Natural history of chronic hepatitis B virus infection in children in Japan: a comparison of mother-to-child transmission with horizontal transmission

Unusual serological profile in hepatitis B virus (HBV) infection associated with a probable clinical case of acute exacerbation of pre-existing chronic HBV infection

BACKGROUND

Acute or chronic HBV infection in an individual can be laboratory characterized according to the serological profile of the viral markers in the bloodstream, and the dynamics monitoring of these markers is necessary to assess the disorder course and the infection outcome. However, under certain circumstances unusual or atypical serological profiles may be observed in both acute and chronic HBV infection. They are considered as such because they do not properly characterize the form or infection clinical phase or because they seem inconsistent, considering the viral markers dynamics in both clinical contexts. This manuscript comprises the analysis of an unusual serological profile in HBV infection.

METHODS AND RESULTS

This clinical-laboratory study, had as reference a patient who presented clinical profile suggestive of acute HBV infection after recent exposure, whose laboratory data were initially compatible with this clinical presentation. However, the serological profile analysis and its monitoring demonstrated unusual pattern of viral markers expression, which has been observed in several clinical contexts, and is often associated a number of agent- or host-related factors.

CONCLUSION

The serological profile analyzed here, associated with the biochemical markers serum levels found, is indicative of active chronic infection, consequence of viral reactivation. This finding suggests that in the event of unusual serological profiles in HBV infection, if the influence of agent- or host-related factors is not properly considered and neither the viral markers dynamics properly analyzed, there may be mistake in the infection clinical diagnosis, especially when the patient's clinical and epidemiological history is unknown.

Frequent alanine aminotransferase flares and promising antiviral therapy efficacy during the preschool age: An opportunity to achieve HBsAg loss in children with mother-to-child transmitted hepatitis B

Alanine aminotransferase (ALT) flare remains one of the determinants of initiating antiviral therapy in children with chronic hepatitis B (CHB). Insufficient data exist regarding children with CHB attributed to mother-to-child transmission. This study aimed to assess the occurrence of spontaneous ALT flares and identify factors affecting therapy-induced hepatitis B surface antigen (HBsAg) loss in the flare cohort. We retrospectively included untreated children with mother-to-child transmitted CHB. The primary outcomes were spontaneous ALT flares and therapy-induced HBsAg loss. Among 83 untreated children, 73.5% (61/83) experienced spontaneous ALT flares during the median follow-up of 14.6 months (range, 0.1-177.1 months), with 54.1% of the first ALT flares and 44.3% of ALT peaks occurring within 6 years of age. Thirty-six of 61 children with ALT flares received antiviral therapy, nine (25.0%) of whom achieved therapy-induced HBsAg loss with a median duration of 19.3 months (range, 6.5-56.2 months). The age of initiation of antiviral therapy was the sole predictor of therapy-induced HBsAg loss (HR = 0.544, 95% CI 0.353-0.838, p = 0.006). The restricted cubic spline showed a negative relationship between the age of initiation of antiviral therapy and HBsAg loss and identified that 6.2 years of age discriminated children with therapy-induced HBsAg loss. Kaplan-Meier estimations suggested a higher probability of HBsAg loss in children who started antiviral therapy before 6.2 years old (p = 0.03). In conclusion, asymptomatic ALT flares were frequent in preschool-aged children with mother-to-child transmitted CHB, and early initiation of antiviral therapy showed promising effects in those children with ALT flares.

Chronic Hepatitis Is Common and Often Untreated Among Children with Hepatitis B Infection in the United States and Canada

OBJECTIVE

To determine the outcomes of chronic hepatitis B virus (HBV) infection in a large, prospectively studied cohort of children in the US and Canada.

STUDY DESIGN

This was a prospective, observational study of children with chronic HBV enrolled in 7 clinical centers and evaluated at baseline, weeks 24 and 48, and annually thereafter, with analysis of demographic, clinical, physical examination, and blood test data.

RESULTS

Among 362 children followed for a median of 4.2 years, elevated alanine aminotransferase (ALT) levels (>1 upper limit of normal) were present in 72% at last evaluation, including in 60% of children with loss of hepatitis B e antigen during follow-up and 70% of those who were hepatitis B e antigen negative at baseline. Significant ALT flares (male patients ≥400 U/L, female patients ≥350 U/L) occurred in 13 children. Of 129 children who fulfilled the American Association for the Study of Liver Diseases treatment criteria during follow-up, anti-HBV treatment was initiated in only 25. One child died (unrelated to liver disease), 1 developed cirrhosis, but no episodes of cirrhotic decompensation or hepatocellular carcinoma were observed. Decline in platelet count was inversely associated with ALT elevations.

CONCLUSIONS

In a cohort of children with chronic HBV infection in the US and Canada, many children remained at risk of progressive liver disease due to active hepatitis, but major clinical outcomes such as cirrhosis, cancer, and death were rare. Many children who met criteria for treatment remained untreated.

Dynamic profile of the HBeAg-anti-HBe system in acute and chronic hepatitis B virus infection: A clinical-laboratory approach

Wild-type HBV infection is followed by the blood expression of its widely known serological markers of infection, and designated as, hepatitis B virus surface antigen (HBsAg) and its antibody (anti-HBs), anti-HBc antibodies (IgM/IgG), and hepatitis B virus 'e' antigen (HBeAg) and its antibody (anti-HBe). These markers are detected as the infection develops and its kinetic behavior serves as a basis for monitoring the disorder and for diagnosing the clinical form or infection phase. Among these, the HBeAg-anti-HBe system markers demonstrate a dynamic profile whose interpretation, both in the acute or chronic HBV infection context, can offer greater difficulty to the health professionals, due to its particularities. This review offers a revisit to the markers dynamics of this system in the acute and chronic HBV infection and to the clinical and laboratory significance of its expression in these two clinical contexts.

Quantative HBsAg level correlates dendritic cells maturation in chronic hepatitis B patients

BACKGROUND

In order to better understand the role of Dendritic cells (DCs) in Chronic Hepatitis B (CHB), we investigated the frequencies and maturation markers on DCs in CHB patients and its change during entecavir treatment.

METHODS

Twenty-six CHB patients on anti-virus treatment for 48 weeks were included in this study. Patients' blood samples were collected on every 3 months since starting treatment. Samples on baseline and after 48 weeks treatment were examined using flow-cytometry to investigate frequencies and maturation markers of DCs.

RESULTS

The frequencies of myeloid DCs (mDCs) and plasmacytoid DCs (pDCs) were lower in CHB patients than healthy controls on baseline. pDCs frequencies and mDCs maturation markers expression were increased after entecavir (ETV) treatment. Patients with higher baseline HBsAg levels showed a poorer maturation status than those with low baseline HBsAg levels, regardless of changes in HBsAg levels after treatment.

CONCLUSIONS

Entecavir treatment could restore the decreased DCs frequencies in CHB patients and improve DCs maturation levels. Baseline HBsAg level is an important factor that affecting DCs.

Unsatisfying antiviral therapeutic effect in patients with mother-to-child transmissed chronic hepatitis B virus infection: a prospective multi-center clinical study

Background:

Few data are available regarding the progression of liver disease and therapeutic efficacy in chronic hepatitis B virus (HBV) carriers infected by mother-to-child transmission (MTCT). This study aimed to investigate these two aspects by comparing the adult chronic HBV carriers in MTCT group with those in horizontal transmission group.

Methods:

The 683 adult chronic HBV patients qualified for liver biopsy including 191 with MTCT and 492 with horizontal transmission entered the multi-center prospective study from October 2013 to May 2016. Biopsy results from 217 patients at baseline and 78 weeks post antiviral therapy were collected.

Results:

Patients infected by MTCT were more likely to have e antigen positive (68.6% vs. 58.2%, χ² = –2.491, P = 0.012) than those with horizontal transmission. However, in patients with MTCT, levels of alkaline phosphatase (ALP) (P = 0.031), Fibroscan (P = 0.013), N-terminal propeptide of Type III procollagen (PIIINP) (P = 0.014), and Laminin (LN) (P = 0.006) were high, in contrast to the patients with horizontal transmission for whom the levels of albumin (ALB) (P = 0.041), matrix metalloproteinase-3 (MMP-3) (P = 0.001) were high. The 47.2% of patients with MTCT and 36.8% of those with horizontal transmission had significant liver fibrosis (P = 0.013). Following antiviral therapy for 78 weeks, 21.2% and 38.0% patients with MTCT and horizontal transmission acquired hepatitis B e antigen (HBeAg) clearance, respectively (P = 0.043), and the virological response rates were 54.7% and 74.1% in the MTCT and horizontal groups, respectively (P = 0.005). MTCT was a risk factor for HBeAg clearance and virological response.

Conclusion:

Adult patients with MTCT were more prone to severe liver diseases, and the therapeutic efficacy was relatively poor, which underlined the importance of earlier, long-term treatment and interrupting perinatal transmission.

Trial Registration:

NCT01962155; https://clinicaltrials.gov.

Hepatitis B virus-related hepatocellular carcinoma in young adults: Efficacy of nationwide selective vaccination

AIM

Hepatitis B vaccination in infancy was carried out in Japan only when the mother was persistently infected from 1986 to 2016. The aim of the present study was to elucidate the results of vaccination for the prevention of hepatocellular carcinoma in young adults.

METHODS

We studied the number of patients who had liver cancer and died from 1976 to 2017 using a national database. Furthermore, we carried out a nationwide survey focusing on patients with hepatitis B virus-related hepatocellular carcinoma who were diagnosed when aged <40 years from 2007 to 2016.

RESULTS

The national database showed that the number of deaths of patients aged <40 years decreased from 337 in 1986 to 61 in 2016. Among the 122 patients with hepatocellular carcinoma (HCC) who were registered in the survey, just three patients were born after the start of the vaccination in 1986. Liver cirrhosis, defined by a high Fib-4 index (≥3.25), was found in just 12.5% of the patients at the time of the survey. HCC was incidentally diagnosed in 85 of the 122 (69%) patients. More than 60% of the patients (54/88) were dead at the time of the study, which may be attributed to the delay in diagnosis.

CONCLUSIONS

Selective vaccination was effective for the prevention of hepatitis B virus-related HCC. In contrast, many young adults who missed the chance of hepatitis B vaccination and HCC surveillance developed HCC and died. Hepatitis B virus screening in young adults and careful follow up of infected patients are important to prevent HCC development.

Expected Hepatocarcinoma Cancer Rate Due to Escape Mutant among Local Population in Thailand: The Situation after the Implementation of Universal Hepatitis B Vaccination at Birth

Background: Chronic hepatitis B infection is an etiology of hepatocellular carcinoma. The high prevalence of hepatitis B can be seen in several regions including Indochina. In Thailand, a country in Indochina, according to the local public health policies, the universal hepatitis B vaccination is freely given to any infant at birth without charge. Despite the universal vaccination, the hepatitis B seropositive rate is still observed, and it can still be a cause of hepatocellular carcinoma among the hepatitis B carriers in the future. Methods: Here, the authors try to estimate the expected hepatocarcinoma cancer rate due to escape mutant among local population in Thailand, the situation after the implementation of universal hepatitis B vaccination at birth. Results: Based on the present study, the mutant escape contributes to only a few parts of overall estimated cancer cases in the situation that there is an implementation of universal hepatitis B vaccination at birth. Conclusion: Efficacy of theuniversal hepatitis B vaccination is not improved by specific management on escape mutants.

Interferon alpha treatment leads to a high rate of hepatitis B surface antigen seroconversion in Chinese children with chronic hepatitis B

Chronic hepatitis B virus (HBV) infection (CHB) in children remains a public health challenge despite significant success in programme is established to prevent mother-to-child transmission. In particular, CHB in Chinese children are mostly acquired through vertical transmission, which differs from the common infection route reported in other countries and regions. This situation has resulted in a high endemic prevalence of CHB in Chinese adults. Thus, successful treatment of children with CHB will prevent the development of advanced liver diseases in late adulthood. However, there is still no consensus on the clinical guideline to treat paediatric CHB. In this study, we evaluated the potential of interferon alpha (IFNa) treatment for Chinese children with CHB. A total of 41 patients with CHB aged 3-17 years were enrolled in this retrospective study: 21 patients were treated with pegylated (PEG)-IFNa and 20 patients without treatment served as the control group. The rates of HBV DNA suppression, hepatitis B e antigen (HBeAg) clearance and hepatitis B surface antigen (HBsAg) clearance were significantly higher in the PEG-IFNa treatment group than in the control group (P < 0.05 at 48 weeks). Unexpectedly, PEG-IFNa treatment achieved a high rate of HBsAb production, far exceeding the clinical outcome in documented PEG-IFNa-treated CHB adults. Further analysis revealed that younger children (3-6 years old) were more responsive to PEG-IFNa treatment with respect to achieving a protective level of HBsAb in a short treatment cycle than adolescents (10-17 years old). Overall, these results indicate that the immune system of children might have a preserved PEG-IFNa-mediated mechanism to completely control HBV, which can help to design new strategies to treat CHB patients.

Suppression of hepatitis B surface antigen production by combination therapy with nucleotide analogues and interferon in children with genotype C hepatitis B virus infection

AIM

Sustained suppression of hepatitis B surface antigen (HBsAg) production after interferon (IFN) treatment has not been reported for children with genotype C chronic hepatitis B virus (HBV) infection, which is prevalent in Asia. Among children with hepatitis B envelope antigen-positive genotype C chronic HBV infection, we compared the efficacy of combination therapy with nucleotide analogues and IFN-α in 11 children with 12 historical cases treated with IFN monotherapy.

METHODS

The combination of lamivudine and conventional IFN-α was introduced for the first three patients; the other eight patients were treated with entecavir and pegylated IFN.

RESULTS

Demographic factors as well as baseline HBsAg titers and HBV-DNA levels were similar between the two groups. In the combination therapy group, viral loads were suppressed in 9/11 to below 4.0 log copies/mL both at the end of the therapy (EOT) and at 6 months after EOT. In contrast, in the IFN monotherapy group, suppression of viral loads was observed in 2/12 and 3/12 at EOT and at 6 months after EOT, respectively. In the combination therapy group, HBsAg titers dropped from 4.03 at pretreatment to 2.91 log IU/mL at 6 months after EOT with 4/11 showing a drop to below 1000 IU/mL (one patient achieved HBsAg clearance). In contrast, the amount of HBsAg did not change during the corresponding periods in the IFN monotherapy group.

CONCLUSIONS

Our preliminary results suggest that combination therapy might be effective in the suppression of HBsAg production as well as HBV-DNA production for children with genotype C chronic HBV infection.

Misclassification of chronic hepatitis B natural history phase: Insight from new ALT, AST, AKP, and GGT reference intervals in Chinese children

BACKGROUND

The age- and sex-specific reference intervals (RIs) for liver chemistry in children are not available in China. Our study aimed to establish age and gender related RIs for ALT, AST, AKP, and GGT in China, and apply the new RI for ALT in children with chronic hepatitis B to use as a biochemical marker for disease progression.

METHODS

Data were collected from the Children's Healthcare Center. The measurements of ALT, AST, AKP and GGT were performed on a Hitachi 7600 Chemistry Analyzer. Age- and sex-specific RIs were determined using a percentile (3rd-97th) method. The sensitivity and specificity were determined to test the ability of the newly proposed ALT thresholds to classify children with chronic HBV infection.

RESULTS

The age- and sex-specific RIs of ALT, AST, AKP and GGT were established based on 4232 Chinese healthy children. Using the new median ALT threshold, the sensitivity was higher. The detection of chronic HBV infection was 31.2% in boys and 35.5% in girls, while a very slight decrease in specificity was found. Based on the newly proposed RIs of ALT, approximately 16.1% boys and 19.0% girls would be classified in the HBeAg-positive chronic hepatitis phase, but using the current ALT threshold of children's hospitals they were in HBeAg-positive chronic infection phase.

CONCLUSIONS

Based on a large healthy population, we established the sex- and age-specific RIs of ALT, AST, AKP and GGT serum activities for Chinese children. Meanwhile, newly proposed liver chemistry RIs will benefit the understanding of liver function and the natural history of chronic HBV infection in children.

An Assessment of Upper Limits of Normal for ALT and the Impact on Evaluating Natural Course of Chronic Hepatitis B Virus Infection in Chinese Children

BACKGROUND

The current upper limits of normal (ULN) for serum alanine aminotransferase (ALT) are increasingly challenged. We aimed to re-evaluate the ULN for ALT and assess the potential impact on the classification of natural course of chronic hepatitis B virus (HBV) infection in children.

METHODS

Laboratory data obtained from three hospitals in China were retrospectively analysed. In total, 2054 children with chronic HBV infection and 8149 healthy children at age ≤18 years were included in the study.

RESULTS

Age-specific and gender-specific ULNs for ALT, at averages of 30 U/L for boys and 24 U/L for girls, were calculated from the data of healthy children. Using the revised ULNs vs. the current ULNs (40-50 U/L), 31-60% vs. 9-17% of the 2054 HBV-infected children had an abnormal result as seen in their ALT baseline analysis, and the highest abnormality rate was seen in the infants. Data of 516 HBV-infected children were applied for the classification of clinical phase, 28.8% vs. 19.8% of the children were classified into the phases of hepatitis B e antigen (HBeAg-)positive/negative hepatitis. During a median follow-up of 62 months, 39 of 153 children underwent HBeAg seroconversion, whereas 3 of them had persistently "normal" ALT, according to the current ULN.

CONCLUSIONS

The revision of ULN for ALT in children substantially impacts the classification of the natural course of chronic HBV infection. Mild ALT fluctuation is common during the stage childhood, suggesting a need to rethink the current conceptions of immune tolerance and natural course of chronic HBV infection in the children.

Pediatric hepatocellular carcinoma

Pediatric hepatocellular carcinoma (HCC) is the second common malignant liver tumor in children after hepatoblastoma. It differs from the adult HCC in the etiological predisposition, biological behavior and lower frequency of cirrhosis. Perinatally acquired hepatitis-B virus, hepatorenal tyrosinemia, progressive familial intrahepatic cholestasis, glycogen storage disease, Alagille’s syndrome and congenital portosystemic shunts are important predisposing factors. Majority of children (87%) are older than 5 years of age. Following mass immunization against hepatitis-B, there has been a drastic fall in the incidence of new cases of pediatric HCC in the Asia-Pacific region. Management is targeted on complete surgical removal either by resection or liver transplantation. There is a trend towards improving survival of children transplanted for HCC beyond Milan criteria. Chemotherapeutic regimens do not offer good results but may be helpful for down-staging of advanced HCC. Surveillance of children with chronic liver diseases with ultrasound and alpha-fetoprotein may be helpful in timely detection, intervention and overall improvement in outcome of HCC.

Natural History of Chronic Hepatitis B Virus Infection in Ahvaz City, Iran

Objective: A long persistent of Chronic Hepatitis B (CHB) infection may develop liver cirrhosis or hepatocellular carcinoma (HCC) and about one million people die due to HBV -related liver cancer and end-stage liver disease annually worldwide. The natural history of CHB phases comprises four phases: immune tolerant (HBeAg detectable and ALT (Alanine Transaminase) normal, HBeAg-positive immune active (HBeAg detectable, anti-HBe antibodies undetectable and ALT persistently elevated), HBeAg-negative immune active (HBeAg undetectable, anti-HBe antibodies present and ALT persistently elevated), inactive carrier (HBeAg undetectable, anti-HBe antibodies present and ALT normal). The evaluation of chronic hepatitis B phases is a crucial to manage the burden of disease and limit the development of associated complications, such as cirrhosis and hepatocellular carcinoma (HCC). Thus this study conducted to evaluate the natural history of HBV infection in patients with chronic HBV infection in Ahvaz city, Iran. Methods: In this study, 71 non-treated CHB individuals were recruited including 44 (62%) males and 27(38%) females. The sera were tested for HBV markers, HBsAg, HBcIgG, HBeAg, and HBeAb. ALT assay and HBV viral load were carried out for each CHB individual. Results: Based on the analysis of serological, ALT status and viral load, the results showed: immune tolerance 5(7%), eAg+ Immune Clearance 14(19.7%), eAg- Immune Clearance 29 (40.84%) and Inactive Carrier 23 (32.39%). The HBeAg seroconversion was observed in a male age 18 year. Conclusion: The results of the natural history of individuals with chronic hepatitis B phases CHB shows immune tolerance (7%), eAg+ Immune Clearance (19.7%), eAg- Immune Clearance (40.84%) and Inactive Carrier (32.39%). To prevent the consequence of CHB infection, an individual in immune tolerance phase should be tested periodically for ALT level, HBV markers, HBsAg, HBcIgG, HBeAg, HBeAb and HBV viral load. Then decision-making therapy can be applied for CHB patients at early stage of immune clearance.

An expert consensus for the management of chronic hepatitis B in Asian Americans

BACKGROUND

Hepatitis B virus (HBV) infection is common with major clinical consequences. In Asian Americans, the HBsAg carrier rate ranges from 2% to 16% which approximates the rates from their countries of origin. Similarly, HBV is the most important cause of cirrhosis, hepatocellular carcinoma (HCC) and liver related deaths in HBsAg positive Asians worldwide.

AIM

To generate recommendations for the management of Asian Americans infected with HBV.

METHODS

These guidelines are based on relevant data derived from medical reports on HBV from Asian countries as well as from studies in the HBsAg positive Asian Americans. The guidelines herein differ from other recommendations in the treatment of both HBeAg positive and negative chronic hepatitis B (CHB), in the approach to HCC surveillance, and in the management of HBV in pregnant women.

RESULTS

Asian American patients, HBeAg positive or negative, with HBV DNA levels >2000 IU/mL (>10⁴ copies/mL) and ALT values above normal are candidates for anti-viral therapy. HBeAg negative patients with HBV DNA >2000 IU/mL and normal ALT levels but who have either serum albumin <3.5 g/dL or platelet count <130 000 mm³ , basal core promoter (BCP) mutations, or who have first-degree relatives with HCC should be offered treatment. Patients with cirrhosis and detectable HBV DNA must receive life-long anti-viral therapy. Indications for treatment include pregnant women with high viraemia, coinfected patients, and those requiring immunosuppressive therapy. In HBsAg positive patients with risk factors, life-long surveillance for HCC with alpha-fetoprotein (AFP) testing and abdominal ultrasound examination at 6-month intervals is required. In CHB patients receiving HCC treatments, repeat imaging with contrast CT scan or MRI at 3-month intervals is strongly recommended. These guidelines have been assigned to a Class (reflecting benefit vs. risk) and a Level (assessing strength or certainty) of evidence.

CONCLUSIONS

Application of the recommendations made based on a review of the relevant literature and the opinion of a panel of Asian American physicians with expertise in HBV treatment will inform physicians and improve patient outcomes.