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Yuan Q, Haque O, Hong S, Ortiz A, Bethea ED, Sise ME, Markmann JF, Elias N. Influence of donor and recipient hepatitis B virus infection on long-term outcomes after kidney transplantation. Clin Transplant 2021; 35:e14466. [PMID: 34545965 DOI: 10.1111/ctr.14466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/23/2021] [Accepted: 08/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The demand for transplantable kidneys continues to outstrip supply, and the risk of donor-derived infection limits utilization. The effect of donor or recipient HBV status, defined by surface antigen (HBsAg) positivity, on long-term survival outcomes of kidney transplant (KT) is unknown. METHODS We conducted a retrospective cohort study based on Organ Procurement and Transplantation Network (OPTN) data from 2000 to 2019. We identified three cohorts based on donor (D) or recipient (R) HBsAg status: D-R, D-R+, and D+R-. Pairwise comparisons of patient survival (PS) and all-cause graft survival (GS) after propensity score matching were performed to assess the effect of HBV infection in KT recipients. RESULTS Our findings showed that there were no statistically significant differences in PS and GS among D-R, D-R+, and D+R-groups, nor was the patient or GS different between donor and recipient HBsAg+ status. Finally, in 2019 kidney discard rates were 15% higher for HBsAg+ deceased donors compared to HBsAg- donors. CONCLUSIONS HBsAg+ status was not associated with worse PS or GS after KT. Prior to broadly advocating utilization of HbsAg+ kidneys, further studies assessing KT recipient morbidity and safety are necessary.
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Affiliation(s)
- Qing Yuan
- Department of Urology, Chinese PLA General Hospital, Beijing, China.,Center for Transplantation Sciences, and Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Omar Haque
- Center for Transplantation Sciences, and Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Shriners Hospitals for Children, Boston, Massachusetts, USA
| | - Shanjuan Hong
- Center for Transplantation Sciences, and Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andric Ortiz
- Center for Transplantation Sciences, and Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emily D Bethea
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meghan E Sise
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James F Markmann
- Center for Transplantation Sciences, and Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nahel Elias
- Center for Transplantation Sciences, and Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Yap DYH, Tang C, Fung JYY, Seto WK, Ma MKM, Choy BY, Chan TM. Long-term data on entecavir treatment for treatment-naive or lamivudine-resistant chronic hepatitis B infection in kidney transplant recipients. Transpl Infect Dis 2019; 21:e13143. [PMID: 31282041 DOI: 10.1111/tid.13143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/17/2019] [Accepted: 06/23/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Entecavir (ETV) showed short-term efficacy and safety in HBsAg-positive kidney transplant recipients (KTRs), but long-term data are lacking. METHODOLOGY We retrospectively reviewed 30 HBsAg-positive KTRs who received ETV during 2007-2017. RESULTS Eighteen treatment-naïve (Group I) and 12 lamivudine-resistant (Group II) patients received ETV for 48.4 ± 35.2 and 66.0 ± 26.0 months, respectively. Both groups show significant HBV DNA decline, but Group I achieved earlier undetectability after 11.9 ± 9.6 months (compared with 28.8 ± 24.2 months in Group II, P = .033). Group I showed higher rates of undetectable HBV DNA (89%, 94%, 94%, 100%, and 100% at 12, 24, 36, 48, and 60 months, respectively, compared with 25%, 50%, 50%, 91%, and 91% in Group II, P = .003). ALT normalized after 6.0 ± 1.9 and 6.8 ± 2.1 months in Group I and Group II, respectively. Four patients (33.3%) in Group II developed drug resistance (2 had persistent viraemia and 2 had virological breakthrough, at 40.3 ± 15.0 months). Group II showed higher liver stiffness after 5 years (7.7 ± 4.1 kPa, compared with 5.0 ± 1.6 kPa in Group I, P = .046) and incidence of cirrhosis (4 patients [33.3%], compared with 1 [5.6%] patient in Group I, P = .049). Two patients (one in each group) developed hepatocellular carcinoma. Renal allograft function remained stable during follow-up of 63.2 ± 33.4 months for both groups. There was no difference in patient and graft survival between two groups at 5 years (P = .62 and .36, respectively). CONCLUSION ETV showed favorable long-term efficacy and tolerability in treatment-naïve KTRs. One-third of lamivudine-resistant subjects showed non-response or viral breakthrough after ETV treatment.
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Affiliation(s)
- Desmond Y H Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Colin Tang
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - James Y Y Fung
- Division of Gastroenterology and Hepatology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Wai-Kay Seto
- Division of Gastroenterology and Hepatology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Maggie K M Ma
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Bo Ying Choy
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Tak Mao Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
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Lui SL, Yap D, Cheng V, Chan TM, Yuen KY. Clinical practice guidelines for the provision of renal service in Hong Kong: Infection Control in Renal Service. Nephrology (Carlton) 2019; 24 Suppl 1:98-129. [PMID: 30900339 PMCID: PMC7167703 DOI: 10.1111/nep.13497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
| | - Desmond Yap
- Department of MedicineThe University of Hong KongHong Kong
| | - Vincent Cheng
- Department of MicrobiologyQueen Mary HospitalHong Kong
| | - Tak Mao Chan
- Department of MedicineThe University of Hong KongHong Kong
| | - Kwok Yung Yuen
- Department of MicrobiologyThe University of Hong KongHong Kong
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4
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Halegoua-De Marzio D, Fenkel JM, Doria C. Hepatitis B in Solid-Organ Transplant Procedures Other Than Liver. EXP CLIN TRANSPLANT 2017; 15:130-137. [PMID: 28338458 DOI: 10.6002/ect.2016.0195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transplant is often the best treatment available for patients with end-stage organ failure. Hepatitis B virus infection in transplant procedures other than liver is a major concern because it can be a significant cause of morbidity and mortality after transplant. Due to the increased risk of hepatic complications, such as fibrosing cholestatic hepatitis or histologic deterioration after transplant, systematic use of nucleoside or nucleotide analogues shortly before or at the time of transplant is recommended (tenofovir or entecavir are preferable to lamivudine) in all patients, whatever the baseline histologic evaluation. Sustained viral suppression may result in regression of fibrosis, which in turn may lead to decreased disease-related morbidity and improved survival. Finally, due to the high mortality after nonliver transplant procedures, decompensated cirrhosis from chronic hepatitis B should be considered as a contraindication to nonliver transplant but an indication to combined organ transplant (ie, liver-kidney transplant). Because of the high prevalence of hepatitis B virus exposure in allograft donors and recipients, hepatitis B virus status must be considered during organ allocation. Prevention of hepatitis B virus-related complications in transplant recipients starts with vaccination and donor-recipient matching.
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Affiliation(s)
- Dina Halegoua-De Marzio
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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5
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Ghosh S, Sow A, Guillot C, Jeng A, Ndow G, Njie R, Toure S, Diop M, Mboup S, Kane CT, Lemoine M, Thursz M, Zoulim F, Mendy M, Chemin I. Implementation of an in-house quantitative real-time polymerase chain reaction method for Hepatitis B virus quantification in West African countries. J Viral Hepat 2016; 23:897-904. [PMID: 27353593 DOI: 10.1111/jvh.12561] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/03/2016] [Indexed: 12/16/2022]
Abstract
Hepatitis B virus (HBV) is a major cause of chronic liver disease worldwide. HBV infection is diagnosed by serological tests, while real-time polymerase chain reaction (qRT-PCR) assays are used to quantify viral load, which is a crucial parameter to determine viral replication and to monitor antiviral treatments. However, measuring viral load in resource-limited countries remains nonsystematic, due to the high cost of commercial kits. Here, we describe the development, validation and implementation of a low-cost, in-house qRT-PCR assay to monitor HBV viral load in chronic carriers enrolled in the PROLIFICA programme in the Gambia and Senegal. Over 1500 HBsAg-positive patients, including 210 chronically infected HBV patients, who were given antiviral treatment (tenofovir), were monitored by qRT-PCR using the SYBR Green- and HBV-specific primers. Twenty-four tenofovir-treated patients were followed up and their viral load was tested every 3 months over the 12-month experimental time course. Compared to commercial assays, our in-house assay was shown to be (i) highly reliable, with good intra- and interassay reproducibility over a wide range (45-4.5 × 108 copies mL-1 ), (ii) very similar in the viral loads detected (R2 = .90), (iii) highly sensitive, as it detected loads as low as 30 copies mL-1 (~5 IU mL-1 ), (iv) cheaper (2- to 3-fold), (v) easier to implement and (vi) more rapid. Based on our experience, we recommend this assay as a reliable alternative to commercial assays, for monitoring HBV viraemia in resource-limited, highly endemic countries to reduce the cost and technical obstacles associated with commercial kits.
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Affiliation(s)
- S Ghosh
- INSERM U1052, CNRS UMR5286, Centre de Recherche en Cancérologie de Lyon Université Claude Bernard, Lyon, France
| | - A Sow
- La Dantec, Dakar, Senegal
| | - C Guillot
- INSERM U1052, CNRS UMR5286, Centre de Recherche en Cancérologie de Lyon Université Claude Bernard, Lyon, France
| | - A Jeng
- MRC, The Gambia Unit, Banjul, The Gambia
| | - G Ndow
- MRC, The Gambia Unit, Banjul, The Gambia
- Department of Hepatology, Imperial College London, London, UK
| | - R Njie
- MRC, The Gambia Unit, Banjul, The Gambia
- Laboratory Services and Biobank Group (DIR/LSB), IARC, Lyon, France
| | - S Toure
- MRC, The Gambia Unit, Banjul, The Gambia
| | - M Diop
- La Dantec, Dakar, Senegal
| | | | | | - M Lemoine
- Department of Hepatology, Imperial College London, London, UK
| | - M Thursz
- Department of Hepatology, Imperial College London, London, UK
| | - F Zoulim
- INSERM U1052, CNRS UMR5286, Centre de Recherche en Cancérologie de Lyon Université Claude Bernard, Lyon, France
- Department of Hepatology, Hospices Civils de Lyon, Lyon, France
| | - M Mendy
- Laboratory Services and Biobank Group (DIR/LSB), IARC, Lyon, France
| | - I Chemin
- INSERM U1052, CNRS UMR5286, Centre de Recherche en Cancérologie de Lyon Université Claude Bernard, Lyon, France.
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Lai CL, Yuen MF. Management of chronic hepatitis B in patients from special populations. Cold Spring Harb Perspect Med 2015; 5:5/6/a021527. [PMID: 26033083 DOI: 10.1101/cshperspect.a021527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Here we review the management of chronic hepatitis B (CHB) in four special categories of patients: CHB in pregnancy, in patients on immunosuppressive treatments, in patients undergoing liver transplantation, and in patients coinfected with human immunodeficiency virus (HIV) or hepatitis C virus (HCV).
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Affiliation(s)
- Ching-Lung Lai
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong 999077, China
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong 999077, China
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7
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Yap DY, Chan TM. Antiviral treatment for chronic hepatitis B infection in renal transplant recipients. Int J Organ Transplant Med 2015. [DOI: 10.1016/j.hkjn.2015.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Yasui S, Fujiwara K, Nakamura M, Miyamura T, Yonemitsu Y, Mikata R, Arai M, Kanda T, Imazeki F, Oda S, Yokosuka O. Virological efficacy of combination therapy with corticosteroid and nucleoside analogue for severe acute exacerbation of chronic hepatitis B. J Viral Hepat 2015; 22:94-102. [PMID: 24750410 DOI: 10.1111/jvh.12258] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 02/09/2014] [Indexed: 12/19/2022]
Abstract
The short-term prognosis of patients with severe acute exacerbation of chronic hepatitis B (CHB) leading to acute liver failure is extremely poor. We have reported the efficacy of corticosteroid in combination with nucleoside analogue in the early stages, but virological efficacy has not been documented. Our aim was to elucidate the virological efficacy of this approach. Thirteen patients defined as severe acute exacerbation of CHB by our uniform criteria were prospectively examined for virological responses to treatment. Nucleoside analogue and sufficient dose of corticosteroids were introduced as soon as possible after the diagnosis of severe disease. Of the 13 patients, 7 (54%) survived, 5 (38%) died and 1 (8%) received liver transplantation. The decline of HBV DNA was significant between the first 2 weeks (P = 0.02) and 4 weeks (P < 0.01). Mean reduction in HBV DNA during the first 2 weeks was 1.7 ± 0.9 log copies per mL in overall patients, 2.1 ± 0.8 in survived patients and 1.2 ± 0.9 in dead/transplanted patients. The decline of HBV DNA was significant between the first 2 weeks (P = 0.03) and 4 weeks (P = 0.02) in survived patients, but not in dead/transplanted patients. Our study shows that corticosteroid treatment in combination with nucleotide analogue has sufficient virological effect against severe acute exacerbation of CHB, and a rapid decline of HBV DNA is conspicuous in survived patients.
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Affiliation(s)
- S Yasui
- Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Relia N, Kaushik C, Shailesh F, Swaminathan S. Quiz Page September 2014. Am J Kidney Dis 2014. [DOI: 10.1053/j.ajkd.2014.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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10
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Yap DYH, Yung S, Tang CSO, Seto WK, Ma MKM, Mok MMY, Kwan LPY, Chan GCW, Choy BY, Yuen MF, Chan TM. Entecavir treatment in kidney transplant recipients infected with hepatitis B. Clin Transplant 2014; 28:1010-5. [PMID: 24974788 DOI: 10.1111/ctr.12410] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2014] [Indexed: 01/13/2023]
Abstract
Although nucleotide/side analogs improve the clinical outcome of hepatitis B surface antigen-positive (HBsAg+) kidney transplant recipients (KTR), a significant proportion of subjects have developed resistance to lamivudine (LAM). We retrospectively analyzed the efficacy and tolerability of entecavir (ETV) in HBsAg+ KTR at Queen Mary Hospital during 2005-2013. Twenty-one patients (10 treatment-naïve, 11 with LAM resistance) were included (duration of ETV treatment 34.7 ± 22.9 months, range 6-75 months). ETV treatment led to a decline of hepatitis B virus (HBV) DNA titer compared to baseline and is more significant in the treatment-naïve group (treatment-naïve: p = 0.028, <0.001 and <0.001; LAM-resistant p = 0.273, 0.180, and 0.109 after 12, 24, and 36 months). The cumulative rate of HBV DNA undetectability at 12, 24, and 36 months was 60%, 100%, and 100% for treatment-naïve group, and 27%, 45%, and 45% for LAM-resistant group, respectively. Time-to-HBV DNA undetectability and time-to-alanine transaminase (ALT) normalization were 15.7 ± 4.6 and 12.6 ± 3.7 months for treatment-naïve patients, and 24.5 ± 4.2 and 28.2 ± 3.5 months for those with LAM resistance. Genotypic resistance to ETV emerged after 20.0 ± 3.5 months with increase in ALT and HBV DNA in two patients with LAM resistance, but was not observed in the treatment-naïve group. Allograft dysfunction, de novo cirrhosis, or hepatocellular carcinoma did not occur during follow-up.
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Affiliation(s)
- Desmond Y H Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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11
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Liver abnormalities in the immunosuppressed. Best Pract Res Clin Gastroenterol 2013; 27:597-618. [PMID: 24090945 DOI: 10.1016/j.bpg.2013.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 06/21/2013] [Indexed: 01/31/2023]
Abstract
The immunosuppressed state may arise due to medical illness or drug therapy, which can result in a diverse array of liver derangements. This article discusses the commonly-encountered immunosuppressed conditions and the associated specific liver diseases. Due to the frequency of blood-borne viral disease globally, viral hepatitis (hepatitis B and C) during chemotherapy, transplantation and the increasingly utilised biological therapies for autoimmune disorders is discussed. An overview of human immunodeficiency virus co-infection with hepatitis B and C is provided. This article aims to highlight the variety of liver diseases which can occur in clinically relevant, particularly iatrogenic, immunosuppressed conditions, and summarise learning and practice points for clinicians. Recognition and prevention of viral liver disease is crucial and early involvement of experts prior to administration of immunosuppressive therapy is advised.
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Long-term effects of prophylactic and therapeutic lamivudine treatments in hepatitis B surface antigen-positive renal allograft recipients. Clin Exp Nephrol 2013; 18:144-50. [DOI: 10.1007/s10157-013-0807-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 04/07/2013] [Indexed: 01/07/2023]
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Protocol for the use of light upon extension real-time PCR for the determination of viral load in HBV infection. Methods Mol Biol 2012; 903:273-82. [PMID: 22782825 DOI: 10.1007/978-1-61779-937-2_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Real-time PCR has engendered wide acceptance for quantitation of hepatitis B virus (HBV) DNA in the blood due to its improved rapidity, sensitivity, reproducibility, and reduced contamination. Here we describe a cost-effective and highly sensitive HBV real-time quantitative assay based on the light upon extension real-time PCR platform and a simple and reliable HBV DNA preparation method using silica-coated magnetic beads.
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Mori N, Suzuki F, Kawamura Y, Sezaki H, Hosaka T, Akuta N, Kobayashi M, Saito S, Suzuki Y, Arase Y, Ikeda K, Kobayashi M, Kumada H. Determinants of the clinical outcome of patients with severe acute exacerbation of chronic hepatitis B virus infection. J Gastroenterol 2012; 47:1022-9. [PMID: 22370817 DOI: 10.1007/s00535-012-0561-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 02/07/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Severe acute exacerbation of chronic hepatitis B can sometimes occur and lead to hepatic failure and death. The objective of this study was to elucidate the predictors of progression to hepatic decompensation during severe acute exacerbation. METHODS We prospectively analyzed 37 consecutive patients with acute exacerbation of chronic hepatitis B (accompanied by jaundice and coagulopathy) for clinical outcome and factors that influenced the development of severe acute exacerbation, including viral kinetics. RESULTS Fourteen (37.8%) patients progressed to severe acute exacerbation (accompanied by encephalopathy). Multivariate analysis identified serum bilirubin (>5 mg/dl, P = 0.002) as a significant determinant of progression to hepatic failure and prothrombin activity (<45%, P = 0.028) and as a determinant of liver-related death. The hepatitis B virus (HBV) DNA level before therapy was measured in 25 patients. HBV DNA levels increased or did not change from before commencement of treatment in all 11 patients who progressed to severe acute exacerbation. On the other hand, HBV DNA levels did not change or increased in 8 of 14 patients (57%) with acute exacerbation (P = 0.02). CONCLUSIONS Serum bilirubin and prothrombin activities were significant predictors of clinical outcome in patients with severe acute exacerbation of chronic hepatitis B. Viral kinetics until commencement of therapy can predict the severity of acute exacerbation of chronic hepatitis B.
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Affiliation(s)
- Nami Mori
- Department of Hepatology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan
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Lin X, Zhang S, Huang Q, Wei L, Zheng L, Chen Z, Jiao Y, Huang J, Fu S, Huang R. Protective effect of Fufang-Liu-Yue-Qing, a traditional Chinese herbal formula, on CCl4 induced liver fibrosis in rats. JOURNAL OF ETHNOPHARMACOLOGY 2012; 142:548-556. [PMID: 22658988 DOI: 10.1016/j.jep.2012.05.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 05/23/2012] [Indexed: 06/01/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Chinese prescription Fufang-Liu-Yue-Qing (FLYQ) has long been employed clinically to treat chronic hepatitis B, and we have reported its beneficial effects on liver fibrosis in vitro. The present study was investigated to verify protective effects of FLYQ on liver fibrosis in a rat model and to investigate the underlying mechanisms which have not been explored yet. MATERIALS AND METHODS Liver fibrosis was established by intragastric administration of 2 ml/kg CCl(4) twice a week for 12 weeks. During the experiment, the model group received CCl(4) only, and the normal control group received an equal volume of saline. Treatment groups received not only CCl(4) for 12 weeks, but also the corresponding drugs, colchicine (1.00 mg/kg/day) or FLYQ (300, 150, 75 mg/kg/day) from 5 to 12 weeks. RESULTS Analysis experiments showed that FLYQ could significantly alleviate liver injury, as indicated by decreasing levels of ALT, AST, ALP, GGT, IL-6 and TNF-α. Moreover, FLYQ could effectively inhibit collagen deposition and reduce the pathological tissue damage. Research on mechanism showed that FLYQ was able to markedly reduce lipid peroxidation, recruit the anti-oxidative defense system, promote ECM degradation by modulating the levels of TIMP-1 and MMP-2, and induce HSC apoptosis by down-regulating bcl-2 mRNA, as well as inhibit the expressions of α-SMA and TGF-β(1) proteins. CONCLUSIONS Our results show that FLYQ is effective in attenuating hepatic injury and fibrosis in the CCl(4)-induced rat model, which should be developed as a new drug for treatment of liver fibrosis and even cirrhosis.
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Affiliation(s)
- Xing Lin
- Guangxi Medical University, Nanning 530021, China
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Zhang Y, Guo J, Dong H, Zhao X, Zhou L, Li X, Liu J, Niu Y. Hydroxysafflor yellow A protects against chronic carbon tetrachloride-induced liver fibrosis. Eur J Pharmacol 2011; 660:438-44. [DOI: 10.1016/j.ejphar.2011.04.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 04/04/2011] [Accepted: 04/12/2011] [Indexed: 01/22/2023]
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17
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Zhang XQ, Jiang L, You JP, Liu YY, Peng J, Zhang HY, Xu BY, Mao Q. Efficacy of short-term dexamethasone therapy in acute-on-chronic pre-liver failure. Hepatol Res 2011; 41:46-53. [PMID: 20973887 DOI: 10.1111/j.1872-034x.2010.00740.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM Acute-on-chronic pre-liver failure (pre-ACLF) is defined as a severe acute episode of chronic hepatitis B characterized by serum bilirubin of 171 µmol/L or more, alanine aminotransferase of five times or more the upper limit of normal and prothrombin activity of more than 40%, having a potential for progression to acute-on-chronic liver failure (ACLF). This study is to evaluate the efficacy of short-term dexamethasone in pre-ACLF. METHODS One hundred and seventy patients were assigned to dexamethasone therapy and control group at a ratio of 1:2. For the two groups, we compared biochemical indicators, the incidence of ACLF and mortality. The influential factors on the mortality of patients with pre-ACLF were studied by Cox proportional hazards models. RESULTS The significantly lower incidence of ACLF and higher survival rate were observed in patients on dexamethasone therapy (8.9%, 96.4%, respectively) than in control patients (70.2%, 52.6%, respectively; P < 0.001). Dexamethasone treatment was an independent factor influencing the survival rate (P < 0.001, odds ratio = 0.055, 95% confidence interval = 0.013-0.225). During 4 weeks of treatment, serum bilirubin levels of survival patients were significantly lower in the dexamethasone group than control group. CONCLUSION Five-day dexamethasone therapy is effective in improving the liver function and survival rate of patients with pre-ACLF.
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Affiliation(s)
- Xu-Qing Zhang
- Department of Infectious Diseases, Southwest Hospital, Third Military Medical University, Chongqing, China
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Fujiwara K, Yasui S, Okitsu K, Yonemitsu Y, Oda S, Yokosuka O. The requirement for a sufficient period of corticosteroid treatment in combination with nucleoside analogue for severe acute exacerbation of chronic hepatitis B. J Gastroenterol 2010; 45:1255-62. [PMID: 20614156 DOI: 10.1007/s00535-010-0280-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Accepted: 06/11/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND The prognosis of severe acute exacerbation of chronic hepatitis B is very poor if signs of liver failure appear. We have reported the efficacy of the early introduction of sufficient doses of corticosteroids (CSs) and nucleoside analogues (NAs), but the optimal period of immunosuppressive therapy has not been well demonstrated. In this study, we analyzed patients with severe acute exacerbation of chronic hepatitis B treated with CSs and NAs, prospectively, in order to clarify the factors affecting their outcome. METHODS Ten patients, admitted to our liver unit between 2000 and 2009, were defined as having severe exacerbation of chronic hepatitis B based on our uniform criteria, and were enrolled in this study. NAs and sufficient doses of CS were introduced as soon as possible after making the diagnosis of severe disease prospectively. RESULTS Seven of the 10 patients recovered. The absence of fulminant hepatitis on admission, the improvement of prothrombin time (PT) activity and the decline of hepatitis B virus (HBV) DNA during the first 2 and 4 weeks, respectively, were significant in the recovered patients, while the worsening of total bilirubin level during 4 weeks, especially between week 2 and week 4, was significant in those who died. CONCLUSIONS In severe acute exacerbation of chronic hepatitis B, more than a few weeks of CS treatment in combination with an NA is required in the early stage, whereas a short period of conventional pulse therapy would be insufficient for treating this condition.
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Affiliation(s)
- Keiichi Fujiwara
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
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19
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Long-term outcome of renal transplant recipients with chronic hepatitis B infection-impact of antiviral treatments. Transplantation 2010; 90:325-30. [PMID: 20562676 DOI: 10.1097/tp.0b013e3181e5b811] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Antiviral treatment has improved the short-term outcome of kidney transplant recipients with chronic hepatitis B infection, but its long-term impact, especially in patients who have developed drug resistance, remains uncertain. METHODS Sixty-three hepatitis B surface antigen positive (HBsAg+) and 63 HBsAg- patients who have undergone kidney transplantation from 1985 to 2008 were retrospectively reviewed and their clinical outcomes were compared. RESULTS With lamivudine as initial treatment, 62% of patients developed drug resistance after 4 years. Lamivudine resistance was associated with a higher incidence of chronic hepatitis but had no significant impact on liver stiffness score or patient survival during follow-up. Salvage treatment with adefovir or entecavir was well tolerated, and resulted in a three-log decrease in hepatitis B deoxynucleic acid after 6 months and normalization of alanine aminotransferase in 75% of patients. The survival rate of HBsAg+ patients transplanted in the recent era of antiviral treatment was 81% at 10 years. Treatment of hepatitis B with nucleoside/nucleotide analogues resulted in significantly improved patient survival (83% vs. 34% at 20 years, P=0.006). Although antiviral treatment was associated with reduced mortality because of liver complications (P=0.036), liver-related deaths still accounted for 40% of mortalities in HBsAg+ patients in the era of antiviral therapies and 22.2% of all deaths that occurred in patients who had received antiviral treatment. CONCLUSION Treatment of HBsAg+ renal transplant recipients with nucleoside/nucleotide analogues confers long-term survival benefit, and that rescue therapy with adefovir or entecavir is effective and well tolerated in patients who had developed resistance to lamivudine.
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20
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Abstract
Hepatitis B virus is a common cause of acute liver failure. It can be especially problematic in patients coinfected with hepatitis C, hepatitis D or human immunodeficiency virus. In addition, immunosuppression-associated hepatitis B reactivation is being increasingly recognized following chemotherapy, biologic therapy, and organ transplantation. This article highlights treatment options in these special populations.
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21
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A novel real-time PCR assay for determination of viral loads in person infected with hepatitis B virus. J Virol Methods 2009; 165:9-14. [PMID: 20026193 DOI: 10.1016/j.jviromet.2009.12.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 12/08/2009] [Accepted: 12/10/2009] [Indexed: 11/21/2022]
Abstract
A novel LUX (Light Upon eXtension) primer-based real-time PCR assay was developed and evaluated in this study, which was designed to provide a cost-effective, specific and highly sensitive method for viral load determination of hepatitis B virus (HBV). The assay employed an effective and rapid nucleic acid extraction system based on magnetic beads. To evaluate its efficacy, this new viral DNA preparation method was compared with QIAamp Blood Mini Kit and the results showed a good correlation (r=0.971; P<0.001). The performance of the LUX real-time assay was validated by testing serial dilutions of HBV plasmid DNA (5 to 5 x 10(8)copies/reaction) and a good linear relationship was obtained between the Ct values and the log(10) concentration of the HBV DNA. The assay possessed high sensitivity and the detection limit of this system was as few as 25 copies/ml of serum. A total of 91 positive serum samples were detected to evaluate further the assay and the high specificity was confirmed by melting curve analysis. This assay provides an ideal tool for monitoring the treatment efficacy and studying the relationship between HBV viral load and the stage of disease.
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22
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Tse KC, Yap DYH, Tang CSO, Yung S, Chan TM. Response to adefovir or entecavir in renal allograft recipients with hepatitic flare due to lamivudine-resistant hepatitis B. Clin Transplant 2009; 24:207-12. [PMID: 19758269 DOI: 10.1111/j.1399-0012.2009.01090.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We studied the effects of adefovir or entecavir in six kidney transplant recipients (mean age 45.7 +/- 7.8 yr) who developed hepatitic flare due to lamivudine-resistant hepatitis B virus (HBV) infection, with 18 months of follow-up. All patients had elevated alanine aminotransferase (ALT) levels and HBV DNA >10(5) copies/mL (median 2.15 x 10(8) copies/mL) at baseline. Serum creatinine and creatinine clearance levels were 137.8 +/- 59.7 mumol/L and 62.6 +/- 18.7 mL/min, respectively. Four patients were treated with adefovir and two with entecavir. Median HBV DNA decreased to 1.99 x 10(5) copies/mL (p = 0.028) after six months, 1.5 x 10(4) copies/mL (p = 0.043) after 12 months, and 7.35 x 10(4) copies/mL (p = 0.068) after 18 months of treatment. There was a corresponding improvement in ALT (34.5 +/- 19.1 U/L after 18 months, p = 0.029 compared with baseline). The rate of HBV DNA suppression was variable, and three patients took over six months for the viral load to decrease to <10(5) copies/mL. After 18 months, HBV DNA was <10(5) copies/mL in four patients and <10(2) copies/mL in one patient. Treatment was well-tolerated and renal function remained stable. We conclude that both adefovir and entecavir are effective in the treatment of lamivudine-resistant HBV in renal allograft recipients, and the reduction of HBV DNA to <10(5) copies/mL could be slow.
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Affiliation(s)
- Kai Chung Tse
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong, China
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23
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Ceballos-Viro J, López-Picazo JM, Pérez-Gracia JL, Sola JJ, Aisa G, Gil-Bazo I. Fibrosing cholestatic hepatitis following cytotoxic chemotherapy for small-cell lung cancer. World J Gastroenterol 2009; 15:2290-2. [PMID: 19437574 PMCID: PMC2682249 DOI: 10.3748/wjg.15.2290] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Fibrosing cholestatic hepatitis (FCH) is a variant of viral hepatitis reported in hepatitis B virus or hepatitis C virus infected liver, renal or bone transplantation recipients and in leukemia and lymphoma patients after conventional cytotoxic chemotherapy. FCH constitutes a well-described form of fulminant hepatitis having extensive fibrosis and severe cholestasis as its most characteristic pathological findings. Here, we report a case of a 49-year-old patient diagnosed with small-cell lung cancer who developed this condition following conventional chemotherapy-induced immunosuppression. This is the first reported case in the literature of FCH after conventional chemotherapy for a solid tumor. In addition to a detailed report of the case, a physiopathological examination of this potentially life-threatening condition and its treatment options are discussed.
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24
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Efficacy of combination therapy of antiviral and immunosuppressive drugs for the treatment of severe acute exacerbation of chronic hepatitis B. J Gastroenterol 2009; 43:711-9. [PMID: 18807133 DOI: 10.1007/s00535-008-2222-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Accepted: 05/17/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with severe exacerbation of chronic hepatitis B, sometimes developing into fulminant liver failure, are at high risk for mortality even with antiviral therapy. The efficacy of immunosuppressive therapy in clinically severe exacerbation of chronic hepatitis B has not been well demonstrated. In this study, we evaluated the efficacy of the early introduction of immunosuppressive therapy in combination with antiviral therapy in such patients. METHODS Forty-two patients, 29 men and 13 women, were defined as having severe exacerbation of chronic hepatitis B based on our uniform criteria, and were enrolled in this study. Sixteen patients between 1982 and 1996 were analyzed retrospectively. We defined the criteria of severe disease in 1997, and then began to introduce sufficient doses of corticosteroids prospectively. Nucleoside analogs were administered in combination with corticosteroids after 1999. Twenty-six patients between 1997 and 2007 were analyzed prospectively. RESULTS In the retrospective study between 1982 and 1996, four of 16 (25%) patients recovered. In the prospective study between 1997 and 2007, 17 of 26 (65%) patients recovered; 15 of 17 patients treated with corticosteroids with or without antiviral drugs within 10 days after the diagnosis of severe disease recovered, none of five treated similarly but later than 10 days after the diagnosis recovered, and two of three treated with antiviral drugs recovered. CONCLUSIONS The early introduction of sufficient doses of corticosteroids and nucleoside analogs could be one option for reversing the potential deterioration of patients with clinically severe, life-threatening exacerbation of chronic hepatitis B.
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25
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Gwak GY, Huh W, Lee DH, Choi MS, Lee JH, Koh KC, Kim SJ, Joh JW, Oh HY. The incidence and clinical outcome of YMDD mutants in hepatitis B surface antigen-positive renal allograft recipients after prolonged lamivudine therapy. Transplant Proc 2008; 39:3121-6. [PMID: 18089336 DOI: 10.1016/j.transproceed.2007.06.081] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Revised: 04/16/2007] [Accepted: 06/21/2007] [Indexed: 12/28/2022]
Abstract
Although lamivudine (LAM) is a potent inhibitor of hepatitis B virus (HBV), prolonged therapy may induce the development of LAM-resistant strains, YMDD mutants. Although YMDD mutants have impaired replication that leads to a benign clinical course compared with wild-type virus, some immunosuppressive agents may enhance replication of YMDD mutants, causing a severe hepatitis flare. We retrospectively investigated the incidence and clinical outcomes of YMDD mutants in renal allograft recipients on immunosuppressive treatment. Clinical records of 25 renal allograft recipients, who underwent renal transplantation between December 1997 and February 2006 were hepatitis B surface antigen positive at the time of transplantation, were reviewed. All patients received LAM treatment after renal transplantation. Over 9 to 98 months of follow-up, 16 patients (64.0%) maintained undetectable HBV DNA levels; however, 9 patients (36.0%) showed persistent or increased levels of HBV DNA. Seven were identified as having developed YMDD mutants. Although genotypic analysis was not performed, YMDD mutants were strongly suspected in another two patients, who developed severe hepatic dysfunction combined with high levels of HBV viremia at close to 2 years of LAM therapy. One patient recovered after hepatic transplantation and another patient died of hepatic failure. In conclusion, the incidence of YMDD mutants was similar to that of nonimmunosuppressed individuals; however, the presence of these mutants made it more likely for severe liver disease to develop in renal transplant recipients. Therefore, close monitoring for the development of YMDD mutants should be performed during LAM treatment, especially in this group of patients.
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Affiliation(s)
- G-Y Gwak
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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26
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Akyildiz M, Karasu Z, Zeytunlu M, Aydin U, Ozacar T, Kilic M. Adefovir dipivoxil therapy in liver transplant recipients for recurrence of hepatitis B virus infection despite lamivudine plus hepatitis B immunoglobulin prophylaxis. J Gastroenterol Hepatol 2007; 22:2130-4. [PMID: 18031370 DOI: 10.1111/j.1440-1746.2006.04609.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment of post-transplantation recurrence of hepatitis B virus (HBV) infection despite prophylaxis with hepatitis B immunoglobulin (HBIG) and lamivudine combination therapy is not easy. Because HBV reinfection has a severe course and could result in graft failure in liver transplant recipients, prompt medication is essential. Herein is reported the authors' experience with adefovir dipivoxil (AD) therapy in 11 liver transplant recipients who had HBV reinfection despite the administration of lamivudine and HBIG. METHOD Two-hundred and nine patients underwent liver transplantation (100 deceased donor liver transplantations [DDLT], 109 living donor liver transplantation [LDLT]) due to chronic hepatitis B infection between April 1997 and May 2005 in Ege University Medical School, Liver Transplantation Unit. Patients had prophylaxis with lamivudine and low-dose HBIG combination after liver transplantation. Treatment of recurrence consisted of AD 10 mg once a day and lamivudine 300 mg/daily and HBIG was discontinued in those patients. RESULTS In total there were 11 HBV recurrences: five occurred in DDLT recipients and six in LDLT recipients, at a median follow up of 18 months (range, 6-48 months). In one of 11 patients, pretransplant HBV-DNA and HBeAg were positive. Three patients had a severe course and one patient had fibrosing cholestatic hepatitis. After AD treatment, HBV-DNA level decreased in all patients and became negative in seven patients. Two patients died due to hepatocellular carcinoma recurrence after 12 and 14 months of follow up. Serum creatinine level increased mildly in one patient and no other side-effect was observed, and all patients continued therapy. CONCLUSION Adefovir dipivoxil is a safe, effective treatment option for post-transplant HBV recurrence even among patients with fibrosing cholestatic hepatitis caused by lamivudine-resistant HBV.
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Affiliation(s)
- Murat Akyildiz
- Department of Gastroenterology, Ege University Medical School, Bornova, Izmir, Turkey.
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27
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Wang YC, Kuo MC, Hung CC, Hwang SJ, Tsai JC, Chen HC. Lamivudine reverses severe acute hepatitis B and pancytopenia after renal transplantation: a case report. Transplant Proc 2006; 38:3125-7. [PMID: 17112916 DOI: 10.1016/j.transproceed.2006.08.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Indexed: 11/16/2022]
Abstract
Pancytopenia is rare after acute hepatitis B infection. The use of lamivudine in the treatment of acute hepatitis B-associated pancytopenia in renal transplant recipients has not been documented. Herein we reported a 21-year-old woman who was infected with acute hepatitis B 6 months after renal transplantation, a condition complicated by pancytopenia. Lamivudine reversed the acute hepatitis in 1 month and the pancytopenia after 3 months, without a change in renal function. Lamivudine was maintained for 2 years without a hepatitis flare-up after 4 years.
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Affiliation(s)
- Y-C Wang
- Division of Nephrology, Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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28
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Fujiwara K, Yokosuka O, Kojima H, Kanda T, Saisho H, Hirasawa H, Suzuki H. Importance of adequate immunosuppressive therapy for the recovery of patients with “life-threatening” severe exacerbation of chronic hepatitis B. World J Gastroenterol 2005; 11:1109-14. [PMID: 15754390 PMCID: PMC4250699 DOI: 10.3748/wjg.v11.i8.1109] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: Hepatitis B virus (HBV) re-activation often occurs spontaneously or after withdrawal of immunosuppressive therapy in patients with chronic hepatitis B. Severe exacerbation, sometimes developing into fulminant hepatic failure, is at high risk of mortality. The efficacy of corticosteroid therapy in “clinically severe” exacerbation of chronic hepatitis B has not been well demonstrated. In this study we evaluated the efficacy of early introduction of high-dose corticosteroid therapy in patients with life-threatening severe exacerbation of chronic hepatitis B.
METHODS: Twenty-two patients, 14 men and 8 women, were defined as “severe” exacerbation of chronic hepatitis B using uniform criteria and enrolled in this study. Eleven patients were treated with corticosteroids at 60 mg or more daily with or without anti-viral drugs within 10 d after the diagnosis of severe disease (“early high-dose” group) and 11 patients were either treated more than 10 d or untreated with corticosteroids (“non-early high-dose” group).
RESULTS: Mean age, male-to-female ratio, mean prothrombin time (PT) activity, alanine transaminase (ALT) level, total bilirubin level, positivity of HBeAg, mean IgM-HBc titer, and mean HBV DNA polymerase activity did not differ between the two groups. Ten of 11 patients of the “early high-dose” group survived, while only 2 of 11 patients of the “non-early high-dose” group survived (P<0.001). During the first 2 wk after the introduction of corticosteroids, improvements in PT activities and total bilirubin levels were observed in the “early high-dose” group. Both ALT levels and HBV DNA polymerase levels fell in both groups.
CONCLUSION: The introduction of high-dose corticosteroid can reverse deterioration in patients with “clinically life-threatening” severe exacerbation of chronic hepatitis B, when used in the early stage of illness.
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Affiliation(s)
- Keiichi Fujiwara
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
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29
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Abstract
Follicular non-Hodgkin's lymphoma (NHL) represents the most common indolent lymphoma with a median survival of 10 years. A new prognostic index (FLIPI) provides prognostic information at diagnosis and at relapse. Initial treatments combining monoclonal antibody therapy using rituximab with chemotherapy appear to increase the response rate and decrease the risk of relapse with little increase in toxicity. Promising phase III trial results demonstrating improvements in outcome using rituximab have recently been reported. A number of phase II trials have also demonstrated encouraging activity combining radiolabeled antibodies in sequence with chemotherapy. The role of high-dose therapy and autologous transplantation is becoming more defined, with improvements in progression-free survival observed in the upfront and relapsed setting. The application of allogeneic transplantation, once restricted to young otherwise healthy patients has shown encouraging activity in older, relapsed, and refractory patients using nonmyeloablative conditioning regimens. These new treatment options make the management of newly diagnosed patients both exciting and a challenge.
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MESH Headings
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bone Marrow Transplantation
- Chromosomes, Human, Pair 14/genetics
- Chromosomes, Human, Pair 14/ultrastructure
- Chromosomes, Human, Pair 18/genetics
- Chromosomes, Human, Pair 18/ultrastructure
- Clinical Trials as Topic
- Combined Modality Therapy
- Disease Progression
- Disease-Free Survival
- Genes, bcl-2
- Humans
- Immunoconjugates/therapeutic use
- Immunotherapy
- Lymphoma, Follicular/diagnosis
- Lymphoma, Follicular/drug therapy
- Lymphoma, Follicular/genetics
- Lymphoma, Follicular/pathology
- Lymphoma, Follicular/radiotherapy
- Lymphoma, Follicular/surgery
- Lymphoma, Non-Hodgkin/diagnosis
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/pathology
- Lymphoma, Non-Hodgkin/surgery
- Prognosis
- Remission Induction
- Rituximab
- Salvage Therapy
- Translocation, Genetic
- Transplantation Conditioning
- Transplantation, Autologous
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Affiliation(s)
- David G Maloney
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave, North Seattle, WA 98104, USA.
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30
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Akay S, Karasu Z, Akyildiz M, Tokat Y. Adefovir treatment in posttransplant hepatitis B virus infection resistant to lamivudine plus hepatitis B virus immunoglobulin. Transplant Proc 2004; 36:2768-70. [PMID: 15621144 DOI: 10.1016/j.transproceed.2004.09.062] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Failure of prophylaxis for hepatitis B virus (HBV) recurrence in liver transplant patients with HBV immunoglobulin (HBIG) or lamivudine or both can be associated with rapid development of liver failure. Some of these patients develop a devastating clinicopathological state characterized by jaundice and rapidly progressive liver failure or fibrosing cholestatic hepatitis. We present two liver transplant recipients who experienced HBV recurrence while they were under lamivudine and HBIG prophylaxis. One of them had finding of severe HBV infection; the other, fibrosing cholestatic hepatitis. After commencing adefovir dipivoxil both patients showed improvements in clinical status and laboratory data. At month 4 of treatment, HBV DNA values became negative and liver function tests almost normalized. In addition, in one case showed HBs ag/anti-HBs seroconversion. When failure of prophylaxis with lamivudine and HBIG occurs, adefovir dipivoxil should be considered to be a safe and effective choice for recurrent HBV infections in liver transplant patients.
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Affiliation(s)
- S Akay
- Department of Gastroenterology, Ege University, Izmir 35040, Turkey.
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31
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Abstract
The clinical outcome of HBsAg-positive renal transplant recipients has been adversely affected by potentially fatal acute hepatitic exacerbations and chronic liver disease, in addition to the increased risk of hepatocellular carcinoma. The difficulty in predicting the evolution and severity of liver disease after kidney transplantation further confounds the management of these patients. The clinical course of HBsAg-positive renal transplant recipients can be modified favorably after nucleoside analogue therapy and quantitative HBV DNA assays have become available. The latter allow earlier detection of increased viral replication, before the onset of biochemical abnormality. We have combined serial HBV DNA monitoring with preemptive lamivudine therapy, and our results showed that this strategy markedly improved patient survival. Prolonged treatment, however, was associated with the selection of drug-resistant YMDD variants. Hepatitic flares were common after the development of drug resistance and could lead to decompensation in a small proportion of patients. With careful selection, discontinuation of antiviral treatment was feasible in 18.5% of treated subjects. While the outcome of HBsAg-positive renal allograft recipients should continue to improve with the availability of more effective antiviral agents, financial constraints and the paucity of research data could hamper the optimal adoption of recent advances into clinical practice.
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Affiliation(s)
- T M Chan
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong.
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32
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Lo CM, Cheung ST, Ng IOL, Liu CL, Lai CL, Fan ST. Fibrosing cholestatic hepatitis secondary to precore/core promoter hepatitis B variant with lamivudine resistance: successful retransplantation with combination adefovir dipivoxil and hepatitis B immunoglobulin. Liver Transpl 2004; 10:557-63. [PMID: 15048802 DOI: 10.1002/lt.20133] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Fibrosing cholestatic hepatitis (FCH) is a peculiar variant of hepatitis B virus (HBV) infection in immunocompromised patients characterized by rapid viral replication. Posttransplant patients receiving lamivudine for prophylaxis or treatment of HBV infection may develop drug resistance due to viral mutants, but FCH is rare because escape mutants are usually replication deficient. We report the development of FCH due to lamivudine-resistant HBV mutants in 2 patients at 12 and 13 months after liver transplantation. Rapidly progressive graft failure, accompanied by an escalating HBV DNA level, developed within weeks of onset. Analysis of gene sequence variation by polymerase chain reaction (PCR) and direct sequencing showed that both had a core promoter variant A1762T/G1764A and 1 had a concomitant precore stop codon G1896A variant in prelamivudine and postrecurrence serum samples. Comparison of the HBV polymerase gene in the 2 serum samples revealed a single mutation with methionine-to-isoleucine substitution at codon 552 (M552I) in both patients. "Add-in" treatment with adefovir dipivoxil resulted in a more than 2 to 3log10 reduction in HBV DNA level within 2 weeks and retransplantation was performed with adefovir dipivoxil and hepatitis B immunoglobulin (HBIG) prophylaxis. Both patients were alive at 15 months and 48 months after retransplantation, with normal graft function and serum negative for HBsAg and HBV DNA by quantitative PCR (< 200 copies/mL). The current report demonstrates that recurrent graft infection by precore/core promoter variant with lamivudine-resistant escape mutation may result in FCH. With combination of adefovir and high-dose HBIG, however, long-term survival can be achieved after retransplantation.
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Affiliation(s)
- Chung-Mau Lo
- Centre for the Study of Liver Disease, and Department of Surgery, The University of Hong Kong, Pokfulam, Hong Kong, China.
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33
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Tillmann HL, Wedemeyer H, Manns MP. Treatment of hepatitis B in special patient groups: hemodialysis, heart and renal transplant, fulminant hepatitis, hepatitis B virus reactivation. J Hepatol 2004; 39 Suppl 1:S206-11. [PMID: 14708705 DOI: 10.1016/s0168-8278(03)00364-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Hans Ludger Tillmann
- Department of Gastroenterology, Hepatology and Endocrinology, Medizinische Hochschule Hannover, Carl-Neuberg-Strassel, 30623 Hannover, Germany
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34
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Ho SKN, Yam WC, Leung ETK, Wong LP, Leung JKH, Lai KN, Chan TM. Rapid quantification of hepatitis B virus DNA by real-time PCR using fluorescent hybridization probes. J Med Microbiol 2003; 52:397-402. [PMID: 12721315 DOI: 10.1099/jmm.0.05071-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
A highly sensitive and rapid assay has been developed to quantify hepatitis B virus (HBV) DNA, based on the fluorescence resonance energy transfer principle and real-time PCR, using the LightCycler and a pair of specific fluorescent hybridization probes. This LightCycler real-time PCR assay (LC-PCR) detected HBV DNA in a linear range from 10(1) to 10(8) copies per reaction (250-2.5 x 10(9) copies ml(-1)), with a rapid PCR cycling time of 35 min. The assay was validated with two EUROHEP HBV DNA standards (ad and ay subtypes) and exhibited low intra-assay (< 6 %) and inter-assay (< 16 %) variation for both subtypes over the complete range of 7 orders of magnitude. The assay was evaluated clinically using serum samples from 120 HBsAg(+) individuals and 45 healthy controls who were negative for both HBsAg and anti-HBc. Levels of HBV DNA were measured in these samples using both the LC-PCR and Digene Hybrid Capture II HBV DNA (HCII) assays. The prevalence rates for HBV DNA in the HBsAg(+) serum samples were respectively 95 % (114/120) and 56 % (67/120) by LC-PCR and HCII (P < 0.01). All 67 HCII-positive samples tested positive with LC-PCR, while the 47 discordant samples showed low levels of HBV DNA (down to 265 copies ml(-1)), detectable only by the more sensitive LC-PCR assay. Levels of HBV DNA as measured by the two assays showed good correlation (r = 0.902; P < 0.001). The level of HBV DNA was significantly higher in HBeAg(+) than anti-HBe(+) samples (median 1.5 x 10(7) vs 4.6 x 10(4) copies ml(-1); P < 0.01). It is concluded that this LC-PCR assay is clinically useful for the rapid, sensitive and accurate measurement of HBV DNA.
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Affiliation(s)
- Stephen K N Ho
- Departments of Medicine1 and Microbiology2, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Wing-Cheong Yam
- Departments of Medicine1 and Microbiology2, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Eric T K Leung
- Departments of Medicine1 and Microbiology2, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Lei-Po Wong
- Departments of Medicine1 and Microbiology2, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Jack K H Leung
- Departments of Medicine1 and Microbiology2, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Kar-Neng Lai
- Departments of Medicine1 and Microbiology2, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Tak-Mao Chan
- Departments of Medicine1 and Microbiology2, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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35
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Chien RN, Lin CH, Liaw YF. The effect of lamivudine therapy in hepatic decompensation during acute exacerbation of chronic hepatitis B. J Hepatol 2003; 38:322-7. [PMID: 12586298 DOI: 10.1016/s0168-8278(02)00419-1] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND/AIMS Severe acute exacerbation (AE) of chronic hepatitis B (CHB) can lead to hepatic decompensation and death. The aim of this study was to investigate the effect of lamivudine therapy in hepatic decompensation during such AEs. METHODS In a 10-month period, a total of 60 consecutive AE patients with jaundice and prolonged prothrombin time over 3s were treated with lamivudine 150 mg daily. As a historical control, another 31 CHB patients with AE resulting in hepatic decompensation hospitalized in an immediate past 6-month period were enrolled for comparison. RESULTS Patients in both groups were comparable in clinical and biochemical features. After a median treatment period of 6 weeks (range 1-48 weeks), all of the 25 patients with pretherapy bilirubin level < 20 mg/dl in the treatment group survived, while five (25%) of 20 patients in the control group died (P=0.013; odds ratios, 2.667; 95% confidence interval, 1.787-3.979). However, the mortality rate was similar in patients with pretherapy bilirubin level > or =20 mg/dl in both groups. CONCLUSIONS These results suggest that lamivudine may prevent fatality in CHB patients with hepatic decompensation if therapy starts early enough or before serum bilirubin level rise over 20 mg/dl, but helps little if serum level already risen over that level.
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Affiliation(s)
- Rong-Nan Chien
- Liver Research Unit, Chang Gung Memorial Hospital, Chang Gung University, 199 Tung Hwa North Road, Taipei, 105 Taiwan
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36
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Papatheodoridis GV, Sevastianos V, Burroughs AK. Prevention of and treatment for hepatitis B virus infection after liver transplantation in the nucleoside analogues era. Am J Transplant 2003; 3:250-8. [PMID: 12614278 DOI: 10.1034/j.1600-6143.2003.00063.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Post-transplant prophylaxis with hepatitis B immune globulin (HBIG) has significantly reduced hepatitis B virus (HBV) recurrence rates, but it is rather ineffective in patients with pretransplant viremia. Moreover, long-term HBIG administration is very expensive and may be associated with emergence of escape HBV mutants. Lamivudine has been widely used in the management of HBV transplant patients. Pretransplant lamivudine lowers HBV viremia, decreasing the risk of post-transplant HBV recurrence, but to try and minimize development of resistant HBV strains, it should start within the last 6 months of the anticipated transplantation timing. Preemptive post-transplant lamivudine monotherapy is associated with progressively increasing HBV recurrence rates, but combined therapy with lamivudine and HBIG at relatively low dosage is currently the most effective approach in this setting, even in HBV-DNA-positive patients, who also receive lamivudine in the pretransplant period. The most frequent therapy for post-transplant HBV recurrence is lamivudine, but the increasing resistance rates represent a rather challenging problem. Adefovir dipivoxil and entecavir are currently the most promising agents for lamivudine-resistant HBV strains. All these advances in anti-HBV therapy have made HBV liver disease an indication for liver transplantation irrespective of viral replication status, a complete turn around from 10 years ago.
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37
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Furuta K, Takahashi T, Aso K, Hoshino H, Sato K, Kakita A. Fibrosing cholestatic hepatitis in a liver transplant recipient with hepatitis C virus infection: a case report. Transplant Proc 2003; 35:389-91. [PMID: 12591454 DOI: 10.1016/s0041-1345(02)03976-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- K Furuta
- Department of Surgery, Kitasato University, Kanagawa, Japan
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38
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Tillmann HL, Bock CT, Bleck JS, Rosenau J, Böker KHW, Barg-Hock H, Becker T, Trautwein C, Klempnauer J, Flemming P, Manns MP. Successful treatment of fibrosing cholestatic hepatitis using adefovir dipivoxil in a patient with cirrhosis and renal insufficiency. Liver Transpl 2003; 9:191-6. [PMID: 12548514 DOI: 10.1053/jlts.2003.50010] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Fibrosing cholestatic hepatitis is a deleterious manifestation of hepatitis B virus infection in immunocompromised patients. Without treatment, this condition is usually fatal within weeks of onset. Liver retransplantation has not been successfully performed to date, and treatment intervention was generally unsuccessful before the advent of adefovir dipivoxil. However, concerns have been expressed about the use of this agent in patients who are renally compromised. A 40-year-old liver transplant recipient with hepatitis B virus reinfection, resistance to lamivudine, and fibrosing cholestatic hepatitis complicated by terminal renal impairment and spontaneous bacterial peritonitis was treated with adefovir dipivoxil 10 mg after every dialysis. Since initiating treatment with adefovir dipivoxil 10 mg, a dramatic virologic and clinical improvement was observed in this patient. The patient returned to work full-time within 6 months of starting adefovir dipivoxil without the need for liver retransplantation. Serum HBV DNA (Amplicor HBV; Roche Diagnostics, Basle, Switzerland) decreased by 6 log(10) copies/mL and became negative (< 400 copies/mL) within 8 weeks of treatment and remains negative at the last available assessment. The patient continues to require renal dialysis, but is generally well. Creatinine clearance improved from 8 mL/min to 16 mL/min during the course of treatment. No adverse events related to adefovir dipivoxil were observed. Adefovir dipivoxil resulted in significant clinical improvement in this patient with hepatitis B virus-induced fibrosing cholestatic hepatitis, despite the presence of renal impairment and lamivudine resistance.
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Affiliation(s)
- Hans L Tillmann
- Department of Gastroenterology, Hepatology, and Endocrinology, Medizinische Hochschule Hannover, Hannover, Germany
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39
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Chan TM, Fang GX, Tang CSO, Cheng IKP, Lai KN, Ho SKN. Preemptive lamivudine therapy based on HBV DNA level in HBsAg-positive kidney allograft recipients. Hepatology 2002; 36:1246-52. [PMID: 12395336 DOI: 10.1053/jhep.2002.36156] [Citation(s) in RCA: 142] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hepatitis B surface antigen (HBsAg)-positive kidney transplant recipients have increased liver-related mortality. The impact of lamivudine treatment on patient survival, the optimal time to start treatment, and the feasibility of discontinuing treatment have not been determined. This study examined these issues with a novel management protocol. Serum hepatitis B virus (HBV) DNA levels were measured serially in HBsAg-positive kidney transplant recipients, and lamivudine was administered preemptively to patients with increasing HBV DNA levels with or without elevation of aminotransferase levels. Outcomes of patients who underwent transplantation before or after institution of this preemptive management strategy (in January 1996) were compared. Eleven de novo patients (91.7%) who underwent transplantation between 1996 and 2000 and 15 existing patients (39.5%) who underwent transplantation between 1983 and 1995 received preemptive lamivudine therapy for 32.6 +/- 13.3 months. The treatment criteria were met by de novo patients at 8.4 +/- 6.2 months (range, 1-18 months) after transplantation. Suppression of HBV DNA and normalization of aminotransferase levels were achieved in all treated patients, and 21.4% had hepatitis B e antigen (HBeAg) seroconversion. The survival of preemptively managed de novo transplant patients was similar to that of HBsAg-negative controls, whereas HBsAg-positive patients who underwent transplantation before January 1996 had inferior survival (relative risk of death, 9.7 [P <.001]; relative risk of liver-related mortality, 68.0 [P <.0001]). Eleven patients (40.7%) developed lamivudine resistance. Discontinuation of lamivudine was attempted in 12 low-risk patients after stabilization and was successful in 5 (41.7%). In conclusion, preemptive lamivudine therapy based on serial HBV DNA levels and clinical monitoring improved the survival of HBsAg-positive renal allograft recipients. Treatment can be discontinued safely in selected patients after stabilization to minimize the selection of drug-resistant HBV mutants.
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Affiliation(s)
- Tak Mao Chan
- Nephrology Division, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong.
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40
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41
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Abstract
Hepatitis C virus (HCV) infection is present in 2-50% of renal transplant recipients and patients receiving hemodialysis. Renal transplantation confers an overall survival benefit in HCV positive (HCV+) hemodialysis patients, with similar 5-year patient and graft survival to those without HCV infection. However, longer-term studies have reported increased liver-related mortality in HCV-infected recipients. Unfortunately, attempts to eradicate HCV infection before transplant have been disappointing. Interferon is poorly tolerated in-patients with end-stage renal disease and ribavirin is contraindicated because reduced renal clearance results in severe hemolysis. Antiviral therapy following renal transplantation is also poorly tolerated, because of interferon-induced rejection and graft loss. Although the prevalence of hepatitis B virus (HBV) infection has declined in hemodialysis patients and renal transplant recipients since the introduction of routine vaccination and other infection control measures, it remains high within countries with endemic HBV infection (especially Asia-Pacific and Africa). Renal transplantation is associated with reduced survival in HBsAg+ hemodialysis patients. Unlike interferon, lamivudine is a safe and effective antiviral HBV treatment both before and after renal transplantation. Lamivudine therapy commenced at transplantation should prevent early posttransplant reactivation and subsequent progression to cirrhosis and late liver failure. This preemptive therapy should also eradicate early liver failure from fibrosing cholestatic hepatitis. Because cessation of treatment may lead to severe lamivudine-withdrawal hepatitis, most patients require long-term therapy. The development of lamivudine-resistance will be accelerated by immunosuppression and may result in severe hepatitis flares with decompensation. Regular monitoring with liver function tests and HBV DNA measurements should enable early detection and rescue with adefovir. Chronic HCV and HBV infections are important causes of morbidity and mortality in renal transplant recipients. The best predictor for liver mortality is advanced liver disease at the time of transplant, and liver biopsy should be considered in all potential HBsAg+ or HCV+ renal transplant candidates without clinical or radiologic evidence of cirrhosis. Established cirrhosis with active viral infection should be considered a relative contraindication to isolated renal transplantation.
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Affiliation(s)
- Edward Gane
- New Zealand Liver Transplant Unit, Auckland Hospital, New Zealand.
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42
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Kojima H, Abei M, Takei N, Mukai Y, Hasegawa Y, Iijima T, Nagasawa T. Fatal reactivation of hepatitis B virus following cytotoxic chemotherapy for acute myelogenous leukemia: fibrosing cholestatic hepatitis. Eur J Haematol 2002; 69:101-4. [PMID: 12366713 DOI: 10.1034/j.1600-0609.2002.02719.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Hepatitis B virus (HBV) is a well known pathogen that sometimes causes fulminant hepatitis in patients undergoing cytotoxic chemotherapy. Fibrosing cholestatic hepatitis (FCH) is a recently recognized unique variant of viral hepatitis, which has been occasionally reported in HBV-infected recipients of liver, renal, or bone marrow transplantation. We present here a 48-yr-old male in whom HBV was reactivated during post-remission chemotherapy for acute myelogenous leukemia, which resulted in rapidly fatal outcome. He manifested with deterioration of liver function in association with enormous replication of HBV. Liver biopsy showed marked ballooning of hepatocytes, cholestasis, and periportal fibrosis with minimum infiltrates. Immunostaining revealed that hepatocytes were strongly positive for hepatitis B surface antigen. Under the diagnosis of FCH, he was treated with lamivudine and interferon beta, which was not effective. Autopsy showed severe atrophy of the liver and marked degeneration of hepatocytes. Hematologists should be aware that FCH is a fatal complication that can develop under post-chemotherapy immunosuppressed conditions. Although there is no convincing evidence, prophylactic administration of lamivudine seems to be a reasonable strategy.
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Affiliation(s)
- H Kojima
- Division of Hematology, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan.
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43
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Tillmann HL, Trautwein C, Bock CT, Glomb I, Krüger M, Böker KHW, Klempnauer J, Flemming P, Manns MP. Lamivudine transiently reduces viral load and improves liver function in liver transplant recipients with fibrosing cholestatic hepatitis. Am J Gastroenterol 2002; 97:777-8. [PMID: 11926212 DOI: 10.1111/j.1572-0241.2002.05582.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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44
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Jung S, Lee HC, Han JM, Lee YJ, Chung YH, Lee YS, Kwon Y, Yu E, Suh DJ. Four cases of hepatitis B virus-related fibrosing cholestatic hepatitis treated with lamivudine. J Gastroenterol Hepatol 2002; 17:345-50. [PMID: 11982709 DOI: 10.1046/j.1440-1746.2002.02600.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Fibrosing cholestatic hepatitis (FCH) is a rare and extremely severe form of hepatitis B virus (HBV) infection. This condition was originally described in HBV-infected recipients after a liver transplantation. Recently, FCH has been reported not only in liver transplant recipients, but also in other immunosuppressed patients. It is characterized clinically by cholestatic hepatic dysfunction, and pathologically by severe periportal fibrosis, cholestasis, widespread balloon degeneration of hepatocytes, and only a mild infiltration of inflammatory cells. Without treatment, FCH is universally fatal within a few months of diagnosis. There have been only two isolated case reports of FCH with long-term patient survival, and one case report with treatment failure after lamivudine therapy. Because of the rarity of this clinical entity, the therapeutic efficacy of lamivudine in patients with FCH cannot be evaluated systematically. Here, we present four patients with HBV-related FCH treated with lamivudine. One received antineoplastic therapy for acute lymphoblastic leukemia, and the other three were renal graft recipients. Two patients who developed FCH after a renal transplantation survived with an improvement in liver function and were followed up for 20 and 30 months, respectively, and were found to be in good health. However, the other two patients died of sepsis, possibly as a consequence of the immunosuppression with hepatic failure despite lamivudine treatment. Our experience suggests that lamivudine can alter the grave natural history of FCH.
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Affiliation(s)
- Saera Jung
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
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45
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Rosenberg PM, Farrell JJ, Abraczinskas DR, Graeme-Cook FM, Dienstag JL, Chung RT. Rapidly progressive fibrosing cholestatic hepatitis--hepatitis C virus in HIV coinfection. Am J Gastroenterol 2002; 97:478-83. [PMID: 11866292 DOI: 10.1111/j.1572-0241.2002.05459.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Fibrosing cholestatic hepatitis (FCH) is a severe and progressive form of liver dysfunction seen in organ transplant recipients infected with hepatitis B virus or hepatitis C virus (HCV) and has been attributed to cytopathic liver injury. To date, no case of FCH due to HCV has been reported in HIV-positive individuals. We describe two cases of HCV-induced FCH in two patients coinfected with HIV, culminating in rapidly progressive liver failure and death. Histological features and progression in both cases were not consistent with drug effect or obstruction. Late institution of interferon-based therapy was ultimately unsuccessful. The HCV RNA was not markedly elevated in these cases, suggesting that the cytopathic effect of HCV in these patients was not simply a consequence of viral load. FCH may in part explain the accelerated development of cirrhosis previously observed among coinfected patients. Clinicians should remain vigilant for FCH in the HIV/HCV population and consider antiviral treatment in this setting.
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Affiliation(s)
- Peter M Rosenberg
- Department of Pathology, Massachusetts General Hospital, Boston 02114, USA
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46
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Tang S, Ho SKN, Moniri K, Lai KN, Chan TM. Efficacy of famciclovir in the treatment of lamivudine resistance related to an atypical hepatitis B virus mutant. Transplantation 2002; 73:148-51. [PMID: 11792996 DOI: 10.1097/00007890-200201150-00028] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Reactivation of chronic hepatitis B virus (HBV) infection is a major cause of morbidity and mortality after renal transplantation. Although lamivudine is an effective treatment for chronic hepatitis B, the development of drug resistance due to mutations in the tyrosine-methionine-aspartate-aspartate (YMDD) motif is a major concern, especially in immunosuppressed patients who require prolonged therapy. Treatment with famciclovir has not been effective in the majority of patients who developed lamivudine resistance due to methionine-to-valine mutation at position 550, because this mutation has been uniformly associated with leucine-to-methionine mutation at position 526, a mutation that is associated with resistance to famciclovir. We describe a renal transplant recipient with an uncommon lamivudine-resistant HBV variant, in which methionine-to-valine/isoleucine mutation at position 550 was associated with wild-type sequence at position 526. The severe hepatitic flare consequent to the lamivudine resistance in this patient was successfully treated with famciclovir, indicating that both M550V and M550I mutants with preserved wild-type sequence at position 526 of HBV reverse transcriptase are susceptible to famciclovir. Our experience shows that famciclovir can be useful in selected patients with otherwise potentially fatal hepatitic flares related to lamivudine resistance, and that analysis of mutations in the HBV variant can be helpful in the choice of antiviral therapy.
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Affiliation(s)
- Sydney Tang
- Department of Medicine, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong
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47
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48
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Mawson AR, Steele TA. Possible role of retinoids in hepatitis B virus-associated liver damage. Exp Biol Med (Maywood) 2001; 226:734-9. [PMID: 11520938 DOI: 10.1177/153537020222600804] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Liver damage following hepatitis B virus (HBV) infection may be due to the action of retinoids as modulators of viral replication. The reduced rate of survival of liver grafts in patients with HBV infection could also be due to the continued presence of the virus, stimulated by retinoids in the graft tissue. Subject to obtaining empirical support for this hypothesis, the use of retinoid-blocking agents could be explored to reduce the risk of liver damage in HBV infection and to enhance the survival of liver grafts. Continued use of such agents may need to be used in conjunction with anti-viral modalities such as HBV hyperimmune globulin and lamivudine to prevent recurrent liver damage and to increase the long-term viability of the graft.
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Affiliation(s)
- A R Mawson
- Public Health Program, Des Moines University Osteopathic Medical Center, 3200 Grand Avenue, Des Moines, Iowa 50312, USA.
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49
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Nakhoul F, Gelman R, Green J, Khankin E, Baruch Y. Lamivudine therapy for severe acute hepatitis B virus infection after renal transplantation: case report and literature review. Transplant Proc 2001; 33:2948-9. [PMID: 11543804 DOI: 10.1016/s0041-1345(01)02265-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- F Nakhoul
- Department of Nephrology and Molecular Medicine, Rambam Medical Center, Haifa, Israel
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50
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Fontana RJ, Hann HW, Wright T, Everson G, Baker A, Schiff ER, Riely C, Anschuetz G, Riker-Hopkins M, Brown N. A multicenter study of lamivudine treatment in 33 patients with hepatitis B after liver transplantation. Liver Transpl 2001; 7:504-10. [PMID: 11443577 DOI: 10.1053/jlts.2001.24896] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatitis B virus (HBV) infection after liver transplantation (LT) may lead to severe and rapidly progressive graft failure. Antiviral treatment may be of benefit in selected patients with recurrent hepatitis B post-LT. The aim of this prospective open-label study is to determine the safety and efficacy of lamivudine in 33 liver transplant recipients with active HBV infection. The median time from LT to study enrollment was 51 months, all patients were hepatitis B surface antigen positive, and 75% and 94% of subjects had detectable hepatitis B e antigen (HBeAg) and HBV DNA at entry, respectively. The median duration of lamivudine treatment on study was 85 weeks, during which time median HBV DNA levels became undetectable by 16 weeks and 9% of patients lost previously detectable HBeAg. Serum alanine aminotransferase (ALT) levels improved in most patients and normalized in 27% of patients with elevated values pretreatment. Serum bilirubin and albumin levels significantly improved in patients with abnormal values at entry (P <.05). Virological breakthrough was detected in 13 subjects after a median of 61 weeks of lamivudine treatment and was confirmed to be caused by YMDD mutants in all patients tested. None of the patients with virological breakthrough showed a complete loss of clinical response to lamivudine. Serum ALT and bilirubin levels in patients with and without virological breakthrough were not significantly different at last study follow-up. Study results show that lamivudine is safe and effective in liver transplant recipients with recurrent hepatitis B. However, the high rate of virological breakthrough with prolonged therapy indicates the need for further studies of combination antiviral therapy in this patient population. Our results and others further establish the improving long-term outcomes with LT for patients with hepatitis B through advances in prevention of reinfection, as well as the availability of safe and effective antiviral therapies to treat patients with HBV recurrence.
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Affiliation(s)
- R J Fontana
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109-0362, USA.
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