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Downs LO, McNaughton AL, de Cesare M, Ansari MA, Martin J, Woodrow C, Bowden R, Collier J, Barnes E, Matthews PC. Case Report: Application of hepatitis B virus (HBV) deep sequencing to distinguish between acute and chronic infection. Wellcome Open Res 2021; 5:240. [PMID: 33458253 PMCID: PMC7802106 DOI: 10.12688/wellcomeopenres.16157.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 11/20/2022] Open
Abstract
Deep sequencing of the full-length hepatitis B virus (HBV) genome provides the opportunity to determine the extent to which viral diversity, genotype, polymorphisms, insertions and deletions may influence presentation and outcomes of disease. Increasing experience with analysis of HBV genomic data opens up the potential for using these data to inform insights into pathophysiology of infection and to underpin decision making in clinical practice. We here set out to undertake whole genome HBV sequencing from an adult who presented acutely unwell with a new diagnosis of HBV infection, and tested positive for both HBV anti-core IgM and IgG, possibly representing either acute hepatitis B infection (AHB) or chronic hepatitis B with an acute reactivation (CHB-AR). The distinction between these two scenarios may be important in predicting prognosis and underpinning treatment decisions, but can be challenging based on routine laboratory tests. Through application of deep whole-genome sequencing we typed the isolate as genotype-D1, and identified several minority variants including G1764A and G1986A substitutions in the pre-core promoter and pre-core regions, which support CHB-AR rather than AHB. In the longer term, enhanced deep sequencing data for HBV may provide improved evidence to distinguish between acute and chronic infection, to predict outcomes and to stratify treatment.
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Affiliation(s)
- Louise O. Downs
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Medawar Building, South Parks Rd, Oxford, OX1 3SY, UK
| | - Anna L. McNaughton
- Nuffield Department of Medicine, University of Oxford, Medawar Building, South Parks Rd, Oxford, OX1 3SY, UK
| | - Mariateresa de Cesare
- Wellcome Centre for Human Genetics, Wellcome Centre for Human Genetics, Oxford, OX3 9DU, UK
| | - M. Azim Ansari
- Wellcome Centre for Human Genetics, Wellcome Centre for Human Genetics, Oxford, OX3 9DU, UK
| | - Jacqueline Martin
- Department of Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Charles Woodrow
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Rory Bowden
- Wellcome Centre for Human Genetics, Wellcome Centre for Human Genetics, Oxford, OX3 9DU, UK
| | - Jane Collier
- Department of Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Eleanor Barnes
- Nuffield Department of Medicine, University of Oxford, Medawar Building, South Parks Rd, Oxford, OX1 3SY, UK
- Department of Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
- Oxford NIHR BRC, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Philippa C. Matthews
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Medawar Building, South Parks Rd, Oxford, OX1 3SY, UK
- Oxford NIHR BRC, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
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Downs LO, McNaughton AL, de Cesare M, Ansari MA, Martin J, Woodrow C, Bowden R, Collier J, Barnes E, Matthews PC. Case Report: Application of hepatitis B virus (HBV) deep sequencing to distinguish between acute and chronic infection. Wellcome Open Res 2020; 5:240. [PMID: 33458253 PMCID: PMC7802106 DOI: 10.12688/wellcomeopenres.16157.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2020] [Indexed: 01/01/2024] Open
Abstract
Deep sequencing of the full-length hepatitis B virus (HBV) genome provides the opportunity to determine the extent to which viral diversity, genotype, polymorphisms, insertions and deletions may influence presentation and outcomes of disease. Increasing experience with analysis of HBV genomic data opens up the potential for using these data to inform insights into pathophysiology of infection and to underpin decision making in clinical practice. We here set out to undertake whole genome HBV sequencing from an adult who presented acutely unwell with a new diagnosis of HBV infection, and tested positive for both HBV anti-core IgM and IgG, possibly representing either acute hepatitis B infection (AHB) or chronic hepatitis B with an acute reactivation (CHB-AR). The distinction between these two scenarios may be important in predicting prognosis and underpinning treatment decisions, but can be challenging based on routine laboratory tests. Through application of deep whole-genome sequencing we typed the isolate as genotype-D1, and identified several minority variants including G1764A and G1986A substitutions in the pre-core promoter and pre-core regions, which support CHB-AR rather than AHB. In the longer term, enhanced deep sequencing data for HBV may provide improved evidence to distinguish between acute and chronic infection, to predict outcomes and to stratify treatment.
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Affiliation(s)
- Louise O. Downs
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Medawar Building, South Parks Rd, Oxford, OX1 3SY, UK
| | - Anna L. McNaughton
- Nuffield Department of Medicine, University of Oxford, Medawar Building, South Parks Rd, Oxford, OX1 3SY, UK
| | - Mariateresa de Cesare
- Wellcome Centre for Human Genetics, Wellcome Centre for Human Genetics, Oxford, OX3 9DU, UK
| | - M. Azim Ansari
- Wellcome Centre for Human Genetics, Wellcome Centre for Human Genetics, Oxford, OX3 9DU, UK
| | - Jacqueline Martin
- Department of Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Charles Woodrow
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Rory Bowden
- Wellcome Centre for Human Genetics, Wellcome Centre for Human Genetics, Oxford, OX3 9DU, UK
| | - Jane Collier
- Department of Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Eleanor Barnes
- Nuffield Department of Medicine, University of Oxford, Medawar Building, South Parks Rd, Oxford, OX1 3SY, UK
- Department of Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
- Oxford NIHR BRC, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Philippa C. Matthews
- Department of Infectious Diseases and Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Medawar Building, South Parks Rd, Oxford, OX1 3SY, UK
- Oxford NIHR BRC, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
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Sarin SK, Kumar M, Lau GK, Abbas Z, Chan HLY, Chen CJ, Chen DS, Chen HL, Chen PJ, Chien RN, Dokmeci AK, Gane E, Hou JL, Jafri W, Jia J, Kim JH, Lai CL, Lee HC, Lim SG, Liu CJ, Locarnini S, Al Mahtab M, Mohamed R, Omata M, Park J, Piratvisuth T, Sharma BC, Sollano J, Wang FS, Wei L, Yuen MF, Zheng SS, Kao JH. Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update. Hepatol Int 2016; 10:1-98. [PMID: 26563120 PMCID: PMC4722087 DOI: 10.1007/s12072-015-9675-4] [Citation(s) in RCA: 1763] [Impact Index Per Article: 220.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023]
Abstract
Worldwide, some 240 million people have chronic hepatitis B virus (HBV), with the highest rates of infection in Africa and Asia. Our understanding of the natural history of HBV infection and the potential for therapy of the resultant disease is continuously improving. New data have become available since the previous APASL guidelines for management of HBV infection were published in 2012. The objective of this manuscript is to update the recommendations for the optimal management of chronic HBV infection. The 2015 guidelines were developed by a panel of Asian experts chosen by the APASL. The clinical practice guidelines are based on evidence from existing publications or, if evidence was unavailable, on the experts' personal experience and opinion after deliberations. Manuscripts and abstracts of important meetings published through January 2015 have been evaluated. This guideline covers the full spectrum of care of patients infected with hepatitis B, including new terminology, natural history, screening, vaccination, counseling, diagnosis, assessment of the stage of liver disease, the indications, timing, choice and duration of single or combination of antiviral drugs, screening for HCC, management in special situations like childhood, pregnancy, coinfections, renal impairment and pre- and post-liver transplant, and policy guidelines. However, areas of uncertainty still exist, and clinicians, patients, and public health authorities must therefore continue to make choices on the basis of the evolving evidence. The final clinical practice guidelines and recommendations are presented here, along with the relevant background information.
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Affiliation(s)
- S K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - M Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - G K Lau
- Division of Gastroenterology and Hepatology, Humanity and Health Medical Centre, Hong Kong SAR, China
- The Institute of Translational Hepatology, Beijing, China
| | - Z Abbas
- Department of Hepatogastroenterlogy, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - H L Y Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - C J Chen
- Genomics Research Center, Academia Sinica, National Taiwan University, Taipei, Taiwan
| | - D S Chen
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - H L Chen
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - P J Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - R N Chien
- Liver Research Unit, Chang Gung Memorial Hospital and University, Chilung, Taiwan
| | - A K Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Ed Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - J L Hou
- Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Guangzhou, China
| | - W Jafri
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - J Jia
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | | | - C L Lai
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - H C Lee
- Internal Medicine Asan Medical Center, Seoul, Korea
| | - S G Lim
- Division of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore
| | - C J Liu
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - S Locarnini
- Research and Molecular Development, Victorian Infectious Diseases Reference Laboratory, Melbourne, Australia
| | - M Al Mahtab
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - R Mohamed
- Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - M Omata
- Yamanashi Hospitals (Central and Kita) Organization, 1-1-1 Fujimi, Kofu-shi, Yamanashi, 400-8506, Japan
| | - J Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - T Piratvisuth
- NKC Institute of Gastroenterology and Hepatology, Prince of Songkla University, Songkhla, Thailand
| | - B C Sharma
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
| | - J Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - F S Wang
- Treatment and Research Center for Infectious Diseases, Beijing 302 Hospital, Beijing, China
| | - L Wei
- Peking University Hepatology Institute, Beijing, China
| | - M F Yuen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Hong Kong, Pofulam, Hong Kong
| | - S S Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
| | - J H Kao
- Graduate Institute of Clinical Medicine and Hepatitis Research Center, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Puri P. Acute exacerbation of chronic hepatitis B: the dilemma of differentiation from acute viral hepatitis B. J Clin Exp Hepatol 2013; 3:301-12. [PMID: 25755518 PMCID: PMC3940633 DOI: 10.1016/j.jceh.2013.08.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 08/28/2013] [Indexed: 12/12/2022] Open
Abstract
Exacerbations of chronic hepatitis B are common in endemic countries. Acute exacerbation of chronic hepatitis B virus (CHB-AE) causing derangement of liver functions may be seen in a flare of HBV in immune clearance phase or as a reactivation of HBV in patients with inactive or resolved HBV infection. While reactivation of HBV is usually seen in HBsAg positive patients, it is being increasingly recognized in patients with apparently resolved HBV infection who do not have HBsAg in serum but have IgG antibody to core antigen (anti-HBc) in the serum, especially so in patients on chemotherapy, immunosuppressive therapy or undergoing hematopoietic stem cell transplantation. In an icteric patient who is HBsAg positive, it may be difficult to differentiate CHB-AE from acute viral hepatitis B (AVH-B). Both may have similar clinical presentation and even IgM anti-HBc, the traditional diagnostic marker of AVH-B, may also appear at the time of exacerbation of CHB. The differentiation between CHB-AE and AVH-B is important not only for prognostication but also because management strategies are different. Most cases of AVH-B will resolve on their own, HBsAg clearance is achieved spontaneously in 90-95% of adults and treatment is rarely indicated except in the few with severe/fulminant disease. In contrast, in CHB-AE, the onset of jaundice may lead to decompensation of liver disease and treatment is warranted. The mechanisms of acute exacerbation and the differentiating features between AVH-B and CHB-AE are reviewed.
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Key Words
- AFP, alfa feto-protein
- ALF, acute liver failure
- ALT, alanine amino-transferase
- AVH-B, acute viral hepatitis B
- CHB-AE, chronic hepatitis B with acute exacerbation
- HAART, highly active antiretroviral therapy
- HBV, hepatitis B virus
- HBVDNA
- HBsAg
- HIV, human immunodeficiency virus
- IFNγ, interferon gamma
- IL, interleukin
- IgM anti-HBc
- LSM, liver stiffness measurement
- NK, natural killer
- NKT, natural killer T
- NUC, nucleoside
- S/CO, sample to the cut-off value
- S/N, signal-to-noise
- TNF, tumor necrosis factor
- Treg, T regulatory
- acute hepatitis B
- chronic hepatitis B
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Affiliation(s)
- Pankaj Puri
- Address for correspondence: Pankaj Puri, Department of Gastroenterology, Army Hospital (R&R), Subroto Park, New Delhi 110010, India.
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Kuo YH, Chen CH, Wang JH, Hung CH, Tseng PL, Lu SN, Changchien CS, Lee CM. Extended lamivudine consolidation therapy in hepatitis B e antigen-positive chronic hepatitis B patients improves sustained hepatitis B e antigen seroconversion. Scand J Gastroenterol 2010; 45:75-81. [PMID: 20030580 DOI: 10.3109/00365520903394550] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Longer lamivudine (LAM) consolidation therapy after hepatitis B e antigen (HBeAg) seroconversion has been demonstrated to reduce the cumulative relapse rate. However, the optimal interval of LAM consolidation therapy remains controversial. We evaluated the post-treatment durability of LAM-induced HBeAg seroconversion and the length of LAM consolidation therapy required to maintain sustained HBeAg seroconversion. MATERIAL AND METHODS This retrospective study included 401 naive HBeAg-positive chronic hepatitis B patients who were treated with LAM 100 mg daily for at least 24 weeks (range 24-258 weeks). Among them, 124 patients who achieved a complete response (HBeAg seroconversion, alanine aminotransferase normalization, hepatitis B virus DNA < 200 copies/ml) at the end of LAM therapy were followed up for at least 48 weeks (range 48-350 weeks). RESULTS Of the 124 complete responders, 42 (33.87%) achieved a sustained response (persistent response >or= 48 weeks). However, the cumulative relapse rates at 48 and 96 weeks post-treatment were 54.03% and 68.4%, respectively. Multivariate analysis revealed pretreatment age <or= 34 years [hazard ratio (HR) 2.25; 95% confidence interval (CI) 1.40-3.62; p < 0.001] and LAM consolidation therapy >or= 48 weeks (HR 2.44; 95% CI 1.35-4.40; p = 0.003) to be independent factors for predicting a sustained response. CONCLUSIONS LAM-induced HBeAg seroconversion is not durable in Taiwan. However, a duration of LAM consolidation therapy > 48 weeks may be favorable for maintaining durable HBeAg seroconversion.
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Affiliation(s)
- Yuan-Hung Kuo
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Niao-Sung, Taiwan
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Alexander G, Baba CS, Chetri K, Negi TS, Choudhuri G. High rates of early HBeAg seroconversion and relapse in Indian patients of chronic hepatitis B treated with Lamivudine: results of an open labeled trial. BMC Gastroenterol 2005; 5:29. [PMID: 16164746 PMCID: PMC1242224 DOI: 10.1186/1471-230x-5-29] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2004] [Accepted: 09/15/2005] [Indexed: 01/20/2023] Open
Abstract
Background The use of Lamivudine in chronic hepatitis B (CHB) is well known, however the reported rate of HBeAg sero-conversion and its durability post-treatment have varied considerably. We undertook the present study to study the effect of Lamivudine on HBeAg loss and seroconversion rates in Indian patients of CHB in relation to frequency, predictors and durability. Methods We treated 60 patients of e antigen positive CHB (with active viral replication and ongoing necro-inflammatory activity) with Lamivudine. They were followed up by monthly aminotransferases, and 3 monthly HBeAg and anti-HBe. Those who attained HBeAg sero-conversion were advised to discontinue Lamivudine after 6 months and followed up every 3 months thereafter, to see for relapse. Treatment was given for maximum of 3 years if not sero-converted. Results The annual incremental loss of HBeAg in patients receiving Lamivudine was 25 (41.6%) at end of 1st year, 33 (55%) at 2nd year and 35 (58.3%) at 3rd year. The corresponding rates for full sero-conversion were 17/60 (28.6%), 22/60 (36.6%) and 24/60 (40%) in the 3 years. HBeAg loss correlated with increased pre-therapy ALT levels (p = 0.002) and decreased pretreatment HBV-DNA levels (p = 0.004). The presence of cirrhosis had no influence on the rate of HBeAg loss. Relapse occurred in 35% (7/20) post-treatment at median time of 6 months. Conclusion Indian patients showed a higher rate of HBeAg sero-conversion in the first year of Lamivudine treatment. This correlated with baseline ALT and inversely with HBV-DNA levels. Relapse rate after treatment was high and occurred soon after stopping treatment.
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Affiliation(s)
- George Alexander
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Chalamalasetty S Baba
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kamal Chetri
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - TS Negi
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Gourdas Choudhuri
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Shin JW, Park NH, Park JH, Park JH, Jeong ID, Bang SJ, Joo KR, Kim DH. Efficacy of lamivudine re-treatment for relapsed patients after an initial lamivudine therapy in HBeAg-positive chronic hepatitis B. J Viral Hepat 2005; 12:393-7. [PMID: 15985010 DOI: 10.1111/j.1365-2893.2005.00606.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
The efficacy of lamivudine re-treatment in chronic hepatitis B (CHB) patients who relapse after HBeAg seroconversion with lamivudine has not been investigated. The aim of this study was to evaluate the efficacy of lamivudine re-treatment in relapsed patients. Among 192 patients who had achieved HBeAg seroconversion with lamivudine at a dose of 100 mg/day, 121 patients discontinued lamivudine. Relapse occurred in 49 patients (40.5%). Thirty-three relapsed patients received lamivudine re-treatment for at least 6 months. The mean duration of lamivudine re-treatment was 16 months and the follow-up period was 8.9 months. HBeAg seroconversion was achieved in 23 patients (69.7%). The cumulative HBeAg seroconversion rates at 5, 9, and 12 months were 60, 64, and 67%, respectively. The mean time to HBeAg seroconversion in lamivudine re-treatment was shorter than that in the initial therapy (4.7 months vs. 9.7 months). Viral breakthrough occurred in six (18.2%) patients. All patients with viral breakthrough were accompanied by elevation of serum alanine aminotransferase (ALT) levels. Among 15 patients who discontinued lamivudine re-treatment after HBeAg seroconversion, relapse occurred in six patients (40%). All relapses occurred within 9 months after the discontinuation of lamivudine re-treatment. In conclusion, lamivudine re-treatment in relapsed patients after initial lamivudine therapy had a higher response rate and shorter duration to HBeAg seroconversion than during the initial therapy. However, HBeAg seroconversion induced by lamivudine re-treatment was not durable.
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Affiliation(s)
- J W Shin
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Korea
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Cacciola I, Spatari G, Pollicino T, Costantino L, Zimbaro G, Brancatelli S, Fenga C, Caccamo G, Squadrito G, Raimondo G. Virological profiles in hepatitis B virus inactive carriers: monthly evaluation in 1-year follow-up study. Liver Int 2005; 25:555-63. [PMID: 15910493 DOI: 10.1111/j.1478-3231.2005.01048.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
UNLABELLED STUDY SUBJECT: We longitudinally evaluated the virological behaviour and the hepatitis B virus (HBV) genomic variability in inactive HBV surface antigen (HBsAg) chronic carriers. PATIENTS AND METHODS Fourteen HBsAg-positive healthy workers (13 inactive carriers and 1 with active HBV infection) were followed up for 12 months by monthly evaluation of aminotransferase, HBV DNA, and IgM anti HBV core antigen (IgM anti-HBc) values. Moreover, HBV serum isolates from each case were amplified, cloned and sequenced to evaluate the presence of the potentially clinical relevant core-promoter and precore mutations. The same technical procedures were used to examine the S gene of isolates from 3 randomly selected inactive carriers and the patients with active HBV infections. RESULTS Aminotransferase values were constantly normal in all cases. Viremia levels appear to fluctuate widely over time in each individual case, although the HBV DNA remained below 2 x 10(4) copies/ml in all samples. Only four serum samples from two inactive carriers had IgM anti-HBc values higher than the specific cut-off limit of the assay. Either wild type or core-promoter/precore HBV variants or a mixture of them were detected in the inactive carriers. S gene nucleotide homology among the clones from the three inactive carriers and the subject with active infection was 98.9%, 98.3%, 98.1% and 98.2%, respectively. CONCLUSIONS The degree of suppression of HBV replication in inactive carriers is variable over time, and the entity and quality of HBV variability is comparable between active and inactive carriers.
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Affiliation(s)
- Irene Cacciola
- Unità di Epatologia Clinica e Biomolecolare, Dipartimento di Medicina Interna, Universita di Messina, Messina, Italy
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9
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Ma SY, Lau GKK, Cheng VCC, Liang R. Hepatitis B reactivation in patients positive for hepatitis B surface antigen undergoing autologous hematopoietic cell transplantation. Leuk Lymphoma 2003; 44:1281-5. [PMID: 12952220 DOI: 10.1080/1042819031000083343] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hepatitis due to reactivation of hepatitis B virus is an important cause of liver-related morbidity and mortality in hepatitis B surface antigen (HBsAg) positive patients undergoing autologous hematopoeitic cell transplantation. With the recent introduction of sensitive serum HBV DNA quantitation assay, the diagnosis of hepatitis B reactivation can now be made more reliably. As these hepatitis are driven by the host immune response to a surge of hepatitis B viral load, the availability of effective nucleoside analogues which can inhibit hepatitis B viral replication has opened up new approaches to this previously untreatable condition. Up till now, two such nucleoside analogues, lamivudine and adefovir dipivoxil, have been approved for the treatment of chronic hepatitis B infection. However, further studies are needed to determine which nucleoside analogues should be chosen in this transplant setting. Due to the high dose chemotherapy generally needed in autologous hematopoeitic cell transplantation, there is a high risk of post-transplant hepatitis B reactivation. Hence, all HBsAg positive patients undergoing autologous hematopoeitic cell transplantation should preferably be treated pre-emptively with nucleoside analogous. An alternative approach is to defer treatment with nucleoside analogous until there is evidence of hepatitis B virological reactivation. However, the latter approach would need the patient's hepatitis B viral load be monitored at a very close interval and might not be cost-effective.
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Affiliation(s)
- Shing-Yan Ma
- Division of Hematology, University Department of Medicine, The University of Hong Kong, Hong Kong SAR, People's Republic of China
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10
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Lee CM, Ong GY, Lu SN, Wang JH, Liao CA, Tung HD, Chen TM, Changchien CS. Durability of lamivudine-induced HBeAg seroconversion for chronic hepatitis B patients with acute exacerbation. J Hepatol 2002; 37:669-74. [PMID: 12399235 DOI: 10.1016/s0168-8278(02)00267-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Lamivudine-induced hepatitis B e antigen (HBeAg) seroconversion in patients with chronic hepatitis B was reported to be durable by several studies but controversy still exists. The aim of this study was to evaluate the durability of the responses of lamivudine treatment. METHODS Among 53 chronic hepatitis B patients who had acute exacerbation and had finished lamivudine therapy after at least 6 months of treatment, 31 patients achieved full HBeAg seroconversion twice at least 1 month apart, and subsequently stopped lamivudine therapy. Post-treatment monitoring was continued for up to 87 weeks. Alanine transaminase (ALT), HBeAg and hepatitis B virus (HBV) DNA were used as indicators for relapse. RESULTS The cumulative relapse rates at 48 and 72 weeks post-treatment were 45.4% and 56.3%, respectively. During follow up, normal ALT levels precluded relapse while ALT levels over two times the upper limit of normal indicated relapse, which correlated well with HBeAg or HBV DNA reappearance. Patients older than 25 years were more likely to experience post-treatment relapse. CONCLUSIONS Lamivudine-induced full HBeAg seroconversion was not durable in the Taiwanese population. ALT levels were useful for relapse detection. Age was the only independent predictive factor for relapse.
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Affiliation(s)
- Chuan-Mo Lee
- Liver Unit, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
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Lau GKK, Leung YH, Fong DYT, Au WY, Kwong YL, Lie A, Hou JL, Wen YM, Nanj A, Liang R. High hepatitis B virus (HBV) DNA viral load as the most important risk factor for HBV reactivation in patients positive for HBV surface antigen undergoing autologous hematopoietic cell transplantation. Blood 2002; 99:2324-30. [PMID: 11895763 DOI: 10.1182/blood.v99.7.2324] [Citation(s) in RCA: 183] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The risk factors for hepatitis due to hepatitis B virus (HBV) reactivation in patients positive for hepatitis B surface antigen (HBsAg) treated with autologous hematopoietic cell transplantation (HCT) are unknown. We evaluated 137 consecutive patients (23 positive for HBsAg, 37 positive for hepatitis B surface antibody, and 77 negative for HBV) who underwent HCT. Serial serum ALT were measured before transplant and after transplant at 1 to 4 weekly intervals for the first year and then at 2 to 12 weekly intervals thereafter. Before HCT, basic core promoter (T(1762)/A(1764)) and precore (A(1896)) HBV variants were determined in HBsAg-positive and HBV DNA-positive (by polymerase chain reaction assay) patients by direct sequencing and serum HBV DNA quantitation using the Digene Hybrid Capture II assay. Cox proportional hazards analysis was used to assess the association between pretransplantation HBV virologic and host factors and occurrence of hepatitis due to HBV reactivation. After HCT, hepatitis due to HBV reactivation was more common in HBsAg-positive patients than in HBsAg-negative patients (hazard ratio, 33.3; 95% confidence interval [CI], 7.35-142.86; P <.0001). HBsAg-positive patients with detectable serum HBV DNA before HCT (on Digene assay) had a significantly higher risk of hepatitis due to HBV reactivation than HBsAg-positive patients with no detectable serum HBV DNA (adjusted hazard ratio, 9.35; 95% CI, 1.65-52.6; P =.012). Thus, we found that hepatitis due to HBV reactivation is common in HBsAg-positive patients undergoing autologous HCT. A high HBV DNA level (>10(5) copies/mL) was the most important risk factor for HBV reactivation, and its lowering by administration of nucleoside analogues before transplantation should be considered.
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Affiliation(s)
- George K K Lau
- Division of Gastroenterology and Hepatology, University Department of Medicine, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, People's Republic of China
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12
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Xunrong L, Yan AW, Liang R, Lau GK. Hepatitis B virus (HBV) reactivation after cytotoxic or immunosuppressive therapy--pathogenesis and management. Rev Med Virol 2001; 11:287-99. [PMID: 11590667 DOI: 10.1002/rmv.322] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In an endemic area for chronic hepatitis B infection, reactivation of this virus is a serious cause of morbidity and mortality in patients undergoing cytotoxic or immunosuppressive therapy. Careful prospective serological testing has shown that hepatitis B virus reactivation is a two-staged process. The initial stage occurs during intense cytotoxic or immunosuppressive therapy and is characterised by enhanced viral replication, as reflected by increases in the serum levels of hepatitis B virus DNA, hepatitis B e antigen, hepatitis B virus DNA polymerase and infection of naïve hepatocytes with hepatitis B virus. The second stage is related to restoration of immune function following withdrawal of cytotoxic or immunosuppressive therapy, which causes rapid immune-mediated destruction of infected hepatocytes. Clinically, this can lead to hepatitis, hepatic failure and even death. The occurrence and severity of hepatitis B virus reactivation after various cytotoxic or immunosuppressive therapy is unpredictable and treatment has been disappointing, largely due to the late administration of therapy. Recently, pre-emptive treatment of chronic hepatitis B patients undergoing cytotoxic or immunosuppressive therapy, with potent nucleoside analogues has shown some promising results. Further controlled studies are needed to define the incidence and risk factors of hepatitis B reactivation so that pre-emptive treatment with nucleoside analogues could be administered to those patients at high risk of disease.
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Affiliation(s)
- L Xunrong
- University Department of Medicine, Queen Mary Hospital, 102 Pokfulum Road, Hong Kong SAR, China
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13
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Perrillo RP. Acute flares in chronic hepatitis B: the natural and unnatural history of an immunologically mediated liver disease. Gastroenterology 2001; 120:1009-22. [PMID: 11231956 DOI: 10.1053/gast.2001.22461] [Citation(s) in RCA: 284] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute flares in chronic hepatitis B are common and may be caused by a number of identifiable and potentially treatable factors. The common link for many of these exacerbation episodes is a change in the immunologic response to hepatitis B virus (HBV), and this may have no identifiable cause or be triggered by an increase in viral replication or genotypic change. It is important to keep in mind the clinical situations in which patients are at increased risk of reactivated infection and secondary exacerbations. Reactivation is frequently induced by medical treatments such as cancer chemotherapy, antirejection drugs used in organ transplantation, and corticosteroids. The immunologic flares that often result from sudden withdrawal of these medications can be life-threatening unless recognized and treated promptly with antivirals, and there is increasing experience that preemptive antiviral treatment can diminish their occurrence and improve the outcome. The experience with lamivudine and other nucleoside analogues has increased our understanding of the molecular events behind hepatitis flares that occur when chronic hepatitis B is treated with drugs that potently inhibit HBV DNA polymerase. However, not all flares are explainable by events related to HBV infection alone. Depending on the population studied, as many as 20%-30% of flares may be caused by infection with other hepatotropic viruses, and this situation may inhibit HBV replication. Proper understanding of the etiology and effective treatment of acute flares in chronic hepatitis B requires an appreciation of high-risk clinical situations, assessment of HBV replication status, and testing for other viruses when appropriate.
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Affiliation(s)
- R P Perrillo
- Section of Gastroenterology and Hepatology, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, Louisiana 70121, USA.
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Song BC, Suh DJ, Lee HC, Chung YH, Lee YS. Hepatitis B e antigen seroconversion after lamivudine therapy is not durable in patients with chronic hepatitis B in Korea. Hepatology 2000; 32:803-6. [PMID: 11003626 DOI: 10.1053/jhep.2000.16665] [Citation(s) in RCA: 264] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
It has been suggested that hepatitis B e antigen (HBeAg) seroconversion after lamivudine therapy is durable in Caucasians with chronic hepatitis B (CHB). However, little is known whether it is also durable in endemic areas of hepatitis B virus (HBV) infection. We evaluated the posttreatment durability of lamivudine-induced HBeAg seroconversion and the predictive factors for relapse in Korean patients with CHB. We retrospectively analyzed 98 HBeAg-positive patients with CHB who were treated with lamivudine between August 1996 and December 1997. Lamivudine was given at a dose of 150 mg per day. After HBeAg seroconversion, lamivudine was continued for an additional 2 to 4 months, and posttreatment monitoring continued for up to 24 months. HBeAg seroconversion was achieved in 34 of the 98 patients (34.7%). The mean duration of treatment in these seroconverters was 9.3 +/- 3.0 months. During the follow-up period, the cumulative relapse rates at 1 year and 2 years posttreatment were 37.5% and 49.2%, respectively. Most relapses were accompanied by elevation of serum alanine transaminase (94%) and reappearance of HBeAg (81%). Pretreatment serum HBV DNA levels and the duration of additional lamivudine therapy after HBeAg seroconversion were 2 independent predictive factors for posttreatment relapse. In conclusion, lamivudine-induced HBeAg seroconversion was not durable in this endemic area. And the duration of additional lamivudine therapy after HBeAg seroconversion significantly affected the posttreatment relapse. Further studies are needed to determine the duration of lamivudine and to elucidate the cause of high relapse after HBeAg seroconversion in endemic areas of HBV.
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Affiliation(s)
- B C Song
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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15
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A case-controlled study on the use of HBsAg-positive donors for allogeneic hematopoietic cell transplantation. Blood 2000. [DOI: 10.1182/blood.v96.2.452] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractTo compare the clinical and serological outcomes of patients receiving donors' marrow positive or negative for hepatitis B surface antigen (HBsAg), we studied 18 patients of allogeneic hematopoietic cell transplantation receiving HBsAg-positive marrow (group 1) and 18 receiving HBsAg-negative marrow (group 2). The recipients of the 2 groups were matched for hepatitis B virus (HBV) serology, sex, age, underlying hematological diseases, conditioning regimen, and prophylaxis against graft-versus-host diseases. Eight (44.4%) recipients in group 1 and 2 (11.1%) in group 2 suffered from HBV-related hepatitis posttransplant (P = .03). Furthermore, HBV-related hepatic failure was seen in 6 group 1 patients, but in none of the group 2 patients (P = .007). Five of the 9 (55.5%) HBsAg-negative recipients in group 1 became positive after receiving HBsAg-positive marrow. Serum HBV DNA was positive in all 5 donors of these patients, but in none of the donors of recipients who remained HBsAg negative (P = .008). Group 1 patients developing HBV-related hepatitis posttransplant were more likely to have a donor carrying a precore A1896 and/or core promoter T1762/A1764 HBV variant (62.5% versus 0%, P = .007). This study has demonstrated that a high incidence of HBV-related hepatitis was associated with the use of HBsAg-positive marrow for transplant, and a high viral load in the donor appeared to predispose recipients to the development of HBV-related hepatitis posttransplant. Further clinical trials will be necessary to determine the optimal management approach to this problem, including the use of the antiviral agents in the donors and the recipients.
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Abstract
To compare the clinical and serological outcomes of patients receiving donors' marrow positive or negative for hepatitis B surface antigen (HBsAg), we studied 18 patients of allogeneic hematopoietic cell transplantation receiving HBsAg-positive marrow (group 1) and 18 receiving HBsAg-negative marrow (group 2). The recipients of the 2 groups were matched for hepatitis B virus (HBV) serology, sex, age, underlying hematological diseases, conditioning regimen, and prophylaxis against graft-versus-host diseases. Eight (44.4%) recipients in group 1 and 2 (11.1%) in group 2 suffered from HBV-related hepatitis posttransplant (P = .03). Furthermore, HBV-related hepatic failure was seen in 6 group 1 patients, but in none of the group 2 patients (P = .007). Five of the 9 (55.5%) HBsAg-negative recipients in group 1 became positive after receiving HBsAg-positive marrow. Serum HBV DNA was positive in all 5 donors of these patients, but in none of the donors of recipients who remained HBsAg negative (P = .008). Group 1 patients developing HBV-related hepatitis posttransplant were more likely to have a donor carrying a precore A1896 and/or core promoter T1762/A1764 HBV variant (62.5% versus 0%, P = .007). This study has demonstrated that a high incidence of HBV-related hepatitis was associated with the use of HBsAg-positive marrow for transplant, and a high viral load in the donor appeared to predispose recipients to the development of HBV-related hepatitis posttransplant. Further clinical trials will be necessary to determine the optimal management approach to this problem, including the use of the antiviral agents in the donors and the recipients.
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17
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Stanojevic M, Zerjav S, Jevtovic DJ, Markovic LJ. HBsAg as the antigen component of circulating immune complexes in HIV-infected patients. Biomed Pharmacother 2000; 54:163-7. [PMID: 10840593 DOI: 10.1016/s0753-3322(00)89049-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Seeing the same transmission pattern of HIV and HBV coinfection by these two agents is not an uncommon feature. Immunity impairment due to HIV infection can be the cause of a higher rate of HBV replication with less intensive liver damage and less effective immune response to HBV, while the pathological course in both infections involves elevated levels of circulating immune complexes (CIC). These were the reasons for us to examine the frequency of HBsAg involvement as the antigen component of circulating immune complexes formed in sera of HIV-infected patients in different stages of HIV disease. We tested 67 sera of HIV-positive patients in different stages of HIV disease for the presence of HBsAg and HIV antigen p24 (with and without acid dissociation of immune complexes), for the presence of anti-Hbc antibodies and circulating immune complexes. HBsAg was positive in 13.8% sera prior to and 33.8% after acid pretreatment. Anti-HBc antibodies were present in 76.9% serum samples tested. Fifty percent of sera were positive for both HBsAg and p24 antigen after dissociation of immune complexes. The level of CIC was elevated in 65.9% of sera. Our results suggest that HBsAg is commonly associated in immune complexes formed in the sera of HIV-infected patients and that they may simultaneously contain HIV and HBsAg in patients coinfected with both agents. This may contribute to their mutual interaction and influence the diagnosis and follow-up of patients.
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Affiliation(s)
- M Stanojevic
- Institute for Infectious and Tropical Diseases CCS, University of Belgrade, Yugoslavia
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18
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Sperotto A, Silvestri F, Fanin R, Damiani D, Geromin A, Cerno M, Stocchi R, Patriarca F, Baccarani M. Feasibility of autologous stem cell transplantation in chronic carriers of hepatitis B and hepatitis C virus. Leuk Lymphoma 2000; 36:323-30. [PMID: 10674904 DOI: 10.3109/10428190009148853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
There are several reports describing acute liver decompensation in chronic carriers of HBsAg after withdrawal of chemotherapy or immunosuppressive therapy; recently the same was also reported for chronic HCV-RNA carriers. We retrospectively evaluated hepatic toxicity in eleven patients (6 carriers of HCV-RNA and 5 of HBsAg) autotransplanted at our Institution between March '92 and June '98. Male/female ratio was 7/4, median age 41 years (26-56). Nine patients (4 HBsAg) were affected by non-Hodgkin's lymphoma, 1 (HCV-RNA) by chronic myelogenous leukaemia and 1 (HBsAg) by breast cancer. In the immediate post-transplant period in only 1 patient (HBsAg carrier and affected by breast cancer) was hepatitis documented (at about 1 month from transplant) with an elevation of transaminase levels (x20-40 n.v.). Neither other complications, nor toxic deaths were observed. During the post-transplant follow-up (median 31 months, range 9-83) no hepatic abnormalities were observed. All patients are alive at 56 months (20-122) from diagnosis. Currently 10/11 patients are in complete remission, while 1 patient, affected by follicular centre lymphoma, is alive with disease 52 months from autologous stem cell transplantation. Our study shows that both conventional therapy and high-dose chemotherapy can be performed safely in chronic hepatitis B and C virus carriers.
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Affiliation(s)
- A Sperotto
- Department of Medical and Morphological Research, University Hospital, Udine, Italy
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19
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Lau GK, Lee CK, Liang R. Hepatitis B virus infection and bone marrow transplantation. Crit Rev Oncol Hematol 1999; 31:71-6. [PMID: 10532191 DOI: 10.1016/s1040-8428(98)00042-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- G K Lau
- University Department of Medicine, Queen Mary Hospital, Hong Kong, SAR, People's Republic of China
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20
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Dou HY, Wu JC, Peng WL, Chang C, Chi WK, Chu YD, Hu CP. Analysis of T cell receptor Vbeta gene usage during the course of disease in patients with chronic hepatitis B. J Biomed Sci 1998; 5:428-34. [PMID: 9845846 DOI: 10.1007/bf02255931] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The T cell receptor (TCR) is a heterodimeric molecule expressed on the surface of T cells and recognizes foreign peptides presented by the major histocompatibility complex on the surface of antigen-presenting cells or virus-infected cells. Analysis of TCR usage by T cells which recognize hepatitis B virus (HBV) provides further insight into the participation of T cell populations during the course of disease. In this study, we examined the T-cell-proliferative response and the TCR Vbeta gene usage of peripheral blood mononuclear cells in 3 patients with clinical evidence typical of chronic hepatitis B. All 3 patients had significant T-cell proliferative responses against HBV core antigen (HBcAg) during the remission stage, while no responses were detected during the acute exacerbation stage. In addition, the TCR Vbeta7 gene was utilized more frequently in T cells recognizing HBcAg during remission, while TCR Vbeta1 and Vbeta2 were utilized at a higher percentage during acute exacerbation. On the contrary, the T cell proliferative response against HBV surface antigen was undetectable and no specific Vbeta gene was utilized more frequently by all 3 patients, regardless of disease state. Our longitudinal studies, although based on a small sample of patients, demonstrate that the population of HBcAg-activated T cells alters during the course of disease in chronic hepatitis B patients.
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Affiliation(s)
- H Y Dou
- Institute of Microbiology and Immunology, National Yang-Ming University, Taipei, Taiwan, ROC
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21
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Lau GK, Liang R, Wu PC, Lee CK, Lim WL, Au WY. Use of famciclovir to prevent HBV reactivation in HBsAg-positive recipients after allogeneic bone marrow transplantation. J Hepatol 1998; 28:359-68. [PMID: 9551671 DOI: 10.1016/s0168-8278(98)80307-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIMS Reactivation of chronic hepatitis B viral infection causes significant morbidity and mortality after bone marrow transplantation. Recently, nucleoside analogues, such as famciclovir, were found to have a direct suppressive effect on hepatitis B virus replication in both in vitro and in vivo studies. We have studied the effect of famciclovir on the incidence of hepatitis B virus reactivation and hepatitis after allogeneic bone marrow transplantation. METHODS Eight hepatitis B surface antigen (HBsAg)-positive patients who received allogeneic bone marrow transplantation were given oral famciclovir 250 mg three times daily, starting at least 1 week prior to bone marrow transplantation and continuing for 24 weeks after transplantation. Clinical and serological outcomes in these patients were compared with 24 HBsAg-positive recipients of allogeneic bone marrow transplantation who did not receive famciclovir (historical controls). RESULTS After bone marrow transplantation, there were five patients with hepatitis B virus reactivation among those who received famciclovir 250 mg three times daily. Four of these patients responded to increased dosages of 500 mg three times daily and did not develop hepatitis. The remaining patient suffered from hepatitis related to hepatitis B virus reactivation. Compared to historical controls, there were fewer cases of hepatitis due to hepatitis B virus reactivation and veno-occlusive disease. The median follow-up was 701.6 days (range: 50-2346 days) with ten deaths (three due to hepatic failure related to HBV reactivation) in those who did not receive famciclovir and one death (due to hepatic failure related to graft-versus-host disease) in those who received famciclovir. CONCLUSIONS Use of famciclovir significantly reduced hepatitis due to hepatitis B virus reactivation in HBsAg-positive recipients after allogeneic bone marrow transplantation.
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Affiliation(s)
- G K Lau
- Department of Medicine, Queen Mary Hospital, Hong Kong.
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22
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Gilson RJ, Hawkins AE, Beecham MR, Ross E, Waite J, Briggs M, McNally T, Kelly GE, Tedder RS, Weller IV. Interactions between HIV and hepatitis B virus in homosexual men: effects on the natural history of infection. AIDS 1997; 11:597-606. [PMID: 9108941 DOI: 10.1097/00002030-199705000-00007] [Citation(s) in RCA: 225] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Hepatitis B virus (HBV) and HIV infections share risk-factors; therefore coinfection is common. Interactions have been reported but controlled studies have been limited. Our objective was to study the effect of HIV infection on the natural history of chronic HBV infection and the reverse effect of the HBV carrier state on HIV infection. DESIGN Prospective observational cohort study. SETTING Open-access outpatient HIV/genitourinary medicine clinic at a Central London hospital. PATIENTS Total of 152 untreated homosexual male HBV carriers and 212 HBV surface antigen-negative controls (41.4 and 70.3% HIV-seropositive, respectively). OUTCOME MEASURES The rate of loss of serum HBV e antigen (HBeAg) and its reappearance in HIV-infected and HIV-uninfected HBV carriers; serum HBV DNA levels measured by dot-blot hybridization assay), HBV DNA polymerase activity and liver transaminase activities, the progression of HIV infection to symptomatic disease or AIDS in HIV-infected compared with HBV-HIV coinfected patients. RESULTS In HIV-infected HBV carriers, serum HBV DNA polymerase activity was higher, alanine aminotransferase was lower and loss of serum HBeAg (mean follow-up, 2.8 years) occurred at a lower rate when compared with HIV-uninfected HBV carriers (estimated relative hazard, 0.39; 95% confidence interval, 0.161-0.942) Concomitant chronic HBV infection had no detectable effect on the rate of progression of HIV disease after correction for lead-time bias. CONCLUSION This study strengthens the evidence for a significant effect of HIV infection on the natural history of chronic HBV infection, which by prolonging the period of infectivity could have an important impact on the epidemiology of HBV infection in regions, or patient groups, with high HIV seroprevalence. There was no evidence of an important effect of HBV carriage on HIV disease progression.
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Affiliation(s)
- R J Gilson
- Department of Sexually transmitted Diseases, University College London Medical School, UK
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23
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di Martino V, Lunel F, Cadranel JF, Hoang C, Parlier Y, Le Charpentier Y, Opolon P. Long-term effects of interferon-alpha in five HIV-positive patients with chronic hepatitis B. J Viral Hepat 1996; 3:253-60. [PMID: 8914005 DOI: 10.1111/j.1365-2893.1996.tb00051.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic hepatitis B viral infection is common in human immunodeficiency virus (HIV) carriers, but the effectiveness of interferon therapy is still unknown. We report the results of a long-term pilot study of five patients, who were infected with HIV and chronic hepatitis B, treated by interferon. Five males co-infected with HIV and hepatitis B virus (HBV) (mean age 27 years) were given a 6-month course of interferon (IFN)-alpha 2b 5 million units (MU) three times weekly. On initiating the treatment, their CD4 lymphocyte count was 340-553 mm-3, their CDC stage was IIa-III; all had histologically proven chronic hepatitis, with Knodell's score ranging from 6-10, and active HBV replication (HBV DNA and hepatitis B e antigen (HBeAg) were detectable). There was no associated hepatitis delta virus (H delta V) or hepatitis C virus (HCV) infection. Follow-up was for 53 months on average (24-74 months). After the treatment, hepatitis B e antibody (HBeAb) and hepatitis B s antibody (HBsAb) seroconversion was observed in one patient, HBeAb seroconversion alone in two patients, HBV DNA was absent from serum in three patients, and HBV DNA significantly decreased in one patient. The serum alanine aminotransferase (ALT) activity was normal in four patients. Histological improvement was obtained in four patients. The HIV stage remained unchanged in all patients during the whole follow-up. These preliminary results suggest that interferon can be successfully used in immunocompetent HIV carriers with chronic hepatitis B as well as in HIV-negative patients.
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Affiliation(s)
- V di Martino
- Service d'Hépato-Gastroentérologie, Groupe hospitalier Pitie-Salpetriere, Paris, France
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25
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Fung JJ, Rakela J, Pinna A, Todo S. Liver transplantation for hepatitis B: what have we learned and what does the future hold? LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1995; 1:274-80. [PMID: 9346582 DOI: 10.1002/lt.500010417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- J J Fung
- Pittsburgh Transplantation Institute, University of Pittsburgh Medical Center, PA, USA
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Mels GC, Bellati G, Leandro G, Brunetto MR, Vicari O, Borzio M, Piantino P, Fornaciari G, Scudeller G, Angeli G. Fluctuations in viremia, aminotransferases and IgM antibody to hepatitis B core antigen in chronic hepatitis B patients with disease exacerbations. LIVER 1994; 14:175-81. [PMID: 7968277 DOI: 10.1111/j.1600-0676.1994.tb00071.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We studied the relationships between the serum levels of viremia, aminotransferases and IgM anti-HBc, measured by monthly quantitative assays, in 52 untreated chronic hepatitis B patients (41 anti-HBe+, 11 HBeAg+) followed up for 12-20 months. Forty hepatitis exacerbations were observed in 17/41 anti-HBe+ (41.5%) and in 6/11 HBeAg+ patients (54.5%) (p = NS); all but one were clinically asymptomatic. We analyzed the fluctuations in the serum levels of the three parameters before, during and after the hepatitis exacerbations and found this chronological sequence of events in 96.2% of them: HBV-DNA increase-->ALT flare-->IgM anti-HBc increase. These results suggest that both antiviral immune reactions and ALT flares were triggered by quantitative variations in viremia. HBV-DNA baseline levels before flares were lower in anti-HBe+ (3.9 +/- 1.2 pg/ml) than in HBeAg+ patients (35.3 +/- 5.4 pg/ml) (p < 0.0001) and there was an inverse correlation between basal values and viremia level increases at the time of disease exacerbations (p < 0.001). This suggests that for a hepatitis exacerbation to occur, low basal viremia needed to increase markedly, while moderate increases in HBV-DNA serum levels were sufficient to trigger ALT flares in patients with elevated basal viremia. In conclusion, asymptomatic hepatitis B exacerbations are frequent in the natural history of chronic HBV infection, and monthly monitoring of HBV-DNA, ALT and IgM anti-HBc appears to be a suitable method to evaluate their frequencies and entities. This method can be a helpful guide for clinical and therapeutic decision-making in the single patient with chronic hepatitis B.
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Affiliation(s)
- G C Mels
- Department of Internal Medicine, Bolognini Hospital, Seriate, Italy
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28
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Catterall AP, Murray-Lyon IM, Zuckerman AJ, Harrison TJ. Southern hybridisation analysis of HBV DNA in peripheral blood leucocytes and of different cell types: changes during the natural history and with interferon-alpha therapy in patients with hepatitis B virus infection. J Med Virol 1994; 43:269-75. [PMID: 7931189 DOI: 10.1002/jmv.1890430314] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Hepatitis B virus (HBV) DNA was evaluated in peripheral blood mononuclear cells (PBMC) from 50 individuals utilising Southern hybridisation analysis. HBV DNA sequences were detected in PBMC from 16/29 (55 percent) of chronic hepatitis B virus (HBV) carriers with serum HBeAg and HBV DNA, compared with 1/8 (13%) of carriers with anti-HBe and HBV DNA negative (P = NS). Two of 7 patients with previous HBV infection and chronic liver disease had detectable HBV DNA in PBMC. Of the 19 patients with HBV DNA in PBMC, 18 had high molecular weight species. In addition, five of these had free, monomeric HBV DNA and six patients had low molecular weight bands. For nine of the above patients, total peripheral blood leucocytes were separated into PBMC and polymorphonuclear cells. Four had HBV DNA in PBMC only, two only in polymorphonuclear cells and three in both types of cell. Eleven patients with chronic HBV infection were studied at monthly intervals for 6 months. Six were untreated and five received IFN-alpha. Three patients who responded to IFN-alpha had HBV DNA present in PBMC before therapy, and two became negative. Two of 3 untreated patients had intermittent HBV DNA in PBMC and the other remained persistently negative. Of the patients positive on more than one occasion, the pattern of HBV DNA was similar. Peripheral blood leucocytes often contain multimers of free HBV DNA, more commonly in patients with serum HBeAg and HBV DNA and may occur even in the absence of serum HBsAg. These findings have implications for recurrence of disease after hepatic transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- A P Catterall
- Department of Gastroenterology, Charing Cross Hospital, London, England
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Villeneuve JP, Desrochers M, Infante-Rivard C, Willems B, Raymond G, Bourcier M, Côté J, Richer G. A long-term follow-up study of asymptomatic hepatitis B surface antigen-positive carriers in Montreal. Gastroenterology 1994; 106:1000-5. [PMID: 8143967 DOI: 10.1016/0016-5085(94)90760-9] [Citation(s) in RCA: 119] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND/AIMS Prospective studies from the Far East and Alaska have shown an increased mortality from cirrhosis and/or hepatocellular carcinoma in asymptomatic hepatitis B virus (HBV) carriers. The magnitude of this risk in apparently healthy North American carriers remains undefined. METHODS The outcomes of 317 asymptomatic hepatitis B surface antigen-positive carriers from the Montreal area were examined after 16 years of follow-up. A majority of carriers were of French Canadian origin, were positive for antibody to hepatitis B e antigen, and had normal serum transaminase levels; institutionalization in orphanages as infants or children was the most important epidemiological risk factor, suggesting horizontal transmission of HBV during childhood. RESULTS At follow-up, mean age was 46 +/- 8 years; 3 carriers had died of HBV-related cirrhosis, 1 of alcoholic cirrhosis, and 9 of causes unrelated to liver disease. No carrier died of hepatocellular carcinoma; had the risk of hepatocellular carcinoma been similar to that reported from the Far East and Alaska, 17 cases of hepatocellular carcinoma-related deaths would have been expected. During follow-up, the annual negativation rate for hepatitis B surface antigen was 0.7%. CONCLUSIONS In asymptomatic HBV carriers from Montreal, a majority are "healthy" carriers and remain asymptomatic after 16 years of follow-up and the risk of death from HBV-related cirrhosis and/or hepatocellular carcinoma is low.
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Affiliation(s)
- J P Villeneuve
- Department of Medicine, Hôpital Saint-Luc, Montreal, Canada
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30
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Maruyama T, Iino S, Koike K, Yasuda K, Milich DR. Serology of acute exacerbation in chronic hepatitis B virus infection. Gastroenterology 1993; 105:1141-51. [PMID: 8405860 DOI: 10.1016/0016-5085(93)90960-k] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Liver injury in many patients with chronic hepatitis B is sporadic and is often characterized by acute exacerbations alternating with relatively normal liver function. The aim of this study was to perform detailed serological and biochemical analysis during periods of active liver disease to better understand the mechanisms responsible for the cyclic nature of liver injury. METHODS A series of serum samples from 19 hepatitis B e antigen (HBeAg)-positive patients were analyzed for alterations in serum hepatitis B virus (HBV) DNA, HBeAg, anti-HBe production, and HBeAg-specific immune complex formation before, during, and after spontaneous acute exacerbations of liver injury. RESULTS This analysis revealed significant correlations between increasing levels of serum HBV DNA, HBeAg, HBeAg-specific immune complexes, and liver injury. These results suggest that increases in viral replication and accumulation of viral proteins in the serum and intracellularly and the subsequent immune response play an important role in initiating acute exacerbations of liver injury in chronic hepatitis B infection. CONCLUSIONS We propose that production of the secreted and cellular forms of the nucleoprotein reaches a threshold level and elicits specific immune responses, which mediate liver injury.
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Affiliation(s)
- T Maruyama
- Department of Molecular Biology, Scripps Research Institute, La Jolla, California
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31
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Colloredo Mels G, Bellati G, Leandro G, Brunetto MR, Vicari O, Piantino P, Borzio M, Angeli G, Ideo G, Bonino F. Role of IgM antibody to hepatitis B core antigen in the diagnosis of hepatitis B exacerbations. ARCHIVES OF VIROLOGY. SUPPLEMENTUM 1993; 8:203-11. [PMID: 8260865 DOI: 10.1007/978-3-7091-9312-9_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
IgM anti-HBc levels were measured by the IMx Core-M Abbott assay in 939 serum samples in order to define a specific and sensitive cut-off value for diagnosis of chronic hepatitis B. The sera used were obtained from 52 chronic HBV patients and 10 HBV carriers with HCV or HDV co-infections and 155 asymptomatic subjects without evidence of liver disease. A Youden index value of 95.4% with 98% sensitivity and 97.4% specificity was obtained for an IMx Index value of 0.204 as cut-off. A one-year follow-up study with monthly tests has shown that quantitative analysis of IgM anti-HBc can serve as a noninvasive tool for monitoring HBV infection, and provides an accurate diagnosis of hepatitis B exacerbations. Significant elevations of IgM anti-HBc levels were associated with hepatitis B exacerbations in 96.2% of the cases but with none of the ALT flare-ups observed in HCV or HDV infected individuals. These results suggest that quantitative analysis of IgM anti-HBc provides the highest degree of confidence in definition of spontaneous and therapy-induced exacerbations or remissions of hepatitis B.
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Affiliation(s)
- G Colloredo Mels
- Department of Internal Medicine, Bolognini Hospital, Seriate, Bergamo, Italy
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Abstract
Serologic tests are the most accurate method of identifying a viral cause for a liver disorder and distinguishing between the different forms of viral hepatitis. Although such characteristics of viral hepatitis as route of transmission and incubation period may be helpful in differential diagnosis, they seldom are sufficient to make an exact diagnosis. Laboratory tests or liver biopsy may help to differentiate liver disorders but again usually do not identify the form of viral hepatitis that is present. However, liver biopsy is often of value in patients with chronic hepatitis to determine the severity of disease, aid in prognosis, and, in some cases, serve as a guide to antiviral therapy.
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Affiliation(s)
- S Kumar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine
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33
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Gayno S, Marcellin P, Loriot MA, Martinot-Peignoux M, Levy P, Erlinger S, Benhamou JP. Detection of serum HBV-DNA by polymerase chain reaction (PCR) in patients before reactivation of chronic hepatitis B. J Hepatol 1992; 14:357-60. [PMID: 1500699 DOI: 10.1016/0168-8278(92)90183-p] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Reactivation of chronic hepatitis B is characterized by the reappearance of HBV-DNA in serum. The purpose of the study was to determine whether, before reactivation, HBV-DNA would be detectable in serum, using a sensitive procedure of detection, namely polymerase chain reaction (PCR). We studied 17 patients with chronic hepatitis B who experienced an episode of reactivation, defined by the reappearance of HBV-DNA in serum. None of these 17 sera had HBV-DNA demonstrable by dot-blot hybridization nor liquid hybridization in sera collected before reactivation. Using PCR, HBV-DNA was detected, before reactivation, in 13 of the 17 episodes of reactivation tested with Southern-blot and hybridization. HBV-DNA was not detectable with PCR in the serum of four patients who subsequently experienced an episode of reactivation. In conclusion, our results show low level HBV replication before reactivation in most, but not all, HBs-positive, HBV-DNA-negative patients. This suggests that reactivation may occur even in patients with no HBV-DNA demonstrable in serum with PCR prior to reactivation.
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Affiliation(s)
- S Gayno
- Service d'Hépatologie, Hôpital Beaujon, Clichy, France
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34
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Levy P, Marcellin P, Martinot-Peignoux M, Degott C, Nataf J, Benhamou JP. Clinical course of spontaneous reactivation of hepatitis B virus infection in patients with chronic hepatitis B. Hepatology 1990; 12:570-4. [PMID: 2401462 DOI: 10.1002/hep.1840120320] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The purposes of this study were (a) to describe the clinical and biochemical manifestations associated with spontaneous reactivation of hepatitis B virus as defined by the reappearance of hepatitis B virus DNA in serum using dot-blot hybridization and (b) to determine whether the clinical and biochemical manifestations associated with hepatitis B virus reactivation were different in patients with and without human immunodeficiency virus-1 infection. During 1 yr, 110 French patients were admitted to Hôpital Beaujon for chronic hepatitis B. Fourteen were found to have hepatitis B virus reactivation; of these, three were anti-human immunodeficiency virus-1-positive. These 14 patients were HBsAg-positive for 60 mo (range = 6 to 180 mo). Clinical manifestations related to reappearance of hepatitis B virus DNA were present in 11 patients. HBeAg/anti-HBe status did not change in nine patients in whom hepatitis B virus reactivation would not have been recognized without hepatitis B virus DNA testing. Cirrhosis was present in nine patients. Four patients, of whom two were anti-human immunodeficiency virus-1-positive, had fulminant liver failure. Two patients died; one was anti-human immunodeficiency virus-1-positive. One patient was given an emergency transplant.
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Affiliation(s)
- P Levy
- Service d'Hépatologie, INSERM U-24, Clichy, France
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35
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Williams SJ, Farrell GC. Serial antipyrine clearance studies detect altered hepatic metabolic function during spontaneous and interferon-induced changes in chronic hepatitis B disease activity. Hepatology 1989; 10:192-7. [PMID: 2744731 DOI: 10.1002/hep.1840100212] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The present study was performed to establish whether sequential determinations of antipyrine clearance, using a simplified two-point test, are sensitive and specific indicators of changes in chronic hepatitis B disease activity. Sixteen patients were studied on four or more occasions during 18 to 30 months. Eleven patients were treated with recombinant human alpha-interferon (2.5, 5.0 or 10 X 10(6) per m2, intramuscularly, three times per week, for 24 weeks), and five patients were untreated controls. Among seven patients, (six interferon-treated and one control) who lost hepatitis B e antigen from serum, antipyrine clearance improved by 46% (range: 20 to 160%) from 0.37 +/- 0.14 ml per kg per min (mean +/- S.D.) to 0.54 +/- 0.13 ml per kg per min, p less than 0.005. This change paralleled the loss of symptoms and reduction of serum ALT levels (from 206 +/- 189 IU per liter (mean +/- S.D.) to 38 +/- 12 IU per liter, p less than 0.005). Conversely, antipyrine clearance declined to previous levels when reactivation of chronic hepatitis B with reappearance of HBeAg in serum occurred. Regardless of changes in hepatitis B serology, when serum ALT values fluctuated by more than 20% (presumed to reflect fluctuations in necroinflammatory activity of the liver disease), antipyrine clearance also changed whereas serum albumin and bilirubin concentrations and prothrombin time did not. It is concluded that antipyrine clearance is a more sensitive and specific parameter than conventional indices for assessing hepatic metabolic function during changes in chronic hepatitis B disease activity. Remission in disease with loss of HBeAg from serum is associated with improved hepatic metabolic function as determined by the antipyrine clearance test.
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Affiliation(s)
- S J Williams
- Department of Medicine, University of Sydney, Westmead Hospital, New South Wales, Australia
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36
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Infection chronique a virus de l'hepatite B. Aspects cliniques, biologiques et histologiques : A propos de 30 Cas. Med Mal Infect 1989. [DOI: 10.1016/s0399-077x(89)80226-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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