Hepatitis B: epidemiology and natural history

Risk Factors for Development of Cirrhosis in Chronic Viral Hepatitis B Patients Who Had Persistent Viral Suppression With Antiviral Therapy

Background and aims

Chronic viral hepatitis B (CHB)-infected patients occasionally develop cirrhosis despite having persistent viral suppression with antiviral therapy. We aimed to identify risk factors for developing cirrhosis in hepatitis B virus (HBV)-suppressed patients.

Methods

We conducted a case-control study involving 120 noncirrhotic CHB-infected patients achieving viral suppression with antiviral treatment, with 40 cases developing cirrhosis and 80 age-, sex-, and Fibrosis-4 (FIB-4)-matched controls. Clinical and laboratory data at viral suppression, including body mass index (BMI), comorbidities, pretreatment HBV viral load, HBe antigen status, hepatitis C virus (HCV) and HIV coinfections, liver chemistries, and AST to Platelets Ratio Index (APRI) values, were retrospectively abstracted. Risk factors for cirrhosis post-HBV suppression were identified using Cox proportional hazard analysis.

Results

Case and control groups had similar ages (51.4 ± 9.9 vs. 51.4 ± 10.2 years), proportions of males (80% vs. 80%), and FIB-4 values (1.32 vs. 1.31). The cirrhosis group showed significantly higher BMI (25.1 vs. 22.7, P = 0.01) and more diabetes prevalence (50.0% vs. 26.3%, P = 0.01), while other comorbidities and laboratory parameters were comparable (P > 0.05). By univariate analysis, BMI >23 kg/m2, diabetes, and APRI >0.7 were significantly associated with cirrhosis, with hazard ratios (HRs) (95%CI) of 2.99 (1.46-6.13), 2.31 (1.23-4.36), and 2.71 (1.05-6.99), P = 0.003, 0.010, and 0.039, respectively. In multivariate analyses adjusted for APRI, BMI>23 kg/m2 remained significantly associated with cirrhosis (aHR: 2.76, P = 0.006), while diabetes showed borderline significance (aHR: 1.99, P = 0.072).

Conclusions

In HBV-infected patients achieving viral suppression with therapy, a BMI >23 kg/m2 increases the risk of cirrhosis. Therefore, a comprehensive approach addressing metabolic factors is imperative for preventing disease progression in HBV-infected patients.

Modelling the dynamics of acute and chronic hepatitis B with optimal control

This article examines hepatitis B dynamics under distinct infection phases and multiple transmissions. We formulate the epidemic problem based on the characteristics of the disease. It is shown that the epidemiological model is mathematically and biologically meaningful of its well-posedness (positivity, boundedness, and biologically feasible region). The reproductive number is then calculated to find the equilibria and the stability analysis of the epidemic model is performed. A backward bifurcation is also investigated in the proposed epidemic problem. With the help of two control measures (treatment and vaccination), we develop control strategies to minimize the infected population (acute and chronic). To solve the proposed control problem, we utilize Pontryagin's Maximum Principle. Some simulations are conducted to illustrate the investigation of the analytical work and the effect of control analysis.

Epidemiology and Estimating the Risk Factors for the Transfer of Hepatitis B Virus Using Multivariate Analysis Model: A Retrospective Case-Control Study

Background and aims: Hepatitis B virus (HBV) is one of the important public health diseases in Iran. Therefore, to control the prevalence of the disease, knowledge is required regarding the risk factor of HBV. Accordingly, the aim of this study was to determine the risk factors of HB transmission. Methods: A retrospective case-control study was conducted on the possible risk factors of HBV transmission. To this end, a total of 171 patients with HBV infection and 171 controls from Rasoul-eAkram hospital were investigated during 2015-2018. All subjects were directly evaluated using a faceto-face questionnaire about demographic aspects. Finally, HBV infection and its risk factors among the subjects were detected using hepatitis B surface antigen test. Results: Overall, 171 HBV patients including 77 (42%) males and 93 (58%) females were evaluated. The mean age of the participants was 40 ± 13 years. Univariate logistic analysis showed that HBV infection in these cases was associated with addiction injection (odds ratio [OR] = 4.08, CI:1.3- 9.57), family history (OR = 4.52, CI: 1.27-10.7), and having a history of blood transfusion (OR = 3.16, CI: 1.52-5.37). There were no significant relationships between the liver function tests, alcohol consumption, the history of dental visits, and HBV participants. In addition, the logistic-regression model proved that patients with a history of HBV-infected parents (At least one of them) and addiction injection were severely subject to HB infection. In other words, there was a significant association between a history of HBV-infected parents and addiction injection and HB infection. Conclusion: In general, HBV infection was strongly related to having a family member infected with hepatitis B, suffering from addiction injection, and having blood injection.

Effect of Metabolic Syndrome on the Clinical Outcomes of Chronic Hepatitis B Patients with Nucleos(t)ide Analogues Treatment

BACKGROUND

No data are available about the effect of MS on oral nucleos(t)ide analogues (NUCs) treatment and clinical outcomes in chronic hepatitis B (CHB) patients.

AIMS

We aimed to elucidate whether coexistence of MS and CHB affects the long-term prognosis of CHB patients with oral NUCs treatment.

METHODS

We performed a retrospective data analysis for a total of 587 CHB patients who started oral NUCs treatment for the first time in our institution from January 2006 to March 2016.

RESULTS

Among the 587 patients, 70 (11.9%) had MS, but 517 (88.1%) had no evidence of MS when oral NUCs treatment was initiated. Cumulative occurrence rates of viral breakthrough, genotypic resistance, HCC, disease progression (PD), and overall adverse outcomes (OAO) were significantly higher in CHB patients with MS than in those without MS, although HBV-DNA suppression and cumulative occurrence rates of HBeAg negative conversion and seroconversion were not significantly different between the two groups. The overall survival (OS) was also significantly shorter in CHB patients with MS than in those without MS. Multivariate analysis indicated that the MS was an independent, poor prognostic factor for occurrence of genotypic resistance (adjusted hazard ratio [aHR], 22.3; 95% confidence interval [CI] 6.61-75.02; P < 0.001), HCC (aHR, 3.98; 95% CI 2.07-7.66; P < 0.001), PD (aHR, 6.18; 95% CI 3.43-11.14; P < 0.001), OAO (aHR, 8.10; 95% CI 4.68-14.02; P < 0.001), and OS (aHR, 12.29; 95% CI 2.25-67.24; P < 0.001).

CONCLUSIONS

MS is an independent determinant of poor prognosis in CHB patients receiving oral NUCs treatment.

Role of HLA-DP and HLA-DQ on the clearance of hepatitis B virus and the risk of chronic infection in a multiethnic population

BACKGROUND & AIMS

HBV infection exhibits geographical variation in its distribution in South America. While HBV rates are low in central Argentina, the north-western region exhibits intermediate HBV rates. Unfortunately, the reasons that could explain this difference are still unknown.

METHODS

A total of 1440 Argentines were recruited and grouped into HBV patients, HBV-resolved individuals and healthy controls. Genetic ancestry was assessed by analysis of biparental lineages and ancestry autosomal typing. SNPs of HLA-DPA1 (rs3077), HLA-DPB1 (rs9277542), HLA-DQB1 (rs2856718) and HLA-DQB2 (rs7453920) were determined, and HBV genotyping was performed by phylogenetic analysis in HBV patients.

RESULTS

Native American ancestry prevailed in the north-western region when compared with central Argentina (P<.0001). However, no differences were observed among the three groups of each region. The distribution of HBV genotypes revealed significant differences (P<.0001). Three SNPs (rs3077, rs9277542 and rs7453920) showed a significant association with protection against chronic HBV and viral clearance in both regions. The remaining SNP showed a significant association with susceptibility to chronic HBV. The frequency rates of rs3077-T, related to protection against chronic HBV and viral clearance, were lower in north-western Argentina when compared with central Argentina. The same uneven frequency rates were observed for SNP rs9277542.

CONCLUSIONS

This is the first study addressing the associations between the HLA-DP and HLA-DQ loci and the protection against chronic HBV and viral clearance in a multiethnic South American population. The uneven distribution of HLA-DP and HLA-DQ supports the HBV epidemiological differences observed in these two regions of Argentina with dissimilar ancestry genetic background.

The prevalence of hepatitis B virus infection in HIV-positive and HIV-negative infants: KwaZulu-Natal, South Africa

Background

The prevalence of hepatitis B virus (HBV) amongst South African infants and children has been reported in the pre-HIV era. Despite the reported high prevalence of HIV in the general population of South Africa, the rate of HIV/HBV co-infection amongst infants and children remains poorly reported.

Objectives

We describe the prevalence of HBV infection amongst HIV-positive and HIV-negative infants by molecular methods of diagnosis using dried blood spot samples.

Methods

This retrospective cross-sectional study was conducted between July 2011 and December 2011 in an academic referral laboratory offering viral diagnostic services to the entire KwaZulu-Natal province of South Africa. A total of 322 study samples were collected from discarded residual dried blood spot samples following routine infant diagnosis of HIV. Equal proportions of HIV-positive and HIV-negative infant specimens were studied. Statistical differences in the prevalence of HBV between the HIV-positive and HIV-negative samples were calculated using the Pearson chi-square test, and a p-value < 0.05 was considered statistically significant. Further testing for HBV DNA using a nested polymerase chain reaction method was performed.

Results

The overall prevalence of HBV was 10%. In the HIV-positive group, 21 of 161 infants tested positive for HBV compared with 12 of 161 HIV-negative infants who tested positive for HBV. The proportion of infants infected with HBV was marginally higher amongst HIV-positive infants (13.0%; 95% CI 6.8–19.9) compared with HIV-negative infants (7.5%; 95% CI 2.5–13.7; P = 0.098), though not statistically significant.

Conclusion

The finding of a 10% HBV prevalence in this infant cohort is clinically significant. The non-statistically significant difference in HBV prevalence between the HIV-positive and HIV-negative infants suggests that high prevalence of HBV infection in children may be a problem independent of HIV.

Hepatitis B e antigen-positive and high levels of alanine aminotransferase are associated with prevalence of metabolic syndrome in chronic HBV patients

OBJECTIVE

The interactions between hepatitis B virus (HBV) infection and metabolic syndrome (MS) have not been elucidated. This study was aimed to investigate the relationship between metabolic profile and HBV infection.

METHODS

A retrospective cross-sectional study including patients infected by HBV (HBV group, n=121) and healthy volunteers (control group, n=263) was conducted, serum HBV viral load and markers, serum alanine aminotransferase (ALT) levels and MS were analyzed. Factors associated with prevalence of MS were explored with multivariate adjusted logistic regression analyses.

RESULTS

The prevalence of MS was 9.9% in HBV infected patients and 19.4% in controls (p=0.011). Factors associated with the prevalence of MS were (odds ratio, 95% confidence interval, p value): hepatitis B e antigen (HBeAg) positive (0.368, 0.107-0.653, 0.008) and high levels of ALT (0.183, 0.120-0.268, <0.001) in HBV patients. But clinical and virological factors (including age, HBV DNA level, male gender, BMI, and fatty liver) were not found to be associated with prevalence of MS in HBV patients who were HBeAg positive with high levels of ALT.

CONCLUSION

These findings suggest that HBeAg positive and high levels of ALT are independently associated with lower prevalence of MS in HBV patients. But HBV DNA may not have impact on the lipid metabolism. HBV-related immune reactions may play a certain role in the mechanism of MS.

Genetic association of human leukocyte antigens with chronicity or resolution of hepatitis B infection in thai population

BACKGROUND

Previous studies showed that single nucleotide polymorphisms (SNPs) in the HLA-DP, TCF19 and EHMT2 genes may affect the chronic hepatitis B (CHB). To predict the degree of risk for chronicity of HBV, this study determined associations with these SNPs.

METHODS

The participants for this study were defined into 4 groups; HCC (n = 230), CHB (n = 219), resolved HBV infection (n = 113) and HBV uninfected subjects (n = 123). The HLA-DP SNPs (rs3077, rs9277378 and rs3128917), TCF19 SNP (rs1419881) and EHMT2 SNP (rs652888) were genotyped.

RESULTS

Due to similar distribution of genotype frequencies in HCC and CHB, we combined these two groups (HBV carriers). The genotype distribution in HBV carriers relative to those who resolved HBV showed that rs3077 and rs9277378 were significantly associated with protective effects against CHB in minor dominant model (OR = 0.45, p<0.001 and OR = 0.47, p<0.001). The other SNPs rs3128917, rs1419881 and rs652888 were not associated with HBV carriers.

CONCLUSIONS

Genetic variations of rs3077 and rs9277378, but not rs3128917, rs1419881 and rs652888, were significantly associated with HBV carriers relative to resolved HBV in Thai population.

Metabolic syndrome association with fibrosis development in chronic hepatitis B virus inactive carriers

BACKGROUND AND AIM

There are few data of fibrosis development in chronic hepatitis B (CHB) patients classified as inactive carriers. The aim of this study is to determinate the prevalence of significant fibrosis and probable cirrhosis measured by FibroScan in real inactive CHB carriers and investigate the relationship with virological, epidemiological, and metabolic factors.

METHODS

Cross-sectional cohort study including CHB inactive carriers. Liver stiffness measurement was performed with transient elastography (FibroScan). Significant fibrosis (≥ F2) was defined as stiffness > 7.5 kPa, and probable cirrhosis as > 11.8 kPa. Factors associated with significant fibrosis were explored with univariate and multivariate adjusted logistic regression analyses.

RESULTS

Ninety-six CHB inactive carriers were analyzed. Of them, 24 (25%) had significant fibrosis and 7 (7%) probable cirrhosis; mean stiffness was 6.2 ± 2.3 kPa. Of them, 24% had metabolic syndrome, with higher FibroScan value than those without (8.4 kPa vs 5.5 kPa, P < 0.001). Factors associated with significant fibrosis were (odds ratio, 95% confidence interval, P value): central obesity (7.1, 1.8-27.9, 0.005), elevated fasting glucose (4.3, 1.3-27.9, 0.036), reduced high-density lipoprotein cholesterol (5.2, 1.2-23.6, 0.032) and elevated triglycerides (6.2, 1.4-28.3, 0.019). Factors as age, sex, transaminases, hepatitis B virus DNA or genotype were not related with liver fibrosis. The presence of metabolic syndrome has a 69% of positive predictive value and 89% of negative predictive value for significant fibrosis.

CONCLUSION

Different components of metabolic syndrome are associated with fibrosis development in CHB inactive carriers. In the absence of metabolic syndrome, significant fibrosis is uncommon in this population.

Knockdown of HBV surface antigen gene expression by a lentiviral microRNA-based system inhibits HBV replication and HCC growth

Current options for the treatment of hepatitis B virus (HBV) infections, a common liver cancer risk factor, are limited. While RNA interference (RNAi) technologies have been shown to inhibit HBV replication, the consequent effects on hepatocellular carcinoma (HCC) cell growth are not fully understood. The aim of this study was to evaluate the effect of RNAi-mediated decrease in the HBV surface antigen (HBsAg) gene on HBV replication and HCC growth. A lentiviral microRNA-based system expressing siRNAs targeting the HBsAg gene (LVshHBS) was developed and transfected into HepG2.2.15 cells (HBV stably expressing line). We found that LVshHBS significantly inhibited the HBsAg mRNA and protein levels in the HepG2.2.15 cells, while HBsAg secretion into the culture supernatant decreased by 70%. BALB/c (nu/nu) mice were injected with HepG2.2.15 cells transduced with LVshHBS or control vectors to investigate the effect of inhibiting the HBsAg on the development of tumour growth in a human HCC nude mice model. Compared with the control, the tumour growth in nude mice was significantly decreased after injection with LVshHBS. Microarray analysis of tumour-related genes in LVshHBS-transduced HepG2.2.15 cells showed that the expressions of genes involved in cell cycle, differentiation and oncogenesis such as ACP2, BHLHB2, CLK3, CTSC, FOS, NR1D1, PIM1 and SEPT6 genes were downregulated, while that of the E2F3 gene was upregulated. In conclusion, lentiviral microRNA-based RNAi against the HBsAg gene not only inhibits HBV replication but also inhibits the growth of HCC. Downregulation of growth-related genes is implicated in this mechanism of inhibition.

Relationship between the -572G/C polymorphism in IL-6 gene promoter and hepatitis virus B infection in Chinese Han population

AIM: To evaluate the association of IL-6 gene promoter polymorphism with the infection of hepatitis B virus (HBV) in Chinese population.

METHODS: The genome DNA was obtained from blood samples and three IL-6 promoter polymorphisms (G-174C, G-572C and G-597A) were evaluated using PCR-RFLP in 160 HBV-infected patients and 212 healthy controls. Frequencies of single-nucleotide polymorphisms (SNPs) in the control group were compared with those of the HBV infection. Furthermore, subgroups of chronic carriers were compared among them. For cases and controls, the distribution of gender, age, smoking, drinking and Hardy-Weinberg equilibrium equation of the IL-6 genotype was determined using Chi-square Test; and the diversity of age using Mann-Whitney U-test. The unconditional Logistic regression model was used to analyze the statistical association of genotypes in two groups adjusted for confused factors.

RESULTS: No polymorphism at position -174 and -597 was detected in all participants, but significant difference was found in the polymorphism at position -572 between the cases and controls (G/C vs G/G, OR = 2.65, P < 0.05; C/C vs G/G, OR = 3.31, P < 0.05). Subgroups analysis, revealed the odds ratio value in the less than thirty years old group (G/G vs G/C or C/C, OR = 16.92, P < 0.05).

CONCLUSION: The data reveal that the polymorphism at position -572 of the IL-6 gene promoter may be associated with the susceptibility to HBV infection; meanwhile, the age is a coordinative risk factor.

Benefits of early hepatitis B immunization programs for newborns and infants

Despite the availability of safe and effective hepatitis B virus (HBV) vaccines for >20 years, strategies targeting risk groups failed to sufficiently control hepatitis B disease at the population level; this is mainly because of difficulties in risk identification and in program implementation. Hence, the global burden of disease of HBV still is substantial. The World Health Organization recommends universal vaccination against hepatitis B to ultimately eliminate HBV; this recommendation had been progressively implemented to reach 168 countries with a universal program by the end of 2006. However, hepatitis B immunization is currently becoming endangered of losing its place on the agendas of governments, agencies, and international organizations, mainly because of the increasing success of these immunization programs and the interest in newer vaccine-preventable diseases and the related programs.This publication aims to show that vaccination programs targeting newborns and infants are preferable to achieve this goal. The benefits of universal HBV vaccination for newborns and infants are: higher impact on chronic carrier rate and transmission; established potential of high vaccine coverage in this age group; opportunities to combine HBV vaccination with existing universal vaccination programs for newborns and infants; and impact on perinatal transmission, if vaccination is started shortly after birth. Moreover, the safety, immunogenicity, and long-term efficacy of newborn and infant HBV vaccination have been proven extensively. In summary, newborn and infant HBV vaccination programs should be considered the preferred strategy, capable of providing important and sustained impact on global HBV incidence, even if they have a delayed impact on sexual transmission of HBV.

New antiviral choice for chronic hepatitis B: tenofovir disoproxil fumarate

Tenofovir disoproxil fumarate (TDF) is an oral prodrug of tenofovir, a novel, acyclic nucleotide analogue with in vitro activity against HIV-1 and HIV-2. TDF is licensed by American Food and Drug Administration (FDA) in 2001 for the treatment of HIV infection. TDF is currently one of the most widely used nucleotide reverse transcriptase inhibitors (NRTIs) for the treatment of HIV infection. Its efficacy, favorable toxicity profile, and convenient dosing have made this drug one of the most popular first-line treatment. Numerous studies have demonstrated the use of TDF in the treatment of HIV infection. It also has been shown to be effective in HIV/HBV coinfected patients and in patients with wild-type and lamivudine-resistant strains. Accumulating evidence suggests that TDF is more potent in suppressing HBV replication. In this review, we summarize the study progress of TDF in treating HBV infection.

Outcomes from a Canadian public health prenatal screening program for hepatitis B: 1997-2004

BACKGROUND

Without appropriate prophylaxis, the rate of vertical transmission of hepatitis B virus (HBV) can be as high as 95%. Alberta's provincial prenatal program screens all pregnant women for HBV, and provides prophylaxis to infants born to HBV-infected women. Canadian data on the outcomes of such programs are limited.

METHODS

We conducted a retrospective review of data from pregnant Albertan women who were Hepatitis B Surface Antigen (HBsAg) positive from 1997-2004. We describe the frequency of hepatitis B immunoglobulin (HBIG) and vaccine administration, follow-up serology and pregnancy outcomes.

RESULTS

In total, 1,485 HBsAg-positive pregnant women were identified; an average of 186 women annually (range: 125-216). Of the 980 infants eligible to have completed prophylaxis and serological follow-up, 82.0% were appropriately immunized and serologically tested, 11.3% had complete immunization but no serology testing and 6.6% were incompletely immunized. Of infants with complete immunization and follow-up, 3.7% failed to mount an immune response and 2.1% were infected.

CONCLUSION

A high proportion of infants born to carrier mothers are receiving appropriate post-natal prophylaxis in Alberta. Future research should examine maternal factors that may increase the vertical transmission of HBV.

Safety and tolerability of sequential pegylated IFN-alpha2a and tenofovir for hepatitis B infection in HIV(+) individuals

Chronic hepatitis B virus infections are a major cause of morbidity and mortality in HIV co-infected patients. The standard of care for treating HCV co-infection has been guided by major clinical trials, but the treatment of HBV co-infection has not been as thoroughly studied and the standard of care remains largely untested. The single pill formulation of tenofovir with emtricitabine has become a standard treatment approach in HBV co-infected patients. WU114 was a phase 1 clinical trial that examined the safety and tolerability of sequential treatment of HBV with pegylated interferon-alpha2a plus delayed-initiation tenofovir in HIV co-infected individuals. We postulated that initial HBV viral load reduction with pegylated interferon prior to initiation of nucleoside/nucleotide therapy would increase seroconversion events and durability of HBV virologic suppression. No severe pegylated IFN-alpha2a drug toxicities were seen in either the monotherapy or delayed tenofovir arms. Sequential pegylated interferon and tenofovir-based therapy was tolerable and should be compared with dual nucleoside/nucleotide suppression to determine relative frequencies of seroconversion and durability of HBV suppression in co-infected patients.

Defining Optimal Therapeutic Outcomes in Chronic Hepatitis

The definition of optimal therapeutic response has been evolving concurrent with the advancement of diagnostic tests. What once was considered "therapeutic success" is considered now disease persistence or relapse. As the laboratory tools become increasingly sensitive, it follows that the criteria of successful therapeutic response are becoming more stringent. The main objectives of chronic hepatitis B and C treatment are to achieve eradication of the virus and, with this, reduction or prevention of hepatic injury and disease progression. However, in the case of hepatitis B, viral suppression is for the moment a more realistic therapeutic objective, although eradication still remains the ultimate goal. In chronic hepatitis C, sustained virologic response, defined as the absence of HCV RNA 6 months post-antiviral treatment completion, is within reach. Better test sensitivity allows for additional levels of confidence in the achievements of virus eradication in patients with hepatitis C. Challenges persist despite great advances in the treatment of chronic viral hepatitis. Now that clearer therapeutic outcomes have been refined, more efficacious, and better-tolerated drugs may change the current therapeutic landscape of chronic viral hepatitis B and C.

Factors associated with the intensity of liver fibrosis in renal transplant patients with hepatitis B virus infection

BACKGROUND

Hepatitis B may show a more aggressive course after kidney transplantation, but the factors associated with the progression of fibrosis in this group have not been identified.

OBJECTIVES

To determine the influence of hepatitis B virus (HBV) viral load and host-related factors on the progression of hepatic fibrosis in hepatitis B virus-infected renal transplant recipients.

PATIENTS AND METHODS

Renal transplant patients positive for HBV surface antigen (HBsAg) and submitted to a liver biopsy because of evidence of viral replication were included. Patients with advanced fibrosis (METAVIR F3-F4) were compared with patients with mild fibrosis (F0-F2) regarding sex, age, estimated time since infection, post-transplant time, donor type, history of renal transplantation, alanine aminotransferase, anti-hepatitis C virus, HBeAg and quantitative hepatitis B virus-DNA. Logistic regression analysis was applied to identify variables independently associated with more advanced fibrosis.

RESULTS

Fifty-five patients (75% men, 41+/-11 years) with a mean post-transplant time of 5+/-4 years were included. HBeAg was detected in 67% of the patients and anti-hepatitis C virus in 35%. The median hepatitis B virus-DNA level was 2.8 x 10(8) copies/ml. Seventeen (31%) patients had advanced fibrosis. Using logistic regression analysis, the only variable that showed an independent association with more advanced stages of fibrosis was post-transplant time (P=0.03, odds ratio: 1.2, 95% confidence interval: 1.02-1.45).

CONCLUSION

Hepatitis B virus viral load, although very high, and hepatitis B virus/hepatitis C virus coinfection are not related to the intensity of liver fibrosis in renal transplant patients infected with hepatitis B virus. Post-transplant time was the only factor independently associated with more advanced liver fibrosis, suggesting the influence of immunosuppression on the progression of liver disease in these patients.

Impact of non-alcoholic fatty liver disease on chronic hepatitis B

BACKGROUND

The impact of superimposed non-alcoholic fatty liver disease (NAFLD) is well established in patients with chronic hepatitis C (CH-C), but the impact in patients with chronic hepatitis B (CH-B) is less clear.

AIM

This study aims to evaluate the prevalence of NAFLD in patients with CH-B and the association with viral and host factors, particularly in patients with metabolic syndrome (MS).

DESIGN

Data from patients with CH-B was obtained from our databases. Patients with excessive alcohol use were excluded. Hepatitis B virus (HBV) genotyping by INNO-LIPA was available for some patients. The presence of MS was defined according to the Adult Treatment Panel III (ATP III). All biopsies were read by two hepatopathologists using Metavir, modified histologic activity index (MHAI), as well as a NAFLD pathologic protocol. Patients were classified as (1) those without NAFLD; (2) those with simple hepatic steatosis; (3) and those with superimposed non-alcoholic steatohepatitis (NASH). Factors associated with superimposed NAFLD, its subtypes, and hepatic fibrosis were also analysed.

RESULTS

Subjects included 153 HBV patients [66% male, age 50.5+/-27.5 years, body mass index 24.7+/-3.7 kg/m(2), waist 83.2+/-10.9 cm; 8.5% Caucasian, 67% Asian, aspartate aminotransferase (AST) 63.2+/-88.2 IU/l, alanine aminotransferase (ALT) 98.6+/-164.6 IU/l, glucose 111.6+/-50.5 mg/dl, HBV-DNA 1.8 x 10(8)+/-1.9 x 10(6) copies/ml, 7% with MS, 13% with diabetes, 20% with arterial hypertension and 8.5% with dyslipidaemia]. Liver biopsy was available for 64 subjects [19% had superimposed NAFLD, 13% had superimposed NASH, 86% had some degree of fibrosis, and 39% had advanced fibrosis (Ishak >3)]. Patients with HBV and superimposed NASH were significantly older (55 vs. 42 years, P=0.008), more likely to have hypertension (63% vs. 15%, P=0.006) and dyslipidaemia (50% vs. 8%, P=0.006), and had a larger waist circumference (92 vs. 83 cm, P=0.03). The presence of fibrosis was associated with higher waist circumference (84 vs. 80 cm, P=0.03), higher HBV-DNA (1.9 x 10(8) vs. 5 x 10(6) copies/ml, P=0.005), and elevated ALT >40 IU/l (73.6% vs. 33.3%, P=0.02).

CONCLUSIONS

The components of MS (obesity, hypertension, and dyslipidaemia) are associated with the presence of NASH in patients with CH-B. The presence of hepatic fibrosis seems to be associated with known host and viral factors as well as the presence of abdominal obesity.

Chronic hepatitis B virus carriers in the immunotolerant phase of infection: histologic findings and outcome

BACKGROUND & AIMS

The indication for histologic evaluation of the liver is controversial for patients in the immunotolerant phase of chronic hepatitis B virus (HBV) infection.

METHODS

Results of liver biopsy examination and follow-up evaluation were assessed retrospectively in 40 patients who satisfied the following criteria: presence of hepatitis B surface antigen and hepatitis B e antigen, HBV DNA level greater than 10(7) cp/mL, normal alanine aminotransferase level, absence of co-infection with other viruses, and absence of antiviral or immunosuppressive treatment.

RESULTS

On liver biopsy examination, according to the Metavir scoring system, fibrosis was absent in 20 patients, and mild (F1) in 20 patients. During a median follow-up period of 37.7 months in 31 patients, loss of tolerance was observed at a median age of 30.7 years in 12 (38%): 6 had transition to inactive disease, 3 developed chronic hepatitis, and 3 had a transient increase of alanine aminotransferase levels. Among baseline characteristics, only alanine aminotransferase levels were significantly higher in patients with subsequent loss of tolerance.

CONCLUSIONS

In patients in the immunotolerant phase of chronic HBV infection, liver biopsy examination shows only minimal changes and probably is unnecessary. Loss of tolerance, occurring at a median age of 30.7 years, is characterized by a rapid transition to an inactive carrier state in two thirds of patients, and to chronic hepatitis in one third of patients.

Canadian consensus on medically acceptable wait times for digestive health care

BACKGROUND

Delays in access to health care in Canada have been reported, but standardized systems to manage and monitor wait lists and wait times, and benchmarks for appropriate wait times, are lacking. The objective of the present consensus was to develop evidence- and expertise-based recommendations for medically appropriate maximal wait times for consultation and procedures by a digestive disease specialist.

METHODS

A steering committee drafted statements defining maximal wait times for specialist consultation and procedures based on the most common reasons for referral of adult patients to a digestive disease specialist. Statements were circulated in advance to a multidisciplinary group of 25 participants for comments and voting. At the consensus meeting, relevant data and the results of voting were presented and discussed; these formed the basis of the final wording and voting of statements.

RESULTS

Twenty-four statements were produced regarding maximal medically appropriate wait times for specialist consultation and procedures based on presenting signs and symptoms of referred patients. Statements covered the areas of gastrointestinal bleeding; cancer confirmation and screening and surveillance of colon cancer and colonic polyps; liver, biliary and pancreatic disorders; dysphagia and dyspepsia; abdominal pain and bowel dysfunction; and suspected inflammatory bowel disease. Maximal wait times could be stratified into four possible acuity categories of 24 h, two weeks, two months and six months.

FUTURE DIRECTIONS

Comparison of these benchmarks with actual wait times will identify limitations in access to digestive heath care in Canada. These recommendations should be considered targets for future health care improvements and are not clinical practice guidelines.

Correlation of hepatitis B virus YMDD mutations with the polymorphism of HLA alleles in patients with chronic hepatitis B virus infection

AIM: To investigate the relationship between HBV YMDD mutations and the polymorphism of human leukocyte antigen (HLA) alleles in patients with chronic hepatitis B virus (HBV) infection.

METHODS: Fluorescent hybridization biprobe PCR and melting curve assay (FH-PCR-MC) was used to determine HBV YMDD mutations in serum specimens from 142 patients with chronic HBV infection. HLA-A, B, and DRB1 alleles in peripheral blood mononuclear cells (PBMCs) were detected by polymerase chain reaction-sequence specific primer (PCR-SSP). The PBMCs were collected from 56 of the 142 patients.

RESULTS: YMDD mutations occurred in 56.3% of the 142 patients who received lumivudine treatment. The frequencies of HLA-B*58 and DRB1*03 alleles were significantly lower in YMDD mutation group in comparison with those in YMDD wild group (0.013 vs 0.094, P = 0.036; 0.000 vs 0.063, P = 0.024). The frequency of HLA-A*30 allele was markedly higher in YIDD group than that in YVDD group (0.158 vs 0.024, P = 0.034), while the frequency of HLA-A*33 allele was lower in YIDD group ( 0.119vs 0.000, P = 0.028).

CONCLUSION: YMDD mutation is associated with the polymorphism of HLA alleles in patients with chronic hepatitis B. Individuals with HLA-B*58 and DRB1*03 alleles may have resistance to YMDD mutation. Patients with HLA-A*30 allele may have a susceptibility to YIDD mutation, and those with HLA-A*33 allele are susceptible to YVDD mutation.

Emerging therapeutics for chronic hepatitis B

Hepatitis B is a global health problem. Patients with chronic hepatitis B (CHB) carry a significant risk to eventually develop cirrhotic liver disease. Recent therapeutic advances against CHB offer excellent potential for long-term suppression of hepatitis B virus (HBV) replication during antiviral therapy, and occasionally a durable remission off medication. Selection of appropriate patients for antiviral therapy depends on identification of HBV replication and an elevated alanine aminotransferase level or histologic liver injury. Pegylated interferon alpha offers potent immunomodulatory and antiviral activity with the potential for durability, but also with adverse effects and significant cost. The nucleoside or nucleotide analogs, lamivudine, adefovir, and entecavir, suppress HBV replication and are extremely well-tolerated, but long-term or even lifelong therapy is required. Most experience has been gained with lamivudine, but viral resistance occurs frequently. Newer analogs appear to be relatively free of this problem. Approaches using a combination of agents have promise, but have yet to be proven superior to individual drugs alone.

Analysis of the polymorphism of human leukocyte antigen (HLA) class and class alleles in HBV infection

AIM: To test the polymorphism of human leukocyte antigen (HLA) class and class alleles in HBV infection.

METHODS: The polymeric chain reaction/sequence specific primer (PCR-SSP) technique was used to determine HLA-A, B, DR B1 alleles in 61 patients with chronic hepatitis B (CHB), 30 recovered people from HBV infection and 40 healthy people ready to donate their bone marrow in Heilongjiang.

RESULTS: The allele frequencies of HLA-DRB1*12 in the chronic hepatitis B group were markedly higher than that in the normal group and the recovered group(0.230 vs 0.075, P = 0.004, OR = 3.674, 95%CI = 1.445-9.338 and 0.230 vs 0.063, P = 0.004, OR = 4.468, 95%CI = 1.492-13.377), but the allele frequencies of HLA- B*35, DRB1*13 were markedly lower(0.066 vs 0.163, P = 0.027, OR = 0.362, 95%CI = 0.143~0.918 and 0.016 vs 0.008, P = 0.017, OR = 0.174, 95%CI = 0.035-0.859). The allele frequencies of HLA-B*51, A*02 in the recovered group were markedly higher than that in the normal group (0.125 vs 0.025, P = 0.019, OR = 5.587, 95%CI = 1.139-27.027)and the chronic hepatitis B group(0.221 vs 0.360, P = 0.044, OR = 0.507, 95%CI = 0.260-0.986), respectively. HLA-A*69, B*56 were markedly lower in the chronic hepatitis B group than that in the normal group(0.000 vs 0.037, P = 0.031 and 0.000 vs 0.037, P = 0.031).

CONCLUSION: HLA-DRB1*12 was highly associated with the susceptibility to HBV infection and viral persistence. HLA-B*51, A*02 were closely associated with the susceptibility to HBV infection and viral clearance. HLA-B*35, DRB1*13, B*56 and A*69 were associated with the protection to HBV infection.

Evaluation of fluorescent hybridization biprobe PCR and melting curve assay

AIM: To evaluate a fluorescent hybridization biprobe PCR and melting curve assay for detection of (hepatitis B virus) YMDD mutation associated with lamivudine therapy.

METHODS: HBV DNA and YMDD mutations in the 217 clinical serum specimens from patients with chronic HBV infection who were treated with lamivudine (100 mg/d) were detected by the fluorescence quantitative polymerase chain reaction (PCR) using TaqMan probe (FT-PCR) and the fluorescent hybridization biprobe PCR and melting curve assay (FH-PCR-MC), respectively. Seventy-eight positive sera were then genotyped by nested PCR with six pairs of HBV genotype-specific primes (A to F), and the cloned DNA fragments derived from conventional PCR of HBV YMDD of 30 positive sera were sequenced.

RESULTS: Among 217 samples, 75.6%(164/217) were HBV DNA positive, and 67.7% (147/217) were HBV YMDD positive, including YMDD 44.9%(66/147), YIDD 22.5%(33/147),YVDD 17.7%(26/147),YI/VDD 10.9%(16/147), and others 4.0%(6/147). In HBV DNA≥10⁷copies/L, all the positive and mutant rates of YMDD have no significant difference in different HBV DNA levels. Among 78 genotype samples (genotype C 89.8%, B 8.9% and D 1.3%), the positive and mutant rates of YMDD were 100%(78/78) and 58.97%(46/78) respectively. One genotype D was YIDD/YVDD. The mutant rates of YMDD in genotype B and C were 71.4% and 55.7% respectively, but have no marked difference (P >0.5). Using the results by DNA sequencing as reference standard, the relative specificity, sensitivity and over-all accordance of FH-PCR-MC were 96.3% (26/27), 100% (3/3) and 96.7% (29/30) respectively. The results of YMDD typing by FH-PCR-MC were confirmed by the sequencing of clones.

CONCLUSION: The fluorescent hybridization biprobe PCR and melting curve assay kit in detection of HBV YMDD mutation has high sensitivity and specificity. It is a convenient and rapid test kit, and may be used in YMDD genotyping.

A Practical Approach to Management of Chronic Hepatitis B

Chronic hepatitis B (CHB) is one of the important public health problems worldwide. Major advances have been made in the treatment of CHB during the past several years. This article systemically reviews advances in the application of HBV DNA quantitation and three approved drugs for HBV treatment, and presents an updated and practical clinical approach to managing CHB. Highly sensitive PCR-based quantitation of HBV DNA makes it possible to precisely determine pre-treatment HBV load and monitor HBV DNA response during treatment. HBV DNA level, HBeAg status, degree of hepatic histological activity and fibrosis, and serum transaminases are the most important parameters in determining indication, regimen, and duration of HBV treatment. Although interferon alfa-2b, lamivudine, and adefovir are all approved as initial HBV treatment, understanding the advantages and advantages of each agent is important in choosing the best treatment for each individual patient with CHB.