Natural history of hepatitis-associated antigen-positive chronic liver disease

Hepatitis, epidemiology and liver function in hemophiliacs in Sweden

The epidemiology of viral hepatitis and liver function were studied in a retrospective survey of 69 patients with moderate and severe hemophilia A and B, and with severe von Willebrand's disease. Forty-nine patients were on prophylactic self-therapy and 20 on episodic treatment by medical personnel. Serologic markers of viral hepatitis (HBsAg, anti-HBs, anti-HBc, anti-HAV, and in some cases HBeAg and anti-HBe) and liver function tests (ASAT, ALAT, IgG) were followed for up to 12 years. There was a history of clinical hepatitis in 19%, and 96% showed some serologic evidence of exposure to hepatitis B virus. Only one patient was a HBsAg carrier. The prevalence of elevated ASAT and/or ALAT was 65% and the incidence 96%. In 68% of the patients there had been a transaminase elevation for more than 6 months. The clinical picture, serologic markers or liver function tests showed no significant difference between the types of hemophilia, amounts and modes of therapy, or age groups. The chronic hepatitis seen in our hemophiliacs seemed to be a slowly or non-progressive disease.

The woodchuck model of hepatitis B virus infection

The woodchuck hepatitis virus (WHV) was the first of the mammalian and avian hepadnaviruses described after discovery of the virus of hepatitis B (HBV). Woodchucks chronically infected with WHV develop progressively severe hepatitis and hepatocellular carcinoma, which present as lesions that are remarkably similar to those associated with HBV infection in humans. The initial virological studies and studies of pathogenesis utilized woodchucks that had been trapped in the wild and had acquired WHV infection naturally. Research with wild woodchucks was complicated by lack of knowledge of their backgrounds (e.g., dietary history, exposure to parasites or environmental toxins, and source and duration of WHV infection). Breeding colonies of woodchucks have been established and maintained in laboratory animal facilities, and laboratory-reared woodchucks are superior for experimental studies of pathogenesis or hepatocarcinogenesis. It is possible to infect neonatal woodchucks born in the laboratory with standardized inocula and produce a high rate of chronic WHV carriers that are useful for controlled investigations. WHV has been shown experimentally to cause hepatocellular carcinoma, supporting conclusions based on epidemiological and molecular virological studies that HBV is an important etiological factor in human hepatocarcinogenesis. Chronic WHV carrier woodchucks have become a valuable animal model for the preclinical evaluation of antiviral therapy for HBV infection, providing useful pharmacokinetic and pharmacodynamic results in a relevant animal disease model. It also has been shown that the pattern of toxicity and hepatic injury observed in woodchucks treated with certain fluorinated pyrimidines is remarkably similar to that observed in humans that were treated with the same drugs, suggesting the woodchuck has significant potential for the preclincial assessment of antiviral drug toxicity.

Acute exacerbation of chronic hepatitis B virus infection after withdrawal of lamivudine therapy

Acute exacerbations of chronic hepatitis B virus (HBV) infection occur after withdrawal of lamivudine therapy in approximately 16% of patients and are considered of little clinical significance. We observed "lamivudine withdrawal hepatitis" accompanied by jaundice and incipient liver failure, but also followed by complete recovery and viral clearance. To investigate the incidence, severity, timing, and virologic characteristics of "lamivudine withdrawal hepatitis" we monitored 41 patients for at least 6 months after discontinuation of nucleoside analogue therapy. The incidence of hepatitis flares was estimated to be 7 of 41 (17%); in 2 of 41 cases (5%), hepatitis flares were associated with jaundice and incipient liver failure. A noticeable feature of the "lamivudine withdrawal hepatitis" flares were the high HBV-DNA levels at the time of the alanine transaminase (ALT) peak. All were wild-type HBV, even the one that emerged from a lamivudine-resistant strain during therapy. To minimize the risk of liver failure and to enhance the elimination of HBV following flares, lamivudine therapy was reinstituted in an icteric patient. Clinical and biochemical remission ensued, followed by loss of HBV DNA and hepatitis B e antigen (HBeAg) seroconversion. Such a virologic response did not occur in 5 other patients with a nonicteric "lamivudine withdrawal hepatitis," who were not retreated with lamivudine. Hepatitis after withdrawal of lamivudine resembles acute hepatitis B with a predominance of anicteric flares within a time frame of 6 months. Active management of hepatitis flares following withdrawal of nucleoside analogue therapy should be investigated further.

Cost-benefit analysis of interferon therapy in children with chronic active hepatitis B

BACKGROUND

alpha-Interferon is widely accepted for treatment of adults with chronic hepatitis B, but its use remains limited in children, partly because of questions regarding its cost effectiveness. The aim of this study was to evaluate the cost effectiveness of alpha-interferon for children with chronic active hepatitis B.

METHODS

We estimated the cost per year of life saved by alpha-interferon therapy for three cohorts of patients with chronic active hepatitis B treated at 2, 12, or 25 years of age. We assumed that only patients with active viral replication would be treated and that alpha-interferon would prevent cirrhosis and hepatocellular carcinoma in a portion of the population treated. We calculated costs per year of life saved. Medical costs and years of life saved were discounted at 5% per year.

RESULTS

With a 30% response rate to alpha-interferon, there was a net savings in both money and lives in the children's group with a minimal cost per year of life saved for adolescents ($510) and adults ($934). Years of life saved per person were greater for children (1.0) than adults (0.5). With a 6% response rate, estimated costs per year of life saved for children ($5,700) were one-fourth of those of adults ($22,100).

CONCLUSIONS

alpha-interferon therapy for patients with chronic active hepatitis B is cost effective. alpha-Interferon is more cost effective in toddlers than adults because of the smaller dose required and the greater increase in life expectancy of children.

The dynamics of hepatitis B virus infection

We consider a cellular model of infection by the hepatitis B virus and describe how it may be used to account for two important features of the disease, namely (i) the wide variety of manifestations of infection and the age dependence thereof, and (ii) the typically long delay before the development of virus-induced liver cancer (primary hepatocellular carcinoma). The model is based on the assumption that the liver is comprised of both immature and mature hepatocytes, with these two subpopulations of cells responding contrastingly upon infection by the virus.

Survival and prognostic factors in 366 patients with compensated cirrhosis type B: a multicenter study. The Investigators of the European Concerted Action on Viral Hepatitis (EUROHEP)

A multicenter longitudinal study was performed to assess the survival of hepatitis B surface antigen positive compensated cirrhosis, primarily in relation to hepatitis B virus replication and hepatitis delta virus infection, and to construct a prognostic index based on entry characteristics. This cohort study involved nine university medical centers in Europe. Three hundred and sixty-six Caucasian HBsAg positive patients with cirrhosis who had never had clinical manifestations of hepatic decompensation were enrolled and followed for a mean period of 72 months (6 to 202 months). Inclusion criteria were biopsy-proven cirrhosis, information on serum hepatitis B e antigen and antibody to hepatitis D virus at the time of diagnosis and absence of complications of cirrhosis. At entry 35% of the patients were HBeAg positive, 48% of the patients tested were HBV-DNA positive and 20% anti-HDV positive. Death occurred in 84 (23%) patients, mainly due to liver failure (45 cases) or hepatocellular carcinoma (23 cases). The cumulative probability of survival was 84% and 68% at 5 and 10 years, respectively. Cox's regression analysis identified six variables that independently correlated with survival: age, albumin, platelets, splenomegaly, bilirubin and HBeAg positivity at time of diagnosis. According to the contribution of each of these factors to the final model, a prognostic index was constructed that allows calculation of the estimated survival probability. No difference in survival of hepatitis D virus infected and uninfected patients was observed. Termination of hepatitis B virus replication and/or biochemical remission during follow up correlated with a highly significant better survival. These data show that in compensated cirrhosis B, hepatitis B virus replication, age and indirect indicators of poor hepatic reserve and established portal hypertension significantly worsen the clinical course of the disease, whereas hepatitis D virus infection does not influence the prognosis. The highly significant improvement in life expectancy following cessation of hepatitis B virus replication and biochemical remission favors antiviral therapy in those patients with a guarded prognosis, as estimated by a prognostic index.

A cellular model to explain the pathogenesis of infection by the hepatitis B virus

The natural history of infection by the hepatitis B virus (HBV) depends on many factors, including the age and immunological status of the patient, and can range from acute transient infection to subclinical chronic hepatitis. Persistent infection often leads to the development of primary hepatocellular carcinoma. We consider a cellular model of HBV infection based on the hypothesis that the liver contains two populations of cells with contrasting responses to the virus. Our findings show that the model can be used to account for the wide variety of clinical manifestations of infection and can explain the observed age dependence of the main different outcomes of the disease.

Interferon treatment in patients with chronic hepatitis B: a meta-analysis of the published literature

The randomised clinical trials testing the effectiveness of interferon treatment on Chronic Hepatitis B patients were reviewed by means of meta-analysis. Twenty-two trials, published between 1987 and 1990, have identified where 1290 adult patients had been studied. Overall, interferon increased the rates of serum HBV-DNA clearance and amino-transferases normalization about 3 times at one year. However, when an analysis of internal consistency, clinical relevance and methodology of these studies was made, the trials were not sufficient to confirm the clinical effectiveness of the treatment since they had been planned for short-term assessment based on biochemical and viral end points alone. The link of these end points to other outcomes of more obvious clinical relevance (i.e. evolution to cirrhosis or deterioration of cirrhosis, death) is, in fact, questionable and thus the value of a meta-analysis based on currently available trials is uncertain as a source for practical guidelines. We conclude that the effectiveness of interferon in patients with chronic hepatitis B has yet to be confirmed by long-term prospective studies which assess the outcome by clinically meaningful end points such as cirrhosis, liver failure, or death.

Interferon in the management of chronic hepatitis B

Many drugs have been used in the treatment of chronic hepatitis B, but with the exception of interferon, none have proved to be effective. Several studies have found that a sustained loss of viral replication occurs in approximately 40% of patients who started with a 16-week course of recombinant interferon alfa-2b given in a dose of 5 million units daily or 10 million units three times weekly. Moreover, disappearance of hepatitis B surface antigen in serum has been observed in 10-15% of treated patients. Based on these results, the Food and Drug Administration approved the use of this form of interferon in chronic hepatitis B in July 1992. This article reviews the importance of chronic hepatitis B as a health problem as well as the mechanisms of action, benefits, and adverse effects associated with interferon. Particular emphasis is given to the safety and efficacy data for recombinant interferon alfa-2b.

Cost-benefit analysis of a nationwide neonatal inoculation programme against hepatitis B in an area of intermediate endemicity

STUDY OBJECTIVE

The aim was to estimate the costs and benefits of a nationwide neonatal vaccination campaign against hepatitis B in Israel for the 1990-2034 period.

DESIGN

Using morbidity, mortality, utilisation, and cost data from Israeli and international sources, a spreadsheet model was constructed to carry out the cost-benefit analysis.

SETTING

The entire State of Israel, an area of intermediate endemicity.

PARTICIPANTS

The population of Israel from 1990-2034.

MAIN RESULTS

A policy of immunising all Israeli neonates would, for a cost of $13.8 million, reduce the number of cases of hepatitis B during the 1990-2035 period in the cohort from 359,000 to 166,000 and save the nation around $21.5 million in health resources alone, $16.6 million in averted work absences, and a further $0.6 million in averted premature mortality costs. Even when the savings to the health services ($0.6 million) arising from the reduction in hepatocellular carcinoma are excluded, the direct benefit to cost ratio is 1.51/1, still in excess of unity.

CONCLUSIONS

The decision to adopt a nationwide neonatal inoculation policy, starting in January 1992, appears to be not only medically but also economically justifiable.

Analysis of a cellular model to account for the natural history of infection by the hepatitis B virus and its role in the development of primary hepatocellular carcinoma

Infection with the hepatitis B virus (HBV) can have many different outcomes. Transient infection may result in acute hepatitis or may remain subclinical. Persistent infection may also be subclinical, or may involve chronic active hepatitis, and can finally lead to the development of primary hepatocellular carcinoma. A mathematical model is given to account for the many different outcomes of HBV pathogenesis. The model is based on the assumption that the liver contains two cell populations with differing abilities to support active HBV replication and/or viral integration into the genome. The model helps account for the relationship of the different clinical courses of HBV infection to the age when the disease is acquired, together with the state of the immune system of the patient.

Survival and prognostic indicators in hepatitis B surface antigen-positive cirrhosis of the liver

To evaluate indications for new therapies such as liver transplantation and antiviral therapy, survival of histologically proven hepatitis B surface antigen (HBsAg)-positive cirrhosis of the liver was assessed in a cohort of 98 patients followed up for a mean of 4.3 years. The overall survival probability was 92% at 1 year, 79% at 3 years, and 71% at 5 years. Variables significantly associated with the duration of survival were age, serum aspartate aminotransferase levels, presence of esophageal varices, and all five components of the Child-Pugh index (bilirubin, albumin, coagulation factors, ascites, encephalopathy). Multivariate analysis showed that only age, bilirubin, and ascites were independently related to survival. Survival of patients with decompensated cirrhosis (determined by the presence of ascites, jaundice, encephalopathy, and/or a history of variceal bleeding) and those with compensated cirrhosis at 5 years was 14% and 84%, respectively. For patients with compensated liver cirrhosis, hepatitis B e antigen (HBeAg) positivity was also a prognostic factor with a 5-year survival of 72% for HBeAg-positive cirrhosis and 97% for HBeAg-negative cirrhosis; the risk of death was decreased by a factor of 2.2 when HBeAg seroconversion occurred during follow-up. It is concluded that liver transplantation should be considered for patients with decompensated HBsAg-positive liver cirrhosis and antiviral therapy for patients with HBeAg-positive compensated cirrhosis.

Humoral immune response to a yeast-derived hepatitis B vaccine in patients with type 1 diabetes mellitus

The immune response following vaccination with a recombinant hepatitis B vaccine was investigated in 32 patients with Type 1 diabetes mellitus and compared with the outcome in 32 healthy age- and sex-matched volunteers. Participants were vaccinated at 0, 30, and 180 days and in vivo immune response was determined at 30, 60, 90, 180, and 210 days. The number of responders (anti-HBs greater than 1 IU l-1) was significantly lower (p less than 0.05) among patients at 30 (2 vs 11), 60 (17 vs 26), 90 (20 vs 28) and 180 (22 vs 29) days. The number of patients protected (anti-HBs greater than 10 IU l-1) was lower (p less than 0.05) than the number of protected volunteers at 60 (5 vs 14), 90 (10 vs 19), 180 (15 vs 24), and 210 days (24 vs 31). After the complete course of vaccination 8 out of 32 patients were still unprotected against hepatitis B (p less than 0.05). The anti-HBs titre of responders at 210 days was 251 (20, 3162) (geometric mean (-SD, +SD] IU l-1 in patients and 1259 (126, 12589) IU l-1 in control subjects (p less than 0.05). The HLA-antigen DQw1 frequency in the diabetic low responders (anti-HBs less than 100 IU l-1) was 0.27 compared with 0.86 in diabetic adequate responders. No relation between anti-HBs production and concentration of HbA1c could be demonstrated.

Hepatitis B virus markers and antibodies to hepatitis C virus in Japanese patients with hepatocellular carcinoma

Sera from Japanese patients with chronic liver disease were tested for hepatitis B virus (HBV) markers and antibodies to hepatitis C virus (anti-HCV), and the results were correlated to the presence of hepatocellular carcinoma. In chronic non-A, non-B liver disease, anti-HCV prevalence was high both in patients with hepatocellular carcinoma (78/89, 88%) and without it (66/84, 79%), while previous HBV infection was more common in patients with hepatocellular carcinoma (65/89, 73%) than in those without it (46/84, 55%) (P less than 0.05). Coexistence of anti-HCV and antibodies to HBV was observed frequently in patients with hepatocellular carcinoma (56/89, 63%) compared with patients without it (39/84, 46%) (P less than 0.05). In chronic HBV carriers, anti-HCV was more common in patients with hepatocellular carcinoma (12/38, 32%) than in those without it (3/62, 5%) (P less than 0.01). These results suggest that infection with the two viruses may be a risk factor for more serious liver disease.

Hepatitis B: the disease

Hepatitis B virus (HBV) is carried by approximately 300 million people in the world. The natural history of the disease in an individual patient depends on the method by which the infection was acquired, whether perinatal, in childhood, as a result of drug abuse, or in the course of health care work. Other important factors determining the course of the disease include an individual's sex and immunological status. Geographic factors also contribute. Changing lifestyles and the use of prophylactic hepatitis B vaccination affect the prevalence in various groups in the community. The clinical course of the disease, possible complications, and a recent classification system for chronic HBsAg carriers are discussed.

Natural course after the development of cirrhosis in patients with chronic type B hepatitis: a prospective study

To examine the early stage of the natural course of liver cirrhosis, a prospective follow-up study was conducted in a series of 76 patients with recent development of cirrhosis during the course of chronic type B hepatitis. During a mean follow-up period of 34.4 months, 45 episodes of acute exacerbation were recorded; the majority of the episodes occurred within 2 years after entry. The calculated annual incidence of acute exacerbation was significantly higher in patients seropositive for hepatitis B e antigen (HBeAg) and/or hepatitis B virus (HBV)-DNA (25.9%) than in those without these markers (11.9%). Three-fourths of the acute exacerbations were attributable to the reactivation of HBV. Spontaneous HBeAg seroconversion to anti-HBe also occurred in the early phase, but less than 30% of the events were preceded by acute exacerbation. Late hepatitis B surface antigen clearance occurred in two patients. Hepatic decompensation, esophageal variceal bleeding and hepatocellular carcinoma developed relatively late in the course of the disease with a calculated annual incidence of 2.3%, 2.3% and 2.8%, respectively. Seven patients (9.2%) died of hepatic failure or variceal bleeding, usually more than 3 years after entry. The estimated 5-year survival rate was 80%. The results suggest that the natural events of chronic HBV infection, including exacerbation, seroconversion and its sequelae could occur after the development of cirrhosis. In addition, these events might be responsible for the clinicopathological changes and the outcomes of these cirrhotic patients.

Prolonged IgM antibodies and histopathological evidence of chronicity in hepatitis A

The case of a young man with hepatitis A and a chronic course is presented. The patient received a short course of steroid therapy for recurrence of symptoms following acute hepatitis A. Thereafter, liver enzymes have remained marginally elevated for 4 years and annual liver biopsies have shown evidence of chronicity. HAV IgM Ab persisted for 1034 days with subsequent development of HAV IgG Ab. The possibility of other viruses in the aetiology and the role of steroids in the development of chronicity are discussed.

Hepatitis B virus infection among women in a shoe factory in Korea

One hundred and sixty five Korean women in a shoe factory in Masan, Korea were evaluated on hepatitis B virus infection by solid-phase radioimmunoassay in 1986. The participants were women of child-bearing ages, mostly in 20's and 30's. About two thirds (105/165) of the subjects had serological evidence of past or present hepatitis B virus infection, and 17% (28/165) were HBsAg-positive. In view of possible risk of vertical transmission of hepatitis B virus, further epidemiological study was considered necessary to establish preventive measures.

Treatment of acute and chronic viral hepatitis

Over the 12 years since the first introduction of interferon for the treatment of chronic hepatitis B, progress has apparently been slow. Nevertheless, it now appears that at least one third of chronic hepatitis virus carriers, particularly those with more severe disease, and a similar, perhaps greater, proportion of those with chronic parenteral non-A, non-B hepatitis, can be successfully treated with alpha-interferon. In the not too distant future, controlled trials of alpha-interferons in these situations will be complete and they will be a yardstick by which other future therapies can be judged. Already a number of trials are in progress to determine which agents might, in addition to interferon, augment the response rates. The situation clinically is analogous to that for tuberculosis in the 1950s and for cancer chemotherapy only a decade or so ago. The prospects of prevention of the progression to cirrhosis, and perhaps in the long term reduction in the incidence of hepatocellular carcinoma, are exciting, and with the introduction of a number of new cytokines available through recombinant technology, each with novel antiviral activities, the future prospects are exciting indeed.

Chronic hepatitis: disease factors at diagnosis predictive of mortality

PURPOSE

Chronic hepatitis is known to be a disease with substantial mortality. The purpose of this study was to identify prognostic factors in a large group of patients with chronic hepatitis. We also wanted to determine whether the aminopyrine breath test (ABT) is of additional prognostic value in evaluation of this disease.

PATIENTS AND METHODS

We studied 94 patients who had had a biopsy-proven diagnosis and an ABT between June 1, 1977, and June 30, 1981. Clinical features and biochemical test results at the time of diagnosis were retrieved from medical records, and histologic severity was assessed by reviewing all liver biopsy specimens under code. Survival was determined at a mean of 60 months. Data were studied with a Cox proportional hazards model to identify predictors of mortality and to control for confounding variables.

RESULTS

Cumulative mortality as of December 31, 1985, was 5 percent in chronic persistent hepatitis, 6 percent in chronic active hepatitis, 29 percent in chronic active hepatitis with bridging necrosis, and 53 percent in chronic active hepatitis with cirrhosis. Histologic severity was a predictor of death (p less than 0.005). Other predictors of mortality were disease caused by hepatitis B virus (p less than 0.005), a high alkaline phosphatase level (p less than 0.025), a low alanine aminotransaminase level (p less than 0.001), and a depressed ABT result (p less than 0.005).

CONCLUSION

The results suggest that patients with chronic hepatitis with one or more of these risk factors have an increased mortality and should be followed closely for liver failure, which may necessitate medical therapy or surgical intervention.

Chronic non-A, non-B hepatitis. A long-term follow-up study in 49 patients

Forty-nine patients with biopsy-verified chronic non-A, non-B hepatitis (NANBH) of both percutaneously transmitted and sporadic types were followed up for up to 20 years (mean, 62 months +/- 44 months). Drug addicts were not included. Twenty-four patients had chronic persistent hepatitis (CPH), and 25 had chronic active hepatitis (CAH) or cirrhosis on the basis of the first biopsy. Patients with CPH were significantly younger than patients with CAH (mean age, 31 and 51 years, respectively; p less than 0.001). Standard laboratory data (means) correlated with histology, but great variations made liver biopsy essential for the diagnosis. Twenty-one patients were rebiopsied, and 24% had more severe lesions. In total, 16 patients (33%) had signs of cirrhosis. The disease seemed to resolve in eight patients (16%), whereas two patients died of it. Some patients with CPH might progress to CAH, and the frequent finding of cirrhosis in CAH implies the possibility of hepatic failure and fatality in chronic NANBH.

Drug disposition in patients with HBsAg-positive chronic liver disease

Chronic infection with hepatitis B virus (HBV) results in a spectrum of hepatic abnormalities ranging from minimal liver dysfunction to severe liver failure. These patients provide an opportunity to examine the relationship between the evolution of the liver disease and the ability to metabolize drugs. We have examined hepatic drug disposition in patients with chronic persistent hepatitis, chronic active hepatitis, and cirrhosis due to HBV infection. Four model drugs were used: two low-extraction capacity-limited drugs (antipyrine and aminopyrine) and two high-extraction flow-limited drugs (ICG and lidocaine). The disposition of the four drugs tested was comparable to that of healthy controls in patients with chronic persistent hepatitis, chronic active hepatitis, and mild cirrhosis. In patients with severe cirrhosis (as defined by the presence of ascites, encephalopathy, or large esophageal varices), there was a significant impairment in the aminopyrine breath test (-31%) and in the clearance of antipyrine (-53%), lidocaine (-49%), and ICG (-54%). These results indicate that impairment of drug clearance occurs only late in the evolution of HBV-related chronic liver disease. This is in keeping with the known slow and insidious progression of the disease.

A pilot study on the effects of prednisone withdrawal on serum hepatitis B virus DNA and HBeAg in chronic active hepatitis B

We investigated the efficacy of a short course of prednisone therapy in 20 patients with histologic evidence of chronic active hepatitis B. Sixteen of 20 prednisone-treated patients who were initially serum hepatitis B virus DNA-positive had a transient elevation of their serum ALT activity on withdrawal of prednisone. Subsequently, 14 of these 16 patients (87.5%) became persistently negative for serum hepatitis B virus DNA, and 10 also lost their HBeAg. In addition, there was a significant fall in serum ALT levels and HBsAg titers up to 12 months of follow-up in the prednisone-treated group. Five of 20 (25%) prednisone-treated patients experienced a transient episode of hepatic decompensation coinciding with the peak of enzyme elevation. To contrast, only 3 of 15 (20%) initially hepatitis B virus DNA-positive matched untreated patients followed during the same time period became negative for serum hepatitis B virus DNA, and no significant changes in serum ALT values or HBsAg titers were noted over the 12-month study period. Thus, patients with chronic active hepatitis B appear to be responsive to immunologic manipulation with prednisone as indicated by a pronounced rebound immune response and clearance of hepatitis B virus DNA with improvement in liver disease activity.

Histologic and clinicopathologic features of Chinese patients with HBsAg-positive chronic active hepatitis

Needle biopsies of both the right and left lobes of the liver were performed during peritoneoscopy in 20 male patients with chronic active hepatitis B in Taiwan. Microscopic study of these biopsy specimens led to the recognition of three groups: 1) five patients in whom the lobular architecture was easily recognizable but in whom necrosis and early intralobular fibrosis were present, along with severe chronic inflammation of the portal tracts; 2) seven patients in whom the livers were characterized by early septal formation and a good regenerative response, but few recognizable lobules with normal architecture; and 3) eight patients in whom the disease had progressed to severe fibrosis with septal formation and tiny pseudolobules, indicative of early cirrhosis. The left lobe was the more severely damaged in 16 of the 20 patients.

A controlled trial of 6 months thrice weekly lymphoblastoid interferon versus no therapy in chronic hepatitis B virus infection. A preliminary analysis of the first 32 patients

A controlled trial of lymphoblastoid interferon versus no therapy in patients positive for HBsAg, HBeAg and DNA polymerase activity with separate randomisation for sexual preference and histology is underway. Thirty two patients have been followed for a minimum period of 6 months of whom 15 have been randomised to receive interferon thrice weekly for 6 months after a 5-day induction phase. Five treated patients developed an hepatitis-like illness during the 3rd month of therapy concurrent with an abrupt and complete loss of DNA polymerase activity from serum. In 3 this was permanent and anti-HBe subsequently developed; 2 of these have also lost HBsAg. In the other 2 patients inhibition of viral replication was transient. In 5 further treated patients DNA polymerase activity was completely inhibited throughout treatment only to return as soon as interferon was withdrawn. In this group serum aminotransferase became normal during treatment. In the remaining 5 treated patients, inhibition of DNA polymerase activity was never complete and serum aminotransferases were unaffected. All the control patients remain seropositive for HBsAg, HBeAg and DNA polymerase activity. The low seroconversion rate in treated patients and the absence of seroconversion in the control group are probably a reflection of the exclusion of patients with marked elevation of serum aminotransferases. The occurrence of an hepatitis-like illness in the 3rd month of therapy in a third of the patients and the loss of HBsAg in 2 of 3 who eventually seroconverted are likely to be a consequence of therapy rather than spontaneous events.(ABSTRACT TRUNCATED AT 250 WORDS)

Natural history of chronic hepatitis B virus-related liver disease and its relationship to serum markers of viral replication

Our understanding of the process whereby replicating Hepatitis B virus is eradicated has been substantially modified by the development of highly sensitive assays of viral replication, such as the detection of HBV-DNA in serum. The implications of these developments on our therapeutic approach in terms of both timing and expectations is discussed.

Primary biliary cirrhosis and chronic active hepatitis: an examination of clinical, biochemical, and histopathological features in differential diagnosis

Seventy four liver biopsies from 59 patients were reviewed by two observers and histologically graded in the absence of clinical information, firstly, to assess the level of agreement with previous diagnoses; secondly, to identify differences between primary biliary cirrhosis and chronic active hepatitis; and, thirdly, to assess the specificity of Shikata orcein staining and antimitochondrial antibody positivity and titre for primary biliary cirrhosis. Thirty six patients with adequate histology were initially selected as typical of primary biliary cirrhosis or chronic active hepatitis; agreement both between observers and with original diagnoses was reached in 26 (72%) (15 with primary biliary cirrhosis (group 1), 11 with chronic active hepatitis (group 2)). In 19 diagnostically difficult patients in whom clinical and original histological findings had been at variance, histological agreement between observers was reached in 17 (group 3) and original underdiagnosis of primary biliary cirrhosis was suggested. The main clinical and histological differences between groups 1 and 2 are discussed in this paper. Although a high grade of positivity for copper associated protein in the Shikata orcein stain was seen only in primary biliary cirrhosis, a high titre of antimitochondrial antibody positivity was not unique to this condition.

Psychosocial impact of chronic infection with hepatitis B virus on British patients

The effects of chronic infection with hepatitis B virus (HBV) on the lives of 40 British patients were studied by means of a questionnaire. The aspects considered were: social, sexual, and family life, physical and psychological health, and work. Thirty six patients considered their lives to have been affected, nine mildly, 14 moderately, and 13 severely. The aspects of life most affected were: sexual (13), psychological (11), physical (5), work (3), social (2), and family (2). Most of the problems encountered were related to infectivity. The availability of vaccines against HBV and of successful antiviral treatment have solved some of the problems, but it remains important for the medical profession to be aware of the multifaceted impact of the carriage of HBV.

Chronic active hepatitis in alcoholic patients

The histologic appearances characteristic of chronic active hepatitis (CAH) were observed in liver biopsies of seven patients among whom alcohol abuse was the only identifiable determinant of liver disease. Clinical, hematologic, biochemical and histologic features in these patients were contrasted with those of 20 patients with typical alcoholic hepatitis. For the CAH group, the liver was less enlarged below the costal margin, a palpable spleen was more frequent, the mean neutrophil count was lower, and there was a lower mean level of transaminase enzymes. In both groups there was minimal evidence of the serologic markers of autoimmune CAH or antecedent hepatitis B virus (HBV) infection. Histologically, all liver biopsies in the CAH group showed perilobular "piecemeal" necrosis, "rosette" formation and dense portal and septal lymphoid infiltrates, in contrast to the fatty change, Mallory bodies and intralobular neutrophil clusters of the alcoholic hepatitis group. In the CAH group, a second liver biopsy was assessed after a period during which alcohol consumption was known; histologic improvement or deterioration correlated with abstinence or continuation of drinking. Thus "alcoholic" CAH has some clinical and histologic features distinct from those of typical alcoholic hepatitis, but the two types were similar in other respects including dependence of the course of disease on continuing use of alcohol.

Primary hepatocellular carcinoma following non-A, non-B posttransfusion hepatitis

In 1964 a 42-year-old woman was hospitalized with clinical and laboratory signs of posttransfusion hepatitis five weeks after administration of six whole blood transfusions. During the following 17 years anicteric chronic liver disease was repeatedly documented by elevations of serum aspartate aminotransferase (SGOT) and alkaline phosphatase enzymes. In 1981 hepatomegaly, progressive jaundice, and a serum alphafetoprotein level of 516,000 ng/ml were observed. Percutaneous liver biopsy showed a primary hepatocellular carcinoma (PHC). Serologic examinations failed to reveal markers for hepatitis B virus including HBsAg, anti-HBs, and anti-HBc by radioimmunoassay; antibody to hepatitis A virus was also absent. This sequence of events demonstrates a presumptive association of PHC and the agent(s) of non-A, non-B viral hepatitis.

Spontaneous disappearance of viral replication and liver cell inflammation in HBsAg-positive chronic active hepatitis: results of a placebo vs. interferon trial

In 20 patients with HBsAg-and HBeAg-positive chronic active hepatitis, we determined the long-term effect of human leukocyte interferon as well as placebo treatment. During the 2-year follow-up period, HBsAg remained present in all patients, but the Dane particle markers HBeAg and DNA polymerase disappeared in two of 10 patients who had received interferon, and in 4 of 10 patients from the placebo group. Patients, with loss of HBeAg initially had HBs antigenemia for a longer period as well as a lower serum concentration of both HBsAg and DNA polymerase, fewer HbcAg-containing hepatocyte nuclei, and higher serum transaminase levels than did the patients in whom HBeAg persisted. Disappearance of Dane particle markers was associated with a decrease in HBsAg titer, appearance of anti-HBe, normalization of the serum transaminases, and morphological transition to inactive chronic hepatitis. We conclude that, in HBsAg- and HBeAg-positive chronic active hepatitis, disappearance of Dane particle markers occurs in approximately 30% of the patients within a 2-year period and that arrest of active viral replication is associated with loss of activity of chronic hepatitis. Treatment with human leukocyte interferon in the doses used in this study did not change the natural course of the disease.

Indications for use of hepatitis B vaccine, based on cost-effectiveness analysis

To formulate indications for the use of hepatitis B vaccine, we examined the cost effectiveness of three strategies: vaccinating everyone; screening everyone and vaccinating those without evidence of immunity; and neither vaccinating nor screening, but passively immunizing those with known exposure. Estimates of the hepatitis attack rate, prevalence of immunity, and frequency of known exposure were made for three representative populations: homosexual men, surgical residents, and the general population of the United States. Screening followed by vaccination of homosexual men and vaccination without prior screening of surgical residents would result in savings of medical costs. Neither screening nor vaccination is the lowest-cost strategy for the general population. Vaccination of susceptible persons will save medical costs for populations with annual attack rates above 5 per cent. Vaccination may be considered cost effective (or cost saving when indirect costs are included) for populations with attack rates as low as 1 to 2 per cent.

Chronic persistent hepatitis: serological classification and meaning of the hepatitis B e system

In order to evaluate the prognostic implications of the hepatitis B e system in patients with chronic persistent hepatitis (CPH), 53 consecutive patients were studied. Fourteen of 16 patients with HBsAg and HBeAg were followed from 12 to 120 months (mean, 38 months). Eleven of the 14 patients were persistently HBeAg positive and five of these developed chronic active hepatitis (CAH) or cirrhosis. A further nine patients were HBsAg positive but HBeAg negative at time of CPH diagnosis (mean follow-up, 47 months). One of these nine patients developed CAH during follow-up. The remaining 28 patients were all HBsAg negative, and only 2 or the 28 patients progressed to CAH or cirrhosis during the time of follow-up (mean, 43 months). It is concluded that the persistence of HBeAg in patients with CPH indicates a serious prognosis with a frequent transition to CAH or cirrhosis.

Natural history of liver disease in chronic hepatitis B surface antigen carriers. Survey of 100 patients from Great Britain

100 consecutive British chronic carriers of hepatitis B surface antigen seen in a London teaching hospital are described. 77 were male homosexuals and only 19 had either symptoms or signs of chronic liver disease. 27 had normal liver function tests and 69 of the remaining patients had minimal changes, chronic persistent hepatitis, chronic active hepatitis, cirrhosis, or hepatocellular carcinoma diagnosed on liver biopsy. The 4 remaining patients did not have a biopsy but did have abnormal liver function tests. Chronic hepatitis B virus infection was an important cause of these conditions. Most patients showed no clinical, biochemical, or histological change during a mean follow-up period of 44 months, and only 9.7% spontaneously seroconverted from hepatitis B antigen positivity to become anti-hepatitis B e antibody carriers. Although the prognosis is good in the medium term, 7 patients died from hepatocellular carcinoma.

Dane particle DNA polymerase and HBeAg: impact on clinical, laboratory, and histologic findings in hepatitis B-associated chronic liver disease

Fifty patients with chronic HBs antigenemia and Dane particle-associated DNA polymerase and HBeAg in their serum were contrasted to 46 HBsAg positive patients who had neither serum DNA polymerase or HBeAg. The time from acute onset and the duration of antigenemia were longer in patients who were DNA polymerase and HBeAg negative than in those who had both serum markers. Cirrhosis, hypoalbuminemia, and sequelae of chronic liver disease were more common in DNA polymerase, HBeAg negative patients than in those who were positive. These findings are consistent with the hypothesis that active viral replication is an early, albeit prolonged stage in the development of advanced HBsAg-associated liver disease.

Deleterious effect of prednisolone in HBsAg-positive chronic active hepatitis

To study the efficacy of corticosteroids in chronic active hepatitis (CAH) positive for hepatitis B surface antigen (HBsAg), we pair-randomized 51 patients to receive either 15 to 20 mg of prednisolone per day or a placebo. After initial remission, the maintenance dosage of prednisolone was 10 mg per day, and the patients were prospectively followed for up to 3 1/2 years. Prednisolone decreased serum bilirubin (P < 0.05) and globulin (P < 0.01) at three months; it delayed other biochemical remission occurring after the second month of medication (P < 0.001); it hastened biochemical relapse (P < 0.0001); and it increased the frequency of complications (P < 0.0001) and the death rate (P < 0.01). We conclude that prednisolone has an overall harmful effect in patients with HBsAg-positive CAH.

An epidemic of type B viral hepatitis: its course and outcome

Between June and August, 1977 there was a small epidemic of type B viral hepatitis in a market town in South-East England during which 4 people developed acute hepatitis. Their close friends and contacts were all negative for hepatitis B surface antigen (HBsAg) at this time. One year later, in July 1978, 3 of the original 4 patients were available for follow-up. All were HBsAg negative but hepatitis B surface antibody (anti-HBs) and hepatitis B core antibody (anti-HBc) positive. Two had disturbed liver function tests and chronic persistent hepatitis on liver biopsy. Also at this time 2 of the original contacts were found to show evidence, from the serum markers, of previous infection by the type B virus. Both had abnormal liver function tests and showed chronic persistent or chronic active hepatitis on liver biopsy. A further subject was identified who had had an overt hepatitis 1 year previously and who also showed evidence of continuing liver disease. The origin of the epidemic and its spread through the group were identified. The varying modes of transmission, and the variation in clinical picture and sequelae are discussed. The importance of anti-HBc as a marker of hepatitis B virus infection is emphasised.

The role of acute hepatitis type A, B, and non-A non-B in the development of chronic active liver disease

In 19 patients followed from biopsy-verified acute viral hepatitis to chronic active liver disease and 74 patients followed to complete resolution verified by a normal liver biopsy, sera from the acute phase were studied for serologic evidence of hepatitis type A and B. Eleven of the 19 patients who developed chronic active liver disease progressed from acute hepatitis type B and 7 from acute hepatitis type non-A non-B. One patient could not be classified because the sera were exhausted. None had serological markers of actual hepatitis type A infection. Of the 74 patients with a histologically complete resolution, the acute episode could be classified as type B hepatitis in 47 and type A hepatitis in 13 patients. The remaining 14 patients were classified as having acute viral hepatitis type non-A non-B. Our findings confirm that type B and non-A non-B hepatitis may give rise to chronic liver disease, whereas type A hepatitis so far has not been demonstrated to initiate a chronic liver disease.

Circulating autoantibodies in patients with acute viral hepatitis. Relation to etiology and clinical course

The prevalences of liver-cell-membrane antibody (LMA), smooth-muscle antibodies, antinuclear antibodies and antimitochondrial antibodies were evaluated in 63 selected patients with acute viral hepatitis of types A, B, and non-A non-B. Twenty patients had a complete, uneventful recovery, 19 patients had fulminant hepatitis, and 24 progressed to a chronic liver disease. Acute-phase and follow-up sera from all patients were tested for antibodies of IgA, IgM, and IgG class. The prevalences of the IgM autoantibodies in the acute-phase sera were not significantly different in the three groups irrespective of clinical outcome. Similar prevalences were found with respect to IgG class; however, antinuclear antibodies of IgG class were predominantly found in acute-phase sera from patients who later progressed to a chronic liver disease. The diagnostic significance of these autoantibodies was stressed by the fact that 85% of the sera with LMA of IgG class and 100% of the follow-up sera with smooth-muscle antibodies of IgG class at a titer at or above 1:128 originated from patients with chronic liver disease. A similar pattern was found for antinuclear antibodies, and testing for all these antibodies of IgA anad IgM class did not yield any further information. In some serum samples LMA could be found independently of smooth-muscle antibody and vice versa, indicating the essential difference between these two autoantibodies.