Reactivation of chronic hepatitis B virus infection by cancer chemotherapy

Chronic hepatitis: pathogenesis and treatment

Current therapies for chronic viral hepatitis, autoimmune "lupoid" chronic active hepatitis, and drug-induced chronic hepatitis are discussed in the context of recent advances in our understanding of the pathophysiology of chronic active liver disease. Accurate diagnosis is the cornerstone of proper treatment; the limitations and pitfalls of conventional techniques are discussed. Current theories of the pathogenesis of chronic hepatitis B are reviewed to provide a framework for the use of antiviral drugs. Data from the early results of therapy with adenine arabinoside, acyclovir, and immunomodulatory agents are reviewed, and the theoretical basis for the use of alpha-interferon as well as preliminary data supporting its efficacy is presented. Strategies for the treatment of chronic delta hepatitis and chronic non-A, non-B viral hepatitis are discussed as well. The immunological changes associated with autoimmune chronic active hepatitis are described to help define those patients with chronic active hepatitis who are likely to respond to immunosuppressive therapy. The recognized hazards of long-term corticosteroid therapy are indicated and guidelines for the management of these patients are suggested. Chronic drug-induced liver disease will usually improve with cessation of the offending agent. An approach to the patient with suspected drug-induced chronic hepatitis is indicated. Finally, the role of liver transplantation is mentioned as the ultimate treatment modality available for endstage liver disease.

Hepatitis B virus and hepatitis B-related viral infection in renal transplant recipients. A prospective study of 90 patients

Hepatitis B virus (HBV) infection may induce severe hepatitis and affect long-term survival of kidney transplant recipients. Persistent viral infection has been shown to occur despite the absence of usual serologic markers. The liver and serum HBV deoxyribonucleic acid (DNA) status of 90 patients were studied prospectively; recently transplanted patients, both hepatitis B virus surface antigen (HBsAg)-positive and negative, with and without liver disease, were investigated with HBV serology, serum HBV DNA, and liver histology. Thirty-four patients had detectable HBsAg, and 21 had viral multiplication at the time of transplantation. Serial HBV DNA determinations performed in 57 of 90 patients disclosed (a) reactivation of HBV replication in 11 of 12 HBsAg-positive patients, (b) increase of viral replication when positive on the initial sample in 6 of 11 patients, and (c) development of HBV replication in 7 of 35 of the HBsAg-negative patients. Moreover, liver HBV DNA studies showed a statistical correlation between the presence of integrated liver HBV DNA and chronic hepatitis in HBsAg-negative patients. This study demonstrates prospectively the significant association of HBsAg-positive as well as HBsAg-negative HBV infection with chronic hepatitis and suggests that immunosuppressive therapy may enhance the viral replication in both HBsAg-positive and negative subjects.

Spontaneous reactivation of hepatitis B in Chinese patients with HBsAg-positive chronic active hepatitis

Eleven patients of Chinese origin experienced spontaneous reactivation of chronic active hepatitis B. Eight HBsAg-positive patients were followed for an average of 15 months prior to, while three others presented during reactivation. Fatigue, hepatomegaly and jaundice were frequent findings. Elevation of both serum ALT (average = 1,212 units per liter) and hepatitis B virus DNA levels were noted in all patients, and reactivation lasted an average of 4.4 months. During resolution, clinical symptoms abated, serum ALT levels reverted toward normal, and in nine patients, the hepatitis B virus DNA values became undetectable. All patients lacked evidence for acute hepatitis A, Epstein-Barr Virus, cytomegalovirus or hepatitis delta virus infection. Histologic findings of liver tissue from eight patients showed piecemeal necrosis and fibrosis. Within the parenchyma, varying degrees of hepatocytolysis with cuffing, perivenular necrosis and acidophilic bodies were noted. Ground-glass cells and regenerative changes also were observed. Cirrhosis was not present in any of the liver biopsies. These findings suggest that spontaneous reactivation of hepatitis B occurs in heterosexual patients with chronic active hepatitis B and contributes to chronic inflammation and to the progression of their liver disease.

A study on plasma prostaglandin E2 levels in hepatitis B carriers and patients with chronic active hepatitis

Prostaglandin E2 (PGE2), one of the major prostaglandins synthesized in human monocyte and macrophage, is able to modulate T lymphocyte reactivity, such as lymphokine secretion and cytotoxicity. Some immunologic abnormalities such as alteration in the synthesis of PGE2 by monocyte and macrophage or in the response of T lymphocytes to PGE2 can be found in clinical disease.

We measured the plasma PGE2 level in the control group and patients with chronic liver disease.

The results were obtained as follows. The mean plasma PGE2 level was 2.65 ± 0.69 pg/ml in the control group. The mean plasma PGE2 level was 9.07 ± 5.89 pg/ml in 15 patients with chronic active hepatitis and was significantly higher than that of the control group (p<0.01). The plasma mean PGE2 level was 4.65 ± 1.59 pg/ml in 8 patients in the healing stage or stable stage of chronic hepatitis and was tend to decrease. However, this decrease is significantly different from that of the control group. The plasma PGE2 level was 3.5 ± 0.92 pg/ml in 4 hepatitis B carriers and was not significantly different from that of the control group (p<0.05).

This results suggest that plasma PGE2 can be used for the measurement of cell-mediated immunity and follow-up study in patients with chronic active hepatitis and hepatitis B carriers.

Spontaneous hepatitis B e antigen to antibody seroconversion and reversion in Chinese patients with chronic hepatitis B virus infection

Five hundred twelve (373 men, 139 women) patients, aged 1-75 yr, with chronic hepatitis B virus infection seen during a 5-yr period were analyzed. Of these, 43.8% were hepatitis B e antigen (HBeAg)-positive, 49.2% were positive for hepatitis B e antibody, and 7% were negative for both HBeAg and hepatitis B e antibody at presentation. The cumulative probability of clearing HBeAg at the end of the first, second, and third years was 17%, 30%, and 34%, respectively. The probability of clearing HBeAg increased with the age of the patients. Reversion to HBeAg occurred in 7.8% of patients who were HBeAg-negative at presentation and 32.3% of HBeAg-positive patients who cleared HBeAg. In 70.6% of these patients, serum hepatitis B virus-deoxyribonucleic acid was persistently positive or became detectable at the time of HBeAg reversion. Most reversions occurred during the "e-window" phase. The reversions were transient in 31.8% of the cases. Recognition of the dynamics of these serologic changes is important in the evaluation of therapeutic regimens aimed at suppression of HBV replication and call for controlled trials with adequate duration of follow-up. Biochemical exacerbation of liver disease accompanied 38.7% of HBeAg to hepatitis B e antibody seroconversions and 34.8% of reversions. Such exacerbations may be mistaken for acute attacks of hepatitis B in patients not previously recognized to be hepatitis B surface antigen carriers and, in the absence of serial serologic data, are indistinguishable from superimposed non-A, non-B hepatitis.

The clinical features and natural history of malignant liver tumours

As a broad generalization, there appears to be little intrinsic difference in the biological behaviour of the common malignant liver tumours in respect of presentation, clinical course, clinical features and prognosis. Whatever the tumour's origin, patients present with some combination of abdominal pain, hepatomegaly, weight-loss and general malaise and death occurs within 3 years of the onset of symptoms. It is the state of the non-tumorous liver (cirrhotic/non-cirrhotic) and the anatomical site of the tumour (as with hilar cholangiocarcinomas) that are responsible for any significant differences. Metastatic carcinoid tumours, epithelioid haemangioendotheliomas, stage IV-S neuroblastomas and the fibrolamellar variant of HCC are exceptions to this rule with a genuinely better prognosis.

Acute exacerbation in chronic type B hepatitis: comparison between HBeAg and antibody-positive patients

The incidence, clinicopathological features and etiology of acute exacerbation occurring in patients with chronic type B hepatitis were assessed prospectively among 385 patients who had HBeAg and 279 who had anti-HBe in serum. During an average follow-up of 23.5 months, acute exacerbations occurred in 197 HBeAg-positive patients and in 56 anti-HBe positive patients, with a calculated annual incidence of 28.6 and 10.3%, respectively (p less than 0.001). The clinical and laboratory findings of acute exacerbations were similar in the HBeAg-positive and anti-HBe positive patients. The mean serum bilirubin and alpha-fetoprotein levels were higher in anti-HBe positive patients (p less than 0.01), but actual differences were small. The histologic features of acute exacerbations were also similar in the HBeAg-positive patients and anti-HBe positive patients. Lobular alterations were the main histologic findings; in addition, one-fourth of patients had bridging necrosis and one-fourth had piecemeal necrosis. Spontaneous reactivation of hepatitis B was the major cause of these exacerbations in both HBeAg-positive patients (91.5%) as well as anti-HBe positive patients (62.5%). Hepatitis delta virus superinfection accounted for a higher percentage of exacerbations in anti-HBe positive patients (14.3%) than in HBeAg-positive cases (6.5%). Hepatitis A and possibly non-A, non-B virus superinfections also contributed to some episodes of exacerbation. Thus, acute exacerbations of disease occurred more frequently in HBeAg-positive patients than in anti-HBe positive patients with chronic type B hepatitis, but the clinicopathological features and etiologies were similar.

Hepatitis D virus (delta agent) superinfection in an endemic area of hepatitis B infection: immunopathologic and serologic findings

In 86 Chinese patients with histologically proven hepatitis B surface antigen (HBsAg) positive chronic hepatitis and serum alanine aminotransferase levels exceeding 200 U/l, antibody to hepatitis D antigen (HDAg) was detected more frequently in sera from hepatitis B e antigen (HBeAg) negative patients (11/35, 31.4%) than in HBeAg positive (4/51, 7.8%) patients (p less than 0.02). 10 liver biopsy specimens (76.9%) from 13 chronic hepatitis B patients with superimposed hepatitis D virus (HDV) infection, showed positive staining for HDAg in their hepatocytes. Neither HBsAg nor hepatitis B core antigen (HBcAg) was found in the liver in 12/13 patients with superimposed HDV infection. However, in liver biopsy specimens from 42 patients without HDV superinfection, HBsAg was stained positively in 41 patients (97.6%), and HBcAg in 24 patients (47.1%). Using dot blot hybridization technique, serum hepatitis B virus (HBV) DNA was detected in 62.1% (41/66) of patients without HDV superinfection, while it was detected only in 10.0% (1/10) of patients who had HDV superinfection. It is concluded that HDV superinfection plays a significant role in Taiwan in HBeAg negative chronic hepatitis B patients with clinical "exacerbation". The data show clear evidence of HDV interfering with the replication of HBV.

Fulminant hepatitis in asymptomatic hepatitis B surface antigen carriers in Greece

Eleven male fulminant hepatitis (FH) patients (mean age: 47.7 +/- 16 years) positive for hepatitis B surface antigen (HBsAg) but negative for IgM antibody to hepatitis B core antigen (IgM anti-HBc) were admitted consecutively to the Athens Hospital for Infectious Diseases between May 1981 and November 1983. Because of the absence of IgM anti-HBc, determined by an enzyme immunoassay, these patients were considered to be HBsAg carriers with a superimposed acute hepatitis. Three of the 11 patients received immunosuppressive chemotherapy during the six months before the onset of the acute hepatitis. None of the patients was homosexual or a drug addict. Infection with hepatitis A virus (HAV), hepatitis B virus (HBV), or hepatitis delta virus (HDV) was detected with serologic markers and/or molecular hybridization techniques. Fulminant hepatitis was attributed to spontaneous reactivation of chronic hepatitis B in four patients, chemotherapy-induced reactivation of chronic hepatitis B in three patients, HDV superinfection in one patient and possible superinfection by non-A, non-B agent(s), HDV, or HDV-like agents in three patients. Reactivation of chronic hepatitis B was an important cause of apparent acute hepatitis in heterosexual male HBsAg carriers from an area with a high prevalence of HBV infection.

T cell-mediated hepatitis in mice infected with lymphocytic choriomeningitis virus. Liver cell destruction by H-2 class I-restricted virus-specific cytotoxic T cells as a physiological correlate of the 51Cr-release assay?

A model for immunologically T cell-mediated hepatitis was established in mice infected with lymphocytic choriomeningitis virus (LCMV). The severity of hepatitis was monitored histologically and by determination of changes in serum levels of the enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST), glutamate dehydrogenase (GLDH), and alkaline phosphatase (AP). Kinetics of histological disease manifestations, increases of liver enzyme levels in the serum, and cytotoxic T cell activities in livers and spleens all correlated and were dependent upon several parameters: LCMV-isolate; LCMV-WE caused extensive hepatitis, LCMV-Armstrong virtually none. Virus dose. Route of infection; i.v. or i.p. infection caused hepatitis, whereas infection into the footpad did not. The general genetic background of the murine host; of the strains tested, Swiss mice and A-strain mice were more susceptible than C57BL or CBA mice; BALB/c and DBA/2 mice were least susceptible. The degree of immunocompetence of the murine host; T cell deficient nu/nu mice never developed hepatitis, whereas nu/+ or +/+ mice always did. B cell-depleted anti-IgM-treated mice developed immune-mediated hepatitis comparably or even more extensively than control mice. Local cytotoxic T cell activity; mononuclear cells isolated from livers during the period of overt hepatitis were two to five times more active than equal numbers of spleen cells. Adoptive transfer of nylon wool-nonadherent anti-Thy-1.2 and anti-Lyt-2 plus C-sensitive, anti-L3T4 plus C-resistant lymphocytes into irradiated mice preinfected with LCMV-WE caused a rapid time- and dose-dependent linear increase of serum enzyme levels. This increase was caused by adoptive transfer of lymphocytes if immune cell donors and recipient mice shared class I, but not when they shared class II histocompatibility antigens. The donor cell dose-dependent increase of these enzymes was first measurable 6-18 h after transfer with 2 X 10(8) cells or 3 X 10(6) cells, respectively. The time-dependent increase caused by the adoptive transfer of 1-2 X 10(8) cells was strictly linear during a period of up to 25-40 h. These results indicate single-hit kinetics of liver cell death and suggest that effector T cells destroy infected liver cells via direct contact rather than via soluble toxic mediators. The results may represent the best in vivo correlate of the in vitro 51Cr-release assay that has been analyzed so far, and strongly support the view that antiviral cytotoxic T cells are directly cytolytic in vivo.(ABSTRACT TRUNCATED AT 400 WORDS)

Adverse prognostic influence of hepatitis B virus infection in acute lymphoblastic leukemia

Liver function test abnormalities were examined in a retrospective survey in a population of 90 children with acute lymphoblastic leukemia (ALL) treated in a similar fashion with therapy, using primarily methotrexate, mercaptopurine, vincristine, and prednisone. A twofold or greater elevation of serum glutamyl pyruvic transaminase (SGPT) was found in 80% of the patients during induction therapy, in 63% of the patients during maintenance therapy, and 31% of the patients who completed therapy. Circulating hepatitis B virus surface antigen (HBsAg) was noted in 26% of patients with liver function test abnormalities during maintenance therapy, and 45% of patients with liver function test abnormalities after the completion of therapy. Hepatitis B virus infection was therefore, the most important single cause of abnormal liver function during remission in our patient population. Though others have asserted that hepatitis B virus infection is relatively benign in immunosuppressed individuals, in our population, this agent often caused severe pathological and clinical sequelae. This may be related to the high frequency (50%) of co-infection with the delta agent in our HBsAg-positive patients. Furthermore, hepatitis B virus surface antigenemia conferred an adverse prognostic influence for these children in terms of their leukemia-free survival.

Trial of specific antigen-mediated leukocyte adherence inhibition test in patients with chronic active hepatitis and hepatitis B carrier

In the pathogenesis of chronic active hepatitis, the importance of cell mediated immunity (CMI) has been emphasized. Leukocyte adherence inhibition (LAI) assay, which is one of the methods for analysis of the reaction of CMI, has been used to analysie the CMI of cancer patients.

The authors tried the specific antigen-mediated LAI assay in 40 patients with chronic active hepatitis, 19 patients carriers of hepatitis B virus, and in the 5 persons who have no anti-HBs in spite of receiving vaccination against HBV, and these were compared with 7 normal control subjects who had been exposed to hepatitis B virus previously.

The results were as follows: The NAI was 52.4±14 (mean ± standard deviation) in 7 normal control subjects who had been exposed to hepatitis B virus previously. The NAI was 20.6 ± 11 (mean ± standard deviation) in 40 patients with chronic active hepatitis. The value was significantly lower than that of the normal control group (P<0.001). The NAI was 49.7±17.8 (mean ± standard deviation) in 19 patients carriers of hepatitis B virus. The value was not significantly different from that of the normal control group (P>0.05). The NAI was 25.1±11 (mean ± standard deviation) in 5 persons who have no anti-HBs in spite of receiving vaccination against HBV. The value was significantly lower than that of the normal control group (P<0.05). In patients with chronic active hepatitis and hepatitis B virus carriers, we checked the LAI assay serially. The value of NAI was increased according to the improvement of clinical symptoms and normalization of transaminase, but the value of NAI was decreased according to the worsening of clinical symptoms and elevation of transaminase.

Clinical, virologic and histologic outcome following seroconversion from HBeAg to anti-HBe in chronic hepatitis type B

Seventy consecutive HBsAg- and HBeAg-positive patients with biopsy-proven chronic hepatitis were followed prospectively with serial determinations of SGPT levels and hepatitis B virus serum markers including HBsAg, HBeAg, anti-HBe and hepatitis B virus DNA. During a period of 1 to 11 years (mean +/- S.D.: 5.0 +/- 2.3 years), 28 patients remained persistently HBeAg positive, most with continuing biochemical and histologic activity, while 41 cases seroconverted to anti-HBe. One patient became HBeAg and anti-HBe negative. After seroconversion, 87.8% of the cases showed sustained normalization of SGPT, and clearance of hepatitis B virus DNA from serum and histologic improvement was documented in 79% of the cases who had a control liver biopsy, while 15.8% developed cirrhosis. In two patients (4.9%), the disease remained active despite seroconversion, and both cases had evidence of continuing hepatitis B virus replication. Finally, reactivation of liver damage and of hepatitis B virus replication was observed in three additional patients (7.3%) who had transiently normalized SGPT after seroconversion. All 70 patients were analyzed for hepatitis delta virus markers, and only two persistently HBeAg-positive cases were found positive for antibody to hepatitis delta virus in serum, one also having hepatitis delta antigen in the liver. These findings indicate that, in chronic hepatitis type B, termination of virus replication is associated in most patients with biochemical and histologic regression of inflammatory activity. After anti-HBe seroconversion has occurred, virus replication and liver disease may persist or reactivate in a small proportion of patients thus giving origin to the well-recognized group of anti-HBe positive, hepatitis B virus DNA-positive chronic hepatitis type B.

Natural history of chronic hepatitis B virus-related liver disease and its relationship to serum markers of viral replication

Our understanding of the process whereby replicating Hepatitis B virus is eradicated has been substantially modified by the development of highly sensitive assays of viral replication, such as the detection of HBV-DNA in serum. The implications of these developments on our therapeutic approach in terms of both timing and expectations is discussed.

Hepatitis B virus. Update on the spectrum of clinical infections and on prophylaxis

Knowledge about hepatitis B virus (HBV) has expanded vastly over the past 20 years, elucidating not only the spectrum of clinical illnesses it causes but also its biologic characteristics. HBV is an important cause of both acute and chronic liver disease in the United States. The most serious outcome of hepatitis B infection is chronic liver disease, which can range from chronic hepatitis eventuating in cirrhosis to primary hepatocellular carcinoma. Molecular biologic studies have shown that HBV-DNA can be integrated into the genome of hepatocytes. This integration may be part of the natural history of chronic hepatitis B infection and may transform normal hepatocytes into neoplastic cells. Immunization with hepatitis B vaccine (Heptavax-B) of persons at high or intermediate risk is an essential means for preventing transmission of hepatitis B. Use of the vaccine after recent exposure to hepatitis B breaks the chain of transmission--an exciting capability. Postexposure immunization of neonates born of HBsAg-positive mothers is particularly important in preventing vertical, or perinatal, transmission of infection.

Hepatitis B virus DNA, HBeAg and delta infection during the course from acute to chronic hepatitis B virus infection

The presence of hepatitis B virus DNA in serum was determined in 57 unselected patients during the course from acute to chronic hepatitis B infection. Forty-six (81%) patients were hepatitis B virus DNA-positive in the first available serum sample. Generally, hepatitis B virus DNA was cleared before or at the same time as HBeAg, but in two patients (4%), hepatitis B virus DNA could be demonstrated after HBeAg clearance. One of the latter patients had hepatitis B virus DNA in the presence of anti-HBe. Both patients became hepatitis B virus DNA-negative. Seven of the hepatitis B virus DNA-positive patients received long-term treatment with prednisone, and three of them continued to be hepatitis B virus DNA positive for more than 10 years. Among the untreated patients hepatitis B virus DNA could be detected for up to 7 years, and 10 patients were hepatitis B virus DNA-positive for three years or more. Twenty-four patients (42%) showed serological signs of delta agent infection. Hepatitis B virus DNA clearance was observed in a significantly higher proportion (87%) of delta-infected patients as compared to patients with no delta infection (45%) (p less than 0.05). In addition patients with delta infection had a significantly increased hepatitis B virus DNA clearance rate as compared to patients without delta markers in their serum (p less than 0.01). In one (8%) delta-infected patient, hepatitis B virus DNA clearance was followed by a fall in transaminases into the normal range as opposed to results in 86% of patients with pure hepatitis B (p less than 0.002).

Combination of short-term prednisolone and adenine arabinoside in the treatment of chronic hepatitis B. A controlled study

The efficacy of adenine arabinoside (Ara-A) alone or in combination with prednisolone utilizing its withdrawal effect was studied in 43 patients with deoxyribonucleic acid polymerase- and hepatitis B e antigen-positive chronic hepatitis. Ten patients were treated with 10 mg/kg body wt of Ara-A alone for 4-8 wk. In 9 cases, prednisolone (40 mg/day) was given at a constant dosage for 4 wk before Ara-A treatment. Fourteen patients received oral prednisolone alone for 4 wk, and 10 patients served as untreated controls. Six of 9 patients (67%) undergoing the combination therapy became seronegative for hepatitis B e antigen, whereas only 4 of 24 patients (17%) treated either with Ara-A alone or prednisolone alone lost the antigen. Two of the 10 untreated patients became seronegative for hepatitis B e antigen during the same follow-up period of 9 mo. This prospective controlled study suggests that the combination of immunomodulation by steroid withdrawal and subsequent Ara-A is more effective in the treatment of patients with chronic liver disease and active hepatitis B virus replication than treatment with Ara-A alone.

Clinical and serological events accompanying changes in hepatitis B viral replication: case reports

We measured serum markers of hepatitis B virus replication in two HBsAg-, HBeAg-positive hepatitis B carriers with chronic active hepatitis and cirrhosis. The first of these patients was HBsAg-, HBeAg-, HBV DNA- and HBV DNA polymerase-positive initially and spontaneously lost HBV DNA polymerase and HBV DNA. During the HBeAg-positive, DNA polymerase-negative "window phase", an increase in viral replication, characterized by the reappearance of HBV DNA and HBV DNA polymerase occurred, together with an aggravation of the underlying chronic hepatitis. In the second HBsAg-, HBeAg-positive carrier, spontaneous fluctuations in HBV replication were associated with clinical deterioration. Delta agent and hepatitis A virus superinfection were excluded. These observations suggest that spontaneous low-grade fluctuations of HBV replication accompanied by an increase in the biochemical activity of the underlying chronic hepatitis can be observed in certain HBV carriers.

Recombinant leukocyte a interferon treatment in patients with chronic hepatitis B virus infection. Pharmacokinetics, tolerance, and biologic effects

Large doses of recombinant leukocyte A interferon were administered to 20 patients with deoxyribonucleic acid polymerase- and hepatitis B e antigen-positive chronic hepatitis B to study the maximum tolerated dose, its pharmacokinetics, and its antiviral activity. The first group of 5 patients received a constant dose of 36 X 10(6) U/day for 28 consecutive days. When it was well tolerated, the second, third, and fourth groups (5 patients each) received 50, 72, and 100 X 10(6) U/day, respectively. All 20 patients completed the 28-day treatment. Hourly and daily profile of serum interferon level showed a dose-dependent effect with an increasing dosage, and cumulative effects during the treatment. The mean peak serum interferon concentration ranged from 93 U/ml on day 1 in the first group to 1271 U/ml on day 28 in the fourth group. Inhibition of serum deoxyribonucleic acid polymerase activity and hepatitis B virus-deoxyribonucleic acid during the treatment was compared between the groups with low doses (36 and 50 X 10(6) U) and high doses (72 and 100 X 10(6) U). Low doses of interferon suppressed deoxyribonucleic acid polymerase activity to the same extent as did the high doses. Prednisolone withdrawal was combined with interferon in 5 patients. Three patients treated with such combination became seronegative for hepatitis B e antigen during the treatment, whereas all 15 with interferon alone remained seropositive. These results suggest that a maximum antiviral effect of recombinant leukocyte A interferon is below the maximum tolerated doses.

Acute and chronic hepatitis in childhood leukemia: a multicentric study from the Italian Pediatric Cooperative Group for Therapy of Acute Leukemia (AIL-AIEOP)

The incidence of acute and chronic liver damage and its relation to hepatitis B virus (HBV) infection was evaluated in 164 consecutive children with acute leukemia seen in ten Italian hemato-pediatric units. Thirteen out of 164 children (7.9%) had acute hepatitis (AH) during treatment, while 8/90 (8.8%) showed an acute exacerbation of liver damage within 6 months after therapy withdrawal. Seven of the 13 children with AH while on therapy were HBsAg positive. In 12/13 cases, liver disease progressed to chronicity. Five of eight children who developed AH after completion of treatment were HBsAg positive. Eighty-nine patients (54.2%) developed biochemical evidence of chronic hepatitis during therapy; 48/89 were followed after cessation of treatment and 33 of them showed persisting evidence of liver cell necrosis. Thirty-three out of 133 children (24.8%) tested for serum HBsAg were found positive: 26 (78.7%) of them developed chronic hepatitis. Sixty-four out of 133 patients were evaluated after cessation of treatment: Chronic hepatitis persisted in 16/22 HBsAg-positive (72.7%) and in 17/42 HBsAg-negative (40.4%) children during follow-up. The outcome of these liver diseases after treatment withdrawal did not differ significantly in relation to HBV serology, suggesting that viral rather than toxic agents were responsible for liver damage also in most HBsAg-negative patients. The high incidence of chronic HBV infection in children with leukemia found in this multicentric study could suggest a need for active immunization with HBV vaccine, but the efficacy of such approach in this clinical setting is still to be validated.

Detection of anti-HBc IgM following prednisone treatment in patients with chronic active hepatitis B virus infection

The effect of a short course of prednisone therapy on serum IgM type antibody to the hepatitis B core antigen (anti-HBc IgM) was studied in 14 male patients with chronic active type B hepatitis. Eleven patients (78.5%) became positive for serum anti-HBc IgM either during or shortly after prednisone withdrawal. Detection of anti-HBc IgM correlated with an increase in hepatitis B virus specific DNA-polymerase activity and was followed by a rise in serum transaminase levels. Six patients with histologic evidence of cirrhosis developed anti-HBc IgM which lasted six or more months after prednisone therapy and had a rapid onset of hepatic decompensation manifested by encephalopathy with ascites and/or variceal bleeding. In 17 untreated chronic active type B hepatitis patients who served as controls, anti-HBc IgM was detected at low levels in only a single serum sample from each of two patients during the same observation period.

Determinants for hepatitis B e antigen clearance in chronic type B hepatitis

A 6-year (mean 24.5 months) longitudinal study has been undertaken in 237 HBeAg-positive patients with clinicopathologically verified chronic hepatitis. HBeAg clearance occurred in 74 patients at a rate of 16% per year, and a cumulative probability of 67% at the end of a 5-year follow-up. HBeAg clearance was preceded by a temporary "exacerbation" with SGPT greater than 300 IU/L in 62% of the patients. On the other hand, irrespective of the level of SGPT elevation, only 23% of such exacerbations were followed by HBeAg clearance. Further analysis indicates that alphafetoprotein greater than 100 ng/ml, frequently associated with bridging hepatic necrosis, during "exacerbation" predicts HBeAg clearance. In addition, patients with chronic lobular hepatitis and chronic active hepatitis have a higher annual HBeAg clearance rate than patients with chronic persistent hepatitis and nonspecific histologic changes (greater than 15% vs less than 8%, P less than 0.03). Short-term immunosuppressive treatment did not delay HBeAg seroconversion. Male patients had a higher annual HBeAg clearance rate than female patients (18.2% vs 8.7%, P less than 0.05). It was concluded that, in addition to the time factor, the nature of chronic hepatitis, the extent of hepatic damage during "exacerbation", and the sex of the patients are important determinants for HBeAg clearance.

Age-specific prevalence and significance of hepatitis B e antigen and antibody in chronic hepatitis B virus infection in Taiwan: a comparison among asymptomatic carriers, chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma

The age-specific prevalence of hepatitis B e antigen (HBeAg) and its antibody (anti-HBe) were studied by radioimmunoassay, and compared in a large series of patients with chronic hepatitis B virus (HBV) infection, including 268 asymptomatic carriers, 389 chronic hepatitis, 114 liver cirrhosis, and 278 hepatocellular carcinoma (HCC). The prevalence of HBeAg/anti-HBe in asymptomatic carriers and patients with chronic hepatitis correlated closely with age as HBeAg prevalence decreased and anti-HBe prevalence increased with increasing age (P less than 0.0005), and is probably due to high infection rate at young age in Taiwan. The prevalence of HBeAg in patients with both cirrhosis and HCC are much significantly lower and had no correlation with age. Two peaks of age-specific prevalence of HBeAg and anti-HBe were observed in patients with HCC, implicating two patterns of HBV infection in these patients. The difference in the prevalence of HBeAg and anti-HBe might indicate that asymptomatic carriers, chronic hepatitis, liver cirrhosis, and HCC are sequential sequelae of HBV infection.

Acute type A hepatitis in three patients with chronic HBV infection

We have studied three patients with chronic HBV infection who had a superimposed bout of type A hepatitis. The patients recovered uneventfully without observing a change in their clinical course afterwards. In one patient we observed transient disappearance of DNA polymerase during type A hepatitis; we have postulated that this is probably related to hepatic necrosis.

Natural history of hepatitis B virus infection in renal transplant recipients--a fifteen-year follow-up

Hepatitis B virus (HBV) markers were measured in 83 immunosuppressed renal transplant patients who were followed for periods of 2 to 15 years. Sixty-nine patients were negative for HBsAg before transplantation, of whom 14 were positive for anti-HBs. The remaining 14 patients were HBsAg positive prior to transplantation. Eighteen patients were identified as being HBsAg positive during the follow-up period. Four patients acquired primary type B hepatitis; one died of submassive hepatic necrosis and the remaining three became chronic HBV carriers with positive HBeAg, DNA polymerase, and HBV DNA. Several patterns of HBV expression were observed in HBsAg-positive patients. Four patients were HBsAg, HBeAg, DNA polymerase, and HBV DNA positive prior to transplantation, and these markers persisted. Reactivation of HBV replication occurred in eight patients, seven of whom were HBsAg positive and HBeAg and anti-HBe negative originally; one patient was anti-HBc positive. A single patient was HBsAg and anti-HBe positive and remained so for 22 months. The remaining previously HBsAg-positive patient is currently HBsAg negative. These serological data suggest that reactivation of HBV replication or continued hepatitis B virion replication occurs as commonly or more commonly than de novo infection in renal transplant recipients. The presence of HBeAg in serum predisposes to long-term Dane particle expression in immunosuppressed patients, whereas anti-HBe-positive carriers may not always be susceptible to reactivation of HBV replication despite immunosuppression.

Primary hepatocellular carcinoma and hepatitis B virus infection in Korea

Serological evidence of hepatitis B virus (HBV) infection and serum alphafetoprotein (AFP) were assayed in sera from 112 Korean patients with primary hepatocellular carcinoma (PHC) and from 63 age- and sex-matched controls. Serological evidence of HBV infection was found in 100% of PHC patients and in 97% of controls. The majority of PHC patients (87%) were positive for hepatitis B surface antigen (HBsAg). In contrast, only 14% of control individuals were positive for HBsAg, but 82% were positive for antibody to HBsAg (anti-HBs). Hepatitis B e antigen (HBeAg) was detected in a high percentage (38%) of HBsAg-positive PHC patients, but in none of the nine HBsAg-positive control individuals. Serum AFP was detectable in 83% of PHC patients but in only one of 63 controls (1.5%). These results document that HBV infection may be the major factor in the development of PHC in this country.