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Schwarzenberg SJ, King WC, Ling SC, Murray KF, Mogul D, Rosenthal P, Rodriguez-Baez N, Teckman J, Schwarz KB. Change in Health-Related Quality of Life in Youth with Chronic Hepatitis B Living in North America: A 5-Year Cohort Study. J Pediatr Gastroenterol Nutr 2023; 77:713-719. [PMID: 37756340 DOI: 10.1097/mpg.0000000000003957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND Greater hepatitis-related symptomology is associated with lower health-related quality-of-life (HRQoL) among untreated youth with chronic hepatitis B (CHB). How HRQoL changes over time in this population is unknown. METHODS Children from 7 hepatology centers in North America positive for hepatitis B surface antigen, not taking anti-viral therapy, were enrolled in the Hepatitis B Research Network. A validated self-report HRQoL measure, the Child Health Questionnaire Child Report (CHQ-CF87), was completed annually by participants 10-17 years, with demographic variables, liver disease symptoms, and laboratory tests. Linear mixed-effects models were used to evaluate the 10 CHQ-CF87 subscale scores over 5 years among participants who completed the CHQ-CF87 at least twice. RESULTS Participants (N = 174) completed the CHQ-CF87 a median of 4 times. Median age was 12 years (interquartile range: 10-14) at baseline; 60% were female, 79% Asian, and 47% adopted. The CHQ-CF87 subscale scores were high at baseline (median range: 75.4-100) and did not differ by time point, except for the Family Activities subscale (mean [95% CI]: 82.3 [79.8-84.8] at baseline; 90.8 [86.1-94.6] week 240). Most subscale scores lacked sufficient individual-level variability in change over time to evaluate predictors. Being White versus Asian predicted a more favorable change in Behavior (6.5 [95% CI: 2.0-11.0]). Older age predicted less favorable change in Mental Health (-0.8 [95% CI: -1.36 to -0.23] per year). Changes in liver enzymes and hepatitis B antigens, DNA, or symptom count were not related to changes in these subscale scores. CONCLUSION HRQoL was generally good and consistent across 5 years in youth with CHB.
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Affiliation(s)
| | - Wendy C King
- the Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Simon C Ling
- the Department of Paediatrics, University of Toronto, and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karen F Murray
- the Department of Pediatrics, University of Washington, Seattle, WA
| | | | - Philip Rosenthal
- the Department of Pediatrics, University of California at San Francisco, San Francisco, CA
| | | | - Jeffrey Teckman
- the Department of Pediatrics, Saint Louis University, Saint Louis, MO
| | - Kathleen B Schwarz
- the Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD
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Perrillo R, Lin HHS, Schwarz KB, Rosenthal P, Lisker-Melman M, Chung RT, Prokunina-Olsson L, Cloherty G, Feld J. Changes in serum hepatitis B surface and e antigen, interferon-inducible protein 10, and aminotransferase levels during combination therapy of immune-tolerant chronic hepatitis B. Hepatology 2022; 76:775-787. [PMID: 35188674 DOI: 10.1002/hep.32400] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/28/2022] [Accepted: 01/30/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Treatment of immune-tolerant (IT) children and adults with combined peginterferon alfa-2a and entecavir results in a decline in serum HBeAg and HBsAg concentrations but rarely results in loss of HBeAg or sustained off-treatment response. Factors associated with declines in these viral antigens during treatment remain unexplored. APPROACH AND RESULTS We investigated the pattern of virologic and biochemical response in 86 participants (59 children, 27 adults) by serial quantitative measurement of HBsAg (qHBsAg), quantitative HBeAg (qHBeAg), HBV RNA, interferon-inducible protein (IP-10), IL-18, and alanine aminotransferase (ALT). Each individual had previously been treated with 8 weeks of entecavir followed by 40 weeks of combined peginteferon and entecavir. We defined the interrelationships between these parameters and virologic response measured as nadir declines from baseline for HBeAg and HBsAg. The patterns of HBsAg and HBeAg decline were similar in pediatric and adult participants. Higher levels of IP-10 were observed during treatment in participants with greater ALT elevations and greater reductions of qHBsAg and qHBeAg. Individuals with peak ALT values exceeding three times the upper limit of normal were significantly more likely to have >1 log10 decline in both viral antigens. HBV DNA became undetectable in 21 of 86 (24%) and HBV RNA in 4 of 77 (5%) during therapy, but both markers remained negative only in those who became HBsAg negative, all of whom also had ALT elevations. CONCLUSIONS Induction of IP-10 during peginterferon treatment in adults and children in the IT phase of chronic HBV infection is associated with ALT elevations and decline in viral antigens, suggesting a degree of interferon-inducible viral control.
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Affiliation(s)
| | - Hsing-Hua S Lin
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | | | | | - Jordan Feld
- Toronto Centre for Liver Disease, University of Toronto University Health Network, Toronto, Canada
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Schwarzenberg SJ, Ling SC, Rosenthal P, Murray KF, Teckman J, Mogul D, Rodriguez-Baez N, Schwarz K. Lessons Learned From Children Enrolled Into the Hepatitis B Virus Research Network Multi-Center Prospective Study. J Pediatr Gastroenterol Nutr 2022; 74:431-433. [PMID: 35045562 DOI: 10.1097/mpg.0000000000003381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Sarah Jane Schwarzenberg
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Simon C Ling
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Karen F Murray
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Jeff Teckman
- Department of Pediatrics, Saint Louis University, Saint Louis, MO
| | - Douglas Mogul
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Norberto Rodriguez-Baez
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kathleen Schwarz
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD
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Terrault NA, Wahed AS, Feld JJ, Cooper SL, Ghany MG, Lisker-Melman M, Perrillo R, Sterling RK, Khalili M, Chung RT, Rosenthal P, Fontana RJ, Sarowar A, Lau DTY, Wang J, Lok AS, Janssen HLA. Incidence and prediction of HBsAg seroclearance in a prospective multi-ethnic HBeAg-negative chronic hepatitis B cohort. Hepatology 2022; 75:709-723. [PMID: 34743343 PMCID: PMC8943823 DOI: 10.1002/hep.32231] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 10/20/2021] [Accepted: 10/24/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Achieving HBsAg loss is an important landmark in the natural history of chronic hepatitis B (CHB). A more personalized approach to prediction of HBsAg loss is relevant in counseling patients. This study sought to develop and validate a prediction model for HBsAg loss based on quantitative HBsAg levels (qHBsAg) and other baseline characteristics. METHODS The Hepatitis B Research Network (HBRN) is a prospective cohort including 1240 untreated HBeAg-negative patients (1150 adults, 90 children) with median follow-up of 5.5 years. Incidence rates of HBsAg loss and hepatitis B surface antibody (anti-HBs) acquisition were determined, and a predictor score of HBsAg loss using readily available variables was developed and externally validated. RESULTS Crude incidence rates of HBsAg loss and anti-HBs acquisition were 1.6 and 1.1 per 100 person-years (PY); 67 achieved sustained HBsAg loss for an incidence rate of 1.2 per 100 PY. Increased HBsAg loss was significantly associated with older age, non-Asian race, HBV phenotype (inactive CHB vs. others), HBV genotype A, lower HBV-DNA levels, and lower and greater change in qHBsAg. The HBRN-SQuARe (sex,∆quantHBsAg, age, race) score predicted HBsAg loss over time with area under the receiver operating characteristic curve (AUROC) (95% CIs) at 1 and 3 years of 0.99 (95% CI: 0.987-1.00) and 0.95 (95% CI 0.91-1.00), respectively. In validation in another cohort of 1253 HBeAg-negative patients with median follow-up of 3.1 years, HBRN SQuARe predicted HBsAg loss at 1 and 3 years with AUROC values of 0.99 (0.98-1.00) and 0.88 (0.77-0.99), respectively. CONCLUSION HBsAg loss in predominantly untreated patients with HBeAg-negative CHB can be accurately predicted over a 3-year horizon using a simple validated score (HBRN SQuARe). This prognostication tool can be used to support patient care and counseling.
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Affiliation(s)
- NA Terrault
- Gastrointestinal and Liver Diseases Division, Keck Medicine of University of Southern California, Los Angeles, California, USA
| | - AS Wahed
- Department of Biostatistics and Epidemiology Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - JJ Feld
- Toronto Center for Liver Disease, University of Toronto, Toronto, Ontario, Canada
| | - SL Cooper
- San Francisco Center for Liver Disease, California Pacific Medical & Research Institute, San Francisco, California, USA
| | - MG Ghany
- Liver Diseases Branch, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - M Lisker-Melman
- Washington University School of Medicine and John Cochran VA Medical Center, St. Louis, Missouri, USA
| | - R Perrillo
- Baylor University Medical Center, Dallas, Texas, USA
| | - RK Sterling
- Section of Hepatology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - M Khalili
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - RT Chung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - P Rosenthal
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - RJ Fontana
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - A Sarowar
- Toronto Center for Liver Disease, University of Toronto, Toronto, Ontario, Canada
| | - DTY Lau
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts, USA
| | - J Wang
- Department of Biostatistics and Epidemiology Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - AS Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - HLA Janssen
- Toronto Center for Liver Disease, University of Toronto, Toronto, Ontario, Canada
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Ling SC, Lin HHS, Murray KF, Rosenthal P, Mogul D, Rodriguez-Baez N, Schwarzenberg SJ, Teckman J, Schwarz KB. Chronic Hepatitis Is Common and Often Untreated Among Children with Hepatitis B Infection in the United States and Canada. J Pediatr 2021; 237:24-33.e12. [PMID: 34022250 PMCID: PMC8478804 DOI: 10.1016/j.jpeds.2021.05.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/25/2021] [Accepted: 05/12/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the outcomes of chronic hepatitis B virus (HBV) infection in a large, prospectively studied cohort of children in the US and Canada. STUDY DESIGN This was a prospective, observational study of children with chronic HBV enrolled in 7 clinical centers and evaluated at baseline, weeks 24 and 48, and annually thereafter, with analysis of demographic, clinical, physical examination, and blood test data. RESULTS Among 362 children followed for a median of 4.2 years, elevated alanine aminotransferase (ALT) levels (>1 upper limit of normal) were present in 72% at last evaluation, including in 60% of children with loss of hepatitis B e antigen during follow-up and 70% of those who were hepatitis B e antigen negative at baseline. Significant ALT flares (male patients ≥400 U/L, female patients ≥350 U/L) occurred in 13 children. Of 129 children who fulfilled the American Association for the Study of Liver Diseases treatment criteria during follow-up, anti-HBV treatment was initiated in only 25. One child died (unrelated to liver disease), 1 developed cirrhosis, but no episodes of cirrhotic decompensation or hepatocellular carcinoma were observed. Decline in platelet count was inversely associated with ALT elevations. CONCLUSIONS In a cohort of children with chronic HBV infection in the US and Canada, many children remained at risk of progressive liver disease due to active hepatitis, but major clinical outcomes such as cirrhosis, cancer, and death were rare. Many children who met criteria for treatment remained untreated.
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Affiliation(s)
- Simon C. Ling
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Hsing-Hua S. Lin
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Karen F. Murray
- Department of Pediatrics, University of Washington, Seattle, WA
| | | | - Douglas Mogul
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD
| | | | | | - Jeffrey Teckman
- Department of Pediatrics, Saint Louis University, Saint Louis, MO
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Johnson Valiente A, Liem KS, Schwarz KB, Rosenthal P, Murray KF, Mogul D, Teckman J, Rodriguez-Baez N, Schwarzenberg SJ, Feld JJ, Wong DK, Lewis-Ximenez LL, Lauer G, Hansen BE, Ling SC, Janssen HLA, Gehring AJ. The Inflammatory Cytokine Profile Associated with Liver Damage is Broader and Stronger in Chronic Hepatitis B Patients Compared to Acute Hepatitis B Patients. J Infect Dis 2021; 225:470-475. [PMID: 34286845 DOI: 10.1093/infdis/jiab373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/20/2021] [Indexed: 11/14/2022] Open
Abstract
Liver damage in hepatitis B is immune driven and correlates with inflammatory markers in patient serum. There is no comparison of these markers to determine if inflammatory profiles are distinct to different types of liver damage across patients at different stages of disease. We measured 25 inflammatory markers in acute hepatitis B, chronic hepatitis B patients with HBeAg seroconversion and chronic patients stopping nucleoside analogue therapy. Myeloid markers dominated the inflammatory profile in all stages of hepatitis B. More inflammatory markers were detectable in chronic patients, including elevated concentrations of cytotoxic effectors Fas ligand, TRAIL and TNF-α.
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Affiliation(s)
- Alexandra Johnson Valiente
- Department of Immunology, University of Toronto, Ontario, Canada.,Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada
| | - Kin Seng Liem
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Kathleen B Schwarz
- Division of Pediatric Gastroenterology, University of California San Diego, San Diego, California, USA.,Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Philip Rosenthal
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | | | - Douglas Mogul
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffery Teckman
- Department of Pediatrics, Saint Louis University, St. Louis, Missouri, USA
| | | | | | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada
| | - David K Wong
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada
| | - Lia L Lewis-Ximenez
- Viral Hepatitis Laboratory, Oswaldo Cruz Institute, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Georg Lauer
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Simon C Ling
- Division of Gastroenterology, Hepatology & Nutrition, the Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada
| | - Adam J Gehring
- Department of Immunology, University of Toronto, Ontario, Canada.,Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario Canada.,Institute of Medical Science, University of Toronto, Ontario, Canada
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Cooper SL, King WC, Mogul DB, Ghany MG, Schwarz KB. Clinical significance of quantitative e antigen in a cohort of hepatitis B virus-infected children and adults in North America. J Viral Hepat 2021; 28:1042-1056. [PMID: 33893706 DOI: 10.1111/jvh.13520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/12/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND In chronic hepatitis B (CHB) viral infection, e antigen positivity (HBeAg+) is associated with high levels of viral replication and infectivity. Furthermore, HBeAg-positive CHB is associated with a liver disease spectrum ranging from none to severe. AIM To assess whether the level of circulating HBeAg is associated with different clinical presentations of HBeAg-positive CHB. METHODS A cross-sectional analysis was conducted among HBV mono-infected participants enrolled in Hepatitis B Research Network (HBRN) cohorts to explore clinical and virological associations with quantitative HBeAg (qHBeAg). RESULTS Among 763 HBeAg+ participants (56% female; 85% Asian; median age 26 years), multivariable median regression modelling significantly associated qHBeAg with liver injury (inverse qHBeAg association with ALT p<.001 and APRI p<.001), and with both race and age (p=0.01). Among Asians, qHBeAg was inversely related to age; a relationship less clear among Blacks and Whites. Among Asians also, median qHBeAg levels were higher among those infected with HBV genotype C versus B (p<0.001), suggesting causal virologic differences. Across all races, median qHBeAg was higher in women (p=.01). Independent of sex, age, race and HBV genotype, qHBeAg was higher in participants with predominant wild-type versus basal core promoter and/or precore 'stop' viral variants (p<0.001). CONCLUSION Lower qHBeAg was observed among HBRN participants with the greatest degree of liver injury independent of demographics and HBV genotype. These data support longitudinal studies to examine the role of qHBeAg in modulating the host immune response and predicting the outcomes of chronic HBV infection.
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Affiliation(s)
| | - Wendy C King
- Graduate School of Public, Health University of Pittsburgh, Pittsburgh, PA, USA
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Lee WM, King WC, Schwarz KB, Rule J, Lok ASF. Prevalence and clinical features of patients with concurrent HBsAg and anti-HBs: Evaluation of the hepatitis B research network cohort. J Viral Hepat 2020; 27:922-931. [PMID: 32364641 DOI: 10.1111/jvh.13312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/06/2020] [Accepted: 03/23/2020] [Indexed: 12/15/2022]
Abstract
The prevalence of concurrent HBsAg and anti-HBs in plasma of persons with chronic hepatitis B virus (HBV) infection is variable and its clinical significance enigmatic. We examined the prevalence and clinical and virological features of concurrent HBsAg and anti-HBs in children and adults with chronic HBV infection living in North America. A total of 1462 HBsAg positive participants in the Hepatitis B Research Network paediatric and adult cohorts were included (median age 41 (range 4-80) years, 48% female, 11% white, 13% black, 73% Asians). Only 18 (1.2%) were found to be anti-HBs positive (≥10 mIU/mL) at initial study evaluation. Distributions of sex, race, HBV genotype and ALT were similar between participants with and without concurrent anti-HBs. Those who were anti-HBs positive appeared to be older (median age 50 vs 41 years, P = .06), have lower platelet counts (median 197 vs 222 × 103/mm3 , P = .07) and have higher prevalence of HBeAg (44% vs 26%, P = .10). They also had lower HBsAg levels (median 2.0 vs 3.5 log10 IU/mL, P = .02). Testing of follow-up samples after a median of 4 years (range 1-6) in 12 of the 18 participants with initial concurrent anti-HBs showed anti-HBs became undetectable in 6, decreased to <10 mIU/mL in 1 and remained positive in 5 participants. Two patients lost HBsAg during follow-up. In conclusion, prevalence of concurrent HBsAg and anti-HBs was low at 1.2%, with anti-HBs disappearing in some during follow-up, in this large cohort of racially diverse children and adults with chronic HBV infection living in North America. Presence of concurrent HBsAg and anti-HBs did not identify a specific phenotype of chronic hepatitis B, nor did it appear to affect clinical outcomes.
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Affiliation(s)
- William M Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wendy C King
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kathleen B Schwarz
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jody Rule
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
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Hepatic Histology in Treatment-naïve Children With Chronic Hepatitis B Infection Living in the United States and Canada. J Pediatr Gastroenterol Nutr 2020; 71:99-105. [PMID: 32265408 PMCID: PMC8491712 DOI: 10.1097/mpg.0000000000002712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Chronic hepatitis B virus infection is a major cause of morbidity and mortality. The aim of the study is to describe the hepatic histology in children chronically infected with hepatitis B virus living in the United States and Canada. METHODS Liver biopsies of 134 treatment-naïve children with chronic hepatitis B virus infection were scored for inflammation, fibrosis, and other histological features, and correlated with clinical and laboratory data. RESULTS Sixty percentage of subjects acquired the infection vertically, 51% were male, and 69% were hepatitis B e antigen-positive at the time of the biopsy. Hepatitis B DNA levels were generally high (mean 7.70 log IU/mL), as was serum alanine aminotransferase (median 120 U/L). Using the Ishak-modified histology activity index scoring system, interface hepatitis was mild in 31%, moderate in 61%, and severe in 6%. Lobular inflammation was mild in 54%, moderate in 29%, and marked in 7%. Portal inflammation was mild in 38% and moderate in 62% of subjects. Eighteen percentage had no fibrosis, 59% had portal expansion without bridging fibrosis, 19% had bridging fibrosis, and 4% had cirrhosis. Alanine aminotransferase positively correlated with inflammation and fibrosis. Neither age, duration of infection, nor Hepatitis B virus DNA levels correlated with fibrosis. Fibrosis-4 index did not correlate with fibrosis but correlated with inflammation. Aspartate aminotransferase/platelet ratio index correlated with both inflammation and fibrosis. CONCLUSIONS Chronic hepatitis B virus infection results in significant inflammation and fibrosis during childhood. Serum alanine aminotransferase is a strong indicator of the severity and extent of hepatic inflammation and fibrosis.
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Abstract
OBJECTIVE The aim of the study was to define chronic HBV phenotypes in a large, cohort of United States and Canadian children utilizing recently published population-based upper limit of normal alanine aminotransferase levels (ULN ALT), compared with local laboratory ULN; identify relationships with host and viral factors. BACKGROUND Chronic hepatitis B virus (HBV) infection has been characterized by phases or phenotypes, possibly associated with prognosis and indications for therapy. METHODS Baseline enrollment data of children in the Hepatitis B Research Network were examined. Phenotype definitions were inactive carrier: HBeAg-negative with low HBV DNA and normal ALT levels; immune-tolerant: HBeAg-positive with high HBV DNA but normal ALT levels; or chronic hepatitis B: HBeAg-positive or -negative with high HBV DNA and abnormal ALT levels. RESULTS Three hundred seventy-one participants were analyzed of whom 274 were HBeAg-positive (74%). Younger participants were more likely be HBeAg-positive with higher HBV DNA levels. If local laboratory ULN ALT levels were used, 35% were assigned the immune tolerant phenotype, but if updated ULN were applied, only 12% could be so defined, and the remaining 82% would be considered to have chronic hepatitis B. Among HBeAg-negative participants, only 21 (22%) were defined as inactive carriers and 14 (14%) as HBeAg-negative chronic hepatitis B; the majority (61%) had abnormal ALT and low levels of HBV DNA, thus having an indeterminant phenotype. Increasing age was associated with smaller proportions of HBeAg-positive infection. CONCLUSIONS Among children with chronic HBV infection living in North America, the immune tolerant phenotype is uncommon and HBeAg positivity decreases with age.
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Rosenthal P, Ling SC, Belle SH, Murray KF, Rodriguez-Baez N, Schwarzenberg SJ, Teckman J, Lin HHS, Schwarz KB. Combination of Entecavir/Peginterferon Alfa-2a in Children With Hepatitis B e Antigen-Positive Immune Tolerant Chronic Hepatitis B Virus Infection. Hepatology 2019; 69:2326-2337. [PMID: 30318613 PMCID: PMC6465180 DOI: 10.1002/hep.30312] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/10/2018] [Indexed: 12/17/2022]
Abstract
The optimal management strategy for children with immune-tolerant chronic hepatitis B virus (HBV) infection remains unknown. The purpose of this clinical trial was to determine the safety and efficacy of therapy with entecavir and peginterferon in a group of children in the immune-tolerant phase of HBV infection. Children with immune-tolerant features of chronic hepatitis B (CHB) received entecavir once-daily in a dose of 0.015 mg/kg (0.5 mg maximum) for 48 weeks; peginterferon alfa-2a (180 µg/1.73m2 subcutaneously) once-weekly was added at the end of week 8 and continued until week 48. The primary endpoint was lack of detectable hepatitis B e antigen (HBeAg) with HBV DNA levels ≤1,000 IU/mL 48 weeks after stopping therapy. Sixty children (75% female), median age 10.9 (range, 3.4-17.9) years, were enrolled. All were positive for hepatitis B surface antigen (HBsAg) and HBeAg and had high levels of HBV DNA with normal or minimally elevated levels of alanine aminotransferase (ALT). Fifty-five children completed the entire 48-week course of therapy. At 48 weeks after treatment ended (week 96), 2 children (3%) achieved the primary endpoint and were also HBsAg negative and anti-hepatitis B surface antigen antibody (anti-HBs) positive. One child was HBeAg positive but HBsAg negative at week 60; another was HBeAg negative but HBsAg positive at week 72, which were their last clinic visits. In the remaining children, serum ALT and HBV DNA levels at week 96 were similar to baseline. Thirty-seven children experienced adverse events (AEs), and 1 had a serious AE (SAE). Conclusion: The combination of entecavir and peginterferon for up to 48 weeks rarely led to loss of HBeAg with sustained suppression of HBV DNA levels in children in the immune-tolerant phase of HBV infection, and treatment was associated with frequent AEs.
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Affiliation(s)
- Philip Rosenthal
- Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Simon C. Ling
- The Hospital for Sick Children, and Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Steven H. Belle
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Karen F. Murray
- Pediatrics, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA, United States
| | - Norberto Rodriguez-Baez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Sarah J. Schwarzenberg
- Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Jeffrey Teckman
- Pediatrics, Saint Louis University, Saint Louis, MO, United States
| | - Hsing-Hua S. Lin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kathleen B. Schwarz
- Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Coffin CS, Fung SK, Alvarez F, Cooper CL, Doucette KE, Fournier C, Kelly E, Ko HH, Ma MM, Martin SR, Osiowy C, Ramji A, Tam E, Villeneuve JP. Management of Hepatitis B Virus Infection: 2018 Guidelines from the Canadian Association for the Study of Liver Disease and Association of Medical Microbiology and Infectious Disease Canada. CANADIAN LIVER JOURNAL 2018; 1:156-217. [PMID: 35992619 PMCID: PMC9202759 DOI: 10.3138/canlivj.2018-0008] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 08/01/2023]
Abstract
Hepatitis B virus (HBV) infection is an important public health problem in Canada. In keeping with evolving evidence and understanding of HBV pathogenesis, the Canadian Association for the Study of Liver Disease periodically publishes HBV management guidelines. The goals of the 2018 guidelines are to (1) highlight the public health impact of HBV infection in Canada and the need to improve diagnosis and linkage to care, (2) recommend current best-practice guidelines for treatment of HBV, (3) summarize the key HBV laboratory diagnostic tests, and (4) review evidence on HBV management in special patient populations and include more detail on management of HBV in pediatric populations. An overview of novel HBV tests and therapies for HBV in development is provided to highlight the recent advances in HBV clinical research. The aim and scope of these guidelines are to serve as an up-to-date, comprehensive resource for Canadian health care providers in the management of HBV infection.
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Affiliation(s)
- Carla S. Coffin
- Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Scott K. Fung
- Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Fernando Alvarez
- Centre hospitalier de l’université de Montréal (CHUM)—CHU Sainte-Justine, Montreal, Québec
| | - Curtis L. Cooper
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario
| | - Karen E. Doucette
- Division of Infectious Diseases, University of Alberta, Edmonton, Alberta
| | - Claire Fournier
- Department of Medicine, Université de Montréal, Montreal, Québec
| | - Erin Kelly
- Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, Ontario
| | - Hin Hin Ko
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Mang M Ma
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta
| | | | - Carla Osiowy
- Viral Hepatitis and Bloodborne Pathogens, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba
| | - Alnoor Ramji
- St. Paul’s Hospital, Vancouver, British Columbia
| | - Edward Tam
- LAIR Centre, Vancouver, British Columbia
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Mogul DB, Brereton N, Carson KA, Pittarelli M, Daniel H, Torbenson M, Schwarz KB. Development of a Dietary Methyl Donor Food Frequency Questionnaire to Assess Folate and Vitamin B 12 Status in Children with Chronic Hepatitis B Virus Infection. J Pediatr 2018; 203:41-46.e2. [PMID: 30243534 DOI: 10.1016/j.jpeds.2018.07.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/10/2018] [Accepted: 07/26/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To develop a dietary methyl donor food frequency questionnaire (DMD-FFQ) that is validated in a cohort of US children and to determine whether the consumption of folate and vitamin B12, principal DMDs, correlates with HBV DNA levels and its methylation density. STUDY DESIGN We developed a semiquantitative DMD-FFQ to estimate intake of folate and vitamin B12 and validated this instrument against a 24-hour dietary recall and biomarkers-red blood cell folate, serum vitamin B12, and homocysteine-in 35 children with chronic HBV infection without other medical comorbidities. Estimates of DMD, as well as the serum biomarkers, were correlated with the methylation density of HBV CpG island 2 and HBV DNA levels. RESULTS Folate per kilogram of body weight by the DMD-FFQ correlated positively with 24-hour recall (r = 0.60; P < .001) and red blood cell folate (r = 0.40; P = .02), and negatively with homocysteine (r = -0.54; P < .001). Vitamin B12 per kilogram by DMD-FFQ also correlated positively with 24-hour recall (r = 0.57; P < .001) and serum vitamin B12 (r = 0.36, P = .04), and negatively with homocysteine (r = -0.44; P = .008). Neither DMD intake (from DMD-FFQ or 24-hour recall) nor serum biomarkers correlated with HBV DNA levels or its methylation density. CONCLUSIONS Our DMD-FFQ correlates well with a 24-hour recall and circulating biomarkers. Although little evidence existed that consumption of these micronutrients correlated with HBV replication, this tool could prove useful for investigating epigenetic modification by diet for several pediatric diseases.
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Affiliation(s)
- Douglas B Mogul
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Nga Brereton
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kathryn A Carson
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Maria Pittarelli
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hubert Daniel
- Department of Pathology, Johns Hopkins Hospital, Baltimore, MD
| | | | - Kathleen B Schwarz
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD
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Abstract
Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections represent a major global public health and economic burden, with an estimated 257 million and 71 million people, respectively, having chronic infection worldwide. The natural history of HBV and HCV in children depends on age at time of infection, mode of acquisition, ethnicity, and genotype. Most children infected perinatally or vertically remain asymptomatic but are at uniquely higher risk of developing chronic viral hepatitis, progressing to liver cirrhosis and hepatocellular carcinoma (HCC), hence classifying HBV and HCV as oncoviruses. This article discusses the epidemiology, virology, immunobiology, prevention, clinical manifestations, evaluation, and the advances in treatment of hepatitis B and C in children.
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Affiliation(s)
- Krupa R Mysore
- Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, 6701 Fannin, Suite 1010, Houston, TX 77030, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, 6701 Fannin, Suite 1010, Houston, TX 77030, USA.
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15
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Ebel NH, Rosenthal P. Editorial: an expert consensus for the management of chronic hepatitis B in Asian Americans. Aliment Pharmacol Ther 2018; 47:1541-1542. [PMID: 29878412 DOI: 10.1111/apt.14620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- N H Ebel
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - P Rosenthal
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
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Terrault NA, Lok ASF, McMahon BJ, Chang KM, Hwang JP, Jonas MM, Brown RS, Bzowej NH, Wong JB. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology 2018; 67:1560-1599. [PMID: 29405329 PMCID: PMC5975958 DOI: 10.1002/hep.29800] [Citation(s) in RCA: 2382] [Impact Index Per Article: 397.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Norah A Terrault
- Division of Gastroenterology/Hepatology, University of California San Francisco, San Francisco, CA
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Brian J McMahon
- Liver Diseases and Hepatitis Program, Alaska NativeTribal Health Consortium, Anchorage, AK
| | - Kyong-Mi Chang
- Division of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center & University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jessica P Hwang
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
| | | | - John B Wong
- Division of Clinical Decision Making, Tufts Medical Center, Tufts University School of Medicine, Boston, MA
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Health-related Quality of Life in Pediatric Patients With Chronic Hepatitis B Living in the United States and Canada. J Pediatr Gastroenterol Nutr 2017; 64:760-769. [PMID: 28169971 PMCID: PMC5403561 DOI: 10.1097/mpg.0000000000001525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of the study was to determine whether selected sociodemographic and hepatitis B virus (HBV)-specific clinical factors are associated with health-related quality of life (HRQoL) among pediatric patients chronically infected with HBV. METHODS Children with chronic HBV enrolled in the Hepatitis B Research Network completed the Child Health Questionnaire at study entry. Caregivers of children 5 to <10 years completed the parent-reported form (CHQ-Parent Report Form); youth 10 to <18 years completed the child-reported CHQ-Child Report Form. We examined univariable associations of the Child Health Questionnaire scores with selected independent variables: sex, adoption status, maternal education, alanine aminotransferase (U/L), aspartate aminotransferase-to-platelet ratio index, and HBV-specific symptom count. RESULTS A total of 244 participants (83 young children 5-<10 years, 161 youth 10-<18 years) were included, all HBV treatment-naïve. Among young children, increased alanine aminotransferase level was negatively associated with CHQ-Parent Report Form psychosocial summary t score (r = -0.28, P = 0.01). No other subscale comparisons for young children were statistically significant. Among youth, adoption was associated with better physical functioning and general health (P < 0.01). Higher maternal education was associated with better role/functioning-physical and -emotional scores (P < 0.05). Maternal education and adoption status were linked with adoption associated with higher maternal education. Increased symptom count in youth was associated with worse HRQoL in subscales measuring bodily pain, behavior, mental health, and self-esteem (P < 0.01). CONCLUSIONS Although overall HRQoL is preserved in children with chronic HBV, some sociodemographic and HBV-related clinical factors were associated with impaired HRQoL in our pediatric patients at baseline. Measurement of HRQoL can focus resources on education and psychosocial support in children and families most in need.
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Clemente MG, Vajro P. An update on the strategies used for the treatment of chronic hepatitis B in children. Expert Rev Gastroenterol Hepatol 2017; 10:649-58. [PMID: 26752166 DOI: 10.1586/17474124.2016.1139450] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic hepatitis B (CHB) in children shows a variety of clinical presentations, which influence its natural course and treatment options. This report provides an overview of the ongoing strategies in pediatric CHB management. Interferon-α represents the first choice of treatment in children showing HBV replication and hepatic inflammation (immune active CHB), while the recommendation is to monitor inactive/immune-tolerant children (normal transaminases and low/absent viral replication). When circumstances preclude the use of Interferon-α and in cases of compensated/decompensated cirrhosis, entecavir for children above 2 years of age or tenofovir for children above 12 years of age are the nucleos(t)ide analogues recommended by the most recent guidelines.
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Affiliation(s)
- Maria Grazia Clemente
- a Pediatric Clinic, Department of Surgical, Microsurgical and Medical Sciences , University of Sassari , Sassari , Italy
| | - Pietro Vajro
- b Pediatrics Unit, Department of Medicine and Surgery , University of Salerno , Baronissi (Salerno) , Italy
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Komatsu H, Inui A. Chronic hepatitis B in children in the United States and Canada: international origins place the disease burden on children even in the era of universal vaccination. Transl Pediatr 2016; 5:1-4. [PMID: 26835398 PMCID: PMC4729037 DOI: 10.3978/j.issn.2224-4336.2015.12.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Haruki Komatsu
- 1 Department of Pediatrics, Toho University Sakura Medical Center, Chiba, Japan ; 2 Department of Pediatric Hepatology and Gastroenterology, Eastern Yokohama Hospital, Kanagawa, Japan
| | - Ayano Inui
- 1 Department of Pediatrics, Toho University Sakura Medical Center, Chiba, Japan ; 2 Department of Pediatric Hepatology and Gastroenterology, Eastern Yokohama Hospital, Kanagawa, Japan
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20
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McMahon BJ. Two Key Components to Address Chronic Hepatitis B in Children: Detection and Prevention. J Pediatr 2015; 167:1186-7. [PMID: 26409308 DOI: 10.1016/j.jpeds.2015.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 09/03/2015] [Indexed: 01/11/2023]
Affiliation(s)
- Brian J McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, Alaska.
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