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Wu WJ, Lin CL, Liu CJ, Huang YW, Hu JT, Yu MW. Lifetime risk of liver-related outcomes and determinants in male inactive carriers of chronic hepatitis B. J Med Virol 2023; 95:e29138. [PMID: 37796044 DOI: 10.1002/jmv.29138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
The full spectrum of risks for the life course of inactive hepatitis B virus (HBV) carriers remains unclear. In this study, 995 untreated HBV carriers (median age: 42.8 years; median follow-up: 30.2 years) were included. Their data were sourced from a population-based cohort study of male civil servants recruited in 1989-1992. Outcomes were identified by active follow-up examinations and linkage with national health insurance research database. At baseline, 483 subjects were inactive carriers, 385 with indeterminate phase, and 127 with other phases. The joint lifetime risk for incident cirrhosis, decompensation, hepatocellular carcinoma, and liver-related deaths was lower for inactive carriers compared to subjects in other phases (p < 0.0001). There was a trend of increase in incidence among inactive carriers; the 5-, 10-, and 20-year cumulative incidences were 1.86%, 6.03%, and 10.07%, respectively. Of the inactive carriers, 37.7% cleared HBsAg and 36.6% had biochemical relapse during the study. Biochemical relapse, obesity, and advanced age were predictors for disease progression in inactive carriers. Virological relapse was the predominant cause of biochemical relapse. Higher HBV-DNA levels (≥1000 copies/mL or 200 IU/mL) and HBV genotype B (vs. C) were associated with higher virological relapse rate. After 30 years, we found that one-time measure of inactive carrier state continued to have the lowest risk compared with other infection phases. Despite a more favorable prognosis, inactive carriers had a non-negligible risk. Our findings of lifetime risk may provide important clues for the management of such patients and consideration of therapeutic strategies aiming to achieve functional cure.
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Affiliation(s)
- Wan-Jung Wu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chih-Lin Lin
- Department of Gastroenterology, Ren-Ai Branch, Taipei City Hospital, Taipei, Taiwan
| | - Chun-Jen Liu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital and Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yi-Wen Huang
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jui-Ting Hu
- Liver Center, Cathay General Hospital Medical Center, School of Medicine, Fu-Jen Catholic University College of Medicine, Taipei, Taiwan
| | - Ming-Whei Yu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
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Li S, Shi L, Xu X, Wang H, You H, Jia J, Kong Y. Systematic review with meta-analysis: Significant histological changes among treatment-naïve chronic hepatitis B patients with normal alanine aminotransferase levels by different criteria. Aliment Pharmacol Ther 2023; 58:648-658. [PMID: 37551720 DOI: 10.1111/apt.17658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/21/2023] [Accepted: 07/21/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND The upper limits of normal (ULNs) of ALT are not consistent across the major international guidelines which may affect the eligibility for antiviral therapy for chronic hepatitis B (CHB). AIM To estimate the proportions of histological changes among treatment-naïve patients with CHB within differently defined ALT ULNs. METHODS We searched PubMed and Embase up to May 15th, 2023, to identify studies of treatment-naïve CHB patients with liver biopsies. We pooled proportions of moderate to severe necroinflammation, significant fibrosis, and cirrhosis in those patients within different ALT ULNs by using random-effect models. RESULTS We included 23 studies with 4010 participants. Within ALT ULN at 40 IU/L, the pooled proportions of moderate to severe necroinflammation, significant fibrosis, and cirrhosis were 33% (95% CI: 26%-42%), 32% (95% CI: 27%-38%), and 3% (95% CI: 1%-5%), respectively. Within ALT ULN at 30 IU/L for men and 19 IU/L for women, the pooled proportion of significant fibrosis remained at 30% (95% CI: 25%-34%; 432 participants). However, it was 21% (95% CI: 11%-37%; 361 participants) even in those within ALT ULN at 20 IU/L. Subgroup analyses suggested a significantly higher proportion of significant fibrosis among studies with prospective design or enrolled patients' mean age >35 or >40 years. CONCLUSIONS Significant histological changes occurred in approximately 1/3 of treatment-naïve CHB patients within ALT ULN at 40 IU/L, whereas the proportion of significant fibrosis was approximately 1/5 even in those within ALT ULN at 20 IU/L.
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Affiliation(s)
- Shun Li
- National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Epidemiology and EBM Unit, Beijing Clinical Research Institute, Beijing, China
| | - Lichen Shi
- National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Epidemiology and EBM Unit, Beijing Clinical Research Institute, Beijing, China
| | - Xiaoqian Xu
- National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Epidemiology and EBM Unit, Beijing Clinical Research Institute, Beijing, China
| | - Hao Wang
- National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Epidemiology and EBM Unit, Beijing Clinical Research Institute, Beijing, China
| | - Hong You
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yuanyuan Kong
- National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Epidemiology and EBM Unit, Beijing Clinical Research Institute, Beijing, China
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Zakalashvili M, Zarkua J, Metreveli D, Abzianidze T, Butsashvili M, Kamkamidze G. Assessment of Viral and Clinical Characteristics Among Patients With Chronic Hepatitis B Virus Infection in Georgia. J Clin Exp Hepatol 2023; 13:624-628. [PMID: 37440940 PMCID: PMC10333931 DOI: 10.1016/j.jceh.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 02/06/2023] [Indexed: 07/15/2023] Open
Abstract
Background Hepatitis B virus infection (HBV) is one of the major healthcare problems in Georgia. To achieve viral hepatitis elimination, gaps in diagnosis and management of chronic HBV infection need to be addressed. The aim of our study was to collect data on clinical and viral characteristics of patients with chronic HBV infection to estimate the proportion of patients who may need antiviral treatment. Methods All relevant deidentified data about demographic, clinical, and viral characteristics were extracted from patients' medical records. Descriptive statistical analyses were done for univariate assessment of demographic, virologic, and clinical characteristics. Chi-square test was used to assess the associations between HBV-DNA level, HBeAg, alanine aminotransferase (ALT), and liver fibrosis. Results In total, 96% (124/129) of patients with chronic HBV infection are HBeAg-negative; 84% (145/173) had no or mild fibrosis, and 3% (6/162) had advanced liver fibrosis/cirrhosis. Sixty-five out of 126 (51%) patients were classified as HBeAg-positive or HBeAg-negative chronic HBV infection (without hepatitis); 11 (9%) as chronic hepatitis B; 46 (37%) had not classified in any of the known HBV phases, while 30 of them (24% out of total) had high viral load and normal ALT. Statistically significant association was seen between high HBV-DNA and HBeAg-positivity (P = .043). High ALT level was also associated with liver fibrosis (P = .015). Significant positive correlation between age and the presence of moderate or advanced liver fibrosis was observed (P = .002). Conclusion This is the first study about the clinical and viral characteristics of patients with chronic HBV infection in Georgia. The vast majority were HBeAg-negative, only 3% had advanced liver diseases; about half of patients had inactive diseases. However, one out of four patients had a high viral load but normal ALT. By the evaluation of HBV phases, we estimated that 12%-36% of patients with chronic HBV monoinfection require antiviral treatment.
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Affiliation(s)
- Mamuka Zakalashvili
- Hepatology and Gastroenterology Department, Medical Center Mrcheveli, Tbilisi, Georgia
- University of Georgia, Tbilisi, Georgia
| | - Jaba Zarkua
- Hepatology and Gastroenterology Department, Medical Center Mrcheveli, Tbilisi, Georgia
- University of Georgia, Tbilisi, Georgia
| | - David Metreveli
- Hepatology and Gastroenterology Department, Medical Center Mrcheveli, Tbilisi, Georgia
| | - Tinatin Abzianidze
- University of Georgia, Tbilisi, Georgia
- Health Research Union / Clinic NeoLab, Tbilisi, Georgia
| | - Maia Butsashvili
- University of Georgia, Tbilisi, Georgia
- Health Research Union / Clinic NeoLab, Tbilisi, Georgia
| | - George Kamkamidze
- University of Georgia, Tbilisi, Georgia
- Health Research Union / Clinic NeoLab, Tbilisi, Georgia
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Predictors of eligibility for reimbursement of antiviral treatment in HBe-Ag negative chronic hepatitis B patients with high ALT levels. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1012592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background/Aim: A liver biopsy is required for the reimbursement of antiviral therapy in Hepatitis B e-antigen (HBe-Ag) negative chronic hepatitis B patients. Liver biopsy is an invasive procedure with potential complications, such as bleeding, pain, pneumothorax, and even death. The study aimed to evaluate simple and non-invasive parameters that may help predict histological criteria that would be eligible for antiviral treatment reimbursement.
Methods: HBeAg-negative chronic hepatitis B patients with alanine transaminase (ALT) levels > upper normal limit (40 IU/L) and HBV DNA viral load > 2000 IU/ml who underwent liver biopsy were enrolled in this retrospective cohort study. ALT, aspartate aminotransferase (AST), alpha-fetoprotein (AFP) values, hepatitis B virus (HBV) DNA levels, platelet count, and hepato-steatosis grade based on ultrasonography were used to predict the eligibility for antiviral therapy reimbursement. Eligibility for reimbursement of antiviral treatment regarding histological criteria defined by National Social Security Institution is based on the hepatitis activity index (HAI) score ≥ 6 and/or fibrosis score ≥ 2 according to Ishak’s scoring system.
Results: One hundred and fifteen patients were included in the study; 79 patients (68.7%) were male. The mean age of patients was 46.51 (11.39). Sixty-two patients (53.9%) had a fibrosis score ≥ 2, and 80 (69.6%) patients had an HAI score ≥ 6. Ninety-two (80%) of the patients fulfilled histological criteria for antiviral treatment reimbursement. Multivariate analysis revealed that age and platelet count were independent predictors of eligibility for antiviral treatment reimbursement. The platelet count cut-off point was 198 x 109 /L for predicting eligibility for antiviral treatment reimbursement.
Conclusion: Most patients (92/115, 80%) with high ALT and DNA viral load were eligible for antiviral treatment reimbursement. Platelet count and age may be used as simple non-invasive parameters for predicting the eligibility for antiviral treatment reimbursement in terms of histological findings.
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A long-term study of liver-related events in Caucasian hepatitis B patients with normal ALT values and high viremia. Acta Gastroenterol Belg 2022; 85:56-61. [PMID: 35304994 DOI: 10.51821/85.1.9160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background and study aims There is ongoing debate whether antiviral therapy should be initiated in hepatitis B e antigen (HBeAg)-negative patients with normal alanine aminotransferase (ALT) levels but high HBV DNA levels >2,000 IU/mL. Since the need for antiviral therapy might be different between Asian and Caucasian patients, we studied the long-term disease outcome in Caucasian patients living in Western Europe. Patients and methods One hundred sixteen patients with high HBV DNA levels (>2,000 IU/mL) at diagnosis were included in the high viremia group, while those with HBV DNA <2,000 IU/mL were used as controls (n = 327). All patients were Caucasian, HBeAg negative, had normal ALT levels and had no significant liver disease at diagnosis. Results Median follow-up was 7 + 9.8 years in the high viremia group and this was 10 + 12.5 years in controls. The cumulative probability of a liver-related event over 10 years was 4.8% vs 0.0% in the control group (p=.008). In multivariable analysis, high viremia group was associated with the occurrence of a liver-related event (hazards ratio (HR) 95% confidence interval (CI): 1.20-11.98, p=.023). In this subgroup, older age at diagnosis (HR 95% CI: 1.01-1.16, p=.023) predicted a higher risk of liver-related event. In the high viremia group, liver-related mortality was 0.9% and none of the patients developed hepatocellular carcinoma. Conclusions HBV DNA >2,000 IU/mL influences the long-term disease outcome in Caucasian HBeAg-negative patients living in Western Europe. Nevertheless, the risk of liver-related events is low.
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Zhang Q, Cai DC, Hu P, Ren H. Low-level viremia in nucleoside analog-treated chronic hepatitis B patients. Chin Med J (Engl) 2021; 134:2810-2817. [PMID: 34759219 PMCID: PMC8668013 DOI: 10.1097/cm9.0000000000001793] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Indexed: 12/14/2022] Open
Abstract
ABSTRACT Low-level viremia (LLV) was defined as persistent or intermittent episodes of detectable hepatitis B virus (HBV) DNA (<2000 IU/mL, detection limit of 10 IU/mL) after 48 weeks of antiviral treatment. Effective antiviral therapies for chronic hepatitis B (CHB) patients, such as entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF), have been shown to inhibit the replication of HBV DNA and prevent liver-related complications. However, even with long-term antiviral therapy, there are still a number of patients with persistent or intermittent LLV. At present, the research on LLV to address whether adversely affect the clinical outcome is limited, and the follow-up treatment for these patients is open to question. At the same time, the mechanism of LLV is not clear. In this review, we summarize the incidence of LLV, the association between LLV and long-term outcomes, possible mechanisms, and management strategies in these patient populations.
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Affiliation(s)
- Qian Zhang
- Department of Infectious Diseases, Institute for Viral Hepatitis, The Key Laboratory of Molecular Biology for Infectious Diseases, Chinese Ministry of Education, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, Guiyang, Guizhou 550001, China
| | - Da-Chuan Cai
- Department of Infectious Diseases, Institute for Viral Hepatitis, The Key Laboratory of Molecular Biology for Infectious Diseases, Chinese Ministry of Education, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Peng Hu
- Department of Infectious Diseases, Institute for Viral Hepatitis, The Key Laboratory of Molecular Biology for Infectious Diseases, Chinese Ministry of Education, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Hong Ren
- Department of Infectious Diseases, Institute for Viral Hepatitis, The Key Laboratory of Molecular Biology for Infectious Diseases, Chinese Ministry of Education, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
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Riveiro-Barciela M, Pericàs JM, Buti M. How to interpret viral markers in the management of chronic hepatitis B infection. Clin Microbiol Infect 2021; 28:355-361. [PMID: 34768018 DOI: 10.1016/j.cmi.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hepatitis B virus (HBV) infection is a global public health issue with several unsolved clinical challenges. As multiple new drugs are under development, HBV markers are gaining importance for both diagnostic and prognostic purposes. OBJECTIVES This review summarizes the most important data on the usefulness of HBV markers in the natural history of this infection, and in predicting clinical and treatment outcomes. SOURCES Selected peer-reviewed publications on HBV markers published between January 2009 and July 2021. CONTENT In addition to the classical markers (e.g. HBV-DNA), newer ones, such as quantitative HBsAg, HBcrAg, HBV-RNA and quantitative anti-HBc, have proven useful for predicting events within the natural history of HBV infection, the development of complications (e.g. hepatocellular carcinoma) and the response to antiviral therapy. Most data regarding the response to treatment have been related to nucleos(t)ide analogues, whereas evidence on new therapeutic agents, such as capsid assembly modulators or small interference RNAs, is promising, but still scarce. IMPLICATIONS Knowledge on the use of viral markers is a key factor for optimizing the clinical appraisal of HBV infection. The new markers have an enhanced ability to predict clinical outcomes. Further studies should expand the current evidence on the use of markers in relation to antiviral agents currently under evaluation. Wide availability of these markers in regions with a high incidence of HBV infection is of paramount importance.
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Affiliation(s)
- Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Juan M Pericàs
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Maria Buti
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
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Charatcharoenwitthaya P, Kaewdech A, Piratvisuth T. Controversies in Treating Chronic HBV: The Role of PEG-interferon-alfa. Clin Liver Dis 2021; 25:741-762. [PMID: 34593151 DOI: 10.1016/j.cld.2021.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pegylated interferon-alpha therapy is one of the first-line chronic hepatitis B treatment. Finite treatment duration, absence of drug resistance, delayed response, and higher hepatitis B surface antigen loss than nucleos(t)ides analog therapy are the advantages of pegylated interferon-alpha treatment. Common side effects and subcutaneous injections requirement limit its use. Identifying patients likely to respond to pegylated interferon-alpha and optimizing treatment is reasonable. Motivating patients to complete the 48-week treatment is necessary. Treatment is stopped or switched to other treatment strategies in patients with stopping rule criteria. Combination therapy with nucleos(t)ides analog may improve response, but remains controversial.
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Affiliation(s)
- Phunchai Charatcharoenwitthaya
- Gastroenterology Division, Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Wang-Lang Road, Bangkok 10700, Thailand
| | - Apichat Kaewdech
- Gastroenterology and Hepatology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Kanchanawanich Road, Songkhla 90110, Thailand
| | - Teerha Piratvisuth
- Gastroenterology and Hepatology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Kanchanawanich Road, Songkhla 90110, Thailand; NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Prince of Songkla University, Kanchanawanich Road, Songkhla 90110, Thailand.
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Buti M, Riveiro-Barciela M, Esteban R. Treatment of Chronic Hepatitis B Virus with Oral Anti-Viral Therapy. Clin Liver Dis 2021; 25:725-740. [PMID: 34593150 DOI: 10.1016/j.cld.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Nucleoside analogues are the drugs most commonly used in the treatment of chronic hepatitis B. They act by inhibiting viral replication and have minimal impact on HBsAg loss. Nucleoside analogues are indicated in patients with chronic hepatitis, cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, and in those with extrahepatic manifestations. Real-world experience has been ongoing for more than 10 years, and the efficacy and safety results obtained are similar to those reported in clinical trials. Prolonged use is needed to maintain suppression of viral replication, prevent the development of liver cirrhosis and decompensated cirrhosis, and to decrease the risk of hepatocellular carcinoma.
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Affiliation(s)
- Maria Buti
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, General Hospital, 5th floor, Barcelona 08035, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
| | - Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, General Hospital, 5th floor, Barcelona 08035, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Rafael Esteban
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, General Hospital, 5th floor, Barcelona 08035, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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Zhang C, Li JW, Wu Z, Zhao H, Wang GQ. Significant Histologic Changes Are Not Rare in Treatment-naive Hepatitis B Patients with Normal Alanine Aminotransferase Level: A Meta-analysis. J Clin Transl Hepatol 2021; 9:615-625. [PMID: 34722176 PMCID: PMC8516830 DOI: 10.14218/jcth.2020.00136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Chronic hepatitis B is the main cause of liver cancer. However, the most neglected group has been treatment-naive chronic hepatitis B patients with normal alanine aminotransferase (ALT). People have tended to subjectively assume that the liver lesions of these patients are not serious and do not need antiviral treatment. However, the truth is not as optimistic as we thought. We aimed in this study to analyze the proportion of significant inflammation or fibrosis in aforementioned patients. METHODS Medline, Embase, and Cochrane Library were searched up to January 10th 2020, to identify studies of these patients with liver biopsy. The double arcsine method was used with a random-effect model to combine the proportion of significant inflammation or fibrosis. Potential heterogeneity was explored by subgroup analysis and meta-regression. Outcome of interests included the proportion of significant inflammation or fibrosis and cirrhosis. The secondary outcome was to find the risk factors of significant histological changes. RESULTS Nineteen eligible studies, with 2,771 participants, were included. The pooled proportion of significant inflammation or fibrosis was 35% [95% confidence interval (CI): 27 to 43] and 30% (95% CI: 25 to 36), respectively. The pooled proportion of cirrhosis was 3% [95% CI: 1 to 5, (12 studies; 1,755 participants)]. In subgroup analysis, old age [vs. young (<40 years-old), 44% vs. 26%, p=0.012] was significantly associated with higher fibrosis stage as well as cirrhosis [vs. young (<40 years-old), 4.8% vs. 1.8%, p<0.001]. CONCLUSIONS About 1/3 of the treatment-naive chronic hepatitis B patients with normal ALT show significant histological changes, and some even have cirrhosis.
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Affiliation(s)
- Chi Zhang
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Xicheng District, Beijing, China
| | - Jia-Wen Li
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Xicheng District, Beijing, China
| | - Zhao Wu
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Xicheng District, Beijing, China
| | - Hong Zhao
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Xicheng District, Beijing, China
- Peking University International Hospital, Beijing, China
- Correspondence to: Gui-Qiang Wang and Hong Zhao, Department of Infectious Diseases and Center for Liver Diseases, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing 100034, China. Tel: +86-13911405123, Fax: +86-10-66551680, E-mail: , (GQW); Tel: +86-13810765943, Fax: +86-10-66551680, E-mail: (HZ)
| | - Gui-Qiang Wang
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Xicheng District, Beijing, China
- The Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, China
- Peking University International Hospital, Beijing, China
- Correspondence to: Gui-Qiang Wang and Hong Zhao, Department of Infectious Diseases and Center for Liver Diseases, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing 100034, China. Tel: +86-13911405123, Fax: +86-10-66551680, E-mail: , (GQW); Tel: +86-13810765943, Fax: +86-10-66551680, E-mail: (HZ)
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Cornberg M, Sandmann L, Protzer U, Niederau C, Tacke F, Berg T, Glebe D, Jilg W, Wedemeyer H, Wirth S, Höner Zu Siederdissen C, Lynen-Jansen P, van Leeuwen P, Petersen J. S3-Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) zur Prophylaxe, Diagnostik und Therapie der Hepatitis-B-Virusinfektion – (AWMF-Register-Nr. 021-11). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:691-776. [PMID: 34255317 DOI: 10.1055/a-1498-2512] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Markus Cornberg
- Deutsches Zentrum für Infektionsforschung (DZIF), Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover; Centre for individualised infection Medicine (CiiM), Hannover.,Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover
| | - Lisa Sandmann
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover
| | - Ulrike Protzer
- Institut für Virologie, Technische Universität München/Helmholtz Zentrum München, München
| | | | - Frank Tacke
- Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Charité Universitätsmedizin Berlin, Berlin
| | - Thomas Berg
- Klinik und Poliklinik für Gastroenterologie und Rheumatologie, Universitätsklinikum Leipzig, Leipzig
| | - Dieter Glebe
- Institut für Medizinische Virologie, Nationales Referenzzentrum für Hepatitis-B-Viren und Hepatitis-D-Viren, Justus-Liebig-Universität Gießen, Gießen
| | - Wolfgang Jilg
- Institut für Medizinische Mikrobiologie und Hygiene, Universität Regensberg, Regensburg
| | - Heiner Wedemeyer
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover
| | - Stefan Wirth
- Zentrum für Kinder- und Jugendmedizin, Helios Universitätsklinikum Wuppertal, Wuppertal
| | | | - Petra Lynen-Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin
| | - Pia van Leeuwen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin
| | - Jörg Petersen
- IFI Institut für Interdisziplinäre Medizin an der Asklepios Klinik St. Georg, Hamburg
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Chang X, Wang J, Chen Y, Long Q, Song L, Li Q, Liu H, Shang Q, Yu Z, Jiang L, Xiao G, Li L, Chen L, Wang X, Li Z, Chen D, Dong Z, An L, Tan L, Chen Y, Yang Y. A novel nomogram to predict evident histological liver injury in patients with HBeAg-positive chronic hepatitis B virus infection. EBioMedicine 2021; 67:103389. [PMID: 34004423 PMCID: PMC8141676 DOI: 10.1016/j.ebiom.2021.103389] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 12/14/2022] Open
Abstract
Background HBeAg-positive chronic infection is a unique phase of chronic hepatitis B virus (HBV) infection. Current guidelines advise against starting antiviral treatment for HBeAg-positive chronic hepatitis B virus (HBV) infection patients, some data suggest treating such patients may reduce the risk of hepatocellular carcinoma. We aimed to explore whether these patients can have evident histological liver injury (EHLI), and develop a non-invasive model for identifying EHLI in such patients. Method We assessed whether HBeAg-positive chronic HBV infection patients can have EHLI defined by Ishak fibrosis stage ≥3 and/or histologic activity index ≥ 9 in a prospective multicenter study. Logistic and Lasso regression was used to select the optimal predictors. We used Akaike information criterion, discrimination improvement, net reclassification improvement to develop and validate models predicting EHLI risk in training cohort and two external validation cohorts. Findings Of these 336 patients met the inclusion criteria, 181(54%) were HBeAg-positive chronic HBV infection, of whom 60 patients (33%) had EHLI, the proportion of significant fibrosis was higher than that of significant inflammation (33% vs. 8%, P < 0.001). Age, liver stiffness measurement, ALT, alkaline phosphatase, and albumin were identified as independent predictors for EHLI and used to develop a nomogram that have been demonstrated having a good performance in predicting EHLI with AUROCs of 0.92(95%CI: 0.86–0.99) in the training cohort (n = 233) and 0.90(95%CI: 0.84–0.95) in validation cohort 1(n = 103), significant correcting current guidelines recommendations overestimating insignificant or significant histological disease. After 72-weeks entecavir treatment for HBeAg-positive chronic HBV infection patients with EHLI identified by nomogram, histological improvement occurred in 40 of 49(82%), 38(78%) had fibrosis reversal, and 35(73%) no longer had EHLI. Interpretation In HBeAg-positive chronic HBV infection patients, 33% has EHLI. The nomogram developed in this study can accurately identify HBeAg-positive chronic HBV infection patients with EHLI, and that responded very well to antiviral therapy. Funding This study was funded by the State Key Projects Specialized on Infectious Disease, Chinese Ministry of science and technology (2013ZX10005002; 2018ZX10725506), National Natural Science Foundation of China (81970525) and Beijing Key Research Project of Special Clinical Application (Z151100004015221).
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Affiliation(s)
- Xiujuan Chang
- Department of Liver Disease, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Jing Wang
- Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, Sichuan 610072, China
| | - Yan Chen
- Department of Liver Disease, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Qinghua Long
- Department of Infection and Liver Disease, Yichun People's Hospital, Yichun, Jiangxi, China
| | - Laicheng Song
- Taihe Traditional Chinese Medicine Hospital, Taihe, Anhui 400038, China
| | - Qin Li
- Fuzhou Infectious Diseases Hospital, Fuzhou, Fujian 350025, China
| | - Huabao Liu
- Traditional Chinese Medicine Hospital of Chongqing, Chongqing 400038, China
| | - Qinghua Shang
- Center of Therapeutic Liver Disease, The 960th Hospital of Chinese PLA, Taian, Shandong 271000, China
| | - Zujiang Yu
- Department of Infectious Disease, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Li Jiang
- Department of Infectious Diseases, Southwest Hospital, Army Military Medical University, Chongqing 400038, China
| | - Guangming Xiao
- Guangzhou 8th People's Hospital, Guangzhou, Guangdong 510060, China
| | - Li Li
- Department of Traditional Chinese Medicine, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
| | - Liang Chen
- Department of Hepatic Diseases, Shanghai Public Health Clinical Center, Shanghai 201508, China
| | - Xiaodong Wang
- Department of Infectious and Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Zhiqin Li
- Department of Infectious Disease, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Da Chen
- Department of Infectious and Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Zheng Dong
- Department of Liver Disease, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Linjing An
- Department of Liver Disease, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Lin Tan
- Department of Liver Disease, Fuyang 2nd People's Hospital, Fuyang, Anhui 236015, China.
| | - Yongping Chen
- Department of Infectious and Liver Diseases, Liver Research Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
| | - Yongping Yang
- Department of Liver Disease, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China.
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Koc ÖM, Robaeys G, Topal H, Bielen R, Busschots D, Fevery J, Koek GH, Nevens F. Outcome in Caucasian patients with hepatitis B e antigen negative chronic infection: A long-term observational cohort study. J Med Virol 2020; 92:3373-3380. [PMID: 32343427 PMCID: PMC7687269 DOI: 10.1002/jmv.25950] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 12/17/2022]
Abstract
Sensitive polymerase chain reaction assays to measure hepatitis B virus (HBV) DNA became only available the last decade. Hence, the long-term outcome of Caucasian patients in Western Europe with hepatitis B e antigen (HBeAg)-negative chronic infection, especially with a baseline HBV DNA level ⩾2000 IU/mL, is still unclear. Out of a cohort of 1936 chronic HBV patients, 413 Caucasian individuals were identified with HBeAg-negative chronic infection, defined as persistently normal alanine aminotransferase (ALT) levels and HBV DNA levels <20 000 IU/mL. During a mean follow-up of 12 years, 366 (88.6%) maintained an HBeAg-negative chronic infection status, whereas 25 (6.1%) developed chronic active hepatitis (CAH). In total, Nine of these 25 CAH cases were related to immunosuppression. In total, 22 (5.3%) individuals had ALT > 2 × upper limit of normal due to non-HBV-related causes. The cumulative probability of spontaneously developing CAH after 10 years was almost exclusively seen in patients with baseline HBV DNA level ⩾2000 IU/mL (11.7% vs 1.2%; P < .001). Advanced liver disease developed significantly more in patients with baseline HBV DNA level ⩾2000 IU/mL (5.2% vs 1.5%; P = .018) and occurred especially in patients with obesity (16.7% vs 4.2%; P = .049). The incidence of hepatocellular carcinoma was 0.0%. Caucasian patients with HBeAg-negative chronic infection and baseline HBV DNA level <2000 IU/mL have an excellent long-term prognosis in the absence of immunosuppressive therapy. However, patients with baseline HBV DNA level ⩾2000 IU/mL are at risk to develop advanced liver disease.
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Affiliation(s)
- Özgür M. Koc
- Department of Gastroenterology and HepatologyZiekenhuis Oost‐LimburgGenkBelgium
- Faculty of Medicine and Life SciencesHasselt UniversityHasseltBelgium
- Department of Medical Microbiology, Medical CentreMaastricht UniversityMaastrichtThe Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
| | - Geert Robaeys
- Department of Gastroenterology and HepatologyZiekenhuis Oost‐LimburgGenkBelgium
- Faculty of Medicine and Life SciencesHasselt UniversityHasseltBelgium
- Department of Gastroenterology and HepatologyUniversity Hospitals KU LeuvenLeuvenBelgium
| | - Halit Topal
- Department of Abdominal SurgeryUniversity Hospitals KU LeuvenLeuvenBelgium
| | - Rob Bielen
- Department of Gastroenterology and HepatologyZiekenhuis Oost‐LimburgGenkBelgium
- Faculty of Medicine and Life SciencesHasselt UniversityHasseltBelgium
| | - Dana Busschots
- Department of Gastroenterology and HepatologyZiekenhuis Oost‐LimburgGenkBelgium
- Faculty of Medicine and Life SciencesHasselt UniversityHasseltBelgium
| | - Johan Fevery
- Department of Gastroenterology and HepatologyUniversity Hospitals KU LeuvenLeuvenBelgium
| | - Ger H. Koek
- School of Nutrition and Translational Research in Metabolism (NUTRIM)Maastricht UniversityMaastrichtThe Netherlands
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical CentreMaastricht UniversityMaastrichtThe Netherlands
- Department of Visceral Surgery and TransplantationUniversity Hospital of the RWTHAachenGermany
| | - Frederik Nevens
- Department of Gastroenterology and HepatologyUniversity Hospitals KU LeuvenLeuvenBelgium
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Sanai FM, Alghamdi M, Dugan E, Alalwan A, Al-Hamoudi W, Abaalkhail F, AlMasri N, Razavi-Shearer D, Razavi H, Schmelzer J, Alfaleh FZ. A tool to measure the economic impact of Hepatitis B elimination: A case study in Saudi Arabia. J Infect Public Health 2020; 13:1715-1723. [PMID: 32988769 DOI: 10.1016/j.jiph.2020.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/31/2020] [Accepted: 09/13/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND No virologic cure exists for hepatitis B virus (HBV) infection, and existing therapies are designed to control viral replication. We aimed to estimate the national prevalence of HBsAg in 2017 and study the impact of an enhanced diagnosis rate and universal treatment administration on HBV-related outcomes in Saudi Arabia. MATERIALS AND METHODS A dynamic transmission and disease burden model was developed to estimate the future economic burden of HBV infection. The infected population was tracked by age and gender-defined cohorts; direct costs (healthcare, screening, diagnostics and treatment) and indirect costs (disability-adjusted life years and the value of a statistical life year) were calculated. The impact of two intervention scenarios (Achieve WHO Targets: diagnose 90% of infections and treat 80% of high viral load patients by 2030; and Diagnose and Treat All: diagnose and treat all infected patients by 2022) were compared against the Base Case scenario (no policy action), with near-universal vaccination coverage rates held constant. A sensitivity analysis of future treatment cost was also conducted. RESULTS In 2017, HBsAg prevalence was estimated at 1.7%, corresponding to 574,000 infections. The same year, there was an estimated incidence of 490 cases of decompensated cirrhosis, 1500 cases of hepatocellular carcinoma (HCC) and 1740 liver-related deaths (LRD). HBsAg prevalence was 0.1% among 5-year-olds and <0.1% among infants. Disease burden outcomes by 2030, as compared with 2015, were as follows - Base Case: LRDs and HCC incidence were projected to increase by 70%. WHO Targets: A 30-35% decline in both HCC incidence and LRDs. Diagnose and Treat All: A 50-55% decline in HCC incidence and LRDs. In all scenarios, HBsAg prevalence among infants and 5-year-olds declined to <0.1% with the Diagnose and Treat all scenario resulting in a prevalence approaching zero in this age group. Annual direct costs are projected to increase and peak by 2022 in both intervention scenarios due to expansion of treatment and diagnostics. However, these are offset by the reduction of indirect economic costs, starting immediately in the WHO Targets scenario and by 2023 in the strategy to diagnose and treat all. Achieving WHO Targets is estimated to achieve a positive return on investment (ROI) by 2021 when examining direct costs and indirect economic losses at a treatment price of $2700 USD per patient yearly. Diagnosing and treating all patients, however, would require at least a 50% reduction in the unit cost of treatment to achieve a positive ROI by 2029. CONCLUSIONS Increased diagnosis and treatment rates of HBV would lead to substantial declines in HCC and LRD. This effect would be dramatically enhanced by administering treatment to all HBV cases regardless of viral load and estimated to be highly cost-effective if treatment prices can be substantially reduced.
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Affiliation(s)
- Faisal M Sanai
- Gastroenterology Unit, Department of Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia.
| | - Mohammed Alghamdi
- Gastroenterology Unit, Department of Medicine, King Fahad Military Medical Complex, Dhahran, Saudi Arabia
| | - Ellen Dugan
- Center for Disease Analysis Foundation, Lafayette, CO, USA
| | - Abduljaleel Alalwan
- Department of Organ Transplant and Hepatobiliary Surgery, King Abdulaziz Medical City and King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Waleed Al-Hamoudi
- Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, Division of Organ Transplant Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Liver Disease Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Faisal Abaalkhail
- Department of Liver Transplantation, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Nasser AlMasri
- Department of Gastroenterology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | - Homie Razavi
- Center for Disease Analysis Foundation, Lafayette, CO, USA
| | | | - Faleh Z Alfaleh
- Liver Disease Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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15
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Quantitative HBcrAg and HBcAb versus HBsAg and HBV DNA in predicting liver fibrosis levels of chronic hepatitis B patients. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:526-536. [PMID: 32921478 DOI: 10.1016/j.gastrohep.2020.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 03/10/2020] [Accepted: 03/31/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the performance of the quantitative markers of hepatitis B core-related antigen (HBcrAg) and anti-hepatitis B core antigen antibodies HbcAb versus hepatitis B surface antigen (HBsAg) and hepatitis B virus DNA (HBV DNA) in predicting liver fibrosis levels in chronic hepatitis B patients. METHODS Two hundred and fifty hepatitis B e antigen (HBeAg)-positive and 245 HBeAg-negative patients were enrolled. With reference to the Scheuer standard, stage 2 or higher and stage 4 liver disease were defined as significant fibrosis and cirrhosis, respectively. A receiver operating characteristic (ROC) curve was used to evaluate the performance of the HBV markers investigated. RESULTS The areas under the ROC curves (AUCs) of HBcrAg in predicting significant fibrosis and cirrhosis in HBeAg-positive patients (0.577 and 0.700) were both close to those of HBsAg (0.617 and 0.762) (both P> 0.05). In HBeAg-negative patients (0.797 and 0.837), they were both significantly greater than those of HBV DNA (0.723 and 0.738) (P=0.0090 and P=0.0079). The AUCs of HBcAb in predicting significant fibrosis and cirrhosis in HBeAg-positive patients (0.640 and 0.665) were both close to those of HBsAg. In HBeAg-negative patients (0.570 and 0.621), they were both significantly less than those of HBcrAg (P <0.0001 and P=0.0001). Specificity in predicting significant fibrosis and sensitivity in predicting cirrhosis in HBeAg-positive patients, using a single cut-off of HBsAg ≤5,000 IU/ml, were 76.5% and 72.7%, respectively. In HBeAg-negative patients, using a single cut-off of HBcrAg>80kU/ml, they were 85.9% and 81.3%, respectively. CONCLUSIONS HBsAg has good performance in predicting liver fibrosis levels in HBeAg-positive and HBeAg-negative patients, and HBcrAg has very good performance in predicting liver fibrosis levels in HBeAg-negative patients.
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16
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Hematological Malignancies and HBV Reactivation Risk: Suggestions for Clinical Management. Viruses 2019; 11:v11090858. [PMID: 31540124 PMCID: PMC6784078 DOI: 10.3390/v11090858] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 12/12/2022] Open
Abstract
It is well known that hepatitis B virus reactivation (HBVr) can occur among patients undergoing treatment for hematological malignancies (HM). The evaluation of HBVr risk in patients undergoing immunosuppressive treatments is a multidimensional process, which includes conducting an accurate clinical history and physical examination, consideration of the virological categories, of the medication chosen to treat these hematological malignancies and the degree of immunosuppression induced. Once the risk of reactivation has been defined, it is crucial to adopt adequate management strategies (should reactivation occur). The purpose of treatment is to prevent dire clinical consequences of HBVr such as acute/fulminant hepatitis, and liver failure. Treatment will be instituted according to the indications and evidence provided by current international recommendations and to prevent interruption of lifesaving anti-neoplastic treatments. In this paper, we will present the available data regarding the risk of HBVr in this special population of immunosuppressed patients and explore the relevance of effective prevention and management of this potentially life-threatening event. A computerized literature search was performed using appropriate terms to discover relevant articles. Current evidence supports the policy of universal HBV testing of patients scheduled to undergo treatment for hematological malignancies, and clinicians should be aware of the inherent risk of viral reactivation among the different virological categories and classes of immunosuppressive drugs.
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Xie Y, Yi W, Zhang L, Lu Y, Hao HX, Gao YJ, Ran CP, Lu HH, Chen QQ, Shen G, Wu SL, Chang M, Ping-Hu L, Liu RY, Sun L, Wan G, Li MH. Evaluation of a logistic regression model for predicting liver necroinflammation in hepatitis B e antigen-negative chronic hepatitis B patients with normal and minimally increased alanine aminotransferase levels. J Viral Hepat 2019; 26 Suppl 1:42-49. [PMID: 31380591 DOI: 10.1111/jvh.13163] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 05/15/2019] [Indexed: 12/26/2022]
Abstract
Liver necroinflammation is the indicator for treating patients with chronic hepatitis B (CHB) infection. However, there is no suitable non-invasive index for diagnosing liver necroinflammation. This study aimed to create a non-invasive index to predict liver necroinflammation in patients who lack clear-cut clinical inflammation parameters. Patients who were hepatitis B e antigen (HBeAg)-negative and underwent liver histological diagnosis, had a normal or minimally increased alanine aminotransferase (ALT) level were enrolled. Liver necroinflammation was defined as histological active index ≥4. A logistic regression model (LRM) was established based on the parameters independently associated with liver necroinflammation. Of all 550 patients, 36.73% had necroinflammation. In patients with an abnormal ALT level, the rate of necroinflammation was 52.49%. The area under the curve (AUC) of the ALT level for predicting necroinflammation was 0.655 (95% confidence interval [CI], 0.609-0.702), and that of the HBV DNA level ≥2000 IU/mL combined with an abnormal ALT level was 0.618. By using the LRM, the AUC improved to 0.769 (95% CI, 0.723-0.815) with a Youden index of 0.519 and diagnostic accuracy of 75.3%. The cutoff value ≥0.7 in the LRM had a specificity of 97.4% and positive predictive value of 85.0% for predicting necroinflammation. By using the cutoff value <0.15 in the LRM, the presence of necroinflammation could be excluded with a negative predictive value of 90.8%. This study indicated that the LRM can be used to effectively diagnose liver necroinflammation in HBeAg-negative patients with CHB who have normal or minimally elevated ALT levels.
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Affiliation(s)
- Yao Xie
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Wei Yi
- Department of Gynecology and Obstetrics, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Lu Zhang
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yao Lu
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hong-Xiao Hao
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yuan-Jiao Gao
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Chong-Ping Ran
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hui-Hui Lu
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Qi-Qi Chen
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Ge Shen
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Shu-Ling Wu
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Ming Chang
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Lei Ping-Hu
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Rui-Yu Liu
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Lei Sun
- Department of Pathology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Gang Wan
- Medical Records and Statistics Department, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Ming-Hui Li
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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Liu Y, Jiang M, Xue J, Yan H, Liang X. Serum HBV RNA quantification: useful for monitoring natural history of chronic hepatitis B infection. BMC Gastroenterol 2019; 19:53. [PMID: 30991954 PMCID: PMC6469196 DOI: 10.1186/s12876-019-0966-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/25/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND As an alternative biomarker of intrahepatic covalently closed circular DNA (cccDNA) transcriptional activity, hepatitis B virus (HBV) RNA may evolve during long-lasting virus-host interactions during chronic hepatitis B viral infection. The distribution pattern of serum HBV RNA levels in the natural course of chronic HBV infection remains unclear. The aim of this study was to evaluate the levels of HBV RNA during the natural course of CHB and the role in distinguishing the natural history of HBV infection. METHODS A total of 291 treatment-naïve chronic HBV carriers were enrolled. Based on the clinical, biochemical, serological, and histological data as well as HBV DNA levels, patients were classified into the following four categories: the immune-tolerant phase (IT,n = 35), HBeAg-positive immune-active phase (EPIA,n = 121), inactive chronic hepatitis B(ICH,n = 77) and HBeAg-negative immune reactive hepatitis (ENH,n = 58) [corrected]. The parameters and distribution patterns of serum HBV RNA were evaluated in relation to viral replication status, immune phase, disease category and Child-Pugh class. The relationships between serum HBV RNA and other serum hepatitis B viral markers were also analyzed. RESULTS Serum HBV RNA levels were significantly lower in the HBeAg-negative patients compared to those in the HBeAg-positive patients, with the lowest levels seen in inactive carriers. In HBeAg-negative patients, serum HBV RNA levels increased if there is reactivation to active hepatitis and showed obvious superiority for the combination of serum HBV DNA (cutoff>3.39 Log copies/mL) and HBsAg (cutoff>2.74 Log IU/mL) in discriminating between 'HBeAg-negative immune reactive' phase and inactive chronic hepatitis B phases of HBeAg-negative chronic HBV infection. Serum HBV RNA levels were positively correlated with serum HBV DNA and HBsAg levels in all chronic HBV-infected patients. A stratified analysis revealed that a correlation between serum HBV RNA and HBV DNA or HBsAg was present in HBeAg-positive patients; however, in HBeAg-negative patients, serum HBV RNA was positively correlated with HBV DNA only. CONCLUSION During the natural course of chronic HBV infection, serum HBV RNA levels vary. Serum HBV RNA can act as a biomarker to predict the natural history of disease in chronic hepatitis B patients. In treatment-naïve HBeAg-negative chronic HBV-infected individuals, serum HBV RNA shows superiority in differentiating the 'HBeAg-negative reactive' phase.
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Affiliation(s)
- Yayun Liu
- Department of Infectious Diseases, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Meng Jiang
- Department of Infectious Diseases, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Jianya Xue
- Department of Infectious Diseases, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Hongli Yan
- Department of Reproductive Medicine Center, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Xuesong Liang
- Department of Infectious Diseases, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
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Liu LZ, Sun J, Hou J, Chan HLY. Improvements in the management of chronic hepatitis B virus infection. Expert Rev Gastroenterol Hepatol 2018; 12:1153-1166. [PMID: 30269597 DOI: 10.1080/17474124.2018.1530986] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The primary goals of managing chronic hepatitis B (CHB) are prevention of liver-related complications and reduction of mortality. Universal vaccination has dramatically reduced the incidence of new infection, but the management of existing CHB patients are still challenging. Areas covered: This review compares the similarities and differences among the latest published regional guidelines on the indications and choices of antiviral therapy. We have summarized advances in virological biomarkers and non-invasive tests for liver fibrosis in disease assessment. Benefits and remaining challenges of current standard of care by peginterferon and nucleos(t)ide analogs (NA) have been presented. Data on combination therapy of peginterferon and NA in seeking functional cure of the disease is also critically discussed. We have also described the improvement in the management of CHB at pregnancy and prophylaxis in patients on chemotherapy and immunosuppressants. Expert commentary: Controversies exist in the assessment of disease activity for selection patients for treatment as well as on the use of tenofovir alafenamide as a safe and cost-effective alternative to tenofovir disoproxil fumarate. Though combination therapy of peginterferon and NA has induced HBsAg seroclearance in a small proportion of patients, peginterferon is not preferred in the future trend of drug development.
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Affiliation(s)
- Lucas Zhihong Liu
- a Department of Infectious Diseases, Nanfang Hospital , Southern Medical University , Guangzhou , China
| | - Jian Sun
- a Department of Infectious Diseases, Nanfang Hospital , Southern Medical University , Guangzhou , China
| | - Jinlin Hou
- a Department of Infectious Diseases, Nanfang Hospital , Southern Medical University , Guangzhou , China
| | - Henry Lik Yuen Chan
- b Department of Medicine and Therapeutics and Institute of Digestive Disease , The Chinese University of Hong Kong , Hong Kong SAR , China
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20
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Kelly EM, Dodge JL, Bacchetti P, Sarkar M, French AL, Tien PC, Glesby MJ, Golub ET, Augenbraun M, Plankey M, Peters MG. Moderate Alcohol Use Is Not Associated With Fibrosis Progression in Human Immunodeficiency Virus/Hepatitis C Virus-Coinfected Women: A Prospective Cohort Study. Clin Infect Dis 2018; 65:2050-2056. [PMID: 29020382 DOI: 10.1093/cid/cix716] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 08/15/2017] [Indexed: 02/07/2023] Open
Abstract
Background Heavy alcohol use can lead to progressive liver damage, especially in individuals with chronic hepatitis C (HCV); however, the impact of nonheavy use is not clear. We studied long-term effects of modest alcohol use on fibrosis progression in a large cohort of women coinfected with human immunodeficiency virus (HIV)/HCV. Methods Alcohol intake was ascertained every 6 months and use categorized as abstinent, light (1-3 drinks/week), moderate (4-7 drinks/week), heavy (>7 drinks/week), and very heavy (>14 drinks/week). Fibrosis progression was defined as the change in Fibrosis-4 Index for Liver Fibrosis (FIB-4) units per year using random-intercept, random-slope mixed modeling. Results Among 686 HIV/HCV-coinfected women, 46.0% reported no alcohol use; 26.8% reported light use, 7.1% moderate use, and 19.7% heavy use (6.7% had 8-14 drinks/week and 13.0% had >14 drinks/week) at cohort entry. Median FIB-4 at entry was similar between groups. On multivariable analysis, compared to abstainers, light and moderate alcohol use was not associated with fibrosis progression (0.004 [95% confidence interval {CI}, -.11 to .12] and 0.006 [95% CI, -.18 to .19] FIB-4 units/year, respectively). Very heavy drinking (>14 drinks/week) showed significant fibrosis acceleration (0.25 [95% CI, .01-.49] FIB-4 units/year) compared to abstaining, whereas drinking 8-14 drinks per week showed minimal acceleration of fibrosis progression (0.04 [95% CI, -.19 to .28] FIB-4 units/year). Conclusions Light/moderate alcohol use was not substantially associated with accelerated fibrosis progression, whereas drinking >14 drinks per week showed increased rates of fibrosis progression. Women with HIV/HCV infection should be counseled against heavy alcohol consumption, but complete abstinence may not be required to prevent accelerated liver fibrosis progression.
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Affiliation(s)
- Erin M Kelly
- Department of Medicine, University of Ottawa, Ontario, Canada
| | | | | | | | - Audrey L French
- Department of Medicine, CORE Center/Stroger Hospital of Cook County, Chicago, Illinois
| | - Phyllis C Tien
- Medicine, University of California, San Francisco.,Department of Veterans Affairs Medical Center, San Francisco, California
| | - Marshall J Glesby
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Elizabeth T Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Michael Augenbraun
- Department of Medicine, State University of New York, Downstate Medical Center, Brooklyn
| | - Michael Plankey
- Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia
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21
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Cristina SJL, Marta CM, Mercedes GS, Almudena PM, Álvaro HM, Luis VSJ, Tesifón PC. Characterization and evaluation of liver fibrosis grade in patients with chronic hepatitis B virus infection and normal transaminases. Clin Mol Hepatol 2018; 24:384-391. [PMID: 29969885 PMCID: PMC6313027 DOI: 10.3350/cmh.2018.0004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 03/13/2018] [Indexed: 12/24/2022] Open
Abstract
Background/Aims The objective of our study was to determine the epidemiological, laboratory, and serological characteristics of patients with chronic hepatitis B virus (HBV) infection and normal transaminases. The study also aimed to evaluate liver damage by measuring the liver fibrosis (LF) grade and to identify possible factors associated with the presence of fibrosis.
Methods A retrospective observational study was conducted in patients with chronic HBV infection and classified as inactive carriers or immune-tolerant. Epidemiological variables of age, sex, immigrant, alcohol consumption, and body mass index (BMI), as well as virological variables (HBV DNA) and transaminase level were collected throughout the follow-up. The LF grade was evaluated by transient elastography. The cutoff value for significant fibrosis (SF) was liver stiffness ≥7.9 kPa.
Results A total of 214 patients were included in the analysis, and 62% of them had a BMI ≥25 kg/m2. During follow-up, 4% of patients showed transaminase elevation (<1.5 times normal). Most patients had a viral DNA level <2,000 IU/mL (83%). Data on LF were available in 160 patients; of these, 14% had SF, 9% F3, and 6% F4. The variables associated with the presence of SF were transaminase alteration during follow-up, as 23% of patients with SF had elevated transaminases versus 3% of patients without SF (P<0.005), and BMI, as the vast majority of patients with SF (88%) had a BMI ≥25 kg/m2 versus 56% of patients without SF (P<0.05).
Conclusions In patients with chronic HBV infection and normal transaminases, liver damage does not seem to be related to DNA levels, alcohol consumption, or immigrant status. SF seems to be associated with transaminase alteration during follow-up and elevated BMI. It is therefore recommended to measure LF grade with validated non-invasive methods in such patients.
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Affiliation(s)
- San Juan López Cristina
- Department of Digestive Diseases, Torrecárdenas Hospital, University of Almería, Almería, Spain
| | - Casado Martín Marta
- Department of Digestive Diseases, Torrecárdenas Hospital, University of Almería, Almería, Spain
| | | | - Porcel Martín Almudena
- Department of Digestive Diseases, Torrecárdenas Hospital, University of Almería, Almería, Spain
| | | | - Vega Sáenz Jose Luis
- Department of Digestive Diseases, Torrecárdenas Hospital, University of Almería, Almería, Spain
| | - Parrón Carreño Tesifón
- Department of Nursing, Physiotherapy and Medicine, University of Almería, Almería, Spain
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22
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Yenilmez E, Çetinkaya RA, Tural E. Diagnostic Dilemma for Low Viremia with Significant Fibrosis; is Hepatitis B Virus DNA Threshold Level a Good Indicator for Predicting Liver Damage? Balkan Med J 2018; 35:326-332. [PMID: 29726399 PMCID: PMC6060975 DOI: 10.4274/balkanmedj.2017.0888] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The most important difficulties about management of hepatitis B are still determining the liver damage and the right time to start antiviral therapy. AIMS To reveal the role of hepatitis B virus DNA threshold level for prediction of liver fibrosis and inflammation in young-aged hepatitis B e-antigen negative chronic hepatitis B patients. STUDY DESIGN Diagnostic accuracy study. METHODS A total of 273 hepatitis B e-antigen negative young chronic hepatitis B patients with any hepatitis B virus DNA levels between 2008 and 2016, who had liver biopsy after at least 6 months follow up period, enrolled in this retrospective study. We created two groups as case and control, cases with hepatitis B virus DNA levels below 2000 IU/mL and controls with hepatitis B virus DNA levels over 2000 IU/mL. Having histological activity index ≥4 or/and fibrosis scores ≥2 were defined as significant histological abnormality. Then, we analyzed the relationship between these groups. RESULTS We showed that significant fibrosis may occur in one third of young chronic hepatitis B patients with low viremia (30.2%, n=42/139 in cases, 55.2%, n=74/134 in controls). Among the 42 cases with low viremia and significant fibrosis, 21.4% had alanine aminotransferase level between 40-59 U/L, 42.8% had alanine aminotransferase level between 60-79 U/L, and 35.7% had alanine aminotransferase level over 80 U/L. There was weak correlation between hepatitis B virus DNA threshold level and fibrosis score (p<0.001, rho=0.253). The optimum serum hepatitis B virus DNA threshold level in our study for predicting significant fibrosis was 1293 IU/mL (p<0.001, AUC: 0.657±0.034). The optimum alanine aminotransferase threshold level for predicting significant histological activity index and fibrosis was 64.5 and 59.5 U/L, respectively. The sensitivity and the specificity of 1293 vs 2000 IU/mL hepatitis B virus DNA threshold with 60 U/L alanine aminotransferase threshold level for predicting F≥2 fibrosis score were similar (sensitivity: 0.43 and 0.38, specificity: 0.76 and 0.77, respectively). CONCLUSION Significant fibrosis may occur even in young cases with low viremia. It is not possible to define a single threshold hepatitis B virus DNA level for differentiating inactive carriers from patients with hepatitis B e-antigen-negative chronic hepatitis. Diagnostic accuracy of hepatitis B virus DNA with alanine aminotransferase thresholds for the prediction of significant fibrosis is weak.
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Affiliation(s)
- Ercan Yenilmez
- Department of Infectious Diseases and Clinical Microbiology, İstanbul Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey
| | - Rıza Aytaç Çetinkaya
- Department of Infectious Diseases and Clinical Microbiology, İstanbul Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey
| | - Ersin Tural
- Department of Pediatrics, İstanbul Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey
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23
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Vlachogiannakos J, Papatheodoridis GV. Hepatitis B: Who and when to treat? Liver Int 2018; 38 Suppl 1:71-78. [PMID: 29427495 DOI: 10.1111/liv.13631] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 12/12/2022]
Abstract
As current treatment options almost never achieve eradication of hepatitis B virus (HBV), the most realistic goal for HBV treatment is persistent inhibition of viral replication and ALT normalization. Thus, the decision to start treatment should be based on careful patient selection and individualized decisions. Treatment is generally indicated in chronic hepatitis B patients with HBV DNA >2000 IU/mL, elevated ALT and/or at least moderate histological lesions, while all patients with cirrhosis and detectable HBV DNA should be treated. Patients with HBV DNA >20 000 IU/mL and ALT >2xULN (upper limit of normal), HBV DNA >2000 IU/mL and liver stiffness >9 or >12 kPa in case of normal or ≤5xULN, HBV DNA >2000 IU/mL and a family history of cirrhosis and/or HCC as well as HBeAg-positive patients with HBV DNA >20 000 IU/mL and over 30 years old can begin treatment whatever the liver histology. Moreover, patients with HBV DNA >2000 IU/mL and at least moderate histological lesions can begin treatment whatever the ALT levels. Prophylactic treatment is indicated in HBV-related liver transplantation patients to prevent recurrence, in the last trimester of pregnancy in women with high viraemia to prevent vertical transmission and in patients receiving immunosuppression/chemotherapy to prevent the reactivation of HBV. Treatment is also indicated in patients with co-infections, extrahepatic manifestations and severe acute hepatitis B, or healthcare workers with viraemia. These treatment indications can only change if HBV eradication or at least HBsAg clearance can be achieved in the future in a significant proportion of patients.
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Affiliation(s)
- Jiannis Vlachogiannakos
- Department of Gastroenterology, Laiko General Hospital, Medical School of National and Kapodistrian University of Athens, Athens, Greece
| | - George V Papatheodoridis
- Department of Gastroenterology, Laiko General Hospital, Medical School of National and Kapodistrian University of Athens, Athens, Greece
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24
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Guardiola-Arévalo A, Gómez Rodríguez R, Romero Gutiérrez M, Gómez Moreno AZ, García Vela A, Sánchez Simón R, Gómez Hernando C, Andrés Esteban EM. Hepatitis B virus e antigen-negative chronic infection. Treatment based on glutamic pyruvic transaminase and hepatitis B virus deoxyribonucleic acid cut-off values. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 41:153-162. [PMID: 29279233 DOI: 10.1016/j.gastrohep.2017.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/13/2017] [Accepted: 11/09/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To identify glutamic pyruvic transaminase (GPT) and hepatitis B virus DNA (HBV-DNA) cut-off values at diagnosis in patients with hepatitis B virus e antigen-negative chronic infection (HBeAg(-)), which may be predictors of clinical course, prognosis and/or the need for antiviral therapy. METHODS A retrospective and observational cohort study of patients diagnosed with HBeAg(-) chronic infection (2005-2012). A normal GPT cut-off value at diagnosis that predicts abnormal GPT values in the clinical course of the infection, a baseline HBV-DNA cut-off value that predicts an increase in HBV-DNA above 2,000IU/ml, and GPT and HBV-DNA as predictors of the need for treatment were investigated using ROC curves. RESULTS 126 patients were enrolled (follow-up: 42.1±21.5months), 93 of which had normal GPT levels at diagnosis. In the ROC curve analysis, 900IU/ml was found to be the HBV-DNA cut-off value that best predicted this value's increase above 2,000IU/ml (sensitivity: 90%; specificity: 88%; PPV: 79%; NPV: 100%; diagnostic precision: 89%), while 25mU/ml was the normal GPT cut-off value at diagnosis that best predicted subsequently elevated GPT levels (sensitivity: 95.4%; specificity: 81.6%; PPV: 67%; NPV: 96%; diagnostic precision: 80.6%). Patients with GPT 26-40mU/ml at diagnosis presented with more complications or required more treatment than subjects with GPT≤25mU/ml (P<.05). The combined GPT and HBV-DNA values that elicited the highest treatment need were 38mU/ml of GPT and 6,000IU/ml of HBV-DNA (sensitivity: 75%; specificity: 93.4%; PPV: 60%; NPV: 96.6%). CONCLUSION HBeAg(-) patients with GPT<25mU/ml and HBV-DNA<900IU/ml at diagnosis have positive outcomes and may not require such stringent follow-up in the first years after diagnosis.
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Affiliation(s)
- Antonio Guardiola-Arévalo
- Servicio de Aparato Digestivo, Hospital Virgen de la Salud, Toledo, España; Servicio de Aparato Digestivo, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España.
| | | | | | - Ana Zaida Gómez Moreno
- Servicio de Aparato Digestivo, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - Almudena García Vela
- Servicio de Aparato Digestivo, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
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25
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Oliveri F, Surace L, Cavallone D, Colombatto P, Ricco G, Salvati N, Coco B, Romagnoli V, Gattai R, Salvati A, Moriconi F, Yuan Q, Bonino F, Brunetto MR. Long-term outcome of inactive and active, low viraemic HBeAg-negative-hepatitis B virus infection: Benign course towards HBsAg clearance. Liver Int 2017; 37:1622-1631. [PMID: 28296013 DOI: 10.1111/liv.13416] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/06/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The difference between the long-term outcome of low-viraemic (HBV-DNA≤20 000-IU/mL, LV-AC) and inactive HBsAg carriers (HBV-DNA≤2000-IU/mL, IC) remains to be defined. We studied prospectively 153 HBeAg-negative HBsAg-carriers with baseline HBV-DNA≤20 000-IU/mL and normal transaminases. METHODS IC, LV-AC or chronic hepatitis B (CHB) (HBV-DNA persistently ≤2000-IU/mL, ≤20 000-IU/mL or >20 000-IU/mL respectively) were diagnosed after 1-year, 3-monthly monitoring. Thereafter IC and LV-AC were followed-up for additional 57.2 (8.5-158.3) months. HBV-DNA, HBsAg, HBV"core-related"Antigen (HBcrAg) and total-anti-HBc were quantified at baseline. RESULTS After the 1st year diagnostic follow-up CHB [higher HBV-DNA (P=.005), total-anti-HBc (P=.012), ALT (P=.007) and liver-stiffness (P=.021)] was identified in 20 (13.1%) carriers; baseline HBsAg≤1000IU/HBV-DNA≤2000IU/mL excluded the presence of CHB (NPV-100%). Thereafter, during the long-term follow-up none of 87 IC reactivated, 19 (21.8%) cleared HBsAg [older-age (P=.004), lower HBsAg (P<.001), higher yearly HBsAg decline (P<.001)]. Twenty-five of 46 (54.3%) LV-AC remained stable, 20 (43.5%) became IC and 1 (2.2%) developed CHB. The best single-point CHB and IC diagnostic-accuracies were total-anti-HBc (84.2%, NPV-98.2%) and HBV-DNA/total-anti-HBc/HBcrAg combination (89.5%, 93%-sensitivity, 84.8%-specificity) respectively. CONCLUSIONS Viraemia persistently ≤20 000-IU/mL predicts a benign clinical outcome: it was associated with transition to IC in 43% of LV-AC and to Occult HBV Infection in 20% of IC within 5-years. Nevertheless, 13.1% of individuals with low viraemia at presentation develops CHB within 1 year: 1-year HBV-DNA monitoring resulted the most accurate diagnostic approach that can be limited to at least a half of cases by the single point HBV-DNA/HBsAg quantification. The IC-diagnostic-accuracy combining HBV-DNA/total-anti-HBc/HBcrAg needs to be confirmed in further studies.
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Affiliation(s)
- Filippo Oliveri
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Lidia Surace
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Daniela Cavallone
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Piero Colombatto
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Gabriele Ricco
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Nicola Salvati
- Department of Economics and Management, University of Pisa, Pisa, Italy
| | - Barbara Coco
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Veronica Romagnoli
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Riccardo Gattai
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Antonio Salvati
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Francesco Moriconi
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Quan Yuan
- National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health and School of Life Science, Xiamen University, Xiamen, China
| | - Ferruccio Bonino
- University of Pittsburgh Medical Center Institute for Health, Chianciano-Terme and Fondazione Italiana Fegato, AREA Science Park, Trieste, Italy
| | - Maurizia R Brunetto
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy.,Internal Medicine, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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26
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Coluccio C, Begini P, Marzano A, Pellicelli A, Imperatrice B, Anania G, Delle Fave G, Marignani M. Hepatitis B in patients with hematological diseases: An update. World J Hepatol 2017; 9:1043-1053. [PMID: 28951776 PMCID: PMC5596311 DOI: 10.4254/wjh.v9.i25.1043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 07/13/2017] [Accepted: 08/04/2017] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B virus (HBV) reactivation (HBVr) in patients undergoing immunosuppressive therapy is still a hot topic worldwide. Its prevention and management still represents a challenge for specialists dealing with immunosuppressed patients. Aim of this paper is to provide a critical review of the relevant information emerged in the recent literature regarding HBV reactivation following immunosuppressive treatments for oncohematological tumors. A computerized literature search in MEDLINE was performed using appropriate terms arrangement, including English-written literature only or additional relevant articles. Articles published only in abstract form and case reports not giving considerable news were excluded. Clinical manifestation of HBVr can be manifold, ranging from asymptomatic self-limiting anicteric hepatitis to life-threatening fulminant liver failure. In clusters of patients adverse outcomes are potentially predictable. Clinicians should be aware of the inherent risk of HBVr among the different virological categories (active carriers, occult HBV carriers and inactive carriers, the most intriguing category), and classes of immunosuppressive drugs. We recommend that patients undergoing immunosuppressive treatments for hematological malignancies should undergo HBV screening. In case of serological sign(s) of current or past infection with the virus, appropriate therapeutic or preventive strategies are suggested, according to both virological categories, risk of HBVr by immunosuppressive drugs and liver status. Either antiviral drug management and surveillance and pre-emptive approach are examined, commenting the current international recommendations about this debated issue.
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Affiliation(s)
- Chiara Coluccio
- Digestive and Liver Diseases Department, Sant’Andrea Hospital, School of Medicine and Psychology, Sapienza University, 00189 Rome, Italy
| | - Paola Begini
- Digestive and Liver Diseases Department, Sant’Andrea Hospital, School of Medicine and Psychology, Sapienza University, 00189 Rome, Italy
| | - Alfredo Marzano
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, 10126 Turin, Italy
| | | | - Barbara Imperatrice
- Digestive and Liver Diseases Department, Sant’Andrea Hospital, School of Medicine and Psychology, Sapienza University, 00189 Rome, Italy
| | - Giulia Anania
- Digestive and Liver Diseases Department, Sant’Andrea Hospital, School of Medicine and Psychology, Sapienza University, 00189 Rome, Italy
| | - Gianfranco Delle Fave
- Digestive and Liver Diseases Department, Sant’Andrea Hospital, School of Medicine and Psychology, Sapienza University, 00189 Rome, Italy
| | - Massimo Marignani
- Digestive and Liver Diseases Department, Sant’Andrea Hospital, School of Medicine and Psychology, Sapienza University, 00189 Rome, Italy
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27
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Sanai FM, Farah T, Albeladi K, Batwa F, Dahlan Y, Babatin MA, Al-Ashgar H, AlMana H, Alsaad KS, AlSwat K, Aljumah A, AlTraif IH, Kailani BE, Bzeizi KI. Diminished accuracy of biomarkers of fibrosis in low replicative chronic hepatitis B. BMC Gastroenterol 2017; 17:101. [PMID: 28841822 PMCID: PMC5574089 DOI: 10.1186/s12876-017-0658-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 08/17/2017] [Indexed: 12/19/2022] Open
Abstract
Background We evaluated the diagnostic accuracy of aspartate aminotransferase (AST)-to-platelet ratio index (APRI), fibrosis-4 index (FIB-4), AST/alanine aminotransferase (ALT) ratio (AAR), and age-platelet index (API) for significant fibrosis (Metavir F2–4) in low-replicative (HBV DNA <20,000 IU/mL) chronic hepatitis B virus (HBV) patients. Methods The sensitivity, specificity, and area under the receiver-operating characteristic curve (AUROC) of HBeAg-negative, low-replicative (n = 213) and high-replicative (HBV DNA ≥20,000 IU/mL, n = 153) patients was assessed. Results Overall, 113 patients (30.9%) had F2–4 fibrosis. Of the low and high-replicative patients, 40 (18.8%) and 73 (47.7%) had F2–4, respectively (P < 0.0001). APRI ≥0.5 less frequently identified F2–4 fibrosis in low vs. high-replicative patients (48.7% vs. 69.6%, P = 0.032) and AAR identified it more frequently in low-replicative patients (37.5% vs. 19.4%, P = 0.037). FIB-4 and API were not different (P > 0.05) for identifying F2–4 fibrosis in low and high-replicative patients. Higher specificities were seen at the lowest cut-offs in low vs. high-replicative states for APRI (≥0.5, 98% vs. 68.9%), AAR (84.3% vs. 76.6%), FIB-4 (≥1.45, 97.5% vs. 87.8%) and API (>4, 94.8% vs. 93.8%). At ROC-defined thresholds, APRI (≥0.33), AAR (≥0.93), FIB-4 (≥0.70) and API (>2) showed greater AUROCs for F2–4 diagnosis in low replicative (0.80, 0.62, 0.81 and 0.71, respectively) vs. high-replicative patients (0.73, 0.52, 0.67 and 0.69, respectively). Conclusion All 4 biomarkers in both, low and high-replicative HBV demonstrate modest accuracy for fibrosis diagnosis at conventional cut-offs. Lowering the cut-offs may increase the diagnostic relevance of these biomarkers, particularly for APRI and FIB-4 in low-replicative disease. Electronic supplementary material The online version of this article (doi:10.1186/s12876-017-0658-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Faisal M Sanai
- Liver Disease Research Center, King Saud University, Riyadh, Saudi Arabia. .,Gastroenterology Unit, Department of Medicine, King Abdulaziz Medical City, PO Box: 9515, Jeddah, 21423, Saudi Arabia.
| | - Taha Farah
- Gastroenterology Unit, Department of Medicine, King Abdulaziz Medical City, PO Box: 9515, Jeddah, 21423, Saudi Arabia
| | - Khalid Albeladi
- Gastroenterology Unit, Department of Medicine, King Abdulaziz Medical City, PO Box: 9515, Jeddah, 21423, Saudi Arabia
| | - Faisal Batwa
- Gastroenterology Unit, Department of Medicine, King Abdulaziz Medical City, PO Box: 9515, Jeddah, 21423, Saudi Arabia
| | - Yaser Dahlan
- Gastroenterology Unit, Department of Medicine, King Abdulaziz Medical City, PO Box: 9515, Jeddah, 21423, Saudi Arabia
| | - Mohammed A Babatin
- Division of Gastroenterology, Department of Medicine, King Fahad Hospital, Jeddah, Saudi Arabia
| | - Hamad Al-Ashgar
- Division of Gastroenterology, Department of Medicine, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Hadeel AlMana
- Department of Pathology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Khaled S Alsaad
- Department of Pathology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Khalid AlSwat
- Liver Disease Research Center, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman Aljumah
- Hepatobiliary Sciences & Liver Transplantation, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ibrahim H AlTraif
- Hepatobiliary Sciences & Liver Transplantation, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Bahaa E Kailani
- Gastroenterology Unit, Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Khalid I Bzeizi
- Department of Gastroenterology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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28
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Maasoumy B, Bremer B, Lehmann P, Marins EG, Michel-Treil V, Simon CO, Njoya M, Cornberg M, Paxinos E, Manns MP, Vermehren J, Sarrazin C, Sohn JY, Cho Y, Wedemeyer H. Commutability and concordance of four hepatitis B virus DNA assays in an international multicenter study. Therap Adv Gastroenterol 2017; 10:609-618. [PMID: 28835775 PMCID: PMC5557192 DOI: 10.1177/1756283x17722745] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/17/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND HBV DNA is the most important molecular marker in hepatitis B, used to determine treatment indication and monitoring. Most patients require lifelong hepatitis B virus (HBV) management, thus viral load (VL) monitoring may be performed at different laboratories, with different HBV assays, which may result in different VL results. This multicenter study compares the commutability and concordance of results from four different HBV DNA assays: CAP/CTM HBVv2, HPS/CTM HBVv2 and the new cobas 6800/8800 HBV and cobas 4800 HBV assays. METHODS Across all four assays, HBV limit of detection (LoD) and linearity at lower concentrations were assessed using panels traceable to the World Health Organization international standard, and concordance was investigated at the important medical decision cutoffs 2000 and 20,000 IU/ml, using specimens from HBV-positive patients. RESULTS The calculated LoD via a probit curve was 2.7 IU/ml for cobas 6800/8800 HBV, 2.8 IU/ml for cobas 4800 HBV, 9.6 IU/ml for CAP/CTM HBVv2, and 6.2 IU/ml for HPS/CTM HBVv2. The average accuracy was comparable between cobas 6800/8800 HBV, cobas 4800 HBV and CAP/CTM HBVv2 (0.04-0.05 log10 IU/ml), while a slightly lower accuracy was documented for HPS/CTM HBVv2 (-0.16 log10 IU/ml). A total of 211-245 clinical samples were used for a pairwise comparison. Mean paired log differences ranged from -0.17 log10 IU/ml to -0.01 log10 IU/ml. Coefficient of determination was over 98% for all pairs with high overall percent agreement at the 2000 and 20,000 IU/ml cutoffs (from 91.7% to 96.3%). In a subset of samples with VL±0.5 log10 to the 2000 and 20,000 IU/ml thresholds, concordance was still 72% and 82%, respectively. CONCLUSIONS The new cobas 6800/8800 HBV and 4800 HBV assays show high accuracy in samples with low-level viremia and a high concordance with the established HBV tests, CAP/CTM HBVv2 and HPS/CTM HBVv2, at 2000 and 20,000 IU/ml. Thus, all four HBV assays have high commutability and may be used interchangeably in routine clinical practice.
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Affiliation(s)
| | | | | | - Ed G. Marins
- Roche Molecular Systems Inc., Roche Diagnostics, Pleasanton, CA, USA
| | | | | | - Merlin Njoya
- Roche Molecular Systems Inc., Roche Diagnostics, Pleasanton, CA, USA
| | | | - Ellen Paxinos
- Roche Molecular Systems Inc., Roche Diagnostics, Pleasanton, CA, USA
| | | | | | | | - Ji Yeon Sohn
- Department of Laboratory Medicine, National Cancer Center, Goyang, Republic of Korea
| | - Yunjung Cho
- Korea University College of Medicine, Seoul, Republic of Korea
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Barut S, Gemici Ü, Güneş F, Demir O, Duygu F. Predictors of histological indication for treatment in HBeAg negative chronic HBV infection. J Med Virol 2017; 89:1952-1957. [PMID: 28618019 DOI: 10.1002/jmv.24879] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 06/07/2017] [Indexed: 12/22/2022]
Abstract
In this study, we evaluated the relationship of hepatitis B virus (HBV) DNA levels with liver histology and various other liver related parameters and the predictors of histologically active liver disease requiring treatment (Histological activity ≥6 and/or grade ≥2 by Ishak's classification) in patients with HBeAg negative chronic HBV infection. Demographic data, laboratory findings and liver histology findings of patients with no clinical cirrhosis who underwent liver biopsy considering HBeAg negative chronic hepatitis (HBV DNA >2000 IU/mL) were analyzed. Two hundred and fifteen patients were included in this retrospective study. Treatment indication by histologic findings were 85.7%, 61.2%, and 64%, respectively, in group 1 (HBV DNA ≥200 000), group 2 (HBV DNA 20 000-200 000), and group 3 (HBV DNA 2000-20 000 IU/mL) (P = 0.001). Group 1 was different from other groups in terms of aspartate aminotransferase (AST), alanine aminotransferase (ALT), fibrosis stage, necroinflammatory activity, and platelet count. Multiple logistic regression analysis revealed that, advanced age (cut-off was 46 years), higher than normal AST and HBV DNA ≥200 000 IU/mL (compared to group 3) were found to be the predictors of histologically active disease with treatment indication. Conclusively, most of the patients with HBV DNA ≥200 000 IU/mL showed treatment requiring liver injury, but also a significant portion of the patients with HBV DNA 2000-200 000 IU/mL carried an indication for treatment. Although age (>46 years) and AST (>40 IU/L) can be helpful to predict treatment requirement in patients with HBV DNA 2000-200 000 IU/mL, sufficient effort should be made to find out the significant liver damage.
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Affiliation(s)
- Sener Barut
- Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Gaziosmanpasa University, Tokat, Turkey
| | - Ümit Gemici
- Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Gaziosmanpasa University, Tokat, Turkey
| | - Ferdi Güneş
- Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Gaziosmanpasa University, Tokat, Turkey
| | - Osman Demir
- Faculty of Medicine, Department of Biostatistics, Gaziosmanpasa University, Tokat, Turkey
| | - Fazilet Duygu
- Department of Infectious Diseases and Clinical Microbiology, Ankara Onkology Training and Research Hospital, Ankara, Turkey
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Guardiola Arévalo A, Gómez Rodríguez R, Romero Gutiérrez M, Gómez Moreno AZ, García Vela A, Sánchez Simón R, Gómez Hernando C, Andrés Esteban EM. Characteristics and course of chronic hepatitis B e antigen-negative infection. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 40:59-69. [PMID: 28007350 DOI: 10.1016/j.gastrohep.2016.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 10/28/2016] [Accepted: 11/04/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe the epidemiological, analytical and histological characteristics and clinical course of hepatitis B virus (HBV) carriers with negative HBe antigen. MATERIAL AND METHODS Observational, retrospective cohort study of HBV carriers with negative HBe antigen (2005-2012), with no other causes of liver disease. RESULTS One hundred and thirty-eight patients were included, with mean age 40.5±12.2 years; 54% were women, and 38% were of foreign origin; the number of foreign patients significantly increased (P<.001) over the years. Transaminases were normal in nearly 75% and HBV-DNA was <2,000IU/ml in 56% of patients at diagnosis. There was a gradual decrease in HBV-DNA levels in inactive carriers over the study period. Fibrosis study was performed in 47% of patients by Fibroscan® or liver biopsy: 55.4% normal histology and 6.1% cirrhosis. Just over three quarters of patients (77.77%) were inactive carriers. Treatment was required in 15.5% of patients (20% because of cirrhosis and 80% HBeAg-negative chronic hepatitis B). Five patients cleared HBsAg (annual rate .94%), all of whom presented HBV-DNA <2,000IU/ml at diagnosis. Five patients developed complications (3.6%), 4 of them hepatocellular carcinoma (HCC), of which only 2 had cirrhosis. There was 1 HBV-related death (.72%). CONCLUSION Among HBV carriers with negative HBe antigen, inactive HBs-Ag carriers are predominant. HBV-DNA gradually decreases in the first few years after diagnosis. Morbidity and mortality are low, especially if glutamic pyruvic transaminase (GPT) is normal and HBV-DNA levels are low at diagnosis. Treatment is needed in a considerable number of patients. HCC is the most frequent complication, even in the absence of cirrhosis.
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Affiliation(s)
- Antonio Guardiola Arévalo
- Servicio de Aparato Digestivo, Hospital Virgen de la Salud, Toledo, España; Servicio de Aparato Digestivo, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España.
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Charatcharoenwitthaya P, Phisalprapa P, Pausawasdi N, Rungkaew P, Kajornvuthidej S, Bandidniyamanon W, Chotiyaputta W, Chainuvati S, Tanwandee T. Alanine aminotransferase course, serum hepatitis B virus DNA, and liver stiffness measurement for therapeutic decisions in hepatitis B e antigen-negative chronic hepatitis B. Hepatol Res 2016; 46:1347-1357. [PMID: 26946348 DOI: 10.1111/hepr.12693] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/15/2016] [Accepted: 02/29/2016] [Indexed: 12/14/2022]
Abstract
AIM To evaluate the utility of the combination of alanine aminotransferase (ALT) course, hepatitis B virus (HBV) DNA level, and liver stiffness measurement (LSM) for determining significant liver disease in hepatitis B e antigen (HBeAg)-negative patients. METHODS Three hundred and ninety nine consecutive HBeAg-negative patients with HBV DNA >2000 IU/mL and documented serial measurements of ALT were enrolled to undergo LSM followed by liver biopsy. RESULTS Using ALT <40 IU/L as a normal value, 142 patients had persistently normal ALT (PNALT), whereas 257 had persistently or intermittently elevated ALT (PIEALT) in the prior year. Among patients with HBV DNA of 2000-19 999, 20 000-199 999, and ≥200 000 IU/mL, significant pathological lesions defined as the presence of moderate to severe necroinflammation and/or significant fibrosis by METAVIR scoring was present in 40%, 45%, and 71% of the PIEALT group, and 15%, 31%, and 36% of the PNALT group, respectively. In PNALT patients with HBV DNA <20 000 IU/mL, liver biopsy could be avoided in 88% when LSM <7 kPa is used as an indicator of non-significant liver histology but 12% of those who indeed had significant pathological lesions would be missed. In PIEALT patients with HBV DNA ≥20 000 IU/mL, the need for liver biopsy could be reduced by 53% with a false positive rate of 14% when LSM ≥7 kPa is used as a predictor of significant pathological lesions. CONCLUSION The combination of serial ALT, viral load, and LSM appears to be a promising non-invasive tool. A management algorithm for HBeAg-negative patients comprising these non-invasive measures is proposed with liver biopsy being pursued in selected cases.
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Affiliation(s)
| | | | | | - Pimpattana Rungkaew
- Department of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sorrayut Kajornvuthidej
- Department of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Histologic Disease in Chinese Chronic Hepatitis B Patients With Low Viral Loads and Persistently Normal Alanine Aminotransferase Levels. J Clin Gastroenterol 2016; 50:790-6. [PMID: 27182648 DOI: 10.1097/mcg.0000000000000544] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM We aimed to evaluate the histopathologic characteristics of HBeAg-negative chronic hepatitis B patients with low hepatitis B virus (HBV) DNA levels (<2000 IU/mL) and persistently normal ALT levels and to determine indicators of significant liver disease. METHODS We examined 102 consecutive subjects who underwent percutaneous liver biopsy. Significant predictors of liver disease (stage ≥2 fibrosis or stage 1 fibrosis plus grade ≥2 inflammation), including demographic, clinical, and laboratory variables, were evaluated by means of univariate and multivariate logistic regression analyses. RESULTS Among the patients, 75.5% (77/102) had grade 0-1 inflammation and 77.5% (79/102) had stage 0-1 fibrosis. However, 38.2% (39/102) had significant liver disease. There were no statistically significant differences in clinical parameters such as age, biochemical profile, HBV DNA levels, HBsAg levels, and platelet count between patients with significant and those with nonsignificant liver disease. Patients with significant liver disease had higher values of aspartate transferase-to-platelet ratio index (APRI) and FIB-4 index compared with those with nonsignificant liver disease (0.35±0.21 vs. 0.27±0.12, P=0.02; 1.58±0.97 vs. 1.13±0.54, P=0.009, respectively). The area under the receiver operating characteristic (AUROC) curve of APRI for identifying active liver histology was 0.64 (95% CI, 0.53-0.75; P=0.019); the cutoff value was 0.24 with a sensitivity of 74% and specificity of 55%. In comparison, FIB-4 had equal power (the AUROC was 0.66) in predicting active liver histology. CONCLUSION Among patients presenting with low HBV DNA levels and normal ALT levels, about 38.2% had significant liver disease. Neither serum HBsAg nor HBV DNA levels correlate with liver histology. However, APRI≥0.24 might be considered an indicator of liver biopsy.
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Serum metabolomic signatures discriminate early liver inflammation and fibrosis stages in patients with chronic hepatitis B. Sci Rep 2016; 6:30853. [PMID: 27498553 PMCID: PMC4976343 DOI: 10.1038/srep30853] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 07/08/2016] [Indexed: 02/06/2023] Open
Abstract
Chronic HBV (CHB) infected patients with intermediate necroinflammation and fibrosis are recommended to receive antiviral treatment. However, other than liver biopsy, there is a lack of sensitive and specific objective method to determine the necroinflammation and fibrosis stages in CHB patients. This study aims to identify unique serum metabolomic profile associated with histological progression in CHB patients and to develop novel metabolite biomarker panels for early CHB detection and stratification. A comprehensive metabolomic profiling method was established to compare serum samples collected from health donor (n = 67), patients with mild (G < 2 and S < 2, CHB1, n = 52) or intermediate (G ≥ 2 or S ≥ 2, CHB2, n = 36) necroinflammation and fibrosis. Multivariate models were developed to differentiate CHB1 and CHB2 from controls. A set of CHB-associated biomarkers was identified, including lysophosphatidylcholines, phosphatidylcholines, phosphatidylinositol, phosphatidylserine, and bile acid metabolism products. Stratification of CHB1 and CHB2 patients by a simple logistic index, the PIPSindex, based on phosphatidylinositol (PI) and phosphatidylserine (PS), was achieved with an AUC of 0.961, which outperformed all currently available markers. A panel of serum metabolites that differentiate health control, CHB1 and CHB2 patients has been identified. The proposed metabolomic biosignature has the potential to be used as indicator for antiviral treatment for CHB management.
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Lei JH, Tian Y, Luo HY, Chen Z, Peng F. Guillain-Barré syndrome following acute co-super-infection of hepatitis E virus and cytomegalovirus in a chronic hepatitis B virus carrier. J Med Virol 2016; 89:368-372. [PMID: 27358107 DOI: 10.1002/jmv.24620] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2016] [Indexed: 12/18/2022]
Abstract
Guillain-Barré syndrome (GBS) is a rare neurological complication of hepatitis B. GBS presence in acute hepatitis E virus (HEV) and cytomegalovirus (CMV) infection is also sporadically reported. Here, a rare case of GBS in a chronic Hepatitis B virus carrier co-infected with HEV and CMV was reported. Based on the analysis on the progress of the manifestations and virus serological detection results, it could be concluded that GBS might mostly likely result from super-infection of HEV and CMV. This case report is clinically important in that it provides a good example of differential diagnosis and appropriate treatment on such a rare but life-threatening case. J. Med. Virol. 89:368-372, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jian-Hua Lei
- Department of Infectious Diseases, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Yi Tian
- Department of Infectious Diseases, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Hong-Yu Luo
- Department of Infectious Diseases, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Zi Chen
- Department of Infectious Diseases, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Feng Peng
- Department of Infectious Diseases, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
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Safaie P, Poongkunran M, Kuang PP, Javaid A, Jacobs C, Pohlmann R, Nasser I, Lau DTY. Intrahepatic distribution of hepatitis B virus antigens in patients with and without hepatocellular carcinoma. World J Gastroenterol 2016; 22:3404-3411. [PMID: 27022222 PMCID: PMC4806198 DOI: 10.3748/wjg.v22.i12.3404] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/09/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the intrahepatic expression of hepatitis B surface antigen (HBsAg) and hepatitis B core antigen (HBcAg) in chronic hepatitis B patients with and without hepatocellular carcinoma.
METHODS: A total of 33 chronic hepatitis B patients (mean age of 40.3 ± 2.5 years), comprising of 14 HBeAg positive and 19 HBeAg negative patients; and 13 patients with hepatitis B virus related hepatocellular carcinoma (mean age of 49.6 ± 4.7 years), were included in our study. Immunohistochemical staining for HBcAg and HBsAg was done using standard streptavidin-biotin-immunoperoxidase technique on paraffin-embedded liver biopsies. The HBcAg and HBsAg staining distributions and patterns were described according to a modified classification system.
RESULTS: Compared to the HBeAg negative patients, the HBeAg positive patients were younger, had higher mean HBV DNA and alanine transaminases levels. All the HBeAg positive patients had intrahepatic HBcAg staining; predominantly with “diffuse” distribution (79%) and “mixed cytoplasmic/nuclear” pattern (79%). In comparison, only 5% of the HBeAg-negative patients had intrahepatic HBcAg staining. However, the intrahepatic HBsAg staining has wider distribution among the HBeAg negative patients, namely; majority of the HBeAg negative cases had “patchy” HBsAg distribution compared to “rare” distribution among the HBeAg positive cases. All but one patient with HCC were HBeAg negative with either undetectable HBV DNA or very low level of viremia. Intrahepatic HBcAg and HBsAg were seen in 13 (100%) and 10 (77%) of the HCC patients respectively. Interestingly, among the 9 HCC patients on anti-viral therapy with suppressed HBV DNA, HBcAg and HBsAg were detected in tumor tissues but not the adjacent liver in 4 (44%) and 1 (11%) patient respectively.
CONCLUSION: Isolated intrahepatic HBcAg and HBsAg can be present in tumors of patients with suppressed HBV DNA on antiviral therapy; that may predispose them to cancer development.
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Martinot-Peignoux M, Marcellin P. Virological and serological tools to optimize the management of patients with chronic hepatitis B. Liver Int 2016; 36 Suppl 1:78-84. [PMID: 26725902 DOI: 10.1111/liv.12998] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 10/24/2015] [Indexed: 02/06/2023]
Abstract
Molecular biology techniques are routinely used to diagnose and monitor treatment in patients with chronic hepatitis B (CHB). These tools can detect and quantify viral genomes and analyse their sequences to determine genotype. The increasing use of these tools to monitor patients has greatly improved the management of CHB infection by maximizing the potential for individualized treatment. HBV genotyping has become increasingly important and provides additional information to predict a response to therapy. More sensitive methods to determine HBV DNA levels are now available and the units of measurements have been standardized. HBsAg levels in serum have been shown to reflect active intrahepatic covalently closed circular DNA (cccDNA) and to have additional value in treatment decisions, especially as an on-treatment marker.
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Affiliation(s)
- Michelle Martinot-Peignoux
- INSERM, UMR1149, Centre de Recherche sur l'Inflammation, Paris, France.,Université Denis Diderot Paris 7, Paris, France
| | - Patrick Marcellin
- INSERM, UMR1149, Centre de Recherche sur l'Inflammation, Paris, France.,Université Denis Diderot Paris 7, Paris, France.,Service d'Hépatologie, Hôpital Beaujon AP-HP, Clichy Cedex, France
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Invernizzi F, Viganò M, Grossi G, Lampertico P. The prognosis and management of inactive HBV carriers. Liver Int 2016; 36 Suppl 1:100-4. [PMID: 26725905 DOI: 10.1111/liv.13006] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 10/30/2015] [Indexed: 12/13/2022]
Abstract
Patients with chronic hepatitis B virus (HBV) infection lacking the serum hepatitis B e antigen (HBeAg) and with antibodies against HBeAg (anti-HBe), are the prevalent subgroup of HBV carriers worldwide. The prognosis of these patients is different from inactive carriers (ICs), who are characterized by persistently normal serum alanine aminotransferase (ALT) and low (<2000 IU/ml) serum HBV DNA levels, a serological profile that may also be intermittently observed in patients with HBeAg-negative chronic hepatitis. This is why a confirmed diagnosis of IC requires quarterly ALT and HBV DNA measurements for at least 1 year, while a single-point detection of combined HBsAg <1000 IU/ml and HBV DNA <2000 IU/ml has a robust predictive value for the diagnosis of IC. Characteristically, ICs have minimal or no histological lesions of the liver corresponding to liver stiffness values on Fibroscan of <5 kPa. Antiviral treatment is not indicated in ICs since the prognosis for the progression of liver disease is favourable if there are no cofactors of liver damage such as alcohol abuse, excess weight or co-infection with the hepatitis C virus or delta virus. Moreover, spontaneous HBsAg loss frequently occurs (1-1.9% per year) in these patients while the development of hepatocellular carcinoma (HCC) is rare, at least in Caucasian patients. However, an emerging issue reinforcing the need for clinical surveillance of ICs is the risk of HBV reactivation in patients who undergo immunosuppressive therapy without receiving appropriate antiviral prophylaxis. After diagnosis, management of ICs includes monitoring of ALT and HBV DNA every 12 months with periodic measurement of serum HBsAg levels to identify viral clearance.
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Affiliation(s)
- Federica Invernizzi
- 'A. M. and A. Migliavacca' Center for Liver Disease, Division of Gastroenterology and Hepatology Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università di Milano, Milano, Italy
| | - Mauro Viganò
- Hepatology Unit, Ospedale San Giuseppe, Università degli Studi di Milano, Milano, Italy
| | - Glenda Grossi
- 'A. M. and A. Migliavacca' Center for Liver Disease, Division of Gastroenterology and Hepatology Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università di Milano, Milano, Italy
| | - Pietro Lampertico
- 'A. M. and A. Migliavacca' Center for Liver Disease, Division of Gastroenterology and Hepatology Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università di Milano, Milano, Italy
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Tan Y, Ye Y, Zhou X, Chen L, Wen D. Age as a predictor of significant fibrosis features in HBeAg-negative chronic hepatitis B virus infection with persistently normal alanine aminotransferase. PLoS One 2015; 10:e0123452. [PMID: 25885705 PMCID: PMC4401737 DOI: 10.1371/journal.pone.0123452] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 03/04/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although alanine aminotransferase (ALT) levels reflect the degree of liver damage, not all patients with chronic hepatitis B virus (HBV) infection exhibit persistently elevated ALT levels. In the present study, we aimed to comprehensively evaluate the characteristics of histological abnormalities in a large population of Chinese patients with chronic HBV and persistently normal ALT levels. METHODS In total, 2303 consecutive patients who underwent liver biopsy were screened. Of these patients, 273 were categorized as having persistently normal ALT levels (PNALT), whereas 618 were categorized as having persistently or intermittently elevated ALT levels (PIALT). All these patients had at least three ALT values recorded in the year prior to the baseline liver biopsy. RESULTS Significant necroinflammation was observed in 9.7% (11/113) patients with PNALT, 23.3% (42/180) patients with PIALT (ALT 1-2× upper limit of normal [ULN]), and 27.8% (42/151) patients with PIALT (ALT > 2× ULN), whereas significant fibrosis was observed in 8.8% (10/113) patients with PNALT, 27.8% (42/151) patients with PIALT (ALT 1-2× ULN), and 21.2% (32/151) patients with PIALT (ALT > 2× ULN). Multiple logistic regression analysis indicated that age parameters were associated with significant histological abnormalities in patients with PNALT. The area under the curve showed that age was associated with significant fibrosis characteristics in patients with hepatitis B extracellular antigen (HBeAg)-negative PNALT. CONCLUSION Significant histological abnormalities are not often observed in Chinese patients with PNALT. Interestingly, age appears to be a predictor of significant fibrosis in patients with HBeAg-negative PNALT.
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Affiliation(s)
- Youwen Tan
- Department of Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Hepatosis, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang, China
- * E-mail:
| | - Yun Ye
- Department of Hepatosis, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang, China
| | - Xinbei Zhou
- Department of Hepatosis, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang, China
| | - Li Chen
- Department of Hepatosis, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang, China
| | - Danfeng Wen
- Department of Hepatosis, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang, China
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Elefsiniotis I, Vezali E, Vrachatis D, Hatzianastasiou S, Pappas S, Farmakidis G, Vrioni G, Tsakris A. Post-partum reactivation of chronic hepatitis B virus infection among hepatitis B e-antigen-negative women. World J Gastroenterol 2015; 21:1261-1267. [PMID: 25632200 PMCID: PMC4306171 DOI: 10.3748/wjg.v21.i4.1261] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 08/20/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the frequency and timing of post-partum chronic hepatitis B virus (HBV) reactivation and identify its pre-partum predictors.
METHODS: Forty-one hepatitis B e antigen (HBeAg)-negative chronic HBV infected pregnant women were prospectively evaluated between the 28th and the 32nd week of gestation. Subjects were re-evaluated at 3-mo intervals during the first post-partum year and every 6 mo during the following years. HBV DNA was determined using real-time reverse transcription polymerase chain reaction (Cobas TaqMan HBV Test) with a lower detection limit of 8 IU/mL. Post-partum reactivation (PPR) was defined as abnormal alanine aminotransaminase (ALT) levels and HBV DNA above 2000 IU/mL.
RESULTS: Fourteen out of 41 women (34.1%) had pre-partum HBV DNA levels > 2000 IU/mL, 18 (43.9%) had levels < 2000 IU/mL and 9 (21.9%) had undetectable levels. Fourteen women were lost to follow-up (failure to return). PPR occurred in 8 of the 27 (29.6%) women evaluated, all within the first 6 mo after delivery (5 at month 3; 3 at month 6). Five of the 6 (83.3%) women with pre-partum HBV DNA > 10000 IU/mL exhibited PPR compared with 3 of the 21 (14.3%) women with HBV DNA < 10000 IU/mL (two with HBV DNA > 2000 and the third with HBV DNA of 1850 IU/mL), P = 0.004. An HBV DNA level ≥ 10000 IU/mL independently predicted post-partum HBV infection reactivation (OR = 57.02, P = 0.033). Mean pre-partum ALT levels presented a non-significant increase in PPR cases (47.3 IU/L vs 22.2 IU/L, respectively, P = 0.094).
CONCLUSION: In the present study, PPR occurred in approximately 30% of HBeAg-negative pregnant women; all events were observed during the first semester after delivery. Pre-partum HBV DNA level > 10000 IU/mL predicted PPR.
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Raihan R, Tabassum S, Al-Mahtab M, Nessa A, Jahan M, Shamim Kabir CM, Kamal M, Cesar Aguilar J. Hepatitis B Core Antigen in Hepatocytes of Chronic Hepatitis B: Comparison between Indirect Immunofluorescence and Immunoperoxidase Method. Euroasian J Hepatogastroenterol 2015; 5:7-10. [PMID: 29201677 PMCID: PMC5578511 DOI: 10.5005/jp-journals-10018-1120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 08/09/2014] [Indexed: 12/03/2022] Open
Abstract
Background Hepatitis B virus (HBV) infection has many faces. Precore and core promoter mutants resemble inactive carrier status. The identification of hepatitis B core antigen (HBcAg) in hepatocytes may have variable clinical significance. The present study was undertaken to detect HBcAg in chronic hepatitis B (CHB) patients and to assess the efficacy of detection system by indirect immunofluorescence (IIF) and indirect immunoperoxidase (IIP). Materials and methods The study was done in 70 chronic HBV-infected patients. Out of 70 patients, eight (11.4%) were hepatitis B e antigen (HBeAg) positive and 62 (88.57%) were HBeAg negative. Hepatitis B core antigen was detected by indirect immunofluorescence (IIF) and indirect immunoperoxidase (IIP) methods in liver tissue. Results All HBeAg positive patients expressed HBcAg by both IIF and IIP methods. Out of 62 patients with HBeAg-negative CHB, HBcAg was detected by IIF in 55 (88.7%) patients and by IIP in 51 (82.26%) patients. A positive relation among viral load and HBcAg detection was also found. This was more evident in the case of HBeAg negative patients and showed a positive relation with HBV DNA levels. Conclusion Hepatitis B core antigen can be detected using the IIF from formalin fixed paraffin block preparation and also by IIP method. This seems to reflect the magnitudes of HBV replication in CHB. How to cite this article Raihan R, Tabassum S, Al-Mahtab M, Nessa A, Jahan M, Kabir CMS, Kamal M, Aguilar JC. Hepatitis B Core Antigen in Hepatocytes of Chronic Hepatitis B: Comparison between Indirect Immunofluorescence and Immunoperoxidase Method. Euroasian J Hepato-Gastroenterol 2015;5(1):7-10.
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Affiliation(s)
- Ruksana Raihan
- Department of Microbiology, Faculty of Medicine, AIMST University, Bedong, Kedah, Malaysia.,Department of Virology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh
| | - Shahina Tabassum
- Department of Microbiology, Faculty of Medicine, AIMST University, Bedong, Kedah, Malaysia
| | - Mamun Al-Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh
| | - Afzalun Nessa
- Department of Virology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh
| | - Munira Jahan
- Department of Virology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh
| | | | - Mohammad Kamal
- Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh
| | - Julio Cesar Aguilar
- Department of Biomedical Research, Centre for Genetic Engineering and Biotechnology, Havana City, Cuba
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Jia W, Song LW, Fang YQ, Wu XF, Liu DY, Xu C, Wang XM, Wang W, Lv DX, Li J, Deng YQ, Wang Y, Huo N, Yu M, Xi HL, Liu D, Zhou YX, Wang GQ, Xia NS, Zhang MX. Antibody to hepatitis B core antigen levels in the natural history of chronic hepatitis B: a prospective observational study. Medicine (Baltimore) 2014; 93:e322. [PMID: 25546679 PMCID: PMC4602587 DOI: 10.1097/md.0000000000000322] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Previous studies have revealed antibody to hepatitis B core antigen (anti-HBc) levels as a predictor of treatment response in hepatitis B early antigen (HBeAg)-positive chronic hepatitis B (CHB) patients in both interferon and nucleos(t)ide analog therapy cohorts. However, there is no information about anti-HBc levels in the natural history of CHB. This study aimed to define anti-HBc levels of different phases in the natural history of CHB. Two hundred eleven treatment-naive CHB patients were included in the study. They were classified into 4 phases: immune tolerance (IT) phase (n = 39), immune clearance (IC) phase (n = 48), low or no-replicative (LR) phase (n = 55), and HBeAg-negative hepatitis (ENH, n = 69). Fifty patients who were HBsAg negative and anti-HBc positive were also recruited as past HBV infection (PBI) control group. Anti-HBc levels were measured by a newly developed double-sandwich immunoassay. Correlation of anti-HBc levels with alanine aminotransferase (ALT) and other HBV-related markers within each phase was performed. Serum anti-HBc levels were statistically significant between patients in different phases of CHB (P < 0.001). The median anti-HBc levels were: IT (3.17 log 10 IU/mL), IC (4.39 log 10 IU/mL), LR (3.29 log 10 IU/mL), ENH (4.12 log 10 IU/mL), and PBI (0.61 log 10 IU/mL). There existed a strong correlation in IC (r = 0.489, P < 0.001), a poor correlation in ENH (r = 0.275, P = 0.042), and no correlation in patients with ALT reached 5 times upper limit of normal (r = 0.120, P = 0.616). Anti-HBc levels show significant differences during the natural course of CHB. These results may provide some potentially useful insights into hepatitis B pathogenesis and immune activation against hepatitis B virus.
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Affiliation(s)
- Wei Jia
- From the Center for Liver Diseases and Department of Infectious Diseases (WJ, Y-QF, JL, Y-QD, YW, NH, MY, H-LX, DL, Y-XZ, G-QW), Peking University First Hospital, Beijing; State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics (L-WS, N-SX), National Institute of Diagnostics and Vaccine Development in Infectious Diseases, Xiamen UniversityFujian; and Department of Infectious Diseases (X-FW, D-YL, CX, X-MW, WW, D-XL, M-XZ), Sixth Hospital of ShenyangLiaoning, China
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Constantinescu I, Dinu AA, Boscaiu V, Niculescu M. Hepatitis B virus core promoter mutations in patients with chronic hepatitis B and hepatocellular carcinoma in bucharest, romania. HEPATITIS MONTHLY 2014; 14:e22072. [PMID: 25477976 PMCID: PMC4250966 DOI: 10.5812/hepatmon.22072] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/10/2014] [Accepted: 09/26/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Accurate and personalized molecular virological diagnosis of hepatitis B virus (HBV) infection is crucial for individualized selection of patients for antiviral therapy in Romania. OBJECTIVES We aimed to investigate HBV mutations in Romanian patients with chronic HBV infection, also to match HBV genotypes with HBV mutations identified and clinical outcomes. PATIENTS AND METHODS This was a cross-sectional study. A total of 484 Romanian patients with chronic HBV infection and hepatocellular carcinoma (HCC) were investigated. This was performed in Fundeni Clinical Institute, Bucharest, Romania during January 2005 to August 2010. HBsAg positive patients with chronic HBV infection admitted to Fundeni Clinical Institute were randomly enrolled in the study. Analysis was performed in the Centre for Immunogenetics and Virology, Fundeni Clinical Institute, Bucharest, Romania. Indirect diagnosis was performed with enhanced chemiluminescence method using Architect i2000SR and HBV-DNA was quantified with COBAS TaqMan HBV PCR. Direct sequencing of the PCR-products was performed with the PCR-product sequencing kit. HBV genotyping was performed with INNO-LiPA DR Amplification and INNO-LiPA HBV precore-core. RESULTS We detected two HBV genotypes; A (8.1%) and D (60.5%), and a mixture of genotypes A and D (31.4%) (P < 0.001). Basal core promoter (BCP) A1762T/G1764A and precore (PC) G1896A mutations were detected in these Romanian patients with chronic HBV infection. HBV chronic carriers had mainly genotype D (54.4%) and HBV WT (64.0%). BCP A1762T, G1764A and PC G1896A were significantly associated with HCC-tissue HBV sequencing (75.3%) (P < 0.001). PC G1896A alone was detected in HCC-serum HBV sequencing group (66.7%). CONCLUSIONS Genotype D was the main genotype detected in Romanian patients with chronic HBV infection. Genotype D presented both BCP and PC mutations more frequently.
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Affiliation(s)
- Ileana Constantinescu
- Immunology of Transplantation Discipline, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Center for Immunogenetics and Virology, Fundeni Clinical Institute, Bucharest, Romania
- Corresponding Author: Ileana Constantinescu, Centre for Immunogenetics and Virology, Fundeni Clinical Institute, Bucharest, Romania. Tel: +40-744341984, Fax: +40-213180448, E-mail:
| | - Andrei-Antoniu Dinu
- Center for Immunogenetics and Virology, Fundeni Clinical Institute, Bucharest, Romania
| | - Voicu Boscaiu
- “Gheorghe Mihoc-Caius Iacob” Institute of Statistics and Applied Mathematics, Bucharest, Romania
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Andrade JR, Silva LD, Guimarães CM, Bassetti-Soares E, Cambraia RD, Couto OFM, Teixeira R. Chronic hepatitis B and liver schistosomiasis: a deleterious association. Trans R Soc Trop Med Hyg 2014; 108:159-64. [PMID: 24535152 DOI: 10.1093/trstmh/tru010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Chronic hepatitis B (CHB) and schistosomiasis are prevalent in several countries, but the impact of this association is unknown. We aimed to investigate the prevalence and morbidity of this co-infection in Minas Gerais, an endemic area of schistosomiasis in Brazil. METHODS In total, 406 adults with CHB (HBsAg positive >6 months) were included in a cross-sectional study. CHB was classified as replicative (HBV DNA ≥ 2.000 IU/ml), and low replicative or inactive hepatitis B carriers (HBV DNA <2.000 IU/ml). Schistosomiasis was confirmed by epidemiological and clinical records. Liver biopsies were scored by METAVIR. The risk of severe fibrosis was estimated by multivariate analysis. RESULTS Of the 406 patients, 64.8% (263) were male, and the median age was 45 years (IQR 35-54). In total, 57.9% (235) had replicative CHB, and 31.5% (128) had cirrhosis. Schistosoma mansoni was confirmed in 30.5% (124) patients, 81.5% (101) of which were male with a median age of 47 years (IQR 39.5-54). Of the co-infected patients, 61.3% (76) and 38.7% (48) had replicative and inactive CHB, respectively. Schistosomal portal fibrosis (PF) was detected in 69.4% (86/124) patients. Patients with replicative CHB and schistosomal PF had more advanced fibrosis and severe inflammation compared with patients without schistosomal PF (80.8% vs 43.6% for METAVIR F3-F4, p<0.01; 64.0% vs 39.8% for METAVIR A2-A3, p < 0.01). Age >50 years (OR = 1.10; 95% CI 1.06-1.14, p<0.001), male gender (OR = 2.61, 95% CI 1.12-6.09, p = 0.03), schistosomal PF (OR = 4.56, 95% CI 2.10-9.91, p<0.001) and alcoholism (OR = 2.46, 95% CI 1.16-5.19, p = 0.02) were independently associated with cirrhosis. CONCLUSIONS The association between replicative CHB and schistosomal PF can be a risk factor for more severe liver disease, which can result in deleterious outcomes for patients from endemic areas.
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Affiliation(s)
- J R Andrade
- Viral Hepatitis Center, Gastroenterology Unit, Clinical Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil
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Mamun-Al-Mahtab, Akbar SMF, Uddin H, Khan SI, Rahman S. Early termination of immune tolerance state of hepatitis B virus infection explains liver damage. World J Hepatol 2014; 6:621-625. [PMID: 25232455 PMCID: PMC4163745 DOI: 10.4254/wjh.v6.i8.621] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 05/23/2014] [Accepted: 06/11/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess an early termination of immune tolerance state of chronic hepatitis B virus infection in Bangladesh and its clinical significance.
METHODS: From a series of 167 treatment-naive chronic hepatitis B patients aged between 12 to 20 years (mean ± SD; 17.5 ± 2.8 years), percutaneous liver biopsies of 89 patients who were all hepatitis B e antigen negative at presentation were done. Of them, 81 were included in the study. They had persistently normal or raised serum alanine aminotransferase (ALT) values. A precore mutation (PCM) study was accomplished in 8 patients who were randomly selected.
RESULTS: Forty-four (53.7%) patients had significant necroinflammation (HAI-NI > 7), while significant fibrosis (HAI-F ≥ 3) was seen in 15 (18.5%) patients. Serum ALT (cut off 42 U/L) was raised in 29 (35.8%) patients, while low HBV DNA load (< 105 copies/mL) was observed in 57 (70.4%) patients. PCM was negative in all 8 patients.
CONCLUSION: This study indicates that the current concept of age-related immune tolerance state of HBV infection deserves further analyses in different population groups.
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Zeng LY, Lian JS, Chen JY, Jia HY, Zhang YM, Xiang DR, Yu L, Hu JH, Lu YF, Zheng L, Li LJ, Yang YD. Hepatitis B surface antigen levels during natural history of chronic hepatitis B: A Chinese perspective study. World J Gastroenterol 2014; 20:9178-9184. [PMID: 25083092 PMCID: PMC4112899 DOI: 10.3748/wjg.v20.i27.9178] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 04/23/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the baseline hepatitis B surface antigen (HBsAg) levels during the different phases of chronic hepatitis B (CHB) patients in China.
METHODS: Six hundred and twenty-three hepatitis B virus or un-infected patients not receiving antiviral therapy were analyzed in a cross-sectional study. The CHB patients were classified into five phases: immune-tolerant (IT, n = 108), immune-clearance (IC, n = 161), hepatitis B e antigen negative hepatitis (ENH, n = 149), low-replicative (LR, n = 135), and liver cirrhosis (LC, n = 70). HBsAg was quantified (Abbott ARCHITECT assay) and correlated with hepatitis B virus (HBV) DNA, and serum alanine aminotransferase/aspartate aminotransferase (ALT/AST) in each phase of CHB was also determined.
RESULTS: Median HBsAg titers were different in each phase of CHB (P < 0.001): IT (4.85 log10 IU/mL), IC (4.36 log10 IU/mL), ENH (2.95 log10 IU/mL), LR (3.18 log10 IU/mL) and LC (2.69 log10 IU/mL). HBsAg titers were highest in the IT phase and lowest in the LC phase. Serum HBsAg titers showed a strong correlation with HBV viral load in the IC phase (r = 0.683, P < 0.001). No correlation between serum HBsAg level and ALT/AST was observed.
CONCLUSION: The mean baseline HBsAg levels differ significantly during the five phases of CHB, providing evidence on the natural history of HBV infection. HBsAg quantification may predict the effects of immune-modulator or oral nucleos(t)ide analogue therapy.
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Papatheodoridis GV, Manolakopoulos S, Margariti A, Papageorgiou MV, Kranidioti H, Katoglou A, Kontos G, Adamidi S, Kafiri G, Deutsch M, Pectasides D. The usefulness of transient elastography in the assessment of patients with HBeAg-negative chronic hepatitis B virus infection. J Viral Hepat 2014; 21:517-24. [PMID: 24750382 DOI: 10.1111/jvh.12176] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 08/15/2013] [Indexed: 12/09/2022]
Abstract
Histological severity is often mandatory for the management of HBeAg-negative chronic HBV patients. We evaluated the performance of transient elastography (TE) in this setting. We included 357 untreated HBeAg-negative patients with ≥ 1 reliable liver stiffness measurement (LSM-kPa) by TE: 182 inactive carriers with HBV-DNA < 2000 (n = 139) or 2000-19 999 IU/mL (n = 43) and 175 patients with chronic hepatitis B (CHB). In carriers, HBV-DNA > 2000 and/or LSM > 6.5 were considered as biopsy indications. LSMs did not differ between carriers with low and high viremia, but were lower in carriers than in patients with CHB (5.8 ± 1.7 vs 9.0 ± 5.6, P < 0.001) offering moderate differentiation between these two groups (AUROC: 0.705). LSMs did not change significantly in carriers after 16 (12-24) months. In carriers with a liver biopsy, Ishak's staging scores were similar between cased with low and high viremia but higher in cases with LSM > 6.5 than ≤ 6.5 kPa. Moderate fibrosis (stages: 2-3) was detected in 0/10 carriers with only HBV-DNA > 2000 IU/mL, 2/10 (20%) carriers with only LSM > 6.5 and 5/10 (50%) carriers with both HBV-DNA > 2000 and LSM > 6.5 (P = 0.009). In patients with CHB, LSMs correlated significantly with grading and staging scores and offered excellent accuracy for ≥ moderate, ≥ severe fibrosis or cirrhosis (AUROC ≥ 0.919-0.950). TE can be helpful for the noninvasive assessment of HBeAg-negative chronic HBV patients. In conclusion, LSMs offer excellent accuracy for fibrosis severity in HBeAg-negative patients with CHB and can identify carriers with high risk of moderate fibrosis, which may be present in up to 35% of carriers with LSM > 6.5 kPa and 50% of carriers with LSM > 6.5 kPa and HBV-DNA > 2000 IU/mL.
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Affiliation(s)
- G V Papatheodoridis
- 2nd Department of Internal Medicine, Athens University Medical School, 'Hippokration' General Hospital of Athens, Athens, Greece
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Poor adherence to AASLD guidelines for chronic hepatitis B Management and treatment in a large academic medical center. Am J Gastroenterol 2014; 109:867-75. [PMID: 24732869 PMCID: PMC4624277 DOI: 10.1038/ajg.2014.72] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 02/04/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Adherence to the American Association for the Study of Liver Disease (AASLD) guidelines for the management of chronic hepatitis B (CHB) has not been systematically assessed. We sought to comprehensively evaluate adherence to five key areas of these guidelines. We also evaluated physician and patient factors underlying nonadherence, and predictors of nonadherence such as physician type, patient demographic factors, and phase of CHB infection. METHODS Nine hundred and sixty-two adult patients were retrospectively identified. Each patient chart was reviewed in detail. The primary outcome was adherence to five areas of the AASLD guidelines: (i) timely alanine aminotransferase (ALT)/hepatitis B virus DNA level checks needed to monitor inactive carrier and immune-tolerant phases; (ii) liver biopsy to guide decisions on initiating treatment; (iii) treatment initiation when indicated; (iv) hepatocellular carcinoma (HCC) screening; (v) testing for hepatitis A virus (HAV) immunity, HIV, and hepatitis C virus (HCV) co-infections. RESULTS Sixty percent did not undergo clinically indicated liver biopsies, largely owing to physician nonadherence. Eighty-nine percent of these missed biopsies were needed to further assess possible e-antigen-negative CHB. A high treatment initiation rate was found for the treatment eligible, but 121 patients had unclear treatment eligibility as they warranted, but did not undergo, liver biopsy. Forty-five percent did not have timely HCC screening, although gastroenterology physicians had the highest odds of adherence, and 29% did not have timely CHB lab assessment; patients seen by gastroenterologists had twice the odds compared with primary care physicians of undergoing timely lab monitoring. Thirty-five, 24, and 54% were not tested for HAV, HCV, and HIV co-infections. CONCLUSIONS Our findings show remarkably poor adherence to AASLD guidelines, particularly in the areas of liver biopsy, timely HCC and ALT monitoring, and testing for co-infection. These findings call for greater efforts to meet physician knowledge gaps, incorporation of decision support tools, and improved communication among providers.
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Tseng KC, Chen CY, Tsai HW, Chang TT, Chuang WL, Hsu PI, Liu WC, Cheng PN. Efficacy of entecavir in chronic hepatitis B patients with persistently normal alanine aminotransferase: randomized, double-blind, placebo-controlled study. Antivir Ther 2014; 19:755-64. [PMID: 24583931 DOI: 10.3851/imp2754] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND It is still inconclusive whether chronic hepatitis B (CHB) patients with persistently normal alanine aminotransferase (PNALT) should receive nucleoside/nucleotide analogues. This study is to evaluate the efficacy of entecavir in improving liver histology in CHB patients with PNALT. METHODS In this prospective randomized, double-blind, placebo-controlled study, 380 CHB patients with PNALT were screened, 82 patients received biopsy and 43 patients met the HBV DNA and histology criteria and were randomly assigned to either an entecavir or placebo group for 52 weeks, with 22 and 21 in each group, respectively. The primary objective was to evaluate histological improvement. The secondary objective is to evaluate virological efficacy. RESULTS A total of eight (38.1%) patients in the entecavir group and eight (44.4%) in the placebo group (P=0.752) showed histological improvement. The decrease in total Knodell scores (±sd) was 1.3 ±1.9 in the entecavir group and 1.5 ±2.2 in the placebo group (P=0.803). The subjects with undetectable HBV DNA at week 52 were 16/21 (76.2%) in the entecavir group and 0/18 (0%) in the placebo group (P<0.001). The mean HBV DNA reduction from baseline to week 52 was 4.73 ±0.83 in the entecavir and 0.25 ±0.81 in the placebo group (P<0.001). CONCLUSIONS CHB patients with PNALT receiving entecavir therapy for one year achieved virological efficacy, but not histological benefit. ClinicalTrials.gov number NCT01833611.
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Affiliation(s)
- Kuo-Chih Tseng
- Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, Chia-Yi, Taiwan
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Chao DT, Lim JK, Ayoub WS, Nguyen LH, Nguyen MH. Systematic review with meta-analysis: the proportion of chronic hepatitis B patients with normal alanine transaminase ≤ 40 IU/L and significant hepatic fibrosis. Aliment Pharmacol Ther 2014; 39:349-58. [PMID: 24387289 DOI: 10.1111/apt.12590] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 07/10/2013] [Accepted: 12/01/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic hepatitis B (CHB) may lead to cirrhosis, hepatocellular carcinoma and premature death. Elevated alanine transaminase (ALT) levels ≥ the upper limit of normal (ULN) are a major determinant for initiating anti-viral therapy; however, ALT levels alone may not be predictive of hepatic fibrosis. AIM To determine the proportion of CHB patients with ALT ≤ 40 IU/L and liver fibrosis stage ≥ 2. Secondary goals include subgroup analysis by hepatitis B e antigen (HBeAg) status, high hepatitis B virus (HBV) DNA levels, Asian ethnicity, lower ULN of ≤ 30 IU/L (males) and 19 IU/L (females), and advanced age. METHODS Studies identified in EMBASE and MEDLINE (1/1990-6/2012) using the search criteria: "Hepatitis B"[Mesh] OR "Hepatitis B virus"[Mesh] OR "Hepatitis B, Chronic"[Mesh])) AND "Alanine Transaminase"[Mesh]) and abstracts containing the term 'hepatitis' from recent major U.S. gastroenterology and liver society meetings were considered. RESULTS Among nine studies (N = 830 patients), a significant proportion (20.7%; 95% CI: 16.2-26.0%) of CHB patients with ALT levels ≤ 40 IU/L had significant fibrosis irrespective of HBeAg status, high HBV DNA levels, ethnicity or age, although this proportion may be higher in patients older than 30-40 years old. The corresponding proportion was 27.8% even when the newer ULN of 30 IU/L (males) and 19 IU/L (females) was applied. CONCLUSIONS Approximately one fifth of CHB patients with ALT ≤ 40 IU/L may have significant hepatic fibrosis. The approach to such patients should be individualised, as further evaluation and treatment may be appropriate.
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Affiliation(s)
- D T Chao
- Department of Internal Medicine, University of Pittsburgh Medical Center, Shadyside, Pittsburgh, PA, USA
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Chronic hepatitis B management based on standard guidelines in community primary care and specialty clinics. Dig Dis Sci 2013; 58:3626-33. [PMID: 24122622 DOI: 10.1007/s10620-013-2889-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 09/12/2013] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIMS Prior studies have underlined the need for increased screening and awareness of chronic hepatitis B (CHB), especially in certain high-risk populations. However, few studies have examined the patterns of evaluation and management of CHB between primary care physicians (PCP) and specialists according to commonly-used professional guidelines. Our goal was to examine whether necessary laboratory parameters used to determine disease status and eligibility for antiviral therapy were performed by PCPs and specialists. METHODS We conducted a retrospective study of 253 treatment-naïve CHB patients who were evaluated by PCP only (n=63) or by specialists (n=190) for CHB at a community multispecialty medical center between March 2007 and June 2009. Criteria for CHB management and treatment eligibility were based on the American Association for the Study of Liver Diseases 2007 guideline and the US Panel 2006 algorithm. Required parameters for optimal evaluation for CHB included hepatitis B e antigen (HBeAg), HBV DNA, and alanine aminotransferase (ALT). Preferred antiviral agents for CHB included pegylated interferon, adefovir, and entecavir. RESULTS The majority of patients were Asians (90%) and (54%) with a mean age of 43±11.6 years. Compared to PCPs, specialists were more likely to order laboratory testing for ALT (94 vs. 86%, P=0.05), HBeAg (67 vs. 41%, P<0.0001) and HBV DNA (83 vs. 52%, P<0.0001). The proportion of patients having all three laboratory parameters was significantly higher among those evaluated by specialists compared to PCP (62 vs. 33%, P<0.0001). A total of 55 patients were initiated on antiviral treatment (n=47 by specialists and n=6 by PCPs). Lamivudine was prescribed more often by PCPs than specialists (33 vs. 2%, P=0.05). Preferred agents were used 96% of the time by specialists compared to 67% of those treated by PCPs (P=0.05). CONCLUSION Patients evaluated by specialists for CHB are more likely to undergo more complete laboratory evaluation and, if eligible, are also more likely to be treated with preferred longer-term agents for CHB compared to those evaluated by PCPs only. A collaborative model of care involving both PCP and specialists may further optimize management of patients with CHB.
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