Treatment of children with chronic hepatitis C with recombinant interferon-alpha: a pilot study

Guidance for clinical trials for children and adolescents with chronic hepatitis C

Most children with chronic hepatitis C are infected vertically, have a low natural seroconversion rate, and carry a lifetime risk of cirrhosis and cancer. Affected children are usually asymptomatic, and histological findings are mild with a low risk of progression, although 5% develop significant liver disease in childhood.The use of combination treatment with pegylated interferon-α and ribavirin has changed the outcome and prognosis for this disease, with approximately 60% of children achieving sustained viral clearance. Combination therapy is not ideal for children because pegylated interferon is administered subcutaneously, impairs growth velocity, and both interferon and ribavirin have significant adverse effects that affect compliance. In addition, approximately 50% of children infected with genotype 1 do not respond to therapy. Thus, additional treatment options are required including improvement in dosing, reduction in the length of treatment, and evaluation of new drugs, such as protease inhibitors, which could be more effective for patients infected with genotype 1.The primary goal of treatment is to eradicate the infection. The future clinical trial design should ensure that any new drugs demonstrate noninferiority to the present standard regimen in both children and adults. The measure for documenting substantial improvement above present therapy should be increased viral clearance rate or the same clearance rate, with a shorter duration of treatment and/or fewer adverse effects. We do not believe there is any need for a placebo arm because approved therapy is available and new treatments can be compared with present therapy.Safety measures should include the standard recommended laboratory investigations, growth parameters, quality-of-life or psychological measures, and a requirement for long-term follow-up for up to 5 years.

Treatment of hepatitis C in children: a systematic review

BACKGROUND

Current guidelines recommend children be treated for hepatitis C virus (HCV) using the same principles applied in adults. There are however few published studies which assess the efficacy and safety of HCV therapy in children.

METHODOLOGY/PRINCIPAL FINDINGS

A systematic review of the literature was completed for studies of any design that evaluated HCV therapy in children. The primary outcome was sustained virologic response (SVR), with sub-group analysis of response rates by genotype. There were 4 randomized controlled trials (RCTs) and 31 non-randomized studies, all involving interferon, pegylated interferon (PEG-IFN), or combinations of these drugs with ribavirin. The SVR rate could not be directly compared as the populations and interventions differed across studies. Genotype was not reported or differed substantially from study to study. The overall SVR rate for PEG-IFN and ribavirin ranged from 30 to 100% which is comparable to the rate in adults. Similar to adults, the SVR rates were significantly higher in children with genotype 2 or 3 compared to genotype 1. Adverse effects were primarily flu-like symptoms and neutropenia. There were insufficient data to assess the applicability of the week 12 stop rule (stopping therapy at week 12 if there is less than a 2 log drop in HCV RNA) or the efficacy of shortening therapy to 24 weeks in children with genotype 2 and 3.

CONCLUSIONS/SIGNIFICANCE

Current guidelines for the treatment of HCV in children are based on limited data. Further research is needed to define the optimal therapy for HCV in children.

Response to pegylated interferon alpha-2b and ribavirin in children with chronic hepatitis C

GOALS

The purpose of this communication is to report our observations on the treatment of a diverse group of adolescent patients who were chronically infected with hepatitis C and received pegylated interferon and ribavirin.

BACKGROUND

The currently accepted optimal therapy for adults with chronic hepatitis C is weekly injections of pegylated interferon and twice daily oral ribavirin. Information on interferon alone or in combination with ribavirin for chronic hepatitis C in children is limited. There is no published information on pegylated interferon and ribavirin in pediatric patients who previously failed interferon therapy.

REPORT

Ten patients 11 to 18 years old received weekly pegylated interferon and twice daily ribavirin for hepatitis C. Treatment continued for 48 weeks, except for 1 patient with hepatitis C virus type 3a who was treated for 24 weeks and 1 patient who did not complete the course of treatment. The period of observation continued from November 2002 to December 2004. Within this group were 3 pediatric patients who had previously failed interferon therapy for hepatitis C.

RESULTS

All but 1 patient had a viral response (no detectable virus) at some time during or after the treatment. Three patients achieved sustained viral response (no detectable virus 6 mo after the therapy). One patient who previously failed interferon therapy was among the sustained responders.

CONCLUSIONS

In response to treatment with pegylated interferon and ribavirin, children and adolescents with chronic hepatitis C achieve results similar to those seen in adults. Previous antiviral therapy does not preclude positive response to pegylated interferon and ribavirin.

Interferon alfa-2b in combination with ribavirin for the treatment of chronic hepatitis C in children: efficacy, safety, and pharmacokinetics

Chronic hepatitis C virus (HCV) infection is usually asymptomatic in children, but significant liver disease may occur. We evaluated the efficacy, safety, and pharmacokinetics of interferon alfa-2b and ribavirin in children with chronic HCV. We determined the optimal ribavirin dose in an initial cohort of a phase 1 study and then subsequently used it, in combination with interferon alfa-2b, in a second cohort of this study and a phase 3 trial. The primary efficacy endpoint in all studies was sustained virological response, defined by undetectable serum HCV RNA 24 weeks after completion of therapy. All efficacy and safety analyses were performed on the intent-to-treat population. Children receiving interferon alfa-2b plus ribavirin 15 mg/kg/d in the phase 1 study had the maximum reduction in serum HCV RNA at treatment weeks 4 and 12 with an acceptable safety profile. This ribavirin dose was selected as optimal and used in all subsequent studies. In all, 46% (54/118) of optimally treated children achieved sustained virological response. Sustained virological response was significantly higher in children with HCV genotype 2/3 (84%) than in those with HCV genotype 1 (36%). Adverse events led to dose modification in 37 (31%) and discontinuation in 8 (7%). Multiple-dose interferon alfa-2b and ribavirin peak and trough concentrations and area-under-the-curve were similar between children and adults. In conclusion, interferon alfa-2b in combination with ribavirin is effective and safe in children with chronic hepatitis C virus.

Children with hepatitis C

Hepatitis C affects thousands of children throughout the world. Most children acquire the virus through vertical transmission, although parenteral routes of acquisition are also common. Hepatitis C progresses slowly, with mild biopsy findings and no symptoms in most children and in many adults. However, significant liver inflammation and fibrosis can occur in childhood. Trials of antiviral therapy with interferon and ribavirin have shown these drugs to be effective in almost half of the children treated. Children tend to tolerate therapy well. Further research on the natural history and treatment of hepatitis C in children is needed because the infection can have serious long-term consequences, including end-stage liver disease and hepatocellular carcinoma.

Interferon alpha in the treatment of chronic hepatitis C in children: a meta-analysis [correction of metanalysis]

Children with chronic hepatitis C may be ideal candidates for treatment with interferon alpha (IFNalpha) as they have liver disease at an early stage. However, adverse drug reactions need to be considered. The aim of this study was to conduct a systematic review of literature on interferon therapy of chronic hepatitis C in children, and to perform a meta-analysis of pooled data. A computerized search gave 18 articles on IFNalpha therapy in children with chronic hepatitis C; after exclusion of uncontrolled trials and of trials including patients with comorbidities, data from two studies could be pooled (48 patients). The outcomes assessed were biochemical, defined as normalization of alanine transaminase, and virologic, defined as HCV-RNA loss, both sustained at 24 months after enrollment. Results of the studies were homogenous. Risk difference was 37% (95%CI: 12.9-61) in favour of IFNalpha treated children for sustained biochemical response, and 36.8% (95%CI: 14.3-59.3) in favour of treated children for sustained HCV clearance, respectively. The differences were highly significant (P = 0.007 and P = 0.004, respectively). The histological end-point, as well as side-effects, could not be analysed, due to lack of data. This review identifies the poor methodology of the majority of the published trials. The study provides support for the efficacy of IFNalpha in improving both biochemical and virologic outcomes in chronic hepatitis C in children, but evidence is confined to these surrogate end-points.

Efficacy of interferon-alpha treatment in Japanese children with chronic hepatitis C

BACKGROUND

We investigated the efficacy of natural interferon (IFN)-alpha treatment in 34 Japanese children with chronic hepatitis C.

METHODS

Thirty-four children completed 6 months of therapy with natural IFN-alpha and were followed for 12 months or longer. We examined the serum hepatitis C virus (HCV) RNA titer and liver histology before, during, and after IFN treatment.

RESULTS

At 6 months after the cessation of IFN-alpha treatment, 16 patients (47%) had normal serum alanine aminotransferase concentration and no detectable serum HCV RNA. There were no major side-effects, excluding some influenza-like symptoms during the IFN-alpha treatment. Most genotype 2a patients had a complete response (80%). Moreover, patients who had a low HCV RNA titer (<102 copies/mL) after 1 month of IFN-alpha treatment became complete responders at 6 months after the cessation of treatment. Histological improvement was observed in almost all patients after IFN-alpha treatment.

CONCLUSION

Interferon-alpha treatment is safe and effective for children with chronic hepatitis C and has no serious side-effects. A HCV RNA concentration of <102 copies/mL after 1 month of IFN-alpha treatment and genotype 2a may be useful predictors of long-term IFN efficacy.

Diagnosis and management of paediatric hepatitis C virus infection

Hepatitis C virus (HCV) infection in children is uncommon and there are few guidelines indicating optimal management. It is estimated that 125-250 children are infected vertically with HCV in Australia each year and very few of these children are diagnosed and followed medically. Without accurate diagnosis and follow up, these children cannot be offered optimal care, and are at risk of presenting in adult life with significant liver pathology and long-term sequelae.

Management of chronic hepatitis B and C virus infections

Hepatitis B and C virus (HBV and HCV) infections present an important health problem causing significant morbidity and mortality on a worldwide scale. The younger the subjects infected, the higher the risk predisposing to progression towards chronic infection. Treatment of chronic HBV and HCV infections is aimed at reducing hepatic inflammation and thus improving the symptoms, decreasing the likelihood of long-term sequelae such as hepatocellular carcinoma, and increasing the survival rate. Interferon accelerates the spontaneous course of chronic HBV infection in children with greater disease activity and lower levels of replication. There is limited information on the use of lamivudine and its long-term benefit in children with chronic HBV infection. The response of combination therapy with IFN and ribavirin in children with chronic HCV infection is still under investigation. The long-term clinical and virological effects of various drugs used in chronic HBV and HCV infections on children remain to be evaluated.

Does interferon and ribavirin combination therapy increase the rate of treatment response in children with hepatitis C?

BACKGROUND

Interferon-alpha was the first accepted treatment of chronic hepatitis C. In recent years, adding ribavirin has produced better response rates in adult patients than monotherapy with interferon-alpha. Whether adding ribavirin also improves treatment results in pediatric patients remains unclear.

METHODS

Twelve patients were given 3 million U/m 2 subcutaneous interferon-alpha three times weekly and 15 mg/kg oral ribavirin daily, and 10 patients were given only 3 million U/m 2 subcutaneous interferon-alpha three times weekly for a total of 12 months.

RESULTS

The dropout rate was 22.8% (25% for patients receiving combination treatment versus 20% for those receiving monotherapy). At the end of treatment, viral clearance was achieved in 50% of the patients who received combination treatment versus 30% of those who received monotherapy. After 12 months of posttreatment follow-up, sustained response rates were 30% and 41.7%, respectively. Of those who responded to treatment, 66.7% had received ribavirin whereas 37.5% of nonresponders had received ribavirin therapy.

CONCLUSION

Adding ribavirin to interferon treatment improved end-of-treatment response rates in children with chronic hepatitis C. Tolerance of treatment was similar to tolerance of monotherapy. However, studies of greater numbers of pediatric patients with longer follow-up periods are necessary to determine prolonged sustained response.

An analysis of published trials of interferon monotherapy in children with chronic hepatitis C

BACKGROUND

Although no therapeutic regimen has received Food and Drug Administration approval for treating children with chronic hepatitis C viral infection (CHC), there have been a number of pediatric interferon-alpha (IFN-alpha) trials. The purpose of this study was to perform a critical review of these trials to determine 1) end-of-treatment (ETR) and sustained-response (SR) rates, 2) predictors of response to therapy, and 3) safety of and tolerance to IFN-alpha in children with CHC.

METHODS

Relevant studies in the English-language medical literature and abstracts (January 1990 through November 2000) were identified by searching for manuscripts that contained the key words "children," "hepatitis C," and "interferon." Trials were considered eligible for inclusion in this analysis if criteria for treatment included positive serum polymerase chain reaction for hepatitis C virus RNA (HCV PCR).

RESULTS

Twenty published manuscripts of the use of IFN-alpha in children with CHC were found, of which 12 met our inclusion criteria. Twenty-two abstracts, of which seven met our inclusion criteria, were identified. In the 19 included trials, 366 treated and 105 untreated children were observed; five countries were represented. Average ETR was 54% (0%-91%) and average SR was 36% (0%-73%). The SR in children with genotype 1 was 27% versus 70% for nongenotype 1 ( P = 0.001). Five of 105 (5%) untreated controls exhibited spontaneous viral clearance.

CONCLUSIONS

To date, there is no published large-scale, multicenter, prospective, placebo-controlled randomized trial of the use of IFN-alpha in children with CHC. The data in this review suggest that IFN-alpha in children with CHC does have reasonable efficacy and safety. This review highlights the need for a more systematic design of future pediatric CHC trials. Ideally, such trials would be large scale, prospective, and controlled, and would include HCV genotype and viral load, histology, quality of life measures, and systematic recording of adverse events and of effects of therapy on growth and development.

Hepatitis C virus transmission in a pediatric oncology ward: analysis of an outbreak and review of the literature

Hospital-related hepatitis C virus (HCV) infections continue to occur even after the introduction of blood donor screening. We report an outbreak of HCV in nine patients of a pediatric oncology ward in 1996/1997. Sequencing of the hypervariable genomic region 1 (HVR1) of the E2/NS1 region showed near identity between HCV isolates from these patients as evidence for infection with the same virus. Despite a detailed and careful investigation, the source of infection and the mode of virus transmission could not be established. Based on a review of the current literature about nosocomial HCV infection and HCV infection in children, hypotheses for possible means of transmission in this outbreak are discussed.

Interferon-alpha treatment of chronic hepatitis C in children with hemophilia

BACKGROUND

In children with hemophilia, hepatitis C virus (HCV) is the major cause of chronic liver disease. In this study, long-term efficacy of interferon-alpha was studied to determine the factors that predict a sustained response to interferon therapy in young children with hemophilia who have chronic hepatitis C.

METHODS

Seventeen Korean children with hemophilia and chronic hepatitis C were treated with 3.7 million units/m2 of interferon-alpha2a three times weekly for 6 months. Liver biopsy, pretreatment serum HCV RNA quantitation with competitive reverse transcription assay, and HCV genotyping with reverse hybridization assay were performed.

RESULTS

Hepatitis C virus genotypes 1a, 1b, and 2a were found in three (18%), five (29%), and six (35%) patients, respectively. Interferon-alpha was well tolerated, and the frequency of bleeding did not increase. Of the 17 patients, 7 (41%) had a sustained response for 3 years after the end of therapy. Patients with a sustained response had lower pretreatment serum HCV RNA levels. One (13%) of eight patients with genotype 1 and five (83%) of six with genotype 2 had a sustained response (P < 0.05).

CONCLUSIONS

Interferon-alpha treatment of chronic hepatitis C in children with hemophilia was safe and effective in producing sustained responses. The pretreatment serum HCV RNA level and viral genotype may be predictive factors for sustained response to interferon therapy.

Interferon-alpha and ribavirin in treating children and young adults with chronic hepatitis C after malignancy

OBJECTIVE

Chronic hepatitis C is a major long-term problem for children who survive cancer. Interferon (IFN)-alpha has been shown to be effective in treating patients with chronic hepatitis C; however, the rate of sustained response is low. Combining IFN-alpha and ribavirin (RBV) has been shown to significantly improve the response in adult patients with chronic hepatitis C. The aim of this pilot study was to evaluate the efficacy and safety of a combined virostatic treatment with IFN-alpha and RBV in a small cohort of children and adolescents with chronic hepatitis C and previous malignancy.

METHODS

Twelve patients with a history of a hematooncologic disease (median follow-up: 13.5 years; range: 7-14.7 years) and chronic hepatitis C were treated with recombinant IFN-alpha-2a (6 megaunits/m(2) body surface area, 3 times a week, subcutaneously) combined with RBV (15 mg/kg body weight/day, orally) for 12 months. They were tested monthly for blood counts and liver function, and for serum virus concentrations (hepatitis C virus RNA by polymerase chain reaction) every 3 months.

RESULTS

At the end of the treatment, hepatitis C virus RNA could not be detected in the serum of 8 of the 12 patients; 2 of these patients relapsed soon after therapy withdrawal, whereas 6 patients maintained in sustained virologic and biochemical remission (follow-up: 12 months). Treatment-induced toxicity was moderate and reversible with influenza-like symptoms and a decrease in blood counts in all 12 patients, alopecia in 5 of the 12, hemolysis in 4 of the 12, and weight loss of >10% in 2 of the 12.

CONCLUSIONS

As demonstrated in adults with chronic hepatitis C, treatment with IFN-alpha and RBV also seems to be an effective and safe therapeutic option for children and adolescents with chronic hepatitis C after malignancy.

Treatment of chronic hepatitis C virus infection in children

Hepatitis C virus (HCV) infection may occur in infants and children, although it is much less common than it is in adults. The main transmission routes include mother-to-infant transmission, use of HCV infected blood products, unsterile needles or syringes and other invasive procedures. The natural course of HCV infection in children is variable: some (20-40%) develop an acute resolving infection and spontaneous regression occurs in approximately one-third of infants of HCV infected mothers before 2 years of age. Approximately 60-80% of HCV infected children develop a chronic infection with varying degrees of activity and fibrosis, mostly mild during childhood. However, the potential risks of liver cirrhosis and hepatoma during later life are obvious. Interferon is the main agent used to treat HCV infection in children. The response to interferon at the end of 4-12 months of therapy ranges from 25-90%. A sustained response was found in 36-56% of children 6-36 months after the end of therapy. The duration of therapy is recommended to be 12 months. At the end of 3 months, an evaluation of the response is indicated in the majority of children, except those with thalassemia, in whom evaluation of response should be conducted at the end of 6 months of therapy. The benefit of other therapies, such as combination therapy with interferon and ribavirin in children with hepatitis C is currently under investigation.

Treatment of chronic hepatitis C in children

Chronic hepatitis C is a mild disease in childhood; however, it has a low rate of spontaneous remission over the years and fibrosis seems to increase along with the duration of the illness. Therefore, interferon treatment has been proposed in recent years. Unfortunately, available therapeutic trials include very few children, often with underlying diseases, and the results, sometimes very encouraging, have to be interpreted with caution. Overall, it seems that the rate of end-of-treatment and of sustained response to interferon reported in more recent studies may be similar to that in adults (8-20% for sustained response). HCV genotypes 2 and 3 and low levels of viremia could be factors in the selection of candidates with greater chances of response to interferon.

Hepatitis C virus infection in children

The prevalence of hepatitis C virus (HCV) infection is relatively low in childhood, with anti-HCV prevalence rates of 0.1-0.4% in the Western world. To date, blood transfusion has been the principal route of acquisition of HCV in children, but there is evidence that vertical transmission is overtaking it. The overall risk of vertical perinatal transmission of HCV is about 5%, although it increases with HIV co-infection and higher maternal viraemia. The mode of delivery and breastfeeding do not seem to affect the vertical transmission of HCV. Diagnosis of perinatal transmission relies on determination of ALT levels and the presence of HCV after the second month, while maternal anti-HCV antibodies may persist until 18 months of life. After infancy, a variable percentage of perinatally infected children are anti-HCV negative; thus, detection of HCV-RNA is necessary for accurate diagnosis. The natural history of HCV in childhood is not well understood and the outcome depends on host and viral factors. The rate of progression to chronicity is about 60-80% in both post-transfusion and vertically acquired HCV infection. Compared with adult patients, chronic hepatitis C in children is characterized by both low ALT levels and low viral load, as well as by the mildest histological and immunohistochemical forms of chronic hepatitis. The prognosis is usually worse in multitransfused, thalassaemic children and those who have had cancer. Experience of treatment of chronic hepatitis C in children is limited, with about 40% having a sustained response to the interferon therapy. It is necessary to perform long-term follow-up and multicentre treatment studies to improve knowledge of the natural history of HCV in children, as well as that of the efficacy of anti-viral therapy in childhood.

Dual or Single Hepatitis B and C Virus Infections in Childhood Cancer Survivors: Long-Term Follow-Up and Effect of Interferon Treatment

We conducted a long-term prospective study of 89 cancer survivor children who had acquired hepatitis B virus (HBV) and/or hepatitis C virus (HCV) during treatment for neoplasia, the aim being to evaluate the natural history of the diseases and the effect of interferon (IFN) treatment. Patients were followed up for a median period of 13 years (range, 8 to 20); 46 were infected by HBV, 11 by HCV, and 32 coinfected by HBV and HCV. A spontaneous clearance of hepatitis B surface antigen (HBsAg) occurred more frequently in coinfected patients (19%) than in the HBV-infected (2%; P = .004), with an annual seroconversion rate of 2.1% and 0.2%, respectively (P= .008). Loss of hepatitis Be antigen (HBeAg) occurred in 44% of coinfected and in 28% of HBV-infected patients. Clearance of serum HCV-RNA was observed in 34% and 9%, respectively, of coinfected and HCV-infected patients. Seventeen HBV-infected, 4 HCV-infected, and 16 coinfected patients received -IFN treatment. In the HBV group, 6 patients (35%) cleared serum HBV DNA and seroconverted to anti-HBe; in the HCV-group, none cleared HCV-RNA. In the coinfected group, 1 patient cleared both HBV DNA and HCV-RNA, 6 patients cleared serum HCV-RNA alone, and 1 only HBV DNA and HBeAg. Overall, the diseases showed a mild histological course with no evidence of liver cirrhosis. A reciprocal interference on viral replication between HBV and HCV may occur in coinfected patients. Treatment seems to be effective for selected cases and is justified in view of the uncertain prognosis of the disease in these patients.

Dual or Single Hepatitis B and C Virus Infections in Childhood Cancer Survivors: Long-Term Follow-Up and Effect of Interferon Treatment

We conducted a long-term prospective study of 89 cancer survivor children who had acquired hepatitis B virus (HBV) and/or hepatitis C virus (HCV) during treatment for neoplasia, the aim being to evaluate the natural history of the diseases and the effect of interferon (IFN) treatment. Patients were followed up for a median period of 13 years (range, 8 to 20); 46 were infected by HBV, 11 by HCV, and 32 coinfected by HBV and HCV. A spontaneous clearance of hepatitis B surface antigen (HBsAg) occurred more frequently in coinfected patients (19%) than in the HBV-infected (2%; P = .004), with an annual seroconversion rate of 2.1% and 0.2%, respectively (P= .008). Loss of hepatitis Be antigen (HBeAg) occurred in 44% of coinfected and in 28% of HBV-infected patients. Clearance of serum HCV-RNA was observed in 34% and 9%, respectively, of coinfected and HCV-infected patients. Seventeen HBV-infected, 4 HCV-infected, and 16 coinfected patients received -IFN treatment. In the HBV group, 6 patients (35%) cleared serum HBV DNA and seroconverted to anti-HBe; in the HCV-group, none cleared HCV-RNA. In the coinfected group, 1 patient cleared both HBV DNA and HCV-RNA, 6 patients cleared serum HCV-RNA alone, and 1 only HBV DNA and HBeAg. Overall, the diseases showed a mild histological course with no evidence of liver cirrhosis. A reciprocal interference on viral replication between HBV and HCV may occur in coinfected patients. Treatment seems to be effective for selected cases and is justified in view of the uncertain prognosis of the disease in these patients.

Treatment of chronic hepatitis C in pediatric patients

Although HCV infection in children shares some clinical features with that in adults, it is clearly different in several ways. These differences may have important implications for treatment. Some differences, such as milder disease, less frequent extrahepatic manifestations, and fewer comorbid conditions causing progression, argue against aggressive treatment in childhood. Other factors, such as less severe liver disease, shorter disease duration, possibly higher rates of sustained virologic response, and better tolerance of IFN, may be reasons to pursue treatment before advanced hepatic injury occurs. Given the relatively small number of pediatric patients with HCV infection and the gaps in the current understanding of natural history and effects of therapy in these patients, treatment should be undertaken only in clinical trials, so that careful data collection and monitoring can define more precisely the safety and efficacy of IFN therapy in children.

[The pediatrician and hepatitis C virus]

The recognition that hepatitis C virus can be transmitted perinatally or through blood transfusions warrants particular attention by the pediatrician. This paper highlights the epidemiology, diagnosis, natural history and management of hepatitis C in infants and children.

Interferon treatment of chronic active hepatitis C during therapy of acute lymphoblastic leukemia

Due to concerns that antineoplastic therapy produces prolonged decrease in immune function, interferon treatment of chronic active hepatitis C (CAHC) has been used only at one year or longer after the end of cancer therapy. We report the experience of an 11-year-old who developed symptomatic CAHC at the start of maintenance therapy for testicular relapse of acute lymphoblastic leukemia (ALL). Significant dose reduction of maintenance therapy did not improve the tolerance of antileukemic treatment. In an effort to improve his liver disease and to deliver effective antileukemic therapy, interferon alpha and an alternative maintenance therapy regimen for ALL were initiated. The patient tolerated the combined therapy well. Interferon therapy was continued for 27 months, which was three months from the end of antineoplastic therapy. At that time serum transaminase values were normal, and no HCV viral genome was detectable. Viral genome was detected 10 months later. The combined effects of interferon and antineoplastic therapy resulted in myelosuppression requiring dose reduction of both treatments. The patient remains asymptomatic and with no evidence of recurrent leukemia more than six years from diagnosis of relapse. The effect on the status of this patient's CAHC was similar to that reported among leukemic patients who underwent an interferon course more than one year from the end of antineoplastic therapy. Interferon treatment of CAHC can be given concomitantly with antineoplastic therapy.

De novo hepatitis C in children after liver transplantation

BACKGROUND

We describe the incidence, results of interferon therapy, and outcome of hepatitis C virus (HCV) hepatitis occurring de novo after pediatric orthotopic liver transplantation (OLT).

METHODS AND RESULTS

Of children undergoing OLT between 1984 and September 1996, 321 children survived for more than 1 year. Of these, 13 (4.0%) developed previously undiagnosed HCV disease, as suggested by HCV antibody testing and HCV polymerase chain reaction and confirmed by liver biopsy. Of the 117 children who received transplants before HCV screening of blood products or donors, 10.2% developed de novo HCV disease. The mean age at diagnosis of HCV hepatitis was 13.2+/-5.0 years, and the mean time to diagnosis after OLT was 8.1 years (range, 4-11 years). The mean alanine aminotransferase (ALT) level at diagnosis was 108 IU/ml, and the liver biopsy specimen showed chronic active or chronic persistent hepatitis in 11 children, cirrhosis in 1 child, and nonspecific changes in 1 child. Twelve children were treated with interferon-2alpha; children who weighed > or =20 kg received 3 x 10(6) units every other day, and those who weighed <20 kg received 1.5 x 10(6) units every other day. Four patients developed rapidly progressive liver failure while receiving interferon therapy and required urgent re-transplantation. Three of the four children again developed histologic evidence of recurrent HCV 4-6 months after the second OLT, and all three subsequently died of HCV-induced liver failure. One patient remains alive and well with no evidence of HCV recurrence and a negative HCV RNA. Of the remaining eight children treated with interferon, only two have had a sustained response (normal ALT) and one is now HCV RNA negative. HCV RNA levels did not correlate with outcome or disease severity. HCV antibody levels were unreliable, with two patients having negative HCV antibody but a positive HCV RNA at diagnosis. Six patients were able to be genotyped: four were la and two were 1b.

CONCLUSION

Overall mortality for de novo HCV hepatitis was 23%. Seventy-five percent of children who received a second transplant for HCV hepatitis had early histologic recurrence that led to liver failure and death. Interferon therapy resulted in a sustained improvement in ALT in only 15% of children. The time to onset and progression of clinical disease both in the original graft and the retransplant graft were accelerated compared with nonimmunosuppressed individuals.

Chronic hepatitis virus infection in children

Hepatitis B and C viruses (HBV and HCV) are the two main hepatitis viruses causing chronic liver diseases in children. In hyperendemic areas, nearly half of the primary infection in chronic HBV carriers occurs during the perinatal period through the transmission from hepatitis B e antigen (HBeAg)-positive mothers. The other half are from horizontal transmission mainly through intrafamilial spread or injection using unsterilized needles. During the natural course of chronic HBV infection, spontaneous HBeAg/anti-HBe seroconversion occurs very rarely (2% annually) before 3 years of age. After 3 years of age, the HBeAg seroconversion rate increases gradually to 5% per year. Those with mothers who are hepatitis B carriers tend to clear HBeAg slower than those whose mothers are non-carriers. Transplacental HBeAg may cause T cell tolerance in infected children. Universal HBV immunization programmes have been effective in reducing the hepatitis B carrier rate more than 10-fold, and the incidence of hepatocellular carcinoma in children has also been decreased significantly. Hepatitis C virus infection occurs mainly in high-risk children, such as those who received blood products (blood diseases, malignancies, post-open heart surgery etc.), children of HCV-infected mothers, and in hyperendemic areas, from injection using unsterile needles. Mother-to-infant transmission occurs on average in 5% of infants of viraemic mothers. The maternal HCV-RNA titre is the most important factor determining the infectivity. Chronicity developed in 60-80% of HCV-infected children. Although transient or persistent elevation of aminotransferases occurs frequently in chronically HCV-infected children, liver histology showed minimal or mild changes only. The most prevalent genotype of HCV in children is Ib. Screening of the blood products for HCV antibody has markedly reduced the rate of HCV infection in children at risk. However, vaccine development is needed to prevent mother-to-infant transmission and other routes of infections.

Interferon-alpha treatment of chronic hepatitis C virus infection in children

OBJECTIVES

To determine the safety and efficacy of interferon-alpha therapy of chronic hepatitis C virus (HCV) infection in children.

STUDY DESIGN

This was an open-labeled prospective trial of interferon-alpha-2a (IFN-alpha) in children with evidence of HCV infection for at least 6 months. Twenty-three children were enrolled and treated with IFN-alpha at a dosage of 3 million units/m2 three times weekly. Beginning in 1995 patients defined as complete or partial responders after 6 months were offered an additional 6 months of treatment. Endpoints were alanine aminotransferase normalization and loss of hepatitis C viral ribonucleic acid from serum. Responders were compared with nonresponders for age, gender, duration of infection, pretreatment alanine aminotransferase and hepatitis C viral ribonucleic acid levels, saturation of serum iron-binding capacity, histologic score of chronic hepatitis and viral genotype. Statistical methods used for these comparisons included the Kruskal-Wallis test, the Mann-Whitney two-sample test and the Fisher exact test.

RESULTS

Of the 21 children who completed at least 6 months of treatment, 4 (19%) had complete response, 8 (38%) had partial response and 9 (43%) had no response. Three of the 4 complete responders had prolonged treatment; in 2 the response was maintained. One responder relapsed but responded to a second, longer course of treatment. Four of the 8 partial responders had prolonged therapy and 3 of them became complete responders. One child who was originally a nonresponder lost HCV RNA within the first year after therapy. Thus eventually 7 (33%) of 21 patients were complete responders. After at least 12 months of follow-up on most of these children, no relapses have been observed. No differences in any of the variables tested could be demonstrated between responders and nonresponders, but small sample size limits power. IFN-alpha was discontinued in only one child because of side effects, and temporary dosage adjustments were needed in 4 children.

CONCLUSIONS

IFN-alpha is of some efficacy in the treatment of chronic HCV infection in children. Complete or partial responders at 6 months should undergo prolonged treatment.

Favorable response to lymphoblastoid interferon-alpha in children with chronic hepatitis C

BACKGROUND/AIMS

We investigated the efficacy of interferon therapy for the treatment of children with chronic hepatitis C virus infection.

METHODS

Twenty-four out of 26 children completed the 6-month treatment with lymphoblastoid interferon-alpha and were followed for 12 months or longer. Response to interferon therapy was defined by assaying for circulating HCV-RNA, using a nested PCR, at 6-month intervals after the end of the therapy.

RESULTS

At the end of treatment circulating HCV-RNA was undetectable in 18/24 patients and at 6 months in 12/24. Ten of these 12 primary responders have remained virus free for more than 2 years. One patient remained negative at 12 months. The remaining patient relapsed at 12 months. At 24 months 10 of 18 patients tested negative for HCV-RNA. Serum alanine aminotransferase was normal in 11/24 patients at the end of treatment, at 6 months 12/24 were normal, and at 12 months 11/12 were normal. In eight children with sustained response, repeated liver biopsies revealed a reduction in Knodell's scores for inflammation in the hepatic lobules and in the portal areas. In three of them neither plus nor minus strand of HCV-RNA was detectable in the liver tissue. Responders had a significantly lower level of viremia than non-responders. Side effects of interferon including fever, hair loss, neutropenia, and thrombocytopenia were not serious enough to warrant cessation of interferon treatment.

CONCLUSIONS

Interferon therapy in children with chronic hepatitis C may be beneficial as evaluated by sustained loss of viremia as well as by primary response.

High dosage alpha-interferon for treatment of children and young adults with chronic hepatitis C disease

BACKGROUND

There are limited data on the use of high interferon (IFN) dosage for treatment of children and young adults with hepatitis C virus infection and in those affected by thalassemia major (TM).

OBJECTIVES

To assess the response of children and young adults with chronic hepatitis C disease, including those affected by TM, to high dose natural alpha-interferon (IFN-alpha). To evaluate the effect of iron overload in response to high dose IFN-alpha in young chronic hepatitis C virus thalassemia patients.

METHODS

We conducted a therapeutic trial of natural IFN-alpha, using 10 million units/m2 three times a week for 6 months in 14 chronic hepatitis C patients ages 5 to 28 years; 7 also had TM. The follow-up period lasted 12 months.

RESULTS

Ten patients (73%) showed normal or nearly normal alanine aminotransferase values at the end of follow-up (biochemical response), but only five (35%) were negative for serum hepatitis C virus-RNA (complete responders). Four of the patients (57%) with TM were sustained complete responders. No correlation was found between the initial serum concentration of ferritin and response to IFN therapy. Patients infected with genotype 1b showed a poor response although high dose of natural IFN was used.

CONCLUSIONS

These results indicate that IFN-alpha can be used in children and young patients with chronic hepatitis C disease as well as in those affected by TM. Treatment with high dosage natural IFN-alpha in children and young adults with hepatitis C infection does not appear to be more effective than dosages previously used.

Hepatitis C virus infection in pediatric patients

In contrast to our understanding of hepatitis C virus infection in adults, relatively little is known about the evolution and treatment of HCV infection in pediatric patients. Children at risk for HCV infection include recipients of multiple blood-product transfusions, organ transplantation and infants born to HCV-infected mothers. A proportion of HCV-infected pediatric patients do not have an identifiable risk factor. HCV infection is commonly detected in children previously presumed to have non-A, non-B hepatitis and cryptogenic liver disease. HCV infection usually leads to mild chronic liver disease in children but is also associated with chronic active hepatitis and cirrhosis. Interferon therapy is effective in a proportion of patients with chronic hepatitis C.

Side effects of alpha-interferon therapy and impact on health-related quality of life in children with chronic viral hepatitis

BACKGROUND

Interferon (IFN) is standard therapy for chronic viral hepatitis in children. The aim of this study was to evaluate the side effects of alpha-interferon (IFN) in 94 consecutive children (58 males; age range, 3 to 14 years) affected by chronic viral hepatitis treated with different schedules ranging from 3 to 10 MU and from 3 to 12 months, and the impact of this therapy on health-related quality of life.

METHODS

Side effects were evaluated with clinical and laboratory examinations and were recorded on a diary card. The health-related quality of life was evaluated with a modified version of the Sickness Impact Profile.

RESULTS

All patients experienced at least one adverse reaction to IFN treatment; 80% had more than five side effects. There were no life-threatening reactions. Three children experienced severe reactions (febrile seizure, severe hypertransaminasemia and relapsing episodes of epistaxis, respectively) that required permanent IFN withdrawal. Another child had a febrile seizure requiring temporary IFN withdrawal. In seven children the neutrophil count fell below 1000/mm3 and promptly increased when IFN was temporarily discontinued. The remaining children had mild or moderate clinical and/or laboratory adverse reactions. Age, sex, viral etiology of chronic hepatitis and response to therapy were not significantly associated with the appearance of side effects. The pre-IFN health-related quality of life was good in all children; it deteriorated significantly during IFN therapy and returned to basal standards within 3 months after IFN withdrawal. No patient required suspension of IFN therapy because of worsening of health-related quality of life.

CONCLUSION

Children have a low risk of developing severe IFN-induced side effects. Adverse reactions and worsening of health-related quality of life were tolerable and did not seem to be a limiting factor for IFN therapy in young candidates.

Influence of recombinant interferon alpha on nutritional status and growth pattern in children with chronic viral hepatitis

Anorexia and weight loss are frequently reported as adverse effects during recombinant interferon alpha (rIFN-alpha) treatment. The aim of the present study was to assess both nutritional status and growth of children and adolescents treated with rIFN-alpha for chronic viral hepatitis. Eleven patients aged 4-16 years with histologically proven chronic active hepatitis (hepatitis B, n = 9; hepatitis C, n = 2) receiving rIFN-alpha subcutaneously thrice a week for 6 months were studied. Weight and height increments were assessed during the 6 months before starting rIFN-alpha. Weight and height were measured every 3 months (M0, M3, M6) during the 6 months of rIFN-alpha treatment, then every 6 months during the follow up period (6-36 months). Weight decreased in every child during rIFN-alpha treatment (weight loss varies from 0.5 to 2.6 kg after 3 months of treatment). Weight/age Z-score decreased from 0.12 at M0 to -0.69 at M3 (P < 0.01), then increased between M3 and M6 (-0.33) (P < 0.01), but normalized (0.02) only 6 months after completion of treatment. Nutritional status was significantly impaired during treatment (Z-score for weight/height decreased from 0.18 at M0 to -0.74 at M3, P < 0.01) and recovered progressively thereafter. Height and height velocity were not modified by rIFN-alpha treatment. A reduction of the caloric intake observed between M0 and M3 might explain these features.

CONCLUSION

Significant but transient abnormalities of the nutritional status are encountered constantly at the beginning of rIFN-alpha therapy without any deleterious effect on growth. Information of the families and nutritional intervention during treatment should be required, in order to limit the importance of weight loss.

Hepatitis C infection after blood product transfusion

HCV infection has been demonstrated in multiply transfused children who received blood products or transplanted organs before universal screening in 1990. The risk of active infection is related to the number of transfusions or pooled blood products. Accurate diagnosis of infection is dependent on utilisation of third generation RIBA and identification of HCV RNA by RT-PCR. The natural history of HCV in childhood is undetermined and prospective long term studies should be undertaken. It is likely that about develop chronic hepatitis with progression at some time to cirrhosis and have an increased risk of developing liver cancer. Treatment with interferon alfa may be effective in up to 50% of children and only those children with documented infection with HCV RNA should be selected for treatment. In order to answer important questions about natural history, outcome, and the necessity and efficacy of treatment response, treatment for these children should only be as part of scientifically conducted studies on a multicentre basis.

Interferon-alpha for viral hepatitis

IFN-alpha has emerged as a promising treatment of chronic viral hepatitis. Although therapeutic response to IFN is far from universal, efficacy has been demonstrated; and studies combining IFN-alpha with other agents, as well as trials with new preparations of IFN-alpha, are under way. Children do not represent a large part of the identified population with chronic viral hepatitis. Yet children, by simple virtue of age, are more recently infected. In addition, longer life expectancies can be expected to be associated with greater morbidity from chronic viral hepatitis. Children seem to tolerate therapy with IFN-alpha well. Treatment of children with chronic viral hepatitis should be strongly considered, with protocols designed to ascertain specific pediatric safety and efficacy.

Chronic viral hepatitis in childhood

In endemic areas infection with hepatitis B virus is a common cause of chronic liver disease in childhood. High levels of viral replication and mild ALT abnormalities are the rule in children infected perinatally and many of them are likely to maintain viral replication through their youth. Conversely about 90% of children infected later in life clear HBeAg and achieve sustained remission of liver disease before reaching adulthood. The eventual outcome of infection and disease in these patients remains unpredictable as reactivation of liver damage and viral replication may occur after several years of sustained remission. Cirrhosis is a rare and early complication of chronic HBV infection in children, and a risk factor for hepatocellular carcinoma. IFN therapy can accelerate HBV DNA clearance, improving the spontaneous anti-HBe seroconversion rate in Caucasian children by two to three times. Hepatitis delta is the most severe form of chronic viral hepatitis in childhood. Cirrhosis can be diagnosed in up to 26% of patients at presentation, and few cases respond to IFN therapy. Hepatitis C is relatively rare in children. Before the discovery of HCV, blood transfusions were the most common source of infection. Hepatitis C is usually a mild, asymptomatic disease in otherwise healthy children, but has a poor propensity to spontaneous remission over the years. For this reason, and based on the experience in adults, IFN treatment is now being evaluated.

Lymphoblastoid interferon alfa treatment in chronic hepatitis C

Interferon is becoming the standard treatment in adults for chronic hepatitis C. Twenty one children with histologically proved chronic hepatitis C (10 boys, range 2.5-13 years), who were otherwise healthy, were enrolled in a randomised controlled study to test their response to interferon alfa. Eleven children were treated with lymphoblastoid interferon alfa (3 million units/m2) for 12 months; 10 children received no treatment. All had raised transaminases and positive antihepatitis C virus (HCV) antibodies and HCV-RNA. Alanine aminotransferase (ALT) serum levels became normal in five (45%) treated patients after a mean of three weeks (range 1-6 weeks) and no relapse had occurred by the end of follow up (30th month). Only one (10%) untreated patient had normal ALT serum levels from the 11th until the 30th month. Disappearance of serum HCV-RNA, persisting throughout the follow up period, was observed in the six children (five treated) whose ALT became normal. Biopsy specimens in treated patients showed a significant improvement in Knodell's score (median (SD) basal 9.0 (2.2); final 2.0 (0.4)). Interferon treatment was well tolerated in all. This study confirms the efficacy of interferon in children with chronic hepatitis C, not only by restoring normal ALT serum levels, but also viral clearance and histological amelioration of liver inflammation. Contrary to reports in adults no biochemical and virological relapses occurred in responder children.

Update on viral hepatitis in children

Recent discovery of the two major agents responsible for non-A, non-B hepatitis has led to rapid progress in the diagnosis and prevention of viral hepatitis. Newly implemented vaccine strategies against hepatitis A and hepatitis B are protecting children from infection, and new immunomodulatory therapy with interferon-alpha is being used to eradicate disease in patients chronically infected with hepatitis virus B or C.

Hepatitis C virus infection: clinical aspects and treatment with interferon alfa

Screening for antibodies to hepatitis C virus (HCV) has substantially reduced the risk of HCV infection from transfusion of blood and blood products. Nevertheless, new infections may continue to occur. These infections may be caused by donor infections that escape detection or by insufficient decontamination of blood products during preparation. Frequently, HCV infection becomes chronic, is clinically silent, and can be associated with extrahepatic illnesses and liver cancer. A recent outbreak of HCV infection in patients who received intravenous immunoglobulin has permitted study of this infection in immunocompromised hosts. Some evidence indicates that this infection is more virulent in these patients, and our experience at Children's Hospital, Boston, Massachusetts, substantiates this finding. In this article, epidemiology and modes of transmission of HCV, pathogenesis of HCV infections, differential diagnosis, and clinical features of HCV infection in both children and adults are discussed. Particular attention is given to the serologic findings seen in the spectrum of diseases associated with chronic HCV infection. The mechanisms of action of interferon alfa treatment of HCV infections are discussed. However, results of interferon alfa treatment of patients with HCV infection at Children's Hospital are preliminary.

Recombinant interferon-alfa therapy in children with chronic hepatitis C

The efficacy of recombinant interferon-alfa therapy in children with chronic hepatitis C has been evaluated in a randomized, controlled pilot study including 27 patients, aged 2 to 14 years, without underlying systemic diseases. On entry, all patients had abnormal alanine transaminase (ALT) levels, 22 were hepatitis C virus (HCV) RNA positive, 19 had mild chronic active hepatitis, and 8 had chronic persistent hepatitis on liver biopsy. Fourteen children received 5 MU/m2 of recombinant interferon-alfa2b thrice weekly for 4 months. If at this time ALT had been reduced to at least 50% the baseline level, treatment was continued up to 12 months. The other 13 children remained untreated. The whole follow-up period lasted 24 months. Interferon was stopped at 4 months in 4 children because of an ALT increase (2 cases), unchanged ALT and febrile convulsions (1 case), and slight ALT decrease (1 case). This latter patient, however, had normal ALT at 6 months and throughout further follow-up, and cleared HCV RNA, thus behaving as a sustained responder. All 10 children treated for 12 months had normal levels of ALT, and 9 were HCV RNA negative at the end of treatment. Of the 9 children who could be followed to 24 months, 4 relapsed soon after therapy withdrawal and 5 maintained a sustained biochemical and virologic response. Overall, 6 (43%) of 14 treated children had a sustained ALT normalization associated with HCV RNA clearance as compared with only 1 (7.5%) untreated child who had a sustained ALT normalization but did not clear HCV RNA.(ABSTRACT TRUNCATED AT 250 WORDS)

Interferon-alpha treatment for severe atopic dermatitis

Patients with both severe atopic dermatitis (AD) and chronic myeloid leukemia, chronic hepatitis B, or chronic hepatitis C were treated with interferon-alpha (IFN-alpha). IFN-alpha treatment improved AD. Moreover, there were also significant decreases in serum IgE and IgG4 levels and in in vitro spontaneous IgE and IgG4 production by patients' mononuclear cells.

Response to interferon therapy in children with chronic hepatitis C

We evaluated the effect of interferon therapy and investigated factors that may influence the outcome in 18 children with chronic hepatitis C. A complete response was obtained in 10 children (56%). The titer for pretreatment serum virus ribonucleic acid (< or = 10(7) copies/ml) was correlated significantly with a complete response to therapy.