (ALF) is a rare but challenging clinical syndrome with multiple causes; a specific etiology cannot be identified in 15% of adult and 50% of pediatric cases. The course of ALF is variable and the mortality rate is high. Liver transplantation is the only therapy of proven benefit, but the rapidity of progression and the variable course of ALF limit its use. Currently in the United States, spontaneous survival occurs in approximately 45%, liver transplantation in 25%, and death without transplantation in 30% of adults with ALF. Higher rates of spontaneous recovery (56%) and transplantation (31%) with lower rates of death (13%) occur in children. The outcome of ALF varies by etiology, favorable prognoses being found with acetaminophen overdose, hepatitis A, and ischemia (approximately 60% spontaneous survival), and poor prognoses with drug-induced ALF, hepatitis B, and indeterminate cases (approximately 25% spontaneous survival). Excellent intensive care is critical in management of patients with ALF. Nonspecific therapies are of unproven benefit. Future possible therapeutic approaches include N-acetylcysteine, hypothermia, liver assist devices, and hepatocyte transplantation. Advances in stem cell research may allow provision of cells for bioartificial liver support. ALF presents many challenging opportunities in both clinical and basic research.
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Affiliation(s)
- William M Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical School, Dallas, TX 75390-8887, USA.
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81
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82
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De Maddalena C, Giambelli C, Tanzi E, Colzani D, Schiavini M, Milazzo L, Bernini F, Ebranati E, Cargnel A, Bruno R, Galli M, Zehender G. High level of genetic heterogeneity in S and P genes of genotype D hepatitis B virus. Virology 2007; 365:113-24. [PMID: 17451771 DOI: 10.1016/j.virol.2007.03.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2006] [Revised: 01/30/2007] [Accepted: 03/09/2007] [Indexed: 12/17/2022]
Abstract
The genetic heterogeneity of hepatitis B virus (HBV) genotypes and subgenotypes was investigated by directly sequencing amplified PreS, S and P genes of HBV isolates obtained from the plasma of 99 subjects with chronic HBV infection. Genotype D showed the greatest intragenotypic and intrasubgenotypic divergence: in particular, the a determinant was mutated in 58.2% of the genotype D patients, two of whom showed prototypic vaccine-induced escape mutants at codon 145. Moreover, five sites under significant positive selection were found in the S protein of the D isolates: one in the a determinant and four in the highly hydrophobic C terminal. Our results suggest that careful surveillance of vaccine-induced escape mutants should be considered in populations with highly frequent genotype D infections, and raise questions concerning the possible relationship between the genetic heterogeneity, host immunity and pathogenicity of this HBV genotype.
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Affiliation(s)
- Chiara De Maddalena
- Department of Clinical Sciences Luigi Sacco, Section of Infectious Diseases, University of Milan, Milan, Italy
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83
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84
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Rutherford A, Davern T, Hay JE, Murray NG, Hassanein T, Lee WM, Chung RT. Influence of high body mass index on outcome in acute liver failure. Clin Gastroenterol Hepatol 2006; 4:1544-9. [PMID: 16996806 DOI: 10.1016/j.cgh.2006.07.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Diabetes and obesity affect development of nonalcoholic fatty liver disease. Nonalcoholic fatty liver disease increases susceptibility to hepatic injury and limits regenerative capacity, which might increase adverse outcomes in acute liver failure. There is no difference in the prevalence of diabetes in acute liver failure patients when compared with the general population, but no large studies have examined the relationship of obesity to incidence or outcome of acute liver failure. METHODS Seven hundred eighty-two adult patients with acute liver failure were prospectively enrolled from 1998-2004. Body mass index, history of diabetes, and outcome were recorded. Multivariable logistic regression was used for the analysis. RESULTS Compared with 30.4% of adults in the National Health and Nutrition Examination Survey III, 29.1% of adult patients with acute liver failure were obese (P=.542). Obese patients had 1.63 times the odds of transplantation or death as nonobese patients (1.04-2.55, P=.033). Severely obese patients had 1.93 times the odds of transplantation or death (1.02-3.62, P=.042). There were no differences in the proportion of patients listed for transplantation, with body mass index greater or less than 30, 35, or 40 (P=.264, P=.112, P=.244, respectively). Obese patients had 3.4 times the odds of dying after transplantation (1.29-8.87, P=.01). CONCLUSIONS Obesity does not appear to be more prevalent in acute liver failure. However, obese and severely obese patients had significantly poorer outcomes when they developed acute liver failure. This difference is not explained by weight discrimination in listing patients for transplantation, despite evidence for poorer post-transplant outcomes.
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Affiliation(s)
- Anna Rutherford
- GI Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
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85
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Taylor RM, Davern T, Munoz S, Han SH, McGuire B, Larson AM, Hynan L, Lee WM, Fontana RJ. Fulminant hepatitis A virus infection in the United States: Incidence, prognosis, and outcomes. Hepatology 2006; 44:1589-97. [PMID: 17133489 PMCID: PMC3505613 DOI: 10.1002/hep.21439] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute liver failure (ALF) due to hepatitis A virus (HAV) infection is an uncommon but potentially lethal illness. The aim of this study was to identify readily available laboratory and clinical features associated with a poor prognosis among ALF patients with HAV infection. The presenting features of 29 adults with anti-HAV IgM positive ALF enrolled in the ALFSG_between 1998 and 2005 were reviewed. The HAV patients listed for transplantation by UNOS were also reviewed. Acute HAV accounted for 3.1% of patients enrolled in the ALFSG. At 3 weeks follow-up, 16 had spontaneously recovered (55%), 9 underwent transplantation (31%), and 4 had died (14%). A prognostic model incorporating 4 presenting features (serum ALT <2,600 IU/L, creatinine >2.0 mg/dL, intubation, pressors) had an AUROC for transplant/death of 0.899 which was significantly better than the King's College criteria (0.623, P = .018) and MELD scores (0.707, P = .0503). Between 1988 and 2005, the frequency of patients requiring liver transplantation for HAV in the UNOS database significantly decreased from 0.7 % to 0.1% (P < .001). In addition, the proportion of HAV cases enrolled in the ALFSG significantly decreased from 5% to 0.8% (P = .007). In conclusion, the frequency of HAV patients enrolling in the ALFSG and being listed for liver transplantation in the United States has declined in parallel. A prognostic index consisting of 4 clinical and laboratory features predicted the likelihood of transplant/death significantly better than other published models suggesting that disease specific prognostic models may be of value in non-acetaminophen ALF.
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Affiliation(s)
- Ryan M. Taylor
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Timothy Davern
- University of California at San Francisco, San Francisco, CA
| | | | | | | | | | - Linda Hynan
- University of Texas Southwestern Medical Center, Dallas, TX
| | - William M. Lee
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Robert J. Fontana
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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86
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Abstract
1. The use of low-dose immunosuppressive therapy along with pre- and posttransplantation nucleos(t)ide therapy and posttransplantation hepatitis B immunoglobulin (HBIG) has yielded marked improvements in survival. 2. Lamivudine (Epivir-HBV), adefovir (Hepsera), entecavir (Baraclude), tenofovir (Viread), emtricitabine (Emtriva), and the combination drugs tenofovir + emtricitabine (Truvada) and abacavir + lamivudine (Epzicom) are effective nucleos(t)ide antiviral agents that, in some cases, may help reverse liver disease sufficiently to avoid transplant. 3. In posttransplantation patients, virus suppression with some combination of HBIG and the nucleos(t)ide agents may prevent graft loss and death or the need for a second transplant. 4. In both the pre- and posttransplantation setting, the goal of hepatitis B virus management is complete virus suppression. 5. The use of low-dose intramuscular HBIG is evolving, with studies showing that dosing and cost can be reduced by 50-300% with a customized approach. 6. Elimination of HBIG from the treatment paradigm is currently under evaluation and may be possible with the use of newer medications that have no or low resistance rates. 7. Although there is growing evidence that some types of combination therapy may decrease the chance that drug resistance will develop and increase the likelihood of long-term success in preventing graft loss and death, additional research will be required to determine which combinations will work well in the long term, and which will not.
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Affiliation(s)
- Robert G Gish
- Department of Transplantation and Medicine, California Pacific Medical Center, San Francisco, CA, USA.
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87
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Alvarado-Esquivel C, Sablon E, Conde-González CJ, Juárez-Figueroa L, Ruiz-Maya L, Aguilar-Benavides S. Molecular analysis of hepatitis B virus isolates in Mexico: Predominant circulation of hepatitis B virus genotype H. World J Gastroenterol 2006; 12:6540-5. [PMID: 17072988 PMCID: PMC4100645 DOI: 10.3748/wjg.v12.i40.6540] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the genotypes in Mexican hepatitis B virus (HBV) isolates and characterize their precore and core promoter mutations.
METHODS: Forty-nine HBV isolates of Mexico obtained from sera of 15 hepatitis patients, 6 hemodialysis patients, 20 men seeking HIV testing, and 8 AIDS patients were analyzed. HBV isolates were amplified by PCR, and genotyped by line probe assay (INNO-LiPA HBV Genotyping; INNOGENETICS N V, Ghent, Belgium). HBV genotype confirmation was performed by DNA sequencing part of the sAg region. Precore and core promoter mutation characterization was performed by line probe assay (INNO-LiPA HBV PreCore; INNOGENETICS N V, Ghent, Belgium).
RESULTS: Overall, HBV genotype H was found in 37 (75.5%) out of the 49 isolates studied. HBV genotypes G, A, and D were found in 5 (10.2%), 4 (8.2%), and 3 (6.1%) isolates, respectively. HBV genotype H was predominant in isolates from hemodialysis patients (100%), hepatitis patients (80%), and men seeking HIV testing (75%), and accounted for half of infections in AIDS patients (50%). Six (12.2%) out of the 49 HBV isolates showed both wild type and mutant populations at precore codon 28. These mixed wild type and precore mutant populations were observed in one HBV genotype A isolate and in all HBV genotype G isolates. A dual variant core promoter mutation was observed in 1 (2%) of the isolates, which was genotype H.
CONCLUSION: HBV genotype H is highly predominant in HBV isolates of Mexico followed by genotypes G, A and D. A low frequency of precore and core promoter mutations is observed in HBV Mexican isolates.
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Fontana RJ, Adams PC. "Unintentional" acetaminophen overdose on the rise: who is responsible? Dr Robert J Fontana is interviewed by Paul C Adams. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2006; 20:319-24. [PMID: 16691296 PMCID: PMC2659888 DOI: 10.1155/2006/498157] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Robert J Fontana
- Division of Gastroenterology at the University of Michigan Medical Center, Ann Arbor, Michigan, USA
- Correspondence: Dr Robert J Fontana, 3912 Taubman Center, Ann Arbor, Michigan 48109-0362, USA. Telephone 734-936-4780, fax 734-936-7392, e-mail
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89
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Affiliation(s)
- Stephan Günther
- Bernhard-Nocht-Institute of Tropical Medicine, Hamburg, Germany.
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90
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Nozić D. [Successful lamivudine therapy for chronic hepatitis B in the family]. VOJNOSANIT PREGL 2006; 63:504-7. [PMID: 16758804 DOI: 10.2298/vsp0605504n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Hepatitis B virus infection is a global public health problem since it is a leading cause of liver cirrhosis and hepatocellular carcinoma. An optimal treatment is needed to reduce mortality. Current therapies for chronic hepatitis B include standard and pegilated interferon-alfa and nucleoside and nucleotide analogies, primarily lamivudine and adefovir. Each of the therapies, however has various limitations. CASE REPORT In this paper we presented a father and his daughter with chronic hepatitis B, successfully treated with lamivudine. CONCLUSION In the linked cases of chronic hepatitis B, the choice of antiviral medicine in some patients could also be made on the basis of its efficacy in the persons previously treated with it, even without determining virus genotype.
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Affiliation(s)
- Darko Nozić
- Vojnomedicinska akademija, Klinika za infektivne i tropske bolesti, Beograd, Srbija i Crna Gora.
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91
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Ke WM, Li XJ, Yu LN, Lai J, Li XH, Gao ZL, Chen PJ. Etiological investigation of fatal liver failure during the course of chronic hepatitis B in southeast China. J Gastroenterol 2006; 41:347-51. [PMID: 16741614 DOI: 10.1007/s00535-005-1781-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Accepted: 11/17/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to clarify the relationships between patients who had fatal liver failure during the course of chronic hepatitis B and those who were also superinfected with hepatitis A, C, D, or E virus, as well as their hepatitis B virus e system status, so that suitable measures could be adopted to decrease the mortality of patients with chronic hepatitis B. METHODS This study detected superinfections of hepatitis A, C, D, or E virus and the hepatitis B virus e system status in cases of fatal liver failure during the course of chronic hepatitis B by enzyme-lined immunosorbent assay. RESULTS The frequency of superinfections of hepatitis A, C, D, and E virus was 1.4% (4/282), 6.4% (18/282), 1.8% (5/282), and 28.4% (80/282), respectively, overall, 37.9% (107/282). Hepatitis E was prominent and steady in superinfection rates during the past 12 years. In 62.1% (175/282) of patients, the causes of fatal liver failure were not clear. The serological status frequency of HBeAg(+) and anti-HBe(-), HBeAg(-) and anti-HBe(-), and HBeAg(-) and anti-HBe(+) was 20.6% (22/107), 23.4% (25/107), and 56.1% (60/107), respectively, in the group with superinfections of hepatitis A, C, D, or E virus and 31.4% (55/175), 21.1% (37/175), and 47.4% (83/175), respectively, in the group in which causes were not clear. The serological status HBeAg(+) and anti-HBe(-) was more frequent in the group in which causes were not clear than in the group with superinfections of hepatitis A, C, D, or E virus (P < 0.05). Statistically, there were no differences (P > 0.05) between the serological status HBeAg(-), anti-HBe(-) and HBeAg(-), anti-HBe(+) between the two groups. CONCLUSIONS These results suggest that superinfection (107/282) is an important factor in fatal liver failure. The mortality of chronic hepatitis B can be decreased by strict food sanitation and the use of safe blood products. There were no significant relationships between hepatitis B e antigen seroconversion and fatal liver failure during the course of chronic hepatitis B.
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Affiliation(s)
- Wei-Min Ke
- Department of Infectious Diseases, The Third Affiliated Hospital, Sun Yat-Sen University, Shipai, Guangzhou 510630, P. R. China
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Affiliation(s)
- David Green
- Division of Hematology/Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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