Acute fulminant hepatitis B in a patient with diabetic nephropathy treated successfully with concomitant lamivudine and molecular adsorbents recirculating system

Gender Impacts on the Disease Severity of Overt Acute Hepatitis A: Different from Overt Acute Hepatitis B

BACKGROUND

Acute hepatitis A (AH-A) and acute hepatitis B (AH-B) were found more severe in males and females, respectively, while impacts from underlying liver disease on severity were not excluded in the AH-A study.

AIM

The precise gender-specific impact on the severity of AH-A was investigated and compared with that of AH-B.

METHODS

A case-control study of overt AH-A (n = 118) and AH-B (n = 118) patients without any underlying liver disease was conducted. Overt hepatitis was defined as serum bilirubin ≥ 2 mg/dL and alanine transaminase (ALT) ≥ 10 × upper limit of normal.

RESULTS

Of the AH-A patients, age (95% confidence interval of odds ratio 1.051-1.147) and ALT (1.001-1.002) were associated with hepatic decompensation. Indifferent rates of hepatic decompensation, hepatic failure, and mortality were found between male and female patients. Compared with the AH-B patients, AH-A patients showed lower bilirubin levels (p < 0.001), hepatic decompensation (p = 0.004), and mortality rates (p = 0.013). Among patients < 40 years, the AH-A patients had higher hepatic decompensation rates than AH-B in the male subgroup (15% vs. 2.8%, p = 0.045), while the situation is reverse in the female subgroup (7.7% vs. 48.1%, p = 0.001).

CONCLUSIONS

Overt AH-A was less severe than overt AH-B and, unlike AH-B, had no difference in severity between males and females. Among subgroups < 40 years, AH-A was more severe than AH-B in males, but the situation was reverse in females in terms of hepatic decompensation rates.

Post-transplant withdrawal of lamivudine results in fatal hepatitis flares in kidney transplant recipients, under immune suppression, with inactive hepatitis B infection

OBJECTIVE

To evaluate the consequences of lamivudine withdrawal in kidney transplant recipients, under immunosuppression, with inactive hepatitis B virus (HBV) infection.

INTRODUCTION

HBV infection is more frequent in kidney transplant recipients than in the general population mainly due to the high risk of acquisition during dialysis, before kidney transplantation.

METHODS

The records of hepatitis B surface antigen (HBsAg)-positive, immunosuppressed kidney transplant recipients, where lamivudine was withdrawn after transplantation along with reduction in immunosuppressant dose, admitted to our hospital between 2005 and 2012, were retrospectively evaluated.

DISCUSSION

Three patients aged 33, 42 and 33, experienced hepatitis flares 2-3 months after lamivudine withdrawal. Serum HBV DNA levels were 2.5×10⁷, 3.4×10⁴ and 4×10³ IU/ml in cases 1, 2, and 3, respectively. Lamivudine was re-initiated in all cases which led to rapid viral suppression. However, liver function continued to deteriorate leading to severe jaundice, coagulopathy and encephalopathy. All patients died of acute liver failure within six months after the onset of withdrawal hepatitis.

CONCLUSION

Lamivudine should be continued as long as immunosuppressive therapy lasts.

Management of severe acute to fulminant hepatitis B: to treat or not to treat or when to treat?

Despite a decline in cases of acute hepatitis B and the low hepatitis B virus (HBV) chronicity rates in adults, still some patients progress to HBV-related fulminant liver failure. In this review, we discuss treatment options that may prevent the progression of severe acute hepatitis B to fulminant liver failure and death. In severe acute HBV with prolonged prothrombin time and increased bilirubin, interferon failed to be effective while antiviral treatment, particularly with lamivudine, appears to improve survival (mean survival almost 80%). Outcome without antiviral therapy has remained considerably poor, whereas there is no convincing evidence of amelioration of HBV-targeted immunity. Of note, most patients who died or required transplantation despite lamivudine therapy, were started on lamivudine at advanced stages compared with those survived. This suggests that prompt and timely antiviral therapy is crucial. Owing to the abovementioned results the design of randomized placebo-control trials in the setting of severe acute hepatitis B seems unethical. On the contrary, the design of multicentre double-blind randomized trials to compare the efficacy between lamivudine and entecavir or even tenofovir in acute severe HBV cases is ideally needed, but these studies appear to be very difficult to perform considering that these cases are not frequent and therefore, it is almost impossible to have two arms adequately numerous and homogenous for statistical evaluation. Thus, in the absence of solid evidence based data, the hepatologists could treat their patients with severe acute hepatitis B with lamivudine or the most potent antivirals entecavir or tenofovir.