1
|
Abstract
The diagnosis and treatment of infection with hepatitis B and C has undergone a paradigm shift in the past decade. Although children with these infections are usually asymptomatic with normal liver function, their evaluation and management can often involve complex issues and require specialized expertise. Here the authors review the common clinical scenarios which might be encountered by a general pediatrician, explain the various tests available for diagnosis, and provide practical guidelines for managing these children.
Collapse
Affiliation(s)
- Rohan Malik
- Department of Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Royal Children's Hospital, 50 Flemington Road, Parkville, 3052, Victoria, Melbourne, Australia
| | - Winita Hardikar
- Department of Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Royal Children's Hospital, 50 Flemington Road, Parkville, 3052, Victoria, Melbourne, Australia.
| |
Collapse
|
2
|
Tajiri H, Takano T, Tanaka H, Ushijima K, Inui A, Miyoshi Y, Ozono K, Abukawa D, Endo T, Brooks S, Tanaka Y. Hepatocellular carcinoma in children and young patients with chronic HBV infection and the usefulness of alpha-fetoprotein assessment. Cancer Med 2016; 5:3102-3110. [PMID: 27748053 PMCID: PMC5119965 DOI: 10.1002/cam4.917] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 08/13/2016] [Accepted: 08/18/2016] [Indexed: 12/18/2022] Open
Abstract
The aims of the study were to elucidate the clinical characteristics of patients who developed hepatocellular carcinoma (HCC) related to persistent HBV infection since childhood and to investigate usefulness of assessing alpha‐fetoprotein (AFP) in this population. A nationwide multicenter survey of children with chronic HBV infection was performed. Among 548 patients, 15 patients developed HCC at the median age of 15 years (range 9–36), including 13 males and 2 females. A case–control comparison showed that HBeAg seroconversion and liver cirrhosis were associated with the occurrence of HCC. Of the 15 HCC patients, 5 were treated with interferon and none of them responded to interferon therapy as compared with 12 of the 17 responders in the control group. Of the 15 patients, 10 died and 9 of the 10 who died never visited any medical facilities until diagnosis of HCC, while the remaining 5 surviving patients never stopped their clinic visits. The usefulness of AFP assessment was shown by the findings that AFP levels were elevated in all HCC cases, that elevations in AFP levels were detected prior to the diagnosis in the surviving patients, and that sensitivity of AFP as a diagnostic test for HCC was very high among 40 patients including our 14 and an additional 26 collected from the literature. HBeAg seroconversion and liver cirrhosis are associated with the occurrence of HCC. Regular measurement of AFP might be helpful to watch for the occurrence of HCC when following children and young patients with chronic HBV infection since childhood
Collapse
Affiliation(s)
- Hitoshi Tajiri
- Department of Pediatrics, Osaka General Medical Center, Osaka, Japan
| | - Tomoko Takano
- Department of Pediatrics, Osaka General Medical Center, Osaka, Japan
| | - Hideo Tanaka
- Division of Epidemiology and Prevention, Aichi Cancer Center Research Institute, Nagoya, Japan
| | - Kosuke Ushijima
- Department of Pediatrics, Kurume University Medical Center, Kurume, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama, Japan
| | - Yoko Miyoshi
- Department of Pediatrics, Osaka University Hospital, Suita, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Hospital, Suita, Japan
| | - Daiki Abukawa
- Department of Pediatrics, Miyagi Children's Hospital, Sendai, Japan
| | - Takeshi Endo
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Stephen Brooks
- Department of Microbiology/Immunology, State University of New York at Buffalo, New York
| | - Yasuhito Tanaka
- Department of Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| |
Collapse
|
3
|
Jonas MM, Lok ASF, McMahon BJ, Brown RS, Wong JB, Ahmed AT, Farah W, Mouchli MA, Singh S, Prokop LJ, Murad MH, Mohammed K. Antiviral therapy in management of chronic hepatitis B viral infection in children: A systematic review and meta-analysis. Hepatology 2016; 63:307-18. [PMID: 26566163 DOI: 10.1002/hep.28278] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/04/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED Most individuals with chronic hepatitis B viral (HBV) infection acquired the infection around the time of birth or during early childhood. We aimed to synthesize evidence regarding the effectiveness of antiviral therapy in the management of chronic HBV infection in children. We conducted a comprehensive search of multiple databases from 1988 to December 2, 2014, for studies that enrolled children (<18 years) with chronic HBV infection treated with antiviral therapy. We included observational studies and randomized controlled trials (RCTs). Two independent reviewers selected studies and extracted data. In the 14 included studies, two cohort studies showed no significant reduction in the already low risk of hepatocellular carcinoma or cirrhosis and 12 RCTs reported intermediate outcomes. In RCTs with posttreatment follow-up <12 months, antiviral therapy compared to placebo improved alanine aminotransferase normalization (risk ratio [RR] = 2.3, 95% confidence interval [CI] 1.7-3.2), hepatitis B e antigen (HBeAg) clearance/loss (RR = 2.1, 95% CI 1.5-3.1), HBV DNA suppression (RR = 2.9, 95% CI 1.8-4.6), HBeAg seroconversion (RR = 2.1, 95% CI 1.4-3.3), and hepatitis B surface antigen clearance (RR = 5.8, 95% CI 1.1-31.5). In RCTs with posttreatment follow-up ≥12 months, antiviral therapy improved cumulative HBeAg clearance/loss (RR = 1.9, 95% CI 1.7-3.1), HBeAg seroconversion (RR = 2.1, 95% CI 1.3-3.5), alanine aminotransferase normalization (RR = 1.4, 95% CI 1.1-1.7), and HBV DNA suppression (RR = 1.4, 95% CI 1.1-1.8) but not hepatitis B surface antigen clearance or seroconversion. CONCLUSION In children with chronic HBV infection, antivirals compared to no antiviral therapy improve HBV DNA suppression and frequency of alanine aminotransferase normalization and HBeAg seroconversion.
Collapse
Affiliation(s)
- Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Brian J McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, AK
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
| | - John B Wong
- Department of Medicine, Tufts Medical Center, Boston, MA
| | - Ahmed T Ahmed
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, MN.,Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Wigdan Farah
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, MN.,Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Siddharth Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Mohammad Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, MN.,Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.,Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN
| | - Khaled Mohammed
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, MN.,Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.,Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
4
|
Sokal EM, Paganelli M, Wirth S, Socha P, Vajro P, Lacaille F, Kelly D, Mieli-Vergani G. Management of chronic hepatitis B in childhood: ESPGHAN clinical practice guidelines: consensus of an expert panel on behalf of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Hepatol 2013; 59:814-29. [PMID: 23707367 DOI: 10.1016/j.jhep.2013.05.016] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 05/09/2013] [Accepted: 05/13/2013] [Indexed: 02/06/2023]
Affiliation(s)
- Etienne M Sokal
- Pediatric Gastroenterology & Hepatology, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Cliniques Universitaires Saint Luc, Brussels, Belgium.
| | | | | | | | | | | | | | | |
Collapse
|
5
|
Giacchino R, Cappelli B. Treatment of viral hepatitis B in children. Expert Opin Pharmacother 2010; 11:889-903. [DOI: 10.1517/14656561003642006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
6
|
Abstract
Chronic hepatitis B virus (HBV) infection is a major cause of liver disease throughout the world, leading to cirrhosis and hepatocellular carcinoma in many individuals. Children are more likely to develop chronic HBV infection as they demonstrate greater immunotolerance to the virus, and response to therapy in children remains disappointing. Three therapeutic agents for chronic HBV infection in children have been approved in the USA, including standard IFN-alpha, lamivudine and adefovir. IFN-alpha has been the most effective ( approximately 30% hepatitis B e antigen [HBeAg] seroconversion; 10% hepatitis B surface antigen [HBsAg] seroconversion), although benefits are primarily observed in children with alanine aminotransferase levels over two-times the upper limit of normal and must be weighed against significant side effects. Studies comparing the long-term outcome of chronic hepatitis B in children treated with IFN-alpha and in untreated controls show that the rate of anti-HBeAb seroconversion tends to overlap in treated and untreated patients within a few years of follow-up, suggesting that IFN-alpha simply accelerates a spontaneous event. Lamivudine's virologic response rates mirror those of IFN-alpha (23-31% HBeAg seroconversion) with easier administration and a better safety profile but lower HBsAg seroconversion (2-3%) and high rates of drug resistance. Adefovir data show low rates of resistance and a good safety profile, but virologic response was limited to adolescent patients and was lower than that of lamivudine (16% HBeAg seroconversion; <1% HBsAg seroconversion). Entecavir and tenofovir, both approved therapies for adults with chronic HBV infection, are in trials for use in children. Future therapies will probably include these agents as well as combined therapies. Finally, watchful waiting of children is an option since current therapies are only 30% effective at best, although the long-term impact of therapy in childhood on rates of cirrhosis and hepatocellular carcinoma remains unknown.
Collapse
Affiliation(s)
- Amethyst C Kurbegov
- Pediatric Gastroenterology, University of Colorado Denver School of Medicine, 2121 East La Salle, Ste 205, Colorado Springs, CO 80909, USA.
| | | |
Collapse
|
7
|
Fattovich G, Bortolotti F, Donato F. Natural history of chronic hepatitis B: special emphasis on disease progression and prognostic factors. J Hepatol 2008; 48:335-52. [PMID: 18096267 DOI: 10.1016/j.jhep.2007.11.011] [Citation(s) in RCA: 913] [Impact Index Per Article: 57.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The natural history of chronic hepatitis B virus (HBV) infection and disease is complex and highly variable. We review the natural history of chronic hepatitis B with emphasis on the rates of disease progression and factors influencing the course of the liver disease. Chronic hepatitis B is characterized by an early replicative phase (HBeAg positive chronic hepatitis) and a late low or non-replication phase with HBeAg seroconversion and liver disease remission (inactive carrier state). Most patients become inactive carriers after spontaneous HBeAg seroconversion with good prognosis, but progression to HBeAg negative chronic hepatitis due to HBV variants not expressing HBeAg occurs at a rate of 1-3 per 100 person years following HBeAg seroconversion. The incidence of cirrhosis appears to be about 2-fold higher in HBeAg negative compared to HBeAg positive chronic hepatitis. In the cirrhotic patient the 5-year cumulative risk of developing hepatocellular carcinoma is 17% in East Asia and 10% in the Western Europe and the United States and the 5-year liver related death rate is 15% in Europe and 14% in East Asia. There is a growing understanding of viral, host and environmental factors influencing disease progression, which ultimately could improve the management of chronic hepatitis B.
Collapse
Affiliation(s)
- Giovanna Fattovich
- Department of Surgical and Gastroenterological Sciences, University of Verona, Piazzale L.A. Scuro, 10, Verona 37134, Italy.
| | | | | |
Collapse
|
8
|
Shneider BL, González-Peralta R, Roberts EA. Controversies in the management of pediatric liver disease: Hepatitis B, C and NAFLD: Summary of a single topic conference. Hepatology 2006; 44:1344-54. [PMID: 17058223 DOI: 10.1002/hep.21373] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Benjamin L Shneider
- Division of Pediatric Hepatology, Department of Pediatrics, Mount Sinai School of Medicine, New York, NY, USA.
| | | | | |
Collapse
|
9
|
Abstract
Chronic hepatitis B infection remains a significant health problem worldwide, and acquisition during infancy or childhood causes many of the chronic infections that are responsible for the morbidity associated with this disease. Some children with chronic hepatitis B are candidates for treatment. Two medications are currently licensed for use in children, and it is anticipated that others will be available in the next several years. This article describes rationale for treatment, patient selection and pros and cons of the current and expected therapeutic options.
Collapse
Affiliation(s)
- Maureen M Jonas
- Children's Hospital, and Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
10
|
White FV, Dehner LP. Viral diseases of the liver in children: diagnostic and differential diagnostic considerations. Pediatr Dev Pathol 2004; 7:552-67. [PMID: 15630523 DOI: 10.1007/s10024-004-8101-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Accepted: 09/01/2004] [Indexed: 01/04/2023]
Abstract
This review summarizes the general histologic features of acute and chronic hepatitides and highlights those morphologic findings that may suggest or be diagnostic of a specific agent or etiology. The main epidemiologic, clinical, and pathologic features of the hepatotropic viruses are discussed, with an emphasis on pediatric studies and the differential diagnosis of hepatitis in childhood.
Collapse
Affiliation(s)
- Frances V White
- Department of Pathology and Immunology, Lauren V. Ackerman Laboratory of Surgical Pathology,St. Louis Children's Hospital at the Washington University Medical Center, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | | |
Collapse
|
11
|
Abstract
Children with hepatitis B infection require management by physicians knowledgeable about the natural history of this disorder and experienced in the treatment of children. Selection of appropriate pediatric patients for treatment will prevent some cases of advanced liver disease later in life. New treatments under development for adults may benefit children as well, once they have been rigorously investigated in the pediatric population. Prevention of new HBV infections is an important part of management in children, and working with public health campaigns will hopefully reduce both vertical and horizontal transmission.
Collapse
Affiliation(s)
- Annemarie Broderick
- Department of Paediatrics, University College, Dublin, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12, Ireland
| | | |
Collapse
|
12
|
Abstract
IFN-alpha has emerged as a promising treatment of chronic viral hepatitis. Although therapeutic response to IFN is far from universal, efficacy has been demonstrated; and studies combining IFN-alpha with other agents, as well as trials with new preparations of IFN-alpha, are under way. Children do not represent a large part of the identified population with chronic viral hepatitis. Yet children, by simple virtue of age, are more recently infected. In addition, longer life expectancies can be expected to be associated with greater morbidity from chronic viral hepatitis. Children seem to tolerate therapy with IFN-alpha well. Treatment of children with chronic viral hepatitis should be strongly considered, with protocols designed to ascertain specific pediatric safety and efficacy.
Collapse
Affiliation(s)
- M M Jonas
- Combined Program in Gastroenterology, Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
13
|
Membranous nephropathy following perinatal transmission of hepatitis B virus infection--long-term follow-up study. Pediatr Nephrol 1996. [PMID: 8611364 DOI: 10.1007/s004670050071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In children with hepatitis B-associated membranous glomerulonephritis, the time of onset of the infection and the duration of the carrier state before diagnosis of the renal disease are always unknown. Moreover, follow-up is usually short. We report the unique observation of a French girl who was infected with hepatitis B virus by her mother who had acute hepatitis during the immediate postpartum period; the girl developed proteinuria at 6 years of age. The onset of the infection in the perinatal period, the mild liver abnormalities, and the absence of nephrotic syndrome did not justify any treatment. Spontaneous seroconversion to anti-HBe antibody positive occurred at 12 years of age. Proteinuria gradually diminished and was absent at 18 years. However, HBs antigenemia persists.
Collapse
|
14
|
Levy M, Gagnadoux MF. Membranous nephropathy following perinatal transmission of hepatitis B virus infection--long-term follow-up study. Pediatr Nephrol 1996; 10:76-8. [PMID: 8611364 DOI: 10.1007/bf00863453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In children with hepatitis B-associated membranous glomerulonephritis, the time of onset of the infection and the duration of the carrier state before diagnosis of the renal disease are always unknown. Moreover, follow-up is usually short. We report the unique observation of a French girl who was infected with hepatitis B virus by her mother who had acute hepatitis during the immediate postpartum period; the girl developed proteinuria at 6 years of age. The onset of the infection in the perinatal period, the mild liver abnormalities, and the absence of nephrotic syndrome did not justify any treatment. Spontaneous seroconversion to anti-HBe antibody positive occurred at 12 years of age. Proteinuria gradually diminished and was absent at 18 years. However, HBs antigenemia persists.
Collapse
Affiliation(s)
- M Levy
- Unité de Recherches d'Epidémiologie Génétique INSERM U. 155, Paris, France
| | | |
Collapse
|
15
|
Kacprzak-Bergman I, Hałasa J. Gm and Km phenotype frequencies in children with chronic active hepatitis (CAH) B virus infection. EUROPEAN JOURNAL OF IMMUNOGENETICS : OFFICIAL JOURNAL OF THE BRITISH SOCIETY FOR HISTOCOMPATIBILITY AND IMMUNOGENETICS 1994; 21:373-6. [PMID: 9098446 DOI: 10.1111/j.1744-313x.1994.tb00207.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Patients with CAH, extrahepatic HBV manifestation and healthy children were studied for presence of Gm 1, 2, 3, 10, 21 factors and Km 1 factor. significantly higher frequency of Gm (1, 2, 3, 10, 21) phenotype was shown in CAH group as compared with the other two groups. Relationship between Km factors and examined groups was not found.
Collapse
Affiliation(s)
- I Kacprzak-Bergman
- Department of Pediatric Infectious Diseses, Medical University School, Wrocław, Poland
| | | |
Collapse
|
16
|
Abstract
Over the last several years, much progress has been made in the treatment of adult patients with chronic viral hepatitis and compensated liver disease in the absence of significant other illnesses. However, the treatment of chronic viral hepatitis in other patient populations is still experimental. These groups include children, patients immunocompromised by human immunodeficiency virus infection or immunosuppression following organ transplantation, those with end-stage renal disease, and patients with extrahepatic manifestations of hepatitis viral infection. Data on the treatment of chronic hepatitis in these special populations are reviewed.
Collapse
Affiliation(s)
- K L Lindsay
- Department of Medicine, University of Southern California, Los Angeles 90033
| |
Collapse
|
17
|
Fonga-Djimi H, Gottrand F, Mazingue F, Farriaux JP. Type B hepatitis and primary hepatocellular carcinoma in a nine-year-old French boy. Acta Paediatr 1993; 82:1065. [PMID: 8155928 DOI: 10.1111/j.1651-2227.1993.tb12813.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
18
|
Callea F, Bonetti M, Medicina D, Alberti D, Fabbretti G, Brisigotti M. Hepatic tumor and tumor-like lesions in childhood. JOURNAL OF SURGICAL ONCOLOGY. SUPPLEMENT 1993; 3:170-2. [PMID: 8389165 DOI: 10.1002/jso.2930530545] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Tumors of the liver are rare in infancy and childhood. Some are peculiar to the pediatric age, e.g., hepatoblastoma, infantile hemangioendothelioma, mesenchymal hamartoma, embryonal rhabdomyosarcoma. This review is based upon personal experience with a series of 32 cases. On the basis of the histological features it is proposed that focal modular hyperplasia (FNH) and mesenchymal hamartoma be considered as tumor-like lesions rather than true neoplasms. A few benign epithelial lesions (FNH, adenoma) were associated with inborn error of metabolism. In half of the patients, hepatocellular carcinoma (HCC) developed in perinatally hepatitis B virus (HBV)-infected children. HCC developed in a noncirrhotic liver in a single patient, in whom HBV-DNA integration had occurred.
Collapse
Affiliation(s)
- F Callea
- Department of Pathology, Istituto Giannina Gaslini, Genoa, Italy
| | | | | | | | | | | |
Collapse
|