201
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Lok AS. Should antiviral treatment be extended to patients with chronic hepatitis B and mildly elevated alanine aminotransferase? Hepatology 2010; 51:1107-9. [PMID: 20162620 DOI: 10.1002/hep.23496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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202
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Wu IC, Lai CL, Han SHB, Han KH, Gordon SC, Chao YC, Tan CK, Sievert W, Tanwandee T, Xu D, Neo BL, Chang TT. Efficacy of entecavir in chronic hepatitis B patients with mildly elevated alanine aminotransferase and biopsy-proven histological damage. Hepatology 2010; 51:1185-9. [PMID: 20044806 DOI: 10.1002/hep.23424] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
UNLABELLED Current guidelines for management of chronic hepatitis B recommend treatment for patients presenting with elevated hepatitis B virus (HBV) DNA and alanine aminotransferase (ALT) >2 x upper limit of normal (ULN) or histological evidence of liver disease. Retrospective analyses have demonstrated that significant hepatic necroinflammation and fibrosis were present in a substantial proportion of patients with ALT 1 to 2 x ULN. To assess therapeutic efficacy in this clinical setting, we retrospectively examined treatment endpoints among the subset of nucleoside-naïve chronic hepatitis B (CHB) patients treated in phase 3 clinical trials of entecavir who had both screening and baseline serum ALT 1.3 to 2 x ULN. A total of 1347 patients were randomized to treatment with entecavir or lamivudine. Three hundred thirty-six patients, constituting 25% of the total study population, had screening and baseline ALT 1.3 to 2 x ULN. Clinically significant necroinflammation (Knodell necroinflammation score > or =7) was observed in 60% and 72% of hepatitis B e antigen (HBeAg)-positive and HBeAg-negative patients, respectively, whereas marked fibrosis (Ishak fibrosis score > or =4) was observed in 8% and 15% of HBeAg-positive and HBeAg-negative patients, respectively. Among entecavir-treated HBeAg-negative patients, the proportions of patients achieving histological improvement, HBV DNA <300 copies/mL, and ALT normalization were similar between patients with mildly elevated ALT and those with ALT >2 x ULN. However, entecavir-treated HBeAg-positive patients with mildly elevated ALT had lower response rates for histological improvement, HBV DNA less than 300 copies/mL, ALT normalization, and HBeAg seroconversion than those with ALT greater than 2 x ULN. CONCLUSION This retrospective analysis demonstrated that HBeAg-negative CHB patients treated with entecavir responded similarly irrespective of baseline ALT level. However, HBeAg-positive patients with mildly elevated ALT responded less well to treatment with entecavir than did those with ALT greater than 2 x ULN.
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Affiliation(s)
- I-Chin Wu
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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203
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Choi MS, Yoo BC. Management of chronic hepatitis B with nucleoside or nucleotide analogues: a review of current guidelines. Gut Liver 2010; 4:15-24. [PMID: 20479908 DOI: 10.5009/gnl.2010.4.1.15] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 11/09/2009] [Indexed: 12/21/2022] Open
Abstract
Antiviral treatment of hepatitis B is one of the most rapidly evolving fields in current medicine. Guidelines for the management of chronic hepatitis B (CH-B) have been proposed and revised by many academic societies and groups. Recommendations for nucleoside or nucleotide analogue (NUC) therapy from representative current guidelines are compared herein with each other and with previous guidelines. Several differences among individual recommendations may reflect regional and temporal differences as well as differences in the available data upon which the guidelines are based. Nevertheless, these guidelines share a common principle regarding NUC treatment for CH-B: long-term viral suppression by the drugs with potent antiviral activity and low rate of development of drug resistance to prevent disease progression. A review of the past and current guidelines for the management of CH-B would be useful for evaluating the current status of management of the disease and to identify better solutions for improving the outcome of patients with CH-B.
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Affiliation(s)
- Moon Seok Choi
- Division of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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204
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Gui HL, Wang H, Yang YH, Wu YW, Zhou HJ, Guo SM, Lin LY, Wang L, Cai W, Chen R, Guo Q, Zhou XQ, Bao SS, Xie Q. Significant histopathology in Chinese chronic hepatitis B patients with persistently high-normal alanine aminotransferase. J Viral Hepat 2010; 17 Suppl 1:44-50. [PMID: 20586933 DOI: 10.1111/j.1365-2893.2010.01270.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Current guidelines recommend antiviral therapy for chronic hepatitis B (CHB) patients with elevated alanine aminotransferase (ALT) and high viral load. Scant histological data exist for CHB patients with persistently normal ALT (PNALT) because disease progression is thought to be rare. To identify potential predictors of significant histology in the presence of PNALT, we compared the clinical characteristics and histology of Chinese CHB PNALT patients to those in patients with elevated ALT. Percutaneous liver biopsy was performed in 522 CHB patients with Chinese ethnicity who had not had antiviral treatment. Differences in age, ALT, viral load, hepatitis B e antigen (HBeAg) status and liver histology were compared between eligible PNALT (252) and elevated ALT (270) patients. Of the PNALT patients, 38.5% had normal liver histology, 25.4% had significant necroinflammation and/or fibrosis and 8.4% had established cirrhosis. Furthermore, histopathological differences between patients with high-normal ALT (0.5-1.0 x the upper limit of normal (ULN)) and low-normal ALT (≤ 0.5 x ULN) were evaluated. There was a significantly greater prevalence of histopathology in the high-normal group (40.0%) than in the low-normal group (16.6%) (P < 0.001). Multiple logistic regression identified that significant histopathology findings in PNALT patients correlated with age (P < 0.001) and ALT level (P < 0.001), with age >40 years and ALT >0.5 x ULN predicting significant histopathology. Our data indicate that liver biopsy is recommended in CHB patients >40 years of age, particularly when their ALT is 0.5-1.0 x ULN. The findings above provide evidence for indication of antiviral therapy in patients with PNALT and significant histopathological change.
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Affiliation(s)
- H L Gui
- Department of Infectious Diseases, Ruijin Hospital, Jiaotong University School of Medicine, Shanghai, China
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205
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The clinical value of serum connective tissue growth factor in the assessment of liver fibrosis. Dig Dis Sci 2010; 55:767-74. [PMID: 19294506 DOI: 10.1007/s10620-009-0781-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Accepted: 02/26/2009] [Indexed: 12/14/2022]
Abstract
To explore the relation between connective tissue growth factor (CTGF) in serum and the severity of liver fibrosis, and to determine the clinical value of CTGF in the assessment of liver fibrosis, serum CTGF was tested utilizing enzyme-linked immunosorbent assay (ELISA). The correlation between serum CTGF concentration and fibrosis stage was assessed. The diagnostic performance of CTGF was assessed by comparing the area under the receiver operating characteristic (ROC) curves (AUC) with a panel of fibrosis markers. The correlation coefficient was 0.689 (P < 0.001) between the levels of serum CTGF and fibrosis stages and the AUC of CTGF was 0.841 (95% confidence interval [CI] 0.762-0.920) in distinguishing mild fibrosis from significant fibrosis. The present data revealed that serum CTGF was significantly correlated with the stage of liver fibrosis, suggested that serum CTGF was an indicator for the stage of liver fibrosis, and shown evidence that serum CTGF could be used as a valuable marker for assessing liver fibrosis.
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206
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Ahn SH, Chan HLY, Chen PJ, Cheng J, Goenka MK, Hou J, Lim SG, Omata M, Piratvisuth T, Xie Q, Yim HJ, Yuen MF. Chronic hepatitis B: whom to treat and for how long? Propositions, challenges, and future directions. Hepatol Int 2010; 4:386-95. [PMID: 20305758 PMCID: PMC2836441 DOI: 10.1007/s12072-010-9163-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 12/11/2009] [Indexed: 02/06/2023]
Abstract
Recent guidelines of the American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, and the Asian Pacific Association for the Study of the Liver 2008 update of the "Asian-Pacific consensus statement on the management of chronic hepatitis B" offer comprehensive recommendations for the general management of chronic hepatitis B (CHB). These recommendations highlight preferred approaches to the prevention, diagnosis, and treatment of CHB. Nonetheless, the results of recent studies have led to an improved understanding of the disease and a belief that current recommendations on specific therapeutic considerations, including CHB treatment initiation and cessation criteria, particularly in patient populations with special circumstances, can be improved. Twelve experts from the Asia-Pacific region formed the Asia-Pacific Panel Recommendations for the Optimal Management of Chronic Hepatitis B (APPROACH) Working Group to review, challenge, and assess relevant new data and inform future updates of CHB treatment guidelines. The significance of and controversy about reported findings were discussed and debated in an expert meeting of the Working Group in Beijing, China, in November 2008. This review paper attempts to identify areas requiring improved CHB management and provide suggestions for future guideline updates, with special emphasis on treatment initiation and duration.
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Affiliation(s)
- Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, 250 Sungsanno, Seodaemun-gu, Seoul, 120-752 South Korea
| | - Henry L. Y. Chan
- Department of Medicine and Therapeutics, 9/F, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong People’s Republic of China
| | - Pei-Jer Chen
- Graduate Institute of Clinical Medicine, National Taiwan University Hospital, 7 Chung-Shan S Road, Taipei, Taiwan
| | - Jun Cheng
- Institute of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun East Street, Chaoyang District, 100015 Beijing, People’s Republic of China
| | - Mahesh K. Goenka
- Institute of Gastroenterology and Endoscopy, Apollo Gleneagles Hospitals, 58 Canal Circular Road, Kolkata, 700-054 India
| | - Jinlin Hou
- Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 People’s Republic of China
| | - Seng Gee Lim
- Department of Gastroenterology and Hepatology, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074 Singapore
| | - Masao Omata
- Department of Gastroenterology, University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, 113-0033 Japan
| | - Teerha Piratvisuth
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Prince of Songkla University, Hat Yai, 90110 Thailand
| | - Qing Xie
- Department of Infectious Disease, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, No.197 Rui Jin Er Road, 200025 Shanghai, People’s Republic of China
| | - Hyung Joon Yim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospital, 516, Gojan 1-dong, Danwon-gu, Ansan City, Kyunggi-do, 425-707 Korea
| | - Man-Fung Yuen
- Division of Gastroenterology and Hepatology, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, People’s Republic of China
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207
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Cotler SJ, Dhamija MK, Luc BJ, Siqueira F, Bartram AH, Layden TJ, Wong SS. The prevalence and clinical correlates of elevated ALT levels in an urban Chinatown community. J Viral Hepat 2010; 17:148-52. [PMID: 19674287 DOI: 10.1111/j.1365-2893.2009.01162.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Alanine aminotransferase (ALT) levels are a primary consideration in treatment decisions regarding hepatitis B virus (HBV) infection. Levels can be elevated as a result of HBV-related liver injury or to other causes. The aim of this study was to assess the background prevalence and clinical correlates of elevated ALT levels in Chinese immigrants who were HBsAg negative. Subjects consisted of adults seen in an urban Chinatown Internal Medicine practice between 1, 2006 and 12, 2007. Clinical information was collected retrospectively. An elevated ALT level was defined as >19 U/L for women and >30 U/L for men. The primary analysis focused on 2457 persons who were HBsAg negative. Their mean age was 55 +/- 18 years, 64% were female and 36% were obese. All subjects were ethnically Chinese and 96% were born in Asia. Thirty percent had an elevated ALT level. In univariate analysis, factors associated with elevated ALT included older age (P < 0.001), female gender (P = 0.001), obesity (P < 0.001), diabetes (P < 0.001), hypercholesterolemia (P < 0.001) and hypertension (P < 0.001). In multivariate analysis BMI, diabetes, female gender and hypercholesterolemia were significantly associated with elevated ALT level. An additional analysis focused on a group of patients who were HBsAg positive, HBeAg negative and had HBV-DNA levels <1000 copies/mL. Fifty percent had elevated ALT levels. In conclusion, elevated ALT levels are common among Chinese immigrants without HBV (30%) and are associated with features of the metabolic syndrome. Liver biopsy should be performed in selected patients with HBV to distinguish the cause of ALT elevation before initiating antiviral therapy.
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Affiliation(s)
- S J Cotler
- Department of Medicine, University of Illinois, Chicago, IL, USA.
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208
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Histological changes in chinese chronic hepatitis B patients with ALT lower than two times upper limits of normal. Dig Dis Sci 2010; 55:432-7. [PMID: 19241166 DOI: 10.1007/s10620-009-0724-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Accepted: 01/12/2009] [Indexed: 02/05/2023]
Abstract
The role of ALT as a predictor of liver injury has been questioned. The aim of this study is to use liver biopsy to assess the degree of liver injury in patients with chronic hepatitis B(CHB) whose ALT < 2 x upper limit of normal (ULN). A total of 49.2% of patients in this study had significant inflammation (grade >or=2) and 36.4% had significant fibrosis (stage >or=2). The frequency of serious inflammation and fibrosis was similar in patients with different ALT levels. The level of serum HBV DNA was not significantly associated with the extent of inflammation and fibrosis. Advanced age was a significant independent predictor of histological damage and the presence of more significant inflammation and fibrosis. We conclude that many CHB patients with ALT < 2 x ULN have significant liver inflammation or fibrosis and that liver biopsy is necessary to assess liver damage and should be used to assess the need for anti-viral therapy.
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209
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Hsieh MH, Ho CK, Hou NJ, Hsieh MY, Lin WY, Yang JF, Chiu CC, Huang JF, Chang NC, Wang CL, Dai CY, Chuang WL, Yu ML. Abnormal liver function test results are related to metabolic syndrome and BMI in Taiwanese adults without chronic hepatitis B or C. Int J Obes (Lond) 2009; 33:1309-17. [PMID: 19752878 DOI: 10.1038/ijo.2009.172] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Metabolic syndrome (MS) is considered a cause of abnormal deposition of fat into hepatocytes, which might be associated with hepatic steatosis or abnormal liver function. OBJECTIVE The aim of this study was to explore the factors associated with MS and the relationship between MS and abnormal aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT) levels in Taiwanese subjects without chronic hepatitis B (CHB) or C (CHC). SUBJECTS We enrolled 2539 Taiwanese adults without CHB or CHC (age range: 16-88 years old) and investigated the factors related to MS using the NCEP-ATP (National Cholesterol Education Program-Adult Treatment Panel) III criteria; body mass index (BMI) was measured using Asia-Pacific criteria. RESULTS The prevalence rate of MS in Taiwanese adults without CHB or CHC was 16.9% using the modified ATP III criteria and 15.4% using the International Diabetes Federation criteria. Males had a significantly higher prevalence rate than females (P<0.001), and subjects with MS were significantly older and had significantly higher BMI values and AST, ALT and GGT levels (all P<0.001). In univariate analyses, the abnormality of liver function test results were related to gender, level of fasting sugar, systolic blood pressure, triglyceride, high-density lipoprotein, BMI and MS (all P<0.05). Multivariate analysis showed that the male gender, a higher BMI value and MS were related to abnormal liver function test results. The cutoff value for ALT in relation to MS is 31 IU l(-1) for male and 18 IU l(-1) for female. CONCLUSION The prevalence of MS in Taiwanese adults without hepatitis B or C was found to be high, and MS and BMI were identified as being related to abnormal liver function test results in these adults.
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Affiliation(s)
- M-H Hsieh
- Department of Occupational Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
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210
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Nguyen MH, Garcia RT, Trinh HN, Lam KD, Weiss G, Nguyen HA, Nguyen KK, Keeffe EB. Histological disease in Asian-Americans with chronic hepatitis B, high hepatitis B virus DNA, and normal alanine aminotransferase levels. Am J Gastroenterol 2009; 104:2206-13. [PMID: 19491836 DOI: 10.1038/ajg.2009.248] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES At present there is no clear consensus on how patients with chronic hepatitis B (CHB), high serum hepatitis B virus (HBV) DNA, and normal alanine aminotransferase (NLALT) levels should be managed. This study hypothesizes that a significant proportion of such patients may have histological disease. METHODS We carried out a retrospective study of 101 consecutive treatment-naive patients with CHB who underwent liver biopsies at a community gastroenterology clinic and had high HBV DNA and NLALT (< or = 40 U/l) levels at the time of biopsy. All patients were Asians. ALT levels were observed for a period of time before liver biopsy and were used to classify patients into two groups, namely those with only NLALT levels and those with fluctuating ALT (FLALT) levels. All patients had at least two ALT measurements during this period of time. Significant histology was defined as stage > or = 2 fibrosis or stage 1 fibrosis plus grade > or = 2 inflammation using the Batts-Ludwig scoring system. RESULTS In patients with NLALT levels, the proportions of those with significant histology were 0, 22, and 45% for age < or = 35, 36-50, and >50 years, respectively (n=11, n=27, n=19; P=0.033). In patients who had FLALT levels, the corresponding proportions were 22, 42, and 69% (n=9, n=22, n=13; P=0.091). After adjustments for gender, hepatitis B e antigen (HBeAg) status, and mean pre-biopsy HBV DNA levels, significant predictors of histological disease were older age (odds ratio (OR)=6.2 for age 36-50 years and OR=17.6 for age >50 years compared with age < or = 35 years, P=0.041 and P=0.003, respectively) and FLALT levels (OR=3.6, P=0.008). Sub-analysis of patients with NLALT levels using lower cutoffs (30 U/l for men and 19 U/l for women) showed similar trends. CONCLUSIONS Patients with CHB, high HBV DNA, and NLALT levels and aged more than 35 years or those with FLALT levels may have significant histological disease (22-70%).
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Affiliation(s)
- Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California 94304, USA.
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211
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Assy N, Beniashvili Z, Djibre A, Nasser G, Grosovski M, Nseir W. Lower baseline ALT cut-off values and HBV DNA levels better differentiate HBeAg(-) chronic hepatitis B patients from inactive chronic carriers. World J Gastroenterol 2009; 15:3025-31. [PMID: 19554656 PMCID: PMC2702111 DOI: 10.3748/wjg.15.3025] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine whether new cut-off values for alanine aminotransferase (ALT) and baseline hepatitis B virus (HBV) DNA levels better differentiate HBeAg(-) chronic hepatitis B (CHB) patients from inactive chronic carriers.
METHODS: Ninety-one patients [32 HBeAg(+) CHB, 19 inactive carriers and 40 HBeAg(-) CHB] were followed up for 2 years and were tested for HBV DNA levels by a PCR-based assay. ALT was tested twice during the last 6 mo using new cut-off values: ULN (upper limit of normal) 30 IU/L for males, 19 IU/L for females. Diagnostic accuracy, sensitivity, specificity, positive and negative predictive values were calculated by discriminant analysis.
RESULTS: When using the revised ALT cut-off values, the lowest optimal HBV DNA level that differentiated HBeAg(-) CHB patients from inactive carriers was 50 000 copies/mL. The diagnostic accuracy of HBV DNA to determine inactive carriers with a cut-off of 50 000 copies/mL was similar to the previously recommended cut-off of 100 000 copies/mL (91%). HBV DNA levels were lower than the cut-off value in 95% of inactive carriers and in 28% of HBeAg(-) CHB patients. With ALT < 30 IU/L in men and < 19 IU/L in women and HBV DNA levels < 100 000 copies/mL, the risk of CHB is 5%. On the other hand, if ALT values were > 30 IU in men and > 19 IU in women and baseline HBV DNA levels were > 100 000 copies/mL, the risk is 86%.
CONCLUSION: New cut-off values for ALT together with HBV DNA levels proposed by AASLD (American Association for the Study of Liver Diseases) and NIH (National Institute of Health) consensus seem appropriate to characterize inactive carriers.
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212
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Di Marco V, Craxì A. Chronic hepatitis B: who to treat and which choice of treatment? Expert Rev Anti Infect Ther 2009; 7:281-91. [PMID: 19344242 DOI: 10.1586/eri.09.4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The goal of antiviral therapy in patients with chronic hepatitis B is to prevent, through persistent suppression of HBV replication, cirrhosis and hepatocellular carcinoma. Currently, seven drugs are available: IFN-alpha, pegylated interferon, lamivudine, adefovir dipivoxil, entecavir, telbivudine and tenofovir. The choice of the drugs should always take into consideration the clinical features of patients, the antiviral efficacy of each drug, the risk of developing resistance, the long-term safety profile, the method of administration and the cost of therapy. Ideal candidates for treatment are hepatitis B e antigen-positive patients with a prolonged phase of immune clearance and hepatitis B e antigen-negative patients with elevated levels of serum HBV DNA, abnormal alanine aminotransferase and histologic evidence of moderate or severe liver necroinflammation and/or fibrosis. Patients with compensated or decompensated cirrhosis should be treated, even if alanine aminotransferase levels are normal and/or serum HBV DNA levels are low, in order to prevent disease flare and to improve liver function.
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Affiliation(s)
- Vito Di Marco
- Dipartimento Biomedico di Medicina Interna e Specialistica, Gastroenterology and Hepatology Unit, University of Palermo, Palermo, Italy.
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213
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Wong GLH, Wong VWS, Choi PCL, Chan AWH, Chim AML, Yiu KKL, Chan FKL, Sung JJY, Chan HLY. Increased liver stiffness measurement by transient elastography in severe acute exacerbation of chronic hepatitis B. J Gastroenterol Hepatol 2009; 24:1002-7. [PMID: 19457152 DOI: 10.1111/j.1440-1746.2009.05779.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS The proposed cut-off values for the degree of fibrosis as assessed by liver stiffness measurement (LSM) might not be applicable in severe acute exacerbation of chronic hepatitis B (CHB). We aimed to assess the effect of necroinflammatory activity on LSM in this condition. METHODS We prospectively recruited consecutive patients with severe acute exacerbation of CHB (alanine aminotransferase or ALT > 10x upper limit of normal). The relationship of ALT levels and LSM were serially assessed and liver biopsy was carried out after ALT normalization. RESULTS Eleven patients (10 male, median age 43 years) were followed up for 25 weeks; nine patients received antiviral therapy. Overall, LSM was positively correlated with ALT levels (r = 0.67, P < 0.001). At initial presentation, the median serum ALT and LSM was 1136 (581-2210) IU/L and 26.3 (11.1-33.3) kPa. A progressive reduction in LSM was observed during subsequent visits in parallel with the reduction of ALT levels. At the last visit, the median ALT was 27 (11-52) IU/L and LSM was 7.7 (4.7-10.8) kPa. Among the five patients who had liver biopsy carried out at week 25, four patients had F2 fibrosis (LSM 5.7-8.1 kPa) and one patient had F3 fibrosis (LSM 8.6 kPa). CONCLUSIONS LSM using transient elastography with the current proposed cut-off values might misdiagnose liver cirrhosis in patients suffering from severe acute exacerbation of CHB. LSM should be assessed after normalization of ALT levels in order to accurately assess the degree of fibrosis.
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Affiliation(s)
- Grace L-H Wong
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
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214
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Tai DI, Lin SM, Sheen IS, Chu CM, Lin DY, Liaw YF. Long-term outcome of hepatitis B e antigen-negative hepatitis B surface antigen carriers in relation to changes of alanine aminotransferase levels over time. Hepatology 2009; 49:1859-67. [PMID: 19378345 DOI: 10.1002/hep.22878] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Dar-In Tai
- Liver Research Unit, Chang Gung Memorial Hospital, Chung Gung University College of Medicine, Taipei, Taiwan
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215
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Abstract
Increased treatment options that are more efficacious and safe and new knowledge on the natural history of chronic hepatitis B virus (HBV) infection have expanded the indications for therapy in hepatitis B. The question is no longer "Who should be treated?" but "When should treatment be initiated?" Treatment is clearly indicated in patients with life-threatening liver disease (acute liver failure, decompensated cirrhosis, or severe hepatitis flare) and in those with compensated cirrhosis and high levels of serum HBV DNA. For patients with precirrhotic liver disease, treatment indications should be based on clinical, biochemical, or histological evidence of liver disease, such as elevated alanine aminotransferase (ALT) levels, abnormal histology, and high levels of serum HBV DNA. The cutoff for ALT and HBV DNA values are constantly being revised and should be set at a lower level for older patients who may have been infected for a longer period of time. High serum HBV DNA levels persisting for a few decades are associated with increased risk of clinical outcomes, but there is insufficient data to support the initiation of treatment based on high serum HBV DNA alone, particularly in young patients, those with persistently normal ALT levels, and those with a single high HBV DNA level. The decision to initiate treatment at the time of assessment or to defer treatment should take into consideration other factors such as desire to start a family, occupational requirement, family history of hepatocellular carcinoma, access to care and insurance coverage, and commitment to long-term treatment and medication compliance. All patients who are not initiated on treatment should continue to be monitored so treatment can be started if and when the indication arises.
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Affiliation(s)
- Bulent Degertekin
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI 48109, USA
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216
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Abstract
Liver biopsy plays a central role in treatment algorithms in patients with hepatitis B and remains the gold standard for evaluating hepatic pathology. The pathology of hepatitis B is diverse and reflects the natural history of infection. An acute hepatitic pattern with lobular disarray is seen in acute infection, during acute flares of disease, and with acute hepatitis D superinfection. In chronic hepatitis B, inflammation is less pronounced in the immune-tolerant phase and is prominent during immune-mediated viral clearance. Active inflammation appears to be the driving force for development of fibrosis. Inflammatory grades and fibrosis stage are assigned as is done for hepatitis C. Although current management guidelines recommend liver biopsies only in select patients based on age, viral levels, and hepatitis B e antigen status, these clinical and biochemical parameters do not show consistent correlations with liver histology. Liver biopsy also helps identify preneoplastic lesions including large cell and small cell change. Unlike in other causes of chronic hepatitis, immunostains are widely used and can help determine the phase of infection. Liver biopsies can also identify additional pathology that may contribute to liver disease such as steatohepatitis, iron overload, autoimmune hepatitis, and drug-induced injury. Thus, liver biopsy can play an important role in staging and grading chronic hepatitis B and should be more widely used in assessing the need for therapy.
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Affiliation(s)
- Haresh Mani
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
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217
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Abstract
The initial evaluation of a patient with hepatitis B virus infection should attempt to assess the disease activity and stage in the context of the known natural history of this infection and to properly assess the needs for treatment and surveillance. In addition to a medical history and focused physical examination, the initial evaluation usually requires serological, biochemical, and virological tests to confirm the diagnosis as well as an imaging study to establish a baseline for future monitoring. A liver biopsy is generally not needed but can provide useful information on prognosis, need for surveillance for hepatocellular carcinoma (HCC), and whether to recommend therapy. Follow-up monitoring is aimed at determining disease progression, development of complications, and reassessing the need for treatment. Monitoring frequency should be determined based on the activity and stage of disease. Initiation of screening for HCC should be based on age, race, sex, family history, and stage and duration of disease. The current recommended method of screening and surveillance for HCC is by ultrasonography and alpha-fetoprotein measurements every 6-12 months. Prospective studies are needed to evaluate the role of longitudinal application of noninvasive assays of fibrosis, such as serum fibrosis markers and transient elastography. Better biomarkers and imaging modalities are needed for early detection of HCC. Finally, studies are needed to better refine the indications and to balance the risks and benefits of antiviral therapy.
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Affiliation(s)
- Yaron Rotman
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA.
| | - Thomas A. Brown
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Jay H. Hoofnagle
- Liver Diseases Branch, National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, MD
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218
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Chan HLY, Wong GLH, Wong VWS. A review of the natural history of chronic hepatitis B in the era of transient elastography. Antivir Ther 2009. [DOI: 10.1177/135965350901400405] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Understanding the natural history of chronic hepatitis B is important in order to predict the prognosis, to stratify the risk of hepatocellular carcinoma and to select appropriate candidates for antiviral treatment. Liver fibrosis is the pathogenic process that leads to liver cirrhosis. The study of liver fibrosis in the past has largely been hampered by the invasive nature of a liver biopsy. Most liver biopsy series represent biased populations with more active disease. Transient elastography is a reliable and non-invasive measurement of liver fibrosis that allows the study of liver fibrosis among patients without clinical indication for liver biopsy. Large studies using transient elastography in patients with predominantly normal alanine aminotransferase levels have been reported recently. The different roles of patient age, hepatitis B virus DNA and alanine aminotransferase levels in the risk stratification for advanced liver fibrosis have been defined in hepatitis B e antigen-positive and hepatitis B e antigen-negative chronic hepatitis B patients. The relationship between metabolic syndrome and chronic hepatitis B is also explored. In this review, new insights from studies using transient elastography on the natural history of chronic hepatitis B with special focus on liver fibrosis will be summarized and discussed.
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Affiliation(s)
- Henry Lik-Yuen Chan
- Department of Medicine and Therapeutics and Institute of Digestive Disease, Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics and Institute of Digestive Disease, Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics and Institute of Digestive Disease, Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
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219
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Reijnders JGP, LA Janssen H. New approaches in the management of chronic hepatitis B: role of tenofovir. Infect Drug Resist 2009; 2:13-26. [PMID: 21694884 PMCID: PMC3108728 DOI: 10.2147/idr.s3918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
In the field of HIV management, tenofovir disoproxil fumarate (TDF) plays a pivotal role and has been demonstrated to be a safe and well-tolerated antiviral agent. Recent data showed the efficacy of TDF in the treatment of chronically hepatitis B virus (HBV)-infected patients. TDF was superior to adefovir dipivoxil (ADV) in both nucleos(t)ide-naïve HBeAg-positive and HBeAg-negative HBV patients, and appeared to be one of the most potent antiviral agents so far. In addition, several reports showed that TDF was also effective in the nucleos(t)ide-experienced population, although conflicting results have been presented concerning patients with genotypic resistance to ADV. TDF seems to have a good resistance profile as well. The rtA194T mutation in association with lamivudine resistance may confer resistance to TDF, although both in vivo and in vitro studies regarding this mutation demonstrate conflicting results. As treatment with TDF may be associated with nephrotoxicity, all TDF-treated patients should be monitored for renal function at baseline and periodically thereafter. While the relative roles of interferon vs nucleos(t)ide analogues (NA) as initial anti-HBV therapy remains unclear, TDF will probably become one of the key factors in HBV management both as first-choice NA for nucleos(t)ide-naïve patients and as rescue therapy for nucleos(t)ide-experienced patients.
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Affiliation(s)
- Jurriën GP Reijnders
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Harry LA Janssen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, The Netherlands
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220
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El-Zayadi AR, Badran HM, Saied A, Shawky S, Attia MED, Zalata K. Evaluation of liver biopsy in Egyptian HBeAg-negative chronic hepatitis B patients at initial presentation: implications for therapy. Am J Gastroenterol 2009; 104:906-11. [PMID: 19293791 DOI: 10.1038/ajg.2009.30] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES A subgroup of HBeAg-negative chronic hepatitis B (CHB) patients with alanine aminotransferase (ALT) and/or hepatitis B virus (HBV)-DNA levels below the cutoff values of international guidelines may have significant liver disease and miss the opportunity for early treatment. Histopathological changes of HBeAg-negative CHB patients at initial presentation irrespective of HBV-DNA and/or ALT levels to increase the likelihood of patients for treatment are evaluated. METHODS CHB patients attending Cairo Liver Center from January 2006 to May 2008 had biochemical, serological, and virological screening as well as liver biopsy that was assessed by Metavir score. RESULTS Fifty-two HBeAg-negative CHB patients (46 male and 6 female) with a median age of 37.5 years were included in the study. Significant fibrosis (>or=F2) was found in 26% (5/19) of patients with serum HBV-DNA <2,000 IU/ml, and 53% (21/40) of patients with ALT level <2xULN. Liver biopsy increased candidacy for treatment by nearly 25% before implementation of the recommended lower ALT levels (30 U/l for male and 19 U/l for female patients), and by 21.2% after implementation of the lower ALT level. Implementation of the lower ALT level increased the candidacy of patients for treatment by 4% (two patients), whereas liver biopsy increased eligibility for treatment by 55.8 % (27/49). CONCLUSIONS Liver biopsy is more reliable than either ALT or HBV-DNA levels in the decision to treat Egyptian HBeAg-negative CHB patients, even with the implementation of the recommended lower ALT levels.
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221
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Abstract
Since the introduction of the hepatitis B vaccine and other preventive measures, the worldwide prevalence of hepatitis B infection has fallen. However, chronic infection remains a challenging global health problem, with more than 350 million people chronically infected and at risk of hepatic decompensation, cirrhosis, and hepatocellular carcinoma. An improved understanding of hepatitis B virology, immunology, and the natural course of chronic infection, has identified hepatitis B virus replication as the key driver of immune-mediated liver injury and disease progression. The approval of potent oral antiviral agents has revolutionised hepatitis B treatment since 1998. Conventional and pegylated interferon alfa and nucleoside and nucleotide analogues are widely authorised treatments, and monotherapy with these drugs greatly suppresses virus replication, reduces hepatitis activity, and halts disease progression. However, hepatitis B virus is rarely eliminated, and drug resistance is a major drawback during long term therapy. The development of new drugs and strategies is needed to improve treatment outcomes.
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Affiliation(s)
- Yun-Fan Liaw
- Liver Research Unit, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
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222
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223
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Marugán RB, Garzón SG. DNA-guided hepatitis B treatment, viral load is essential, but not sufficient. World J Gastroenterol 2009; 15:423-30. [PMID: 19152446 PMCID: PMC2653363 DOI: 10.3748/wjg.15.423] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 12/17/2008] [Accepted: 12/24/2008] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B virus (HBV) infection is a global public health problem that concerns 350 million people worldwide. Individuals with chronic hepatitis B (CHB) are at increased risk of developing liver cirrhosis, hepatic de-compensation and hepatocellular carcinoma. To maintain undetectable viral load reduces chronic infection complications. There is no treatment that eradicates HBV infection. Current drugs are expensive, are associated with adverse events, and are of limited efficacy. Current guidelines try to standardize the clinical practice. Nevertheless, controversy remains about management of asymptomatic patients with CHB who are hepatitis B e antigen (HBeAg)-positive with normal alanine aminotransferase, and what is the cut-off value of viral load to distinguish HBeAg-negative CHB patients and inactive carriers. We discuss in detail why DNA level alone is not sufficient to begin treatment of CHB.
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224
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Abstract
The two main goals of hepatitis B therapy are durable viral suppression and avoidance of antiviral resistance. Recent treatment guidelines now recognize the importance of these treatment endpoints in the prevention of end-stage liver disease and hepatocellular carcinoma rather then other surrogate markers such as HBeAg seroconversion and serum alanine aminotransferase normalization, especially in patients who acquired hepatitis B virus infection early in life. A variety of therapeutic options are now available for the treatment of chronic hepatitis B infection, including four nucleos/tide analogues (i.e lamivudine, adefovir, entecavir and telbivudine), along with standard and pegylated interferon. Newer oral nucleos/tide analogues that include tenofovir, emtricitabine and clevudine are soon likely to be approved worldwide. Given the wide array of choices and the complex nature of chronic hepatitis B infection, selection of the appropriate therapeutic agent can be challenging for clinicians. Effective treatment decisions require an understanding of the natural history of hepatitis B and knowledge of its life cycle and molecular biology. This review includes the range of treatment options and criteria for determining when and how to most effectively intervene with antiviral therapy for chronically infected patients positive for the HBeAg.
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225
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Abstract
Chronic hepatitis B virus (HBV) infection is a dynamic state of interactions among HBV, the hepatocytes and the immune system of the patient. Perinatally or early childhood-acquired chronic HBV infection has a long 'immune tolerant phase', when patients are young, and HBeAg seropositive with a high viral load but with no significant liver disease. Persistent or episodic liver injuries during the 'immune clearance phase' may lead to decompensation, fibrosis progression or cirrhosis development in some patients, but may eventually lead to HBV-DNA seroclearance with HBeAg seroconversion and entry into the 'inactive phase' with remission. Hepatitis may relapse, because of reactivation of HBV with precore or basal core promptor mutations, and develop 'HBeAg-negative chronic hepatitis', in some patients. In contrast, HBsAg seroclearance may occur in those with sustained remission. During the course, HBV replication is the key driver of disease progression including development of cirrhosis and hepatocellular carcinoma (HCC). Among the currently available anti-HBV drugs, the most extensive and longest experience has been gained with conventional interferon (IFN)-alpha and lamivudine. A finite course of IFN therapy has long-term benefit in achieving a cumulative response, increasing HBsAg seroclearance and reducing cirrhosis and/or HCC. Maintained virological response to lamivudine therapy has a similar long-term benefit in reducing disease progression. Pegylated IFN and newer nucleos(t)ide analogues may have even better long-term outcomes because of better therapeutic efficacy and/or a low risk of drug resistances. The treatment outcomes are still far from satisfactory. The development of safe and affordable anti-HBV agents/strategies is needed to further improve outcomes.
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Affiliation(s)
- Yun-Fan Liaw
- Liver Research Unit, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan.
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226
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227
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A treatment algorithm for the management of chronic hepatitis B virus infection in the United States: 2008 update. Clin Gastroenterol Hepatol 2008; 6:1315-41; quiz 1286. [PMID: 18845489 DOI: 10.1016/j.cgh.2008.08.021] [Citation(s) in RCA: 362] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 08/18/2008] [Accepted: 08/20/2008] [Indexed: 02/07/2023]
Abstract
Chronic HBV infection is an important public health problem worldwide and in the United States. A treatment algorithm for the management of this disease, published previously by a panel of U.S. hepatologists, has been revised on the basis of new developments in the understanding of the disorder, the availability of more sensitive molecular diagnostic tests, and the licensure of new therapies. In addition, a better understanding of the advantages and disadvantages of new treatments has led to the development of strategies for reducing the rate of resistance associated with oral agents and optimizing treatment outcomes. This updated algorithm was based primarily on available evidence by using a systematic review of the literature. Where data were lacking, the panel relied on clinical experience and consensus expert opinion. The primary aim of antiviral therapy is durable suppression of serum HBV DNA to low or undetectable levels. Assays can now detect serum HBV DNA at levels as low as 10 IU/mL and should be used to establish a baseline level, monitor response to antiviral therapy, and survey for the development of drug resistance. Interferon alfa-2b, lamivudine, adefovir, entecavir, peginterferon alfa-2a, telbivudine, and tenofovir are approved as initial therapy for chronic hepatitis B and have certain advantages and disadvantages. Although all of these agents can be used in selected patients, the preferred first-line treatment choices are entecavir, peginterferon alfa-2a, and tenofovir. Issues for consideration for therapy include efficacy, safety, rate of resistance, method of administration, and cost.
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228
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Wursthorn K, Manns MP, Wedemeyer H. Natural history: the importance of viral load, liver damage and HCC. Best Pract Res Clin Gastroenterol 2008; 22:1063-79. [PMID: 19187867 DOI: 10.1016/j.bpg.2008.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Chronic hepatitis B and hepatitis C virus infections are the major causes of liver disease, hepatocellular carcinoma (HCC) and liver-related mortality worldwide. Among factors known to influence the natural history of viral hepatitis are age at the time of infection, duration of infection, serum alanine aminotransferase (ALT) levels, male sex, alcohol consumption, and coinfections. In hepatitis B, serum HBV DNA concentration emerges as the key factor for predicting the development of liver disease. Even patients with low viraemia seem at increased risk for liver cirrhosis and HCC. Coinfections with hepatitis C, hepatitis D and/or HIV are common and are associated with a more severe liver disease. The course of chronic hepatitis C is variable, but usually fibrosis advances slowly. In addition to the better-known factors- including coinfections with HBV and HIV- progression of liver disease is adversely affected by smoking, hepatic steatosis and insulin resistance.
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Affiliation(s)
- Karsten Wursthorn
- Clinic for Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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229
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Wong GLH, Wong VWS, Choi PCL, Chan AWH, Chim AML, Yiu KKL, Chan HY, Chan FKL, Sung JJY, Chan HLY. Evaluation of alanine transaminase and hepatitis B virus DNA to predict liver cirrhosis in hepatitis B e antigen-negative chronic hepatitis B using transient elastography. Am J Gastroenterol 2008; 103:3071-81. [PMID: 19086958 DOI: 10.1111/j.1572-0241.2008.02157.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS We aimed to investigate the relationship between serum hepatitis B virus (HBV) DNA and alanine transaminase (ALT) levels and the risk of cirrhosis in a large cohort of hepatitis B e antigen (HBeAg)-negative chronic hepatitis B (CHB) patients based on transient elastography. METHODS We prospectively studied treatment-naive HBeAg-negative patients recruited based on territory-wide referrals. We defined possible cirrhosis and probable cirrhosis with two different cutoffs according to the results from a subgroup of patients with histologic proof. RESULTS One thousand one hundred ninety-seven patients with successful liver stiffness measurement (LSM) were studied. In the subgroup of 100 patients with liver biopsy, LSM of > or =8.4 kiloPascal (kPa) had a sensitivity of 90% and LSM of > or =13.4 kPa had a specificity of 94% for liver cirrhosis. Possible and probable cirrhosis were defined as a LSM value > or =8.4 kPa and > or =13.4 kPa, and were present in 31% and 11% of the patients, respectively. The risk of cirrhosis was significantly increased when ALT level was >0.5x upper limit of normal (ULN) or serum HBV DNA >4 log(10) copies/mL. Among patients who have ALT < or =0.5 x ULN and HBV DNA < or =4 log(10) copies/mL, 10% (26/264) and 3% (7/264) had possible and probable cirrhosis respectively, which were significantly lower when compared with 34% (329/887, P < 0.001) and 14% (125/887, P < 0.001) of those who had higher ALT and HBV DNA levels. CONCLUSIONS Liver cirrhosis was common among HBeAg-negative CHB patients. Patients with ALT levels >0.5 x ULN and/or serum HBV DNA >4 log(10) copies/mL have higher risk of cirrhosis and need further assessment for antiviral therapy.
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Affiliation(s)
- Grace Lai-Hung Wong
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
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230
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Degertekin B, Lok AS. Should liver biopsies be performed on all hepatitis B carriers? Gastroenterology 2008; 135:1802; author reply 1802-3. [PMID: 18840439 DOI: 10.1053/j.gastro.2008.09.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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231
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Kennedy PTF, Lee HC, Jeyalingam L, Malik R, Karayiannis P, Muir D, Main J, Thursz M, Goldin R, Smith B, Brown A, Thomas HC. NICE Guidelines and a Treatment Algorithm for the Management of Chronic Hepatitis B: A Review of 12 Years Experience in West London. Antivir Ther 2008. [DOI: 10.1177/135965350801300807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Treatment strategies in chronic hepatitis B (CHB) are evolving as more potent oral antivirals become available. However, drug resistance remains a major challenge and policy guidelines on management are limited by the evidence base. This study aims to review the implications of the National Institute for Health and Clinical Excellence (NICE) guidelines in a cohort of unselected CHB patients in the United Kingdom and to evolve a management algorithm for their treatment. Methods In total, 783 unselected hepatitis B surface antigen-positive patients, were assessed of whom 212 (27%) underwent liver biopsy. Age, alanine aminotransferase, hepatitis B virus DNA and necroinflammatory score were analysed to determine their value as predictors of fibrosis. Patients with biopsy evidence of fibrosis were offered treatment and followed longitudinally. Six-month on-treatment virologic response was evaluated to determine the validity of this strategy in predicting the early emergence of resistance. Results Age, gender and necroinflammatory score were predictors of fibrosis in CHB patients, whereas age >40 years was a predictor of cirrhosis in both hepatitis B e antigen (HBeAg)-positive ( P<0.03) and HBeAg-negative patients ( P<0.003). A total of 81% of HBeAg-positive and 65% of HBeAg-negative CHB patients who required adefovir add-on therapy were identifiable after 6 months of lamivudine monotherapy, by continuing HBV DNA positivity ( P<0.002 and P<0.0001, respectively). Conclusions Advanced liver disease was present in patients falling outside current treatment guidelines, highlighting the importance of liver histology in identifying fibrosis and the need for antiviral therapy. While 6 month on-treatment virologic response as a trigger for instituting add-on therapy may be an improvement on the current recommendations, such a strategy should be integrated into any new treatment algorithm, likely to consist of entecavir and tenofovir.
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Affiliation(s)
- Patrick TF Kennedy
- Department of Hepatology, Imperial College London at St Mary's Hospital, London, UK
| | - Heather C Lee
- Department of Medicine, Imperial College London, London, UK
| | | | - Raza Malik
- Department of Hepatology, Imperial College London at St Mary's Hospital, London, UK
| | - Peter Karayiannis
- Department of Hepatology, Imperial College London at St Mary's Hospital, London, UK
| | - David Muir
- Department of Hepatology, Imperial College London at St Mary's Hospital, London, UK
| | - Janice Main
- Department of Hepatology, Imperial College London at St Mary's Hospital, London, UK
| | - Mark Thursz
- Department of Hepatology, Imperial College London at St Mary's Hospital, London, UK
| | - Robert Goldin
- Department of Hepatology, Imperial College London at St Mary's Hospital, London, UK
| | - Belinda Smith
- Department of Hepatology, Imperial College London at St Mary's Hospital, London, UK
| | - Ashley Brown
- Department of Hepatology, Imperial College London at St Mary's Hospital, London, UK
| | - Howard C Thomas
- Department of Hepatology, Imperial College London at St Mary's Hospital, London, UK
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232
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Papatheodoridis GV, Manesis EK, Manolakopoulos S, Elefsiniotis IS, Goulis J, Giannousis J, Bilalis A, Kafiri G, Tzourmakliotis D, Archimandritis AJ. Is there a meaningful serum hepatitis B virus DNA cutoff level for therapeutic decisions in hepatitis B e antigen-negative chronic hepatitis B virus infection? Hepatology 2008; 48:1451-9. [PMID: 18924246 DOI: 10.1002/hep.22518] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
UNLABELLED The diagnosis of hepatitis B e antigen (HBeAg)-negative chronic hepatitis B indicating therapeutic intervention currently requires serum hepatitis B virus (HBV) DNA >or=2,000 IU/mL. We evaluated the severity of liver histology and the presence of histological indication for treatment in patients with HBeAg-negative chronic HBV infection focusing on those with low viremia and/or normal alanine aminotransferase (ALT). In total, 399 patients with increased ALT and detectable serum HBV DNA (chronic hepatitis B patients) and 35 cases with persistently normal ALT and HBV DNA >2,000 IU/mL (inactive carriers) were included. Histological indication for treatment (grading score >or=7 and/or stage >or=2 in Ishak's classification) was found in 91% (185/203), 82% (75/91), 75% (47/63), and 62% (26/42) of chronic hepatitis B patients with HBV DNA >or=200,000, 20,000-199,999, 2,000-19,999, and <2,000 IU/mL, respectively (P < 0.001). Histological indication for treatment was more frequent in chronic hepatitis B patients with persistently elevated ALT (86% or 275/321), but it was also found in 74% (58/78) of those with transiently normal ALT (P = 0.025). All inactive carriers had HBV DNA <20,000 IU/mL. Histological indication for treatment was present in 17% (6/35) of inactive carriers always due to moderate (stage 2) fibrosis without active necroinflammation. CONCLUSION HBeAg-negative chronic HBV patients with persistently or transiently increased ALT and HBV DNA >or=20,000 IU/mL almost always require therapeutic intervention, but histological indications for treatment are also present in the majority of such cases with HBV DNA <20,000 and even <2,000 IU/mL. In contrast, minimal histological lesions are observed in the majority of HBeAg-negative patients with persistently normal ALT and HBV DNA >2,000 IU/mL, who may not require immediate liver biopsy and treatment but only close follow-up.
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Affiliation(s)
- George V Papatheodoridis
- 2nd Department of Internal Medicine, Athens University Medical School, Hippokration General Hospital of Athens, Athens, Greece.
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233
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Affiliation(s)
- Jules L Dienstag
- Gastrointestinal Unit (Medical Services), Massachusetts General Hospital, and Department of Medicine and Office of the Dean for Medical Education, Harvard Medical School, Boston 02114, USA.
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234
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Khelifa F, Thibault V. [Characteristics of hepatitis B viral strains in chronic carrier patients from North-East Algeria]. ACTA ACUST UNITED AC 2008; 57:107-13. [PMID: 18835106 DOI: 10.1016/j.patbio.2008.07.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Accepted: 07/04/2008] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The goal of the study was to determine the characteristics of chronic hepatitis B virus (HBV) infections in the north-east part of Algeria. Chronic HBV infection remains a global public health issue and Algeria is considered as an intermediate prevalence area. Improving our knowledge on the epidemiology of this infection is a prerequisite to adopt the best preventive and curative strategy. MATERIAL AND METHODS We have studied 75 chronic hepatitis B patients from north-east Algeria. The characteristics of HBV strains were determined by use of serological and molecular testing. Genes encoding part of the precore, the surface and the polymerase were sequenced and phylogenetically analyzed. RESULTS Median age of the patients was 35 years and 80% of them had normal transaminase level. Liver histological lesions were identified in 63% of the patients who benefited from a liver biopsy and 21% of them had cirrhosis. Median viral replication was 3.9 Log IU/ml and 87% of patients had a "precore" mutant serological profile without HBe Ag. Genotype D was predominant (93%) followed by genotype A (5%) and E for one patient. Algerian strains clustered independently from other genotype D reference sequences, suggesting a possible new D subtype. Within the "precore" region, only 16% of the strains did not show any mutation at positions 1762/1764 and 1896. CONCLUSION In this original set of patients from north Algeria, the virologic characteristics of HBV are comparable to what has been described in other Mediterranean countries. Our study raises several important aspects with regard to the prevention and treatment of chronic hepatitis B in Algeria.
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Affiliation(s)
- F Khelifa
- Laboratoire d'hygiène de la Wilaya, institut Pasteur d'Algérie, cité Daksi, Constantine, Algérie.
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235
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Chen EQ, He LL, Wang LC, Lei BJ, Bai L, Liu C, Lei XZ, Tang H. Change of liver histology in chronic hepatitis B patients with alanine aminotransferase less than two-time up limits of normal. Shijie Huaren Xiaohua Zazhi 2008; 16:2476-2481. [DOI: 10.11569/wcjd.v16.i22.2476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the change of hepatic histology in patients with chronic hepatitis B virus (HBV) infection whose alanine aminotransferase (ALT) level is lower than two-time up limit of normal (ULN) and discuss the factors affecting the change of liver histology.
METHODS: According to ALT ≤ 0.5 × ULN, 0.5 × ULN < ALT ≤ 1 × ULN and 1 × ULN < ALT < 2 × ULN, 170 patients were divided into group Ⅰ (n = 39), group Ⅱ (n = 87) and group Ⅲ (n = 44). We retrospectively analyzed whether the change of liver histology was related to ALT level, HbeAg status, HBV DNA duplication and the age of patients.
RESULTS: The rates of grade 2 or 2+ inflammation in group Ⅰ, Ⅱ and Ⅲ were 43.6%, 56.4% and 65.9%, respectively, and the rates of stage 2 or 2+ fibrosis were 38.4%, 48.3% and 61.3%, respectively. There were 5.1%, 8.1% and 18.2% patients with liver cirrhosis (stage 4) in the three groups. The activity of liver inflammation and degree of fibrosis were related to ALT level (F= 4.162, 3.992; both P < 0.05) and the age of patients (F = 32.831, 20.084; both P < 0.05), while the degree of liver fibrosis was related with HbeAg positive rate (χ2 = 7.839, P < 0.05).
CONCLUSION: Of the patients with chronic HBV infection, 55.9% have grade 2 or 2+ inflammation even if ALT level is less than 2 × ULN. Thus for the patient with a long medical history, especially those over 40 years old, conventional liver biopsy should be performed, which may help us decide whether to start antiviral therapy.
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236
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Abstract
The main goals of chronic hepatitis B treatment should be the long-term suppression of viral replication to minimize disease progression and the risk for the development of hepatocellular carcinoma. Treatment end-points, depending on surrogate markers alone, in particular hepatitis B e-antigen seroconversion, may not be ideal for patients who acquire the disease early in life. Currently-available drugs include interferons and oral nucleoside/nucleotide analogs. Although interferon therapy provides a finite treatment period, a significant proportion of patients may not respond, and long-term outcome is inconclusive. Long-term efficacy has been demonstrated for both lamivudine and adefovir. However, prolonged nucleoside/nucleotide analog therapy is associated with the emergence of drug-resistant mutations. Therefore, nucleoside/nucleotide analogs with a high genetic barrier and potent antiviral activity, such as entecavir, should be used to reduce the chance of developing drug-resistant mutations. Drugs with a low genetic barrier, including lamivudine and telbivudine, should be used in conjunction with early testing for antiviral response. This can predict favorable outcomes in the long term. The early detection of drug-resistant mutations should prompt clinicians to either add or switch to another agent with a different drug-resistance profile. There are currently no treatment models in the use of combination or sequential therapy in treatment-naïve patients. To date, long-term treatment appears to be the most effective option. Despite recent advances made with better understanding on the natural history of chronic hepatitis B infection and with newer antiviral drugs available, challenges remain with respect to treatment criteria, treatment end-points, and duration of treatment.
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Affiliation(s)
- James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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237
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Ngo Y, Benhamou Y, Thibault V, Ingiliz P, Munteanu M, Lebray P, Thabut D, Morra R, Messous D, Charlotte F, Imbert-Bismut F, Rousselot-Bonnefont D, Moussalli J, Ratziu V, Poynard T. An accurate definition of the status of inactive hepatitis B virus carrier by a combination of biomarkers (FibroTest-ActiTest) and viral load. PLoS One 2008; 3:e2573. [PMID: 18596917 PMCID: PMC2440801 DOI: 10.1371/journal.pone.0002573] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 05/28/2008] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The combination of transaminases (ALT), biopsy, HBeAg and viral load have classically defined the inactive status of carriers of chronic hepatitis B. The use of FibroTest (FT) and ActiTest (AT), biomarkers of fibrosis and necroinflammatory activity, has been previously validated as alternatives to biopsy. We compared the 4-year prognostic value of combining FT-AT and viral load for a better definition of the inactive carrier status. METHODS AND FINDINGS 1,300 consecutive CHB patients who had been prospectively followed since 2001 were pre-included. The main endpoint was the absence of liver-related complications, transplantation or death. We used the manufacturers' definitions of normal FT (< = 0.27), normal AT (< = 0.29) and 3 standard classes for viral load. The adjustment factors were age, sex, HBeAg, ethnic origin, alcohol consumption, HIV-Delta-HCV co-infections and treatment. RESULTS 1,074 patients with baseline FT-AT and viral load were included: 41 years old, 47% African, 27% Asian, 26% Caucasian. At 4 years follow-up, 50 complications occurred (survival without complications 93.4%), 36 deaths occurred (survival 95.0%), including 27 related to HBV (survival 96.1%). The prognostic value of FT was higher than those of viral load or ALT when compared using area under the ROC curves [0.89 (95%CI 0.84-0.93) vs 0.64 (0.55-0.71) vs 0.53 (0.46-0.60) all P<0.001], survival curves and multivariate Cox model [regression coefficient 5.2 (3.5-6.9; P<0.001) vs 0.53 (0.15-0.92; P = 0.007) vs -0.001 (-0.003-0.000;P = 0.052)] respectively. A new definition of inactive carriers was proposed with an algorithm combining "zero" scores for FT-AT (F0 and A0) and viral load classes. This new algorithm provides a 100% negative predictive value for the prediction of liver related complications or death. Among the 275 patients with the classic definition of inactive carrier, 62 (23%) had fibrosis presumed with FT, and 3 died or had complications at 4 year. CONCLUSION In patients with chronic hepatitis B, a combination of FibroTest-ActiTest and viral load testing accurately defined the prognosis and the inactive carrier status.
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Affiliation(s)
- Yen Ngo
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Yves Benhamou
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Vincent Thibault
- Laboratoire de Virologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Patrick Ingiliz
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | | | - Pascal Lebray
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Dominique Thabut
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Rachel Morra
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Djamila Messous
- Fédération de Biochimie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Frederic Charlotte
- Service d'Anatomie Pathologique Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | | | | | - Joseph Moussalli
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Vlad Ratziu
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
| | - Thierry Poynard
- Service d'Hépato-Gastroentérologie, Groupe Hospitalier Pitié-Salpêtrière, Université Paris VI, CNRS UMR 8149, Paris, France
- * E-mail:
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238
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Beaton M, Adams PC. Assessment of silent liver fibrosis in hemochromatosis C282Y homozygotes with normal transaminase levels. Clin Gastroenterol Hepatol 2008; 6:713-4. [PMID: 18550006 DOI: 10.1016/j.cgh.2008.02.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2007] [Revised: 01/31/2008] [Accepted: 02/03/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Population screening studies for hemochromatosis have demonstrated an increase in liver disease in C282Y homozygotes, but many participants have no evidence of liver dysfunction. Previous studies have suggested that liver fibrosis in hemochromatosis might be silent. The objective of this study was to assess the degree of liver injury in referred C282Y homozygotes who underwent elective liver biopsy and had serum AST and ALT levels < 40 IU/L. METHODS All C282Y homozygotes who underwent liver biopsy with normal AST and ALT levels were included in this study. RESULTS There were 35 men and 16 women in the study with a mean age of 51 years (range, 16-89). The mean serum ferritin level was 637 microg/L (range, 18-2062), and mean liver iron concentration was 131 micromol/g (range, 11-386). There were 42 patients with no fibrosis, 6 patients with fibrosis, and 3 patients with cirrhosis. CONCLUSIONS Silent liver fibrosis with normal transaminase levels is seen in 18% of referred C282Y homozygotes. Studies that have reported on biochemical liver dysfunction in hemochromatosis might have underestimated the prevalence of liver injury from iron overload.
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Affiliation(s)
- Melanie Beaton
- Department of Medicine, University Hospital, London, Ontario, Canada
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239
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Abstract
Large amounts of new data on the natural history and treatment of chronic hepatitis B virus (HBV) infection have become available since 2005. These include long-term follow-up studies in large community-based cohorts or asymptomatic subjects with chronic HBV infection, further studies on the role of HBV genotype/naturally occurring HBV mutations, treatment of drug resistance and new therapies. In addition, Pegylated interferon alpha2a, entecavir and telbivudine have been approved globally. To update HBV management guidelines, relevant new data were reviewed and assessed by experts from the region, and the significance of the reported findings were discussed and debated. The earlier "Asian-Pacific consensus statement on the management of chronic hepatitis B" was revised accordingly. The key terms used in the statement were also defined. The new guidelines include general management, special indications for liver biopsy in patients with persistently normal alanine aminotransferase, time to start or stop drug therapy, choice of drug to initiate therapy, when and how to monitor the patients during and after stopping drug therapy. Recommendations on the therapy of patients in special circumstances, including women in childbearing age, patients with antiviral drug resistance, concurrent viral infection, hepatic decompensation, patients receiving immune-suppressive medications or chemotherapy and patients in the setting of liver transplantation, are also included.
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240
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Liaw YF, Leung N, Kao JH, Piratvisuth T, Gane E, Han KH, Guan R, Lau GKK, Locarnini S. Asian-Pacific consensus statement on the management of chronic hepatitis B: a 2008 update. Hepatol Int 2008; 2:263-83. [PMID: 19669255 PMCID: PMC2716890 DOI: 10.1007/s12072-008-9080-3] [Citation(s) in RCA: 727] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Accepted: 04/09/2008] [Indexed: 12/13/2022]
Abstract
Large amounts of new data on the natural history and treatment of chronic hepatitis B virus (HBV) infection have become available since 2005. These include long-term follow-up studies in large community-based cohorts or asymptomatic subjects with chronic HBV infection, further studies on the role of HBV genotype/naturally occurring HBV mutations, treatment of drug resistance and new therapies. In addition, Pegylated interferon alpha2a, entecavir and telbivudine have been approved globally. To update HBV management guidelines, relevant new data were reviewed and assessed by experts from the region, and the significance of the reported findings were discussed and debated. The earlier "Asian-Pacific consensus statement on the management of chronic hepatitis B" was revised accordingly. The key terms used in the statement were also defined. The new guidelines include general management, special indications for liver biopsy in patients with persistently normal alanine aminotransferase, time to start or stop drug therapy, choice of drug to initiate therapy, when and how to monitor the patients during and after stopping drug therapy. Recommendations on the therapy of patients in special circumstances, including women in childbearing age, patients with antiviral drug resistance, concurrent viral infection, hepatic decompensation, patients receiving immune-suppressive medications or chemotherapy and patients in the setting of liver transplantation, are also included.
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Affiliation(s)
- Yun-Fan Liaw
- Liver Research Unit, Chang Gung University and Memorial Hospital, 199, Tung Hwa North Road, Taipei, Taiwan,
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242
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Should chronic HBV infected patients with normal ALT treated: debate. Hepatol Int 2008; 2:179-84. [PMID: 19669302 DOI: 10.1007/s12072-008-9065-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Accepted: 01/26/2008] [Indexed: 01/04/2023]
Abstract
Alanine aminotransferase (ALT) levels have traditionally been used for treatment decisions in chronic hepatitis B virus (CHBV) infected patients. But recent data have raised doubts on this wisdom, as a significant proportion of CHBV infected patients with normal ALT have high HBVDNA levels and significant liver injury at presentation especially in areas of intermediate to high endemicity. A normal ALT value only identifies patients less likely to respond to current treatments, rather than patients who are not in need of the treatment. Patients with CHBV infection with normal ALT should be considered for treatment based on the HBV DNA levels and histological injury.
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