Cryptogenic chronic liver disease and hepatitis C virus infection in children

Sofosbuvir-velpatasvir in children 3-17 years old with hepatitis C virus infection

BACKGROUND

The safety and efficacy of sofosbuvir-velpatasvir in children aged 3-17 years with chronic hepatitis C virus (HCV) infection of any genotype were evaluated.

METHODS

In this Phase 2, multicenter, open-label study, patients received once daily for 12 weeks either sofosbuvir-velpatasvir 400/100 mg tablet (12-17 years), 200/50 mg low dose tablet or oral granules (3-11 years and ≥17 kg), or 150/37.5 mg oral granules (3-5 years and <17 kg). The efficacy endpoint was sustained virologic response 12 weeks after therapy (SVR12). Dose appropriateness was confirmed by intensive pharmacokinetics in each age group.

FINDINGS

Among 216 patients treated, 76% had HCV genotype 1% and 12% had genotype 3. Rates of SVR12 were 83% (34/41) among 3-5-year-olds, 93% (68/73) among 6-11-year-olds, and 95% (97/102) among 12-17-year-olds. Only two patients experienced virologic failure. The most common adverse events were headache, fatigue, and nausea in 12-17-year-olds; vomiting, cough, and headache in 6-11-year-olds; and vomiting in 3-5-year-olds. Three patients discontinued treatment because of adverse events. Four patients had serious adverse events; all except auditory hallucination (n = 1) were considered unrelated to study drug. Exposures of sofosbuvir, its metabolite GS-331007, and velpatasvir were comparable to those in adults in prior Phase 2/3 studies. Population pharmacokinetic simulations supported weight-based dosing for children in this age range.

INTERPRETATION

The pangenotypic regimen of sofosbuvir-velpatasvir is highly effective and safe in treating children 3-17 years with chronic HCV infection.

Profile of Sofosbuvir and Velpatasvir Combination in the Treatment of Chronic Hepatitis C in Children and Adolescents: Current Evidence

Chronic hepatitis C (HCV) affects up to 3.25 million children and adolescents. Early treatment of HCV in children and adolescents reduces progression to advanced liver disease and cancer. Treatment for HCV has evolved to highly effective direct acting antiviral therapy in adults and now in children ≥3 years of age. This review focuses on the role of sofosbuvir and velpatasvir (SOF/VEL), a newer treatment of children and adolescents with chronic HCV. SOF/VEL is a pangenotypic DAA with primary clearance via the liver and biliary excretion. It has been studied in children and adolescents and is approved in the US for use in children and adolescents ≥3 years of age. Although the data are currently limited, SOF/VEL has demonstrated sustained viral response rates similar to comparable DAAs in the range of 95-98%. To date, side effects have been minimal.

Ledipasvir-Sofosbuvir for 12 Weeks in Children 3 to <6 Years Old With Chronic Hepatitis C

For children under 12 years of age who have chronic hepatitis C virus (HCV) infection, there are currently no approved treatments with direct-acting antiviral agents. We therefore evaluated the safety and efficacy of ledipasvir-sofosbuvir in HCV-infected children aged 3 to <6 years. In an open-label study, patients 3 to <6 years old chronically infected with HCV genotype 1 (n = 33) or 4 (n = 1) received weight-based doses of combined ledipasvir-sofosbuvir as granules (33.75 mg/150 mg for weights <17 kg or 45 mg/200 mg for weights ≥17 kg) for 12 weeks. The primary endpoint was sustained virological response 12 weeks after treatment (SVR12). For the first 14 patients, intensive pharmacokinetic sampling was done on day 10 of treatment. All patients had been infected through perinatal transmission and were treatment naïve. No patients had known cirrhosis. Ten patients (29%) weighed <17 kg. SVR12 was achieved in 97% of patients (33 of 34); the patient who did not achieve SVR12 was 3 years old and discontinued treatment after 5 days because of an adverse event "abnormal drug taste." The most common adverse events were vomiting (24% of patients), cough (21%), and pyrexia (21%). No patients experienced a serious adverse event. Intensive pharmacokinetic analysis of 13 patients for whom data were evaluable confirmed that the doses selected were appropriate. Conclusion: Ledipasvir-sofosbuvir was well tolerated and highly effective in children 3 to <6 years old with chronic HCV infection.

Sofosbuvir and Ribavirin Therapy for Children Aged 3 to <12 Years With Hepatitis C Virus Genotype 2 or 3 Infection

Currently, the only approved hepatitis C virus (HCV) treatment for children aged <12 years is pegylated interferon plus ribavirin. In an open-label study, we evaluated the safety and efficacy of sofosbuvir plus ribavirin for 12 weeks in children aged 3 to <12 years chronically infected with genotype 2 or for 24 weeks in patients with genotype 3. Patients aged 3 to <6 years weighing <17 kg received sofosbuvir 150 mg, and patients aged 3 to <6 years weighing ≥17 kg and all patients aged 6 to <12 years received sofosbuvir 200 mg once daily. Intensive pharmacokinetic sampling conducted in each age group confirmed the appropriateness of sofosbuvir doses. For all patients, ribavirin dosing was determined by baseline weight (up to 1,400 mg/day, two divided doses). The primary efficacy endpoint was sustained virologic response 12 weeks after therapy (SVR12). Fifty-four patients were enrolled (41 aged 6 to <12 years and 13 aged 3 to <6 years). Most were treatment naïve (98%) and infected perinatally (94%). All but one patient achieved SVR12 (53/54, 98%; 95% confidence interval, 90%-100%). The patient who did not achieve SVR12 was a 4-year-old who discontinued treatment after 3 days because of "abnormal drug taste." The most commonly reported adverse events in patients aged 6 to <12 years were vomiting (32%) and headache (29%), and those in patients aged 3 to <6 years were vomiting (46%) and diarrhea (39%). One 3-year-old patient had a serious adverse event of accidental ribavirin overdose requiring hospitalization for monitoring; this patient completed treatment and achieved SVR12. Conclusion: Sofosbuvir plus ribavirin was well tolerated and highly effective in children aged 3 to <12 years with chronic HCV genotype 2 or 3 infection.

Hepatitis C in Pregnancy: A Unique Opportunity to Improve the Hepatitis C Cascade of Care

Hepatitis C has increasingly affected women of child-bearing age over the past few years as a result of the opioid epidemic. In this review, we discuss the effect of hepatitis C on pregnancy outcomes, effect of pregnancy on hepatitis C, as well as implications on management of hepatitis C during pregnancy.

Safety and Efficacy of Ledipasvir-Sofosbuvir With or Without Ribavirin for Chronic Hepatitis C in Children Ages 6-11

Currently, there are no interferon-free treatments available for hepatitis C virus (HCV)-infected patients younger than 12 years. We evaluated the safety and effectiveness of the all-oral regimen ledipasvir-sofosbuvir ± ribavirin in HCV-infected children aged 6 to <12 years. In an open-label study, patients aged 6 to <12 years received ledipasvir 45 mg-sofosbuvir 200 mg as two fixed-dose combination tablets 22.5/100 mg once daily, with or without ribavirin, for 12 or 24 weeks, depending on HCV genotype and cirrhosis status. The primary efficacy endpoint was sustained virologic response 12 weeks after therapy (SVR12). Twelve patients underwent intensive pharmacokinetic sampling to confirm the appropriateness of the ledipasvir and sofosbuvir dosages. Ninety-two patients were enrolled (88 genotype 1, 2 genotype 3, and 2 genotype 4), with a median age of 9 years (range, 6-11). Most were perinatally infected (97%) and treatment-naive (78%). Two were confirmed to have cirrhosis, while the degree of fibrosis was unknown in 55 patients. The overall SVR12 rate was 99% (91/92; 95% confidence interval, 94%-100%). The single patient not reaching SVR relapsed 4 weeks after completing 12 weeks of treatment. The most common adverse events were headache and pyrexia. One patient had three serious adverse events, which were considered to be not related to study treatment: tooth abscess, abdominal pain, and gastroenteritis. The area under the concentration-time curve and maximum concentration values for sofosbuvir, its primary metabolite GS-331007, and ledipasvir were within predefined pharmacokinetic equivalence boundaries (50%-200%) compared to values in adults in phase 2/3 of the ledipasvir and sofosbuvir studies. Conclusion: Ledipasvir-sofosbuvir was well tolerated and highly effective in children 6 to <12 years old with chronic HCV.

The safety and effectiveness of ledipasvir-sofosbuvir in adolescents 12-17 years old with hepatitis C virus genotype 1 infection

No all-oral, direct-acting antiviral regimens have been approved for children with chronic hepatitis C virus (HCV) infection. We conducted a phase 2, multicenter, open-label study to evaluate the efficacy and safety of ledipasvir-sofosbuvir in adolescents with chronic HCV genotype 1 infection. One hundred patients aged 12-17 years received a combination tablet of 90 mg ledipasvir and 400 mg sofosbuvir once daily for 12 weeks. On the tenth day following initiation of dosing, 10 patients underwent an intensive pharmacokinetic evaluation of the concentrations of sofosbuvir, ledipasvir, and the sofosbuvir metabolite GS-331007. The primary efficacy endpoint was the percentage of patients with a sustained virologic response at 12 weeks posttreatment. Median age of patients was 15 years (range 12-17). A majority (80%) were HCV treatment-naive, and 84% were infected through perinatal transmission. One patient had cirrhosis, and 42 did not; in 57 patients the degree of fibrosis was unknown. Overall, 98% (98/100; 95% confidence interval 93%-100%) of patients reached sustained virologic response at 12 weeks. No patient had virologic failure. The 2 patients who did not achieve sustained virologic response at 12 weeks were lost to follow-up either during or after treatment. The three most commonly reported adverse events were headache (27% of patients), diarrhea (14%), and fatigue (13%). No serious adverse events were reported. Area under the concentration-time curve (tau) and maximum concentration values for sofosbuvir, ledipasvir, and GS-331007 were within the predefined pharmacokinetic equivalence boundaries of 50%-200% when compared with adults from phase 2 and 3 studies of ledipasvir and sofosbuvir.

CONCLUSION

Ledipasvir-sofosbuvir was highly effective at treating adolescents with chronic HCV genotype 1 infection; the dose of ledipasvir-sofosbuvir currently used in adults was well tolerated in adolescents and had an appropriate pharmacokinetic profile. (Hepatology 2017;66:371-378).

Consensus Statement of HCV Task Force of the Indian National Association for Study of the Liver (INASL). Part II: INASL Recommendations for Management of HCV in India

The estimated prevalence of hepatitis C virus (HCV) infection in India is between 0.5 and 1.5% with hotspots showing much higher prevalence in some areas of northeast India, in some tribal populations and in certain parts of Punjab. Genotype 3 is the most prevalent type of infection. Recent years have seen development of a large number of new molecules that are revolutionizing the treatment of hepatitis C. Some of the new directly acting agents (DAAs) like sofosbuvir have been called game-changers because they offer the prospect of interferon-free regimens for the treatment of HCV infection. These new drugs have not yet been approved in India and their cost and availability is uncertain at present. Till these drugs become available at an affordable cost, the treatment that was standard of care for the whole world before these newer drugs were approved should continue to be recommended. For India, cheaper options, which are as effective as the standard-of-care (SOC) in carefully selected patients, are also explored to bring treatment within reach of poorer patients. It may be prudent to withhold treatment at present for selected patients with genotype 1 or 4 infection and low levels of fibrosis (F1 or F2), and for patients who are non-responders to initial therapy, interferon intolerant, those with decompensated liver disease, and patients in special populations such as stable patients after liver and kidney transplantation, HIV co-infected patients and those with cirrhosis of liver.

Burden of pediatric hepatitis C

Hepatitis C virus (HCV) is a major health burden infecting 170-210 million people worldwide. Additional 3-4 millions are newly-infected annually. Prevalence of pediatric infection varies from 0.05%-0.36% in the United States and Europe; up to 1.8%-5.8% in some developing countries. The highest prevalence occurs in Egypt, sub-Saharan Africa, Amazon basin and Mongolia. HCV has been present in some populations for several centuries, notably genotypes 1 and 2 in West Africa. Parenteral anti-schistosomal therapy practiced in the 1960s until the early 1980s had spread HCV infection throughout Egypt. Parenteral acquisition of HCV remains a major route for infection among Egyptian children. Insufficient screening of transfusions, unsterilized injection equipment and re-used needles and syringes continue to be major routes of HCV transmission in developing countries, whereas vertical transmission and adolescent high-risk behaviors (e.g., injection drug abuse) are the major routes in developed countries. The risk of vertical transmission from an infected mother to her unborn/newborn infant is approximately 5%. Early stages of HCV infection in children do not lead to marked impairment in the quality of life nor to cognitive, behavioral or emotional dysfunction; however, caregiver stress and family system strain may occur. HCV slowly progresses to serious complications as cirrhosis (1%-2%) and hepatocellular carcinoma (HCC) especially in the presence of risk factors as hemolytic anemias, obesity, treated malignancy, and concomitant human immune deficiency and/or hepatitis B virus co-infection. HCV vaccine remains elusive to date. Understanding the immune mechanisms in patients who successfully cleared the infection is essential for vaccine development. The pediatric standard of care treatment consists of pegylated interferon-α 2a or b plus ribavirin for 24-48 wk. The new oral direct acting antivirals, approved for adults, need further evaluation in children. Sustained virologic response varies depending on the viral load, genotype, duration of infection, degree of aminotransferase elevation, adiposity and single nucleotide polymorphisms of interleukin (IL)-28B locus. The goals of treatment in individual patients are virus eradication, prevention of cirrhosis and HCC, and removing stigmatization; meanwhile the overall goal is decreasing the global burden of HCV. IL-28B polymorphisms have been also associated with spontaneous clearance of vertically acquired HCV infection. The worldwide economic burden of HCV for children, families and countries is estimated to be hundreds of millions of US dollars per year. The United States, alone, is estimated to spend 199-336 million dollars in screening, monitoring and treatment during one decade. The emotional burden of having an HCV infected child in a family is more difficult to estimate.

Managing HCV infection in pediatric age group: suggested recommendations

Hepatitis C virus (HCV) infection in children is different from the adult infection in many ways, like natural course of the disease; duration, therapeutic response and side effects profile of the drug therapy; and prognosis. Special considerations include consideration on what could be the appropriate time to investigate a suspected child, when to institute drug therapy and how to prevent vertical transmission. Although over the past one decade many landmark studies have greatly increased our insight on this subject, yet we are far from developing a consensus statement. In this article, a concise yet comprehensive review of HCV infection in children - diagnosis and treatment - is given, followed by suggested recommendations at the end. It is hoped that these recommendations will help develop local guidelines on this subject.

Interferon and ribavirin treatment results of patients with HBV–HCV co-infection cured of childhood malignancies

OBJECTIVES

We aimed to investigate the virological and clinical characteristics and the results of combination therapy in six oncology patients with hepatitis B virus (HBV)-hepatitis C virus (HCV) co-infection.

METHOD

Six patients (five male and one female; age range 8-14 years), diagnosed with HBV-HCV infections during follow-up at the oncology outpatient clinic during 2000-2001 were included in the study. They had received an average of 25.8 units of blood by transfusion per patient during their treatment for malignancies. Positive serological HBV indicators were determined 20-40 months after the end of chemotherapy. HCV RNA positivity was determined together with HBV at an average of 3.3 months after hepatitis B infection. Patients received interferon-alpha-2b and ribavirin for 12 months.

RESULTS

Both HBV DNA and HCV RNA became negative, and anti-HBe became positive in one patient. One patient had decreased HBV DNA levels and negative HCV RNA and HBeAg, but HBeAg became positive again at 18-months following treatment. Another patient had decreased serum HBV DNA and HCV RNA levels with normal ALT levels at the end of treatment; however, two months after therapy was ceased these values returned to pretreatment levels.

CONCLUSION

We observed that combined treatment is effective in HBV-HCV infection. The effectiveness of combined treatment should be researched with larger groups of co-infected patients.

Chronic hepatitis C in Israeli children

Natural history, epidemiology, and histopathological features of chronic hepatis C (CHC) are well established in adults. Data on histopathological findings of CHC in children are still limited and controversial. We aimed to evaluate the histopathological features of CHC in children in Israel. We reviewed, retrospectively, 20 liver specimens from 20 children with CHC for inflammation and fibrosis, hepatocyte necrosis, fatty changes, cholestasis, bile duct damage, sinusoidal lymphocytosis, and glycogen storage. The most common histological feature was portal inflammation (95%) and lobular inflammation (70%). Sinusoidal lymphocytosis was present in 85% and glycogen storage vacuoles in 40%. Most of the children (80%) had no fibrosis, 15% had mild fibrosis and 5% moderate fibrosis. Advanced fibrosis or cirrhosis was not found. No correlation was found between the age at biopsy and any of the histological parameters. Our study shows that children with CHC have a different phenotype of liver disease with slowly progressive natural history irrespective of duration of the disease.

Children with hepatitis C

An estimated 240,000 children in the United States have antibody to hepatitis C virus (HCV) and 68,000 to 100,000 are chronically infected with HCV. Acute HCV infection is rarely recognized in children outside of special circumstances such as a known exposure from an HCV-infected mother or after blood transfusion. Most chronically infected children are asymptomatic and have normal or only mildly abnormal alanine aminotransferase levels. Although the natural history of HCV infection acquired in childhood seems benign in the majority of instances, the infection takes an aggressive course in a proportion of cases leading to cirrhosis and end-stage liver disease during childhood; the factors responsible for a more aggressive course are unidentified. An optimal approach to management of hepatitis C in children would be prevention, particularly of perinatal transmission, which is now the major cause of new cases of hepatitis C in children. Obstetrical factors may be important determinants of transmission, which, if confirmed, should lead to changes in the care of infected women. Therapy of HCV infection in children is also not well defined. There have been no large randomized, controlled trials of therapy in children with chronic hepatitis C. Small heterogeneous studies of interferon monotherapy have reported sustained virological response rates of 35% to 40%. There are few data regarding the use of combination therapy with interferon and ribavirin in children and no information on the use of peginterferon. Clearly, there are important needs for future epidemiologic and clinical research on hepatitis C in childhood.

Children with hepatitis C

An estimated 240,000 children in the United States have antibody to hepatitis C virus (HCV) and 68,000 to 100,000 are chronically infected with HCV. Acute HCV infection is rarely recognized in children outside of special circumstances such as a known exposure from an HCV-infected mother or after blood transfusion. Most chronically infected children are asymptomatic and have normal or only mildly abnormal alanine aminotransferase levels. Although the natural history of HCV infection acquired in childhood seems benign in the majority of instances, the infection takes an aggressive course in a proportion of cases leading to cirrhosis and end-stage liver disease during childhood; the factors responsible for a more aggressive course are unidentified. An optimal approach to management of hepatitis C in children would be prevention, particularly of perinatal transmission, which is now the major cause of new cases of hepatitis C in children. Obstetrical factors may be important determinants of transmission, which, if confirmed, should lead to changes in the care of infected women. Therapy of HCV infection in children is also not well defined. There have been no large randomized, controlled trials of therapy in children with chronic hepatitis C. Small heterogeneous studies of interferon monotherapy have reported sustained virological response rates of 35% to 40%. There are few data regarding the use of combination therapy with interferon and ribavirin in children and no information on the use of peginterferon. Clearly, there are important needs for future epidemiologic and clinical research on hepatitis C in childhood.

Viral hepatitis. From prevention to antivirals

The challenge of viral hepatitis has been acknowledged and confronted in the last decade. Significant progress in prevention of infection with HAV and HBV may eradicate these serious infections from the United States and other parts of the world in the coming decades. Application of prophylactic strategies to children will be a major mechanism in accomplishing this task. The quest for potent antiviral medications continues. The next critically important development will be ways to prevent new HCV infections and to treat the millions of already infected individuals at risk for the serious consequences of this disease. For pediatricians, realizing these goals requires a greater understanding of perinatal HCV transmission, use of vaccines for prevention of viral hepatitis, and identification of HCV-infected children who are likely to benefit from new therapeutic strategies as they become available.

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

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

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

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

Histopathology of the liver in children with chronic hepatitis C viral infection

Although the epidemiology, natural history, and pathological aspects of chronic hepatitis C are well-defined in the adult population, little is known about the characteristics of chronic hepatitis C infection in children. Reports on the histological features and progression of hepatitis C in children are scarce, and consist primarily of multicenter studies in Japanese and European children. Given the geographic variations in viral genotype and the association of pathology with genotype, whether the Japanese and European studies can be extended to the North American populations is unclear. We report the histopathology of the liver in 40 children with chronic hepatitis C infection treated in a single North American institution. The children included 19 males and 21 females ranging in age from 2.0 to 18.6 years at the time of liver biopsy (mean +/- SD: 11.4 +/- 4.3 years). Our findings indicate that the characteristic histopathological lesions of chronic hepatitis C infection, including sinusoidal lymphocytosis, steatosis, portal lymphoid aggregates/follicles, and bile duct epithelial damage, occur with approximately the same frequencies in children as have been reported in adults. Necroinflammatory activity was generally mild. Portal fibrosis was present in 78% of the specimens, including fibrous portal expansion (26%), bridging fibrosis (22%), bridging fibrosis with architectural distortion (22%), and cirrhosis (8%). Centrilobular pericellular fibrosis, which has not been previously reported in the context of chronic hepatitis C infection in adults or children, was also a prominent feature in our series, occurring with a similar frequency as steatosis or portal lymphoid aggregates/follicles. Our data suggest that in spite of mild histological necroinflammatory activity in general, the stage of fibrosis in children can be severe in spite of relatively short duration of infection.

Chronic unexplained liver disease in children with primary immunodeficiency syndromes

Liver disease may be found in patients with primary immunodeficiency syndromes because of the high risk of infection with hepatotropic viruses related to the treatment with blood derivatives. The prevalence of liver disease in these patients and its etiology, however, is still not completely understood. We have evaluated the prevalence and the etiology of liver disease in children with different forms of primary immunodeficiencies. Thirty patients included in the study underwent molecular studies to detect common hepatotropic viruses, including hepatitis C and G viruses. Liver involvement was found in 11 of 30 (36.6%) patients. All patients with liver disease had deficiencies of specific immunity, with a prevalence in this subgroup of 47.8%. Liver disease was more severe in patients with T and B cell combined immune disorders than in those with a selective T cell immunodeficiency. Moreover, the severity of the disease correlated with an overall more rapid fatal outcome. A viral etiology was found in only six of these patients, whereas in the remaining five patients, no cause of liver injury was identified. In the virally infected patients, hepatitis C virus was the most common viral agent. In patients with immunodeficiencies, there is a high prevalence of liver disease not fully explained on the basis of the common viral infections.

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Hepatitis C virus infection in pediatric patients

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mode of hepatitis C virus infection, epidemiology, and chronicity rate in the general population and risk groups

Since the discovery of the hepatitis C virus (HCV), it has become evident that this infectious agent is a primary cause of posttransfusion and sporadic non-A, non-B hepatitis. Identification and introduction of surrogate markers for posttransfusion hepatitis and later introduction of anti-HCV screening has decreased the incidence of posttransfusion hepatitis. Community-acquired HCV infection is less common than posttransfusion HCV hepatitis. HCV infection may lead to liver cirrhosis without prior evidence of laboratory or histologic infection. Populations at risk for HCV infection include patients receiving organ transplants, health care workers, infants born to HCV-infected mothers, and hemodialysis patients. Intravenous drug abusers and their sexual partners also demonstrate a high rate of HCV infection. Nosocomial HCV transmission may occur despite the observance of universal precautions. Dental or surgical intervention, salivary inoculation, family members infected with HCV, cocaine abuse, HIV infection, and lower socioeconomic status also each correlate with an increased risk of infection. HCV infection is associated with many immune-mediated diseases. There may also be some relationship between human leukocyte antigens and HCV infection. Since there currently is no HCV vaccine, prevention of exposure remains the only possibility for reducing HCV transmission and prevalence.

Hepatitis C infection after blood product transfusion

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

Interferon-alpha for viral hepatitis

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

Lymphoblastoid interferon alfa treatment in chronic hepatitis C

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

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

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

Viral hepatitis. Current concepts for dental practice

The transmission of blood-borne viruses in the dental office is a potential hazard to patients and dental staff, particularly to oral and maxillofacial surgeons. Hepatitis B virus has been a recognized hazard for several years, and in the past oral surgeons and other dental health care staff have been infected as a result of occupational exposure. Hepatitis C virus in contrast does not appear to be a major occupational hazard to dental staff, nevertheless, infection with this virus can lead to significant morbidity and may have oral manifestations. Hepatitis D virus can be nosocomally transmitted, but vaccination against the hepatitis B virus minimizes this problem. Hepatitis E virus is not of clinical relevance to dentistry, although dental staff who are in areas of endemic infection can become infected as a result of enteric transmission. A number of other putative viral agents may also cause hepatitis, but additional data is awaited, and their significance to dental practice is unknown. This article summarizes current data on hepatitis viruses A, B, C, D, and E.

Patterns of antibodies to hepatitis C virus and hepatitis C virus replication in children with chronic non-A, non-B hepatitis

Antibodies to hepatitis C virus (HCV), investigated by second- and third-generation assays, were detected in 74% of 43 children with chronic non-A, non-B hepatitis. The polymerase chain reaction identified HCV ribonucleic acid in 26 (93%) of 28 seropositive and in 1 of 10 seronegative cases. Intermittent HCV ribonucleic acid positivity, suggesting low and fluctuating viremia, was frequent in younger patients.

Viral hepatitis in children with renal disease

Specific and sensitive diagnostic tests are now available to identify type A, B, C, D and E hepatitis. Hepatitis A and E which cause only acute, very rarely fulminant, hepatitis are spread largely by the faecal-oral route, having a brief viraemic phase. Hepatitis B, C and D which are transmitted parenterally and via secretions are often associated with chronic viraemia. Patients with chronic renal disease are at particular risk. Impaired immunity due to disease or drugs increases the propensity to develop a chronic carrier state which may progress to cirrhosis and hepatocellular carcinoma. Limited reports indicate that hepatitis C infection may cause cirrhosis more rapidly than hepatitis B. The emergence of mutants to both hepatitis B and C is a cause for concern. Treatment with interferon is of limited efficacy. Screening of blood products for viral markers and prudent handling of potentially infected materials to avoid contamination of damaged skin or mucous membrane are the best strategies to prevent infection. Hepatitis B vaccination of all newborns, young adolescents and those at risk is the most effective means of reducing the carrier frequency.