Hepatitis B virus infection

Incidence and determinants of spontaneous hepatitis B surface antigen seroclearance: a community-based follow-up study

BACKGROUND & AIMS

Seroclearance of hepatitis B surface antigen (HBsAg) is one of the most important clinical outcomes for chronic hepatitis B treatment trials. Few studies have explored the incidence and determinants of spontaneous seroclearance using a long-term follow-up study. This study aimed to examine the natural history and predictors of HBsAg seroclearance.

METHODS

A total of 3087 individuals with chronic hepatitis B virus infection were enrolled between 1991 and 1992 in this community-based study. Serum samples collected at baseline and follow-up examinations were tested for HBsAg, hepatitis B e antigen (HBeAg), serum hepatitis B virus (HBV)-DNA levels, and anti-hepatitis C virus serostatus. Cox proportional hazards models were used to estimate HBsAg seroclearance rate ratios associated with various determinants.

RESULTS

HBsAg seroclearance occurred in 562 participants during 24,829 person-years of follow-up evaluation, giving a 2.26% annual seroclearance rate. HBV-DNA levels at baseline and follow-up evaluation were the most significant predictor of seroclearance. Higher HBV viral loads conferred lower HBsAg seroclearance rates (P<.001). A spontaneous decrease in follow-up HBV-DNA level (>or=3 log) was associated significantly with seroclearance, showing an adjusted odds ratio of 4.17 (95% confidence interval, 2.55-6.82). Among those with seroclearance, 95.8% had undetectable HBV-DNA levels before seroclearance. Cumulative incidence of HBsAg seroclearance at 60 and 100 months after serum HBV-DNA level decreased to undetectable was 25.8% and 51.3%, respectively.

CONCLUSIONS

This study reveals determinants of HBsAg seroclearance, and suggests that a low viral load is an important factor affecting the natural seroclearance of HBsAg, indicating significant clinical implications for the treatment of chronic HBV.

Hepatitis B surface antigen seroclearance during chronic HBV infection

Hepatitis B surface antigen (HBsAg) seroclearance in chronic HBV infection occurs at an annual incidence of 1-2%. The long-term outcome after HBsAg seroclearance is excellent if there is no pre-existing cirrhosis or viral superinfection. For this reason, HBsAg seroclearance has attracted recent interest in both long-term studies of the natural history of HBV infection and in patients receiving antiviral therapy. Here, we review a diverse range of studies investigating spontaneous HBsAg seroclearance in varied groups of patients and consider the many predictive factors - of both viral and host origin - for seroclearance. Studies to assess the effects of antiviral therapy, and in particular interferon treatment, are also discussed together with virological, biochemical and histological profiles following HBsAg seroclearance and the long-term outcomes.

Does chemotherapy prevent HBV-related hepatocellular carcinoma? Pros

Studies have shown that hepatitis B virus (HBV) replication is the key driver of disease progression, including development of cirrhosis and hepatocellular carcinoma (HCC), in patients with chronic HBV infection. Among the currently available anti-HBV drugs, the most extensive and longest experience has been gained with conventional interferon alpha (IFN) and lamivudine. Both controlled studies and meta-analyses have shown that a finite course of IFN therapy has long-term benefit in achieving cumulative response and corresponding reduction of cirrhosis and/or HCC. Maintained virological response to lamivudine therapy has similar long-term benefits in reducing disease progression. Although emergence of lamivudine drug resistance may negate therapeutic effect, rescue drugs are now available to overcome the adverse effect of drug resistance. Pegylated IFN and newer nucleos(t)ide analogs may have even better long-term outcomes because of better therapeutic efficacy and/or much lower risk of drug resistances. However, the treatment outcomes are still far from satisfactory. The development of safe and affordable anti-HBV agents/strategies is needed to further improve outcomes.

Level of hepatitis B virus DNA in inactive carriers with persistently normal levels of alanine aminotransferase

BACKGROUND & AIMS

Little is known about the level of hepatitis B virus (HBV) DNA in individuals with chronic, inactive HBV infections. Patients who test positive for the antibody to hepatitis B e antigen (anti-HBe) and have normal levels of alanine aminotransferase for more than 10 years have a low risk of HBV reactivation and are considered to be inactive carriers. We investigated HBV DNA levels in inactive carriers and identified factors that correlated with this state among anti-HBe-positive carriers with HBV DNA levels of 10(4) copies/mL or greater (5.26 copies/mL = 1 IU/mL).

METHODS

HBV DNA levels were assayed in 250 inactive carriers with persistently normal alanine aminotransferase levels for more than 10 years. Clinical and virologic features were compared between inactive carriers (with HBV DNA levels > or =10(4) copies/mL) and age-matched patients with HBe antigen-negative chronic hepatitis (controls, n = 90).

RESULTS

The median level of HBV DNA among inactive carriers was 3.70 log(10) copies/mL (range, undetectable to 5.98 log(10) copies/mL). Ninety (36%) had levels of 10(4) copies/mL or greater. Compared with control patients, significant differences of inactive carriers included sex (more female patients), lower HBV DNA levels, and lower prevalence of genotype C virus and the basal core promoter mutation T1762/A1764. The prevalence of the precore mutation A1896 was similar between groups. Multiple logistic regression analyses identified male sex, HBV DNA levels greater than 10(5) copies/mL, and the basal core promoter mutation as independent factors that correlated with active disease.

CONCLUSIONS

Nearly 40% of inactive carriers had HBV DNA levels of 10(4) copies/mL or greater. Female sex, HBV DNA levels of 10(4) to 10(5) copies/mL, and wild-type basal core promoter correlated with inactive carrier state.

Hepatitis B virus DNA level predicts hepatic decompensation in patients with acute exacerbation of chronic hepatitis B

BACKGROUND & AIMS

Acute exacerbations of chronic hepatitis B virus (HBV) infection can lead to hepatic decompensation. It is important to identify factors that predict the development of hepatic decompensation during exacerbation so that antiviral therapy can be initiated immediately.

METHODS

Acute exacerbation, defined by an abrupt increase in alanine aminotransferase (ALT) levels to >5-fold the upper limit of normal, occurred in 110 hepatitis B e antigen (HBeAg)-seropositive non-cirrhotic patients (138 episodes). The patients were monitored every 1 to 2 weeks for serum levels of ALT, bilirubin, albumin, and prothrombin. Sex, age, HBV genotype, ALT level, HBV viral load, and the causes (spontaneous or relapse from antiviral treatment) of exacerbation were included in multivariate logistic regression analyses. The receiver operating characteristic curve was used to identify the optimal cut-off value of serum HBV DNA level to identify patients at risk for decompensation.

RESULTS

Seven of the 138 episodes of acute exacerbation (5.1%) resulted in hepatic decompensation; serum HBV DNA level was the only significant risk factor (P = .003). The area under the receiver operating characteristic curve was 88.6% (P < .001). A serum HBV DNA cut-off value of 1.55 x 10(9) copies/mL predicted decompensation with a sensitivity of 85.7%, a specificity of 85.5%, a negative prediction value of 99.1%, and positive prediction value of 24.0%.

CONCLUSIONS

During acute exacerbation of HBeAg-positive chronic hepatitis B, a serum HBV DNA cut-off value of 1.55 x 10(9) copies/mL can be used to identify patients in need of immediate antiviral therapy.

Androgen receptor promotes hepatitis B virus-induced hepatocarcinogenesis through modulation of hepatitis B virus RNA transcription

Hepatitis B virus (HBV)-induced hepatitis and carcinogen-induced hepatocellular carcinoma (HCC) are associated with serum androgen concentration. However, how androgen or the androgen receptor (AR) contributes to HBV-induced hepatocarcinogenesis remains unclear. We found that hepatic AR promotes HBV-induced hepatocarcinogenesis in HBV transgenic mice that lack AR only in the liver hepatocytes (HBV-L-AR(-/y)). HBV-L-AR(-/y) mice that received a low dose of the carcinogen N'-N'-diethylnitrosamine (DEN) have a lower incidence of HCC and present with smaller tumor sizes, fewer foci formations, and less alpha-fetoprotein HCC marker than do their wild-type HBV-AR(+/y) littermates. We found that hepatic AR increases the HBV viral titer by enhancing HBV RNA transcription through direct binding to the androgen response element near the viral core promoter. This activity forms a positive feedback mechanism with cooperation with its downstream target gene HBx protein to promote hepatocarcinogenesis. Administration of a chemical compound that selectively degrades AR, ASC-J9, was able to suppress HCC tumor size in DEN-HBV-AR(+/y) mice. These results demonstrate that targeting the AR, rather than the androgen, could be developed as a new therapy to battle HBV-induced HCC.

Nomograms for Risk of Hepatocellular Carcinoma in Patients With Chronic Hepatitis B Virus Infection

Purpose

Counseling patients with chronic hepatitis B virus (HBV) on their individual risk of liver disease progression is challenging. This study aimed to develop nomograms for predicting hepatocellular carcinoma risk in patients with chronic hepatitis B.

Patients and Methods

Two thirds of the Risk Evaluation of Viral Load Elevation and Associated Liver Disease/Cancer–Hepatitis B Virus (REVEAL-HBV) study cohort was allocated for model derivation (n = 2,435), and the remaining third was allocated for model validation (n = 1,218). Previously confirmed independent risk predictors included in three Cox proportional hazards regression models were sex, age, family history of hepatocellular carcinoma, alcohol consumption habit, serum ALT level, hepatitis B envelope antigen (HBeAg) serostatus, serum HBV DNA level, and HBV genotype. Regression coefficients were rounded into integer risk scores, and predicted risk over 5- and 10-year periods for each risk score was calculated and depicted in nomograms. The predictive accuracy was evaluated using the area under the receiver operating characteristic curve (AUROC) and the correlation between predicted and observed hepatocellular carcinoma risk.

Results

All selected risk predictors were statistically significant in all models. In each model, either HBeAg seropositivity or HBeAg seronegativity with high viral load (HBV DNA level ≥ 100,000 copies/mL) and genotype C infection had the highest risk scores. All AUROCs for risk prediction nomogram were ≥ 0.82 in both model derivation and validation sets. The correlation coefficients between the observed hepatocellular carcinoma risk and the nomogram-predicted risk were greater than 0.90 in all model derivation and validation sets.

Conclusion

These easy-to-use nomograms based on noninvasive clinical characteristics can accurately predict the risk of hepatocellular carcinoma in patients with chronic hepatitis B. They may facilitate risk communication between patients and clinicians.

On-treatment monitoring of chronic hepatitis B virus infection: an Asian-Pacific perspective

Chronic infection with hepatitis B virus (HBV) is a major global health problem and an important cause of morbidity and mortality from sequelae of liver cirrhosis and hepatocellular carcinoma. In the past decades, better understanding of the natural history and immunopathogenesis of chronic HBV infection and of the development of many powerful antiviral agents has allowed us to improve therapeutic efficacy. Among these agents, nucleos(t)ide analogs are important and potent viral suppressors. However, when administered alone, they are not able to permanently eradicate HBV, and long-term maintenance therapy is required for therapeutic efficacy. Additionally, prolonged treatment is frequently associated with the emergence of drug-resistant HBV mutants. Before an 'ideal' drug(s), or drug combination, with optimal antiviral efficacy and negligible rates of drug resistance becomes available, the on-treatment monitoring approach using serum HBV DNA level as a predictor for therapeutic efficacy and drug resistance is useful. However, most countries in the Asia-Pacific region have low income economies, insufficient medical care systems, and low awareness of the disease among the general population and government officers. The easy approach of the road-map concept using an affordable drug to treat chronic HBV infection is more important in this region. There is already evidence that the long-term outcomes of chronic HBV infection can be improved under well-managed antiviral therapy. Profound and long-lasting suppression of HBV replication, either maintained on-therapy or sustained after stopping therapy, has been identified as the key determinant for achieving the goals of therapy, for reducing liver damage, and for preventing development of cirrhosis and/ or hepatocellular carcinoma.

Pros and Cons of Peginterferon Versus Nucleos(t)ide Analogues for Treatment of Chronic Hepatitis B

The emergence of new and more potent treatment options has markedly changed the treatment landscape of chronic hepatitis B. Both peginterferon and nucleos(t)ide analogues have considerable advantages and limitations, and current treatment guidelines refrain from clearly suggesting a first-line treatment option. Peginterferon offers the advantage of higher sustained response rates in both hepatitis B early antigen (HBeAg)-positive and HBeAg-negative patients, at the price of considerable side effects and high costs. Nucleos(t)ide analogues offer easy daily oral dosing, and newly registered agents can maintain viral suppression for prolonged treatment duration. However, relapse is common after therapy discontinuation and extended therapy therefore often necessary. Prolonged treatment with nucleos(t)ide analogues may enhance chances of virologic and serologic response at the potential cost of the emergence of viral resistance and side effects. Baseline and on-treatment prediction of response may help select patients for peginterferon therapy and can aid individualized treatment decisions concerning therapy continuation or discontinuation.

Relative roles of HBsAg seroclearance and mortality in the decline of HBsAg prevalence with increasing age

OBJECTIVES

Mortality and hepatitis B surface antigen (HBsAg) seroclearance are the two extremes of prognostic destination of chronic hepatitis B virus (HBV) infection. Their relative roles in the decline of HBsAg prevalence with increasing age are unknown.

METHODS

HBsAg-seropositive subjects with near normal alanine aminotransferase (ALT) were followed up every 3 to 12 months for >1 year. Serum HBsAg was assayed at entry and re-assayed at 3- to 5-year intervals. The morbidity and mortality data were obtained from hospital records, cancer registration, and the national mortality database. The mortality and HBsAg-seroclearance rates were examined by survival analysis.

RESULTS

At entry, 1,386 subjects (20.9%) were hepatitis B e antigen (HBeAg) seropositive and 5,235 were HBeAg seronegative. The mean follow-up period was 13.6+/-5.4 years (median 13.2; range 1-29.1). HBsAg seroclearance occurred more frequently (555 cases, 8.4%) than mortality (97 cases, 1.5%; P<0.001; overall HBsAg seroclearance/mortality ratio: 5.6), of which only 40% were liver-related cases. Cox regression analysis revealed that male sex, HBeAg negativity, older age, low maximal ALT level, and hepatic steatosis were factors associated with HBsAg seroclearance. The estimated annual HBsAg seroclearance rate was around 1.05-1.61% after the age of 50 years, whereas the estimated mortality rate was quite low before the age of 60 and increased from 0.41% per year at ages 60-64 to 1.19% per year at ages 70-74 years.

CONCLUSIONS

The HBsAg seroclearance over mortality rate was 5.6 in this cohort. This suggests that HBsAg seroclearance is the main reason for decreasing HBsAg prevalence with increasing age in the population.

Core antigen expression is associated with hepatic necroinflammation in e antigen-negative chronic hepatitis B patients with low DNA loads

Intrahepatic hepatitis B virus (HBV) core antigen (HBcAg) is a hallmark of viral replication in hepatitis B virus e antigen (HBeAg)-positive chronic hepatitis B (CHB). The aim of this study was to evaluate the role of HBcAg in HBeAg-negative CHB. One hundred six HBeAg-negative CHB patients who underwent ultrasonographically guided liver biopsy were reviewed for their HBV DNA load and clinical and histological data. Factors associated with the expression of intrahepatic HBcAg were analyzed. Among the patients, 35 (33%) were positive for HBcAg by immunohistostaining. In patients whose HBV DNA loads were higher than 10(7) copies (cp)/ml, nearly one-half (52%) had detectable HBcAg. Compared with HBcAg-negative patients, HBcAg-positive patients had higher serum alanine transaminase (ALT) and HBV DNA levels and more-severe hepatic necroinflammation. High serum ALT level (>160 U/liter) and HBV viral load were the determinants of HBcAg expression in multivariate analysis. Large amounts of HBcAg expression were frequently detected in patients with high DNA loads, and the patterns of HBcAg distribution were not related to histological activity or HBV DNA levels. In patients with lower HBV DNA loads, the expression of HBcAg was the key factor associated with active hepatic necroinflammation (hazard ratio = 11.25; 95% confidence interval [CI], 1.42 to 89.26; P = 0.022). In conclusion, the expression of HBcAg is not frequent in HBeAg-negative CHB. The expression of intrahepatic HBcAg indicates active hepatic necroinflammation, even in patients with low HBV DNA load. Both HBV viral load and HBcAg expression have implications in the pathogenesis of HBeAg-negative CHB.

Molecular basis and current treatment for alcoholic liver disease

Alcohol use disorders and alcohol dependency affect millions of individuals worldwide. The impact of these facts lies in the elevated social and economic costs. Alcoholic liver disease is caused by acute and chronic exposure to ethanol which promotes oxidative stress and inflammatory response. Chronic consumption of ethanol implies liver steatosis, which is the first morphological change in the liver, followed by liver fibrosis and cirrhosis. This review comprises a broad approach of alcohol use disorders, and a more specific assessment of the pathophysiologic molecular basis, and genetics, as well as clinical presentation and current modalities of treatment for alcoholic liver disease.

Age-specific prognosis following spontaneous hepatitis B e antigen seroconversion in chronic hepatitis B

Hepatitis B e antigen (HBeAg) seroconversion in chronic hepatitis B virus infection confers a favorable prognosis, but untoward outcomes may develop in some patients. The impact of the age of HBeAg seroconversion on prognosis is not clearly known. HBeAg-positive patients with biopsy-proven chronic hepatitis B were followed up long-term. Follow-up studies included liver biochemistry, alpha-fetoprotein, and ultrasonography every 3 to 6 months or more frequently if clinically indicated. Of the patients who underwent spontaneous HBeAg seroconversion, the incidences of HBeAg-negative hepatitis, cirrhosis, hepatocellular carcinoma (HCC), and hepatitis B surface antigen seroclearance were compared between patient groups with different ages at the time of HBeAg seroconversion using Kaplan-Meier survival analysis and Poisson regression model. Spontaneous HBeAg seroconversion was documented in 508 patients. Of the 483 patients who had no evidence of cirrhosis or HCC at the time of HBeAg seroconversion, HBeAg seroconversion occurred before age 30 in 218 patients (group A), between age 31 and 40 in 199 patients (group B), and after age 40 in 66 patients (group C). The 15-year cumulative incidences of HBeAg-negative hepatitis, cirrhosis, and HCC increased with increasing age of HBeAg seroconversion, the lowest being in group A (31.2%, 3.7%, and 2.1%, respectively) and highest being in group C (66.7% [P < 0.0001], 42.9% [P <0.0001], and 7.7% [P = 0.29], respectively). The hazard ratio of HBeAg-negative hepatitis, cirrhosis, and HCC was 2.95, 17.6, and 5.22, respectively, in group C compared with group A.

CONCLUSION

Patients with HBeAg seroconversion before age 30 have excellent prognosis, whereas patients with delayed HBeAg seroconversion after age 40 have significantly higher incidences of HBeAg-negative hepatitis, cirrhosis, and HCC.

End points of therapy in chronic hepatitis B

This review assesses the relevance of the clinical, histological, biochemical and virological end points in the course and outcome of chronic hepatitis B. The pathway and the impact of the variation in these end points are presented, as well as their definitions. The treatment goals are discussed in terms of quality of life and survival. Prevention of the progression of the disease to cirrhosis, decompensated cirrhosis, end-stage liver disease and hepatocellular carcinoma seems to be the best approach to improve survival. As these criteria are long-term end points, easier to use end points assessed in clinical trials as efficacy objectives were also analyzed to determine whether they can be used as accurate surrogate criteria. Results of therapy were then analyzed according to the approved end points and in terms of management of chronic hepatitis B. Finally, an attempt to define new clinical end points is discussed in view of the development of more potent antiviral strategies.

Screening and early treatment of migrants for chronic hepatitis B virus infection is cost-effective

BACKGROUND & AIMS

Persons with chronic hepatitis B virus (HBV) infection are at risk of developing cirrhosis and hepatocellular carcinoma. Early detection of chronic HBV infection through screening and treatment of eligible patients has the potential to prevent these sequelae. We assessed the cost-effectiveness in The Netherlands of systematically screening migrants from countries that have high and intermediate HBV infection levels.

METHODS

Epidemiologic data of the expected numbers of patients with active chronic HBV infection in the target population and information about the costs of a screening program were used in a Markov model and used to determine costs and quality-adjusted life years (QALY) for patients who were and were not treated.

RESULTS

Compared with the status quo, a 1-time screen for HBV infection can reduce mortality of liver-related diseases by 10%. Using base case estimates, the incremental cost-effectiveness ratio (ICER) of screening, compared with not screening, is euros (euro) 8966 per QALY gained. The ICER ranged from euro7936 to euro11,705 based on univariate sensitivity analysis, varying parameter values of HBV prevalence, participation rate, success in referral, and treatment compliance. Using multivariate sensitivity analysis for treatment effectiveness, the ICER ranged from euro7222 to euro15,694; for disease progression, it ranged from euro5568 to euro60,418.

CONCLUSIONS

Early detection and treatment of people with HBV infection can have a large impact on liver-related health outcomes. Systematic screening for chronic HBV infection among migrants is likely to be cost-effective, even using low estimates for HBV prevalence, participation, referral, and treatment compliance.

Entecavir: a review of its use in chronic hepatitis B

Entecavir (Baraclude), a nucleoside analogue, is rapidly phosphorylated to the active intracellular 5'-triphosphate form that inhibits replication of hepatitis B virus (HBV). Oral entecavir is approved in the US, EU and several countries worldwide for the treatment of chronic HBV infection in adults (> or =16 years of age) with evidence of active viral replication and persistently elevated serum ALT and/or AST levels, and/or histological evidence of active disease. In several randomized, double-blind, multicentre trials, oral entecavir was an effective and generally well tolerated treatment in nucleoside-naive and lamivudine-refractory adult patients with chronic HBV infection, irrespective of whether patients were hepatitis B e antigen (HBeAg)-positive or -negative. Furthermore, it was more efficacious, associated with a lower risk of resistance, and more cost effective than lamivudine in these patient populations, with both drugs having a similar tolerability profile. In the EARLY trial, entecavir was significantly more effective than and as well tolerated as adefovir dipivoxil therapy in nucleoside-naive patients. In addition, in a double-blind, multicentre trial, entecavir plus lamivudine-based highly active antiretroviral therapy (HAART) was more effective than placebo plus lamivudine-based HAART in patients co-infected with HBV and HIV. Although the exact position of entecavir relative to other agents, such as tenofovir disoproxil fumarate and adefovir dipivoxil, for the treatment of chronic HBV infection remains to be fully determined, an important aspect in this positioning is the emergence of drug resistance. Hence, entecavir therapy provides a valuable first-line option in nucleoside-naive patients with chronic HBV infection and is a useful alternative in lamivudine-refractory patients.

Hepatitis B virus core variants modify natural course of viral infection and hepatocellular carcinoma progression

BACKGROUND & AIMS

We assessed the influence of genetic variants in the hepatitis B virus (HBV) core, which is a principal immunologic target, on the progression to hepatocellular carcinoma (HCC) in a cohort of 4841 male HBV carriers followed up for 16 years.

METHODS

First, baseline sera from 116 HCC cases and 154 controls nested within the cohort were used for sequencing of the HBV core gene to screen for variants with effects on HCC progression. By applying a high-throughput assay for detecting viral single nucleotide substitutions, we then used a longitudinal study (n = 1143) to examine whether 2 identified variants that lie in the region within or flanking epitopes affected the natural course of hepatitis B through investigating their relationships with time trends for viral load and clinical features.

RESULTS

In the nested case-control study, there were 6 core variants associated with decreased risk of HCC after accounting for viral genotype; 5 lie in the region within or flanking epitopes (P < .04). Each variant correlated with a 0.7- to 1-log decrease in viral load and hepatitis B virus e antigen negativity at baseline. The longitudinal study further showed that the appearance of 2 such variants (T1938C and T2045A) was preceded by long-term diminished viral load and decreased rate of liver abnormalities and was significantly less frequent in individuals with a prolonged immune clearance phase that associated with spectrum of liver disease than those in inactive carrier or reactivation phase.

CONCLUSIONS

HBV core variants affecting the kinetics of host-virus interplay may influence longitudinal viral load and HCC progression.

Seroprevalence of HBV and HCV in primary hepatocellular carcinoma patients in Zimbabwe

BACKGROUND

Primary hepatocellular carcinoma (PHC) is one of the most common cancers in Zimbabwe. Hepatitis B virus (HBV) and hepatitis C virus (HCV) are suspected to play a major role in causing this cancer. The objective of this study was to determine the seroprevalence of HBV and HCV in PHC at Parirenyatwa Referral Hospital in Zimbabwe. We evaluated the serological markers of the two viruses in patients with PHC using commercially available enzyme-linked immunosorbent kits.

RESULTS

Out of the 60 patients with PHC, 48.3% were seropositive for HBV and 20.0% were seropositive for HCV. Co-infection by HCV and HBV was found in 8% of the patients. Only 13.3% of the health controls (blood donors) were positive for HBV. All the controls were negative for HCV.

CONCLUSION

The high seropositivity of HBV and HCV in PHC in Zimbabwe suggested that the two viruses were a major cause of the cancer.

[A 23-year-old asymptomatic HBsAg positive woman]

This paper discusses the case of a young 23-year-old asymptomatic HBsAg woman, diagnosed in the immune-tolerance phase of HBV infection. The monitoring shows the loss of tolerance and eventually the transition to the inactive carrier state. Management strategies are discussed for each phase according to the recent EASL guidelines.

A comparative study of antiviral therapy after resection of hepatocellular carcinoma in the immune-active phase of hepatitis B virus infection

BACKGROUND

The role of antiviral therapy for patients in the immune-active phase of hepatitis B virus (HBV) infection who underwent partial hepatectomy for hepatocellular carcinoma (HCC) is unknown.

METHODS

From January 2004 to June 2007, a nonrandomized comparative study for postoperative antiviral treatment was conducted on patients who underwent curative hepatectomy for advanced HCC. Patients in the treatment group (n = 43) received lamivudine with or without adefovir dipivoxil, while the control group (n = 36) received no antiviral treatment.

RESULTS

The treatment group had a significantly higher HBeAg seroconversion rate (57.2% vs. 5.6%) and a higher HBV DNA suppression rate (87.2% vs. 2.8%) after 12 months of antiviral treatment. The treatment group also had a significantly greater increase in residual liver volume per unit surface area following hepatectomy (78.0 +/- 40.1 cm(3)/m(2) vs. 35.8 +/- 56.0 cm(3)/m(2)) at 6-month postoperation. After a median follow-up of 12 months, there was no significant difference in recurrence rate after surgery between the treatment group and the control group (76.7% and 91.7%). There was a significant difference in the overall survival rate but not in the disease-free survival rate. The 1- and 2-year overall survival rates were 41.9% and 7.0%, respectively, for the treatment group, and 33.3% and 0%, respectively, for the control group. The 1- and 2-year disease-free survival rates were 23.3% and 2.3%, respectively, for the treatment group, and 8.3% and 0%, respectively, for the control group.

CONCLUSION

Although nucleoside analogs did not reduce short-term recurrence rate, they promoted postoperative viral clearance and increased residual liver volume, which significantly enhanced tolerance to subsequent therapy for disease recurrence.

Antiviral therapy of chronic hepatitis B: opportunities and challenges in Asia

Asia comprises more than 40 countries encompassing a wide geographic area with a very large population. Many of these countries have low-income economies together with high endemicity of chronic hepatitis B virus (HBV) infection, which is usually acquired perinatally or during early childhood. The well elucidated natural history of chronic HBV infection, together with the extensive research and the longest experience in the use of therapeutic agents in Asia have provided a great opportunity for Asian patients to benefit from recent advancements. However, treatment of chronic HBV infection is a complex task that requires individualized assessment, thus representing a great challenge for general physicians. The inherent problems of the drugs currently available, together with a lack of awareness of the disease among patients, government, and healthcare practitioners are obstacles to proper management of HBV. The most critical challenge and obstacle is the high cost of medical care and antiviral drugs. Lack of adequate reimbursement for treatment and diagnostic testing makes adherence to treatment guidelines impossible. Hence lamivudine is still widely used in Asia. To address these challenges, the ongoing awareness campaigns, active screening programs, educational activities are needed but must be enhanced. Cost-cutting measures and international support are essential to improve the difficult situation in this part of the world.

A perspective on antiviral resistance

More than 25 years after the licensure of aciclovir and then penciclovir, followed by their respective prodrugs valaciclovir and famciclovir, cases of clinically relevant resistance to these drugs in immunocompetent individuals remain very rare. The aim of this review is to focus on the mechanism of action of these anti HSV drugs and then briefly compare this favourable outcome with that of CMV, HIV, HBV and influenza. A central theme is that resistance is an epiphenomenon of failure to suppress virus replication, so that improved potency and selectivity should be prioritised when developing new drugs rather than activity against resistant strains per se.

Chronic hepatitis B in Asian women of childbearing age

Hepatitis B virus (HBV) infection is a serious clinical problem affecting approximately 2 billion people worldwide. An estimated 350 million live with chronic hepatitis B (CHB) infection and are at an increased risk for serious liver sequelae and death from acute or chronic consequences of CHB infection. Individuals with CHB have a 20-30% risk of early death from complications, including liver cirrhosis and hepatocellular carcinoma. In the Asia-Pacific region, half of the CHB burden results from vertical or mother-to-child transmission, with early childhood horizontal transmission accounting for the remaining half. Screening and vaccination are key factors in the successful prevention and control of HBV infection. Over the last 20 years, the implementation of screening programs and universal HBV vaccination for all individuals born in endemic areas have reduced the prevalence of HBV infection and HBV-related liver diseases among individuals younger than 30 years. Women of childbearing age are key stakeholders in preventing HBV infection and, as such, play a critical role in reducing the vertical and horizontal transmission of HBV. Further efforts are needed to implement screening and educational programs for women of childbearing age, particularly those with CHB, to prevent the transmission of HBV to newborns, spouses, other household members, and sexual partners. In addition, healthcare workers need to learn how to avoid iatrogenic transmission in the healthcare setting. This article reviews these issues and highlights areas in which their engagement with public health efforts serves to improve quality of life and society as a whole.

Incidence and risk factors of progression to cirrhosis in inactive carriers of hepatitis B virus

OBJECTIVES

Most hepatitis B virus (HBV) carriers are incidentally identified as inactive carriers (positive hepatitis B e antibody with normal alanine aminotransferase (ALT) levels), but their long-time outcome and risk of cirrhosis are incompletely understood.

METHODS

A total of 1,965 inactive carriers (mean age: 35.6 years; males: 1,076) were studied. Cirrhosis was diagnosed using a high-resolution real-time ultrasound.

RESULTS

During an 11.5-year mean follow-up, 314 carriers developed reactivation of hepatitis B (ALT was more than twice the upper limit of normal and positive HBV DNA was found using hybridization assays). The risk of reactivation of hepatitis B correlated significantly with advanced age at study entry (P<0.0001) and male sex (P<0.0001). A total of 57 patients developed cirrhosis, with the cumulative incidence being 15% after 25 years. The risk of cirrhosis correlated significantly with advanced age at entry (P=0.004) and reactivation of hepatitis B (P<0.0001). Of the 1,651 carriers without reactivation of hepatitis B, 10 developed cirrhosis, and advanced age at entry was the only significant factor (P=0.03). Of the 314 patients with reactivation of hepatitis B, cirrhosis developed in 47 of them, with the cumulative incidence being 8, 16, 27, and 46% at 5, 10, 15, and 20 years, respectively, after the onset of reactivation. Male sex (P=0.037) and advanced age at reactivation (P=0.006) were the two independent risk factors.

CONCLUSIONS

The so-called inactive carrier state cannot be generally viewed as an innocent long-lasting condition of good prognosis; regular follow-up is necessary.

HBeAg seroconversion as an important end point in the treatment of chronic hepatitis B

During the natural history of chronic hepatitis B virus (HBV) infection, the loss of serum hepatitis B e antigen (HBeAg) and the development of anti-HBe antibodies (HBeAg seroconversion) mark a transition from the immune-active phase of disease to the inactive carrier state. This review examines the evidence from natural history and cohort studies on the relationship between HBeAg seroconversion and disease progression. The role of HBeAg seroconversion as an important milestone in the management of HBeAg-positive patients with chronic hepatitis B (CHB), as well as the advantages and disadvantages of administering a finite course of therapy for HBeAg-positive CHB, is also discussed. The evidence from natural history and cohort studies indicates that spontaneous or treatment-induced HBeAg seroconversion is associated with lower rates of disease progression to cirrhosis and hepatocellular carcinoma, a potential of hepatitis B surface antigen seroconversion, and improved survival rates. Updated guidelines developed by major liver associations recommend stopping oral therapy for HBeAg-positive patients who achieve sustained HBeAg seroconversion with polymerase chain reaction-undetectable HBV-DNA on two separate occasions for 6 or more months apart, taking into consideration the individual's clinical and virologic response to therapy, as well as the severity of liver disease. Thus, early induction of HBeAg seroconversion with interferon-based therapy or oral nucleos(t)ide analogues has important clinical and socioeconomic implications for the management of CHB.

Cancer prevention: from 1727 to milestones of the past 100 years

The rich, multidisciplinary history of cancer prevention recounted here begins with surgical and workplace recommendations of the 1700s and ends with 2009 results of the enormous (35,535 men) Selenium and Vitamin E [prostate] Cancer Prevention Trial (SELECT). This history comprises a fascinating array of chemopreventive, vaccine, surgical, and behavioral science research, both preclinical and clinical. Preclinical milestones of cancer prevention include the 1913 and 1916 mouse studies by Lathrop and Loeb of cancer development associated with pregnancy or cancer prevention through castration (oophorectomy), preventing chemically induced mouse carcinogenesis as early as 1929, energy restriction studies in the 1940s, the 1950s discoveries and later molecular characterizations of field cancerization and multistep carcinogenesis, and the effects of angiogenesis inhibition in genetically engineered mice reported in 2009. The extraordinary panoply of clinical research includes numerous large and smaller chemoprevention studies of nutritional supplements, other dietary approaches, a Bacillus Calmette-Guérin trial in 1976, molecular-targeted agents, and agents to prevent infection-related cancers such as hepatitis B virus vaccine to prevent liver cancer in 1984. Clinical surgical prevention includes removal of intraepithelial neoplasia detected by screening (including Pap testing developed in 1929 and culposcopy for cervical premalignancy and colonoscopy and polypectomy to prevent colorectal cancer begun in the 1960s) and prophylactic surgeries, such as in Lynch syndrome patients begun in 1977. Behavioral studies include smoking cessation and control beginning in the 1950s, obesity control rooted in studies of 1841, and genetic-counseling and cancer-survivorship studies. This history of pioneering events may help in better understanding who we are and what we want to achieve as cancer prevention researchers and practitioners.

Long-term outcome of hepatitis B e antigen-negative hepatitis B surface antigen carriers in relation to changes of alanine aminotransferase levels over time

The baseline alanine aminotransferase (ALT) level was reported to have prognostic value in chronic hepatitis B virus (HBV) infection, during which ALT may change over time. Instead of baseline ALT, this study aimed to study the prognostic value of the height of ALT during the course of chronic HBV infection. A total of 4376 asymptomatic hepatitis B e antigen (HBeAg) negative, surface antigen (HBsAg) carriers with baseline ALT less than 2 times the upper limit of normal (ULN) were monitored with ALT measurement and ultrasonography every 3 to 12 month for over 3 years. Maximal ALT levels during follow-up were correlated with long-term outcomes using morbidity and mortality data from hospital records, cancer registration, and national mortality database. Baseline ALT level was normal in 3673 subjects and increased to abnormal level in 1720 (46.8%) during a mean follow-up period of 13.4 +/- 5.2 (3.0-28.7) years. The incidence of liver cirrhosis, hepatocellular carcinoma (HCC), and mortality increased with increasing maximal ALT level during follow-up, especially in those with maximal ALT of at least 2 times ULN, as compared with those who maintained normal ALT. Cox regression analysis indicated that age at entry, sex, and maximal ALT level during follow-up were significant independent factors associated with the development of cirrhosis, HCC, and mortality whereas cirrhosis was also an independent factor for HCC development and mortality.

CONCLUSION

Persistently normal ALT was associated with excellent long-term prognosis, whereas increasing ALT levels of at least 2 times ULN during follow-up was associated with increasing morbidity and mortality. ALT of at least 2 times ULN is therefore an appropriate threshold for anti-HBV therapy, whereas those with ALT 1 to 2 times ULN require liver biopsy for decision.

Hepatitis B virus reactivation in breast cancer patients receiving cytotoxic chemotherapy: a prospective study

Breast cancer is a rapidly increasing problem in many developing countries, and cytotoxic chemotherapy is now an integral part of its management. In several developing countries, the carriage of hepatitis B virus (HBV) in cancer patients may be as high as 12%, and such patients are at risk of developing fatal HBV reactivation during chemotherapy. HBV reactivation is well recognized in patients with hematological malignancies, but limited data are available on patients with other, more common, cancers, such as breast cancer. Recent data have suggested that increased viral replication, an indication of HBV reactivation, may precede clinical hepatitis. In the absence of serial HBV DNA monitoring, HBV reactivation during chemotherapy may have been underestimated. In this prospective study, breast cancer patients who were hepatitis B surface antigen (HBsAg) seropositive were followed up during chemotherapy. The main objectives were to determine the incidence of HBV reactivation in breast cancer patients undergoing conventional chemotherapy; to investigate whether "serial HBV DNA monitoring" improves the accuracy of diagnosing HBV reactivation when compared with previous schema that only measured HBV DNA at the time of clinical hepatitis ("conventional monitoring"); and to assess the clinical consequences as a result of developing the condition. The secondary objective was to identify risk factors associated with this condition. Over an 18-month period, 41 patients were studied. Ten developed HBV reactivation by conventional monitoring criteria, but with serial HBV DNA monitoring, seven additional patients were diagnosed when increased HBV DNA levels were detected before, but not concomitant with, clinical hepatitis. Thus, a total of 17 patients (41%) developed HBV reactivation. Premature termination of chemotherapy or delay in treatment schedules occurred in 71% of the patients who developed viral reactivation, as compared with 33% in those who did not develop the condition (P = 0.019). No risk factors associated with the development of HBV reactivation could be identified. Serial monitoring of HBV DNA, in addition to liver function, increases the sensitivity of diagnosing of HBV reactivation, and helps explain some cases that would otherwise be labeled as "cryptogenic hepatitis," for which concomitant HBV DNA measured at the time of hepatitis was undetectable. The present study highlights the importance of monitoring HBsAg-seropositive patients who are receiving chemotherapy for common solid tumors such as breast cancer.

Does hepatitis B virus (HBV) genotype influence the clinical outcome of HBV infection?

Between 5 and 10% of adults infected with the hepatitis B virus (HBV) develop a chronic infection lasting longer than 6 months, which may lead to advanced liver disease. HBV can be classified into six genotypic families: A, B, C, D, E and F, but only genotypes A and D are significantly represented in western Europe, where they account for some 90% of cases of infection with HBV. In the present study, we investigated a possible association between HBV genotype A or D and clinical outcome of the infection. We compared the prevalence of these genotypes in a group of patients with chronic active hepatitis to that of a group with acute resolving hepatitis. In patients with chronic active hepatitis, genotype A was found in 28 of 35 patients and genotype D in only four. The remaining three patients were infected with genotype non-A, non-D. In contrast, genotype D was found in 24 of 30 patients with acute hepatitis, whilst genotype A was found in only three patients of this group. Three were infected with genotype non-A, non-D. Our results show a clear association between genotype A and chronic outcome (Ficher's exact test: two-sided P-value, P < 0.0001). They suggest that HBV genotypes may play a role in the virus-host relationship. Possible mechanisms for such a role are discussed.