EASL International Consensus Conference on Hepatitis B. 13-14 September, 2002 Geneva, Switzerland. Consensus statement (long version)

Chronic hepatitis B: Immunological profile and current therapeutic vaccines in clinical trials

More than 250million people worldwide are chronically infected with hepatitis B virus (CHB), and over half a million die each year due to CHB-associated liver complications such as cirrhosis and hepatocellular carcinoma. The translation of immunological knowledge about CHB into therapeutic strategies aiming to a sustainable hepatitis B virus (HBV) clearance has been challenging. In recent years, however, the understanding on the immune effectors required to overcome chronicity has notably increased thanks to preclinical and clinical research. Therapeutic vaccination may prove to be useful for treating CHB patients when coupled with current antiviral agents and other immunomodulatory strategies. This review summarizes current data and future perspectives on therapeutic vaccination. Other treatment alternatives that could be combined with vaccines for a complete cure from hepatitis B virus infection are also discussed.

Liver Failure due to Acute Viral Hepatitis (A-E)

BACKGROUND

Viral hepatitis is still one of the key causes of acute liver failure (ALF) in the world.

METHODS

A selective literature search of the PubMed database was conducted, including current studies, reviews, meta-analyses, and guidelines. We obtained an overview of ALF due to viral hepatitis in terms of epidemiology, course, and treatment options.

RESULTS

Most fulminant viral courses are reported after infection with hepatitis A, B, and B/D, but not with hepatitis C. Hepatitis E is also known to cause ALF but has not gained much attention in recent years. However, more and more autochthonous hepatitis E virus infections have been recently observed in Europe. Reactivation of hepatitis B virus (HBV) under immunosuppressive conditions, such as after intensive chemotherapy, is also an increasing problem. For most viral-induced cases of ALF, liver transplantation represented the only therapeutic option in the past. Today, immediate treatment of HBV-induced ALF with nucleotide or nucleoside analogs is well tolerated and beneficially affects the course of the disease.

CONCLUSION

Although numbers in Western European countries are decreasing rapidly, reliable diagnostic screening for hepatitis A-E is necessary to identify the etiology and to determine those most at risk of developing ALF.

Efficiency and safety of radiofrequency-assisted hepatectomy for hepatocellular carcinoma with cirrhosis: A single-center retrospective cohort study

AIM: To assess the efficiency and safety of radiofrequency-assisted hepatectomy in patients with hepatocellular carcinoma (HCC) and cirrhosis.

METHODS: From January 2010 to December 2013, 179 patients with HCC and cirrhosis were recruited for this retrospective study. Of these, 100 patients who received radiofrequency-assisted hepatectomy (RF+ group) were compared to 79 patients who had hepatectomy without ablation (RF- group). The primary endpoint was intraoperative blood loss. The secondary endpoints included liver function, postoperative complications, mortality, and duration of hospital stay.

RESULTS: The characteristics of the two groups were closely matched. The Pringle maneuver was not used in the RF+ group. There was significantly less median intraoperative blood loss in the RF+ group (300 vs 400 mL, P = 0.01). On postoperative days (POD) 1 and 5, median alanine aminotransferase was significantly higher in the RF+ group than in the RF- group (POD 1: 348.5 vs 245.5, P = 0.01; POD 5: 112 vs 82.5, P = 0.00), but there was no significant difference between the two groups on POD 3 (260 vs 220, P = 0.24). The median AST was significantly higher in the RF+ group on POD 1 (446 vs 268, P = 0.00), but there was no significant difference between the two groups on POD 3 and 5 (POD 3: 129.5 vs 125, P = 0.65; POD 5: 52.5 vs 50, P = 0.10). Overall, the rate of postoperative complications was roughly the same in these two groups (28.0% vs 17.7%, P = 0.11) except that post hepatectomy liver failure was far more common in the RF+ group than in the RF- group (6% vs 0%, P = 0.04).

CONCLUSION: Radiofrequency-assisted hepatectomy can reduce intraoperative blood loss during liver resection effectively. However, this method should be used with caution in patients with concomitant cirrhosis because it may cause severe liver damage and liver failure.

Chronic hepatitis B: Virology, natural history, current management and a glimpse at future opportunities

The host immune system plays an important role in chronic hepatitis B (CHB), both in viral clearance and hepatocellular damage. Advances in our understanding of the natural history of the disease have led to redefining the major phases of infection, with the "high replicative, low inflammatory" phase now replacing what was formerly termed the "immune tolerant" phase, and the "nonreplicative phase" replacing what was formerly termed the "inactive carrier" phase. As opposed to the earlier view that HBV establishes chronic infection by exploiting the immaturity of the neonate's immune system, new findings on trained immunity show that the host is already somewhat "matured" following birth, and is actually very capable of responding immunologically, potentially altering future hepatitis B treatment strategies. While existing therapies are effective in reducing viral load and necroinflammation, often restoring the patient to near-normal health, they do not lead to a cure except in very rare cases and, in many patients, viremia rebounds after cessation of treatment. Researchers are now challenged to devise therapies that will eliminate infection, with a particular focus on eliminating the persistence of viral cccDNA in the nuclei of hepatocytes. In the context of chronic hepatitis B, new definitions of 'cure' are emerging, such as 'functional' and 'virological' cure, defined by stable off-therapy suppression of viremia and antigenemia, and the normalization of serum ALT and other liver-related laboratory tests. Continued advances in the understanding of the complex biology of chronic hepatitis B have resulted in the development of new, experimental therapies targeting viral and host factors and pathways previously not accessible to therapy, approaches which may lead to virological cures in the near term and functional cures upon long term follow-up. This article forms part of a symposium in Antiviral Research on "An unfinished story: from the discovery of the Australia antigen to the development of new curative therapies for hepatitis B."

Estimation of Hepatitis B Virus, Hepatitis C Virus, and Different Clinical Parameters in the Thalassemic Population of Capital Twin Cities of Pakistan

Hepatitis B and C are serious public health problems worldwide. Thalassemia patients are dependent on blood transfusions throughout their life and are at high risk of viral infections. The aim of this study was to estimate the prevalence of hepatitis B/C infections and different clinical parameters in multitransfused thalassemia population. In this study, 262 multitransfused β-thalassemia patients were enrolled from the capital twin cities of Pakistan. The presence of hepatitis B virus (HBV)/hepatitis C virus (HCV), alanine aminotransferase (ALT) level, serum creatinine, serum ferritin, hepatomegaly, splenomegaly, and splenectomy were analyzed. The overall prevalence of HBV and HCV was 3.08% and 55.73%, respectively, with 100% of patients older than 20 years had HCV infection. The ALT levels among HBV- and HCV-positive thalassemia patients were 92.62 ± 41.57 U/L and 98 ± 63.65 U/L, respectively; creatinine values observed were 0.4 ± 0.35 mg/dL (for HBV) and 0.39 ± 0.24 mg/dL (for HCV), while serum ferritin levels were 6865.87 ± 1649.13 ng/dL (for HBV) and 5445.95 ± 3059.28 ng/dL (for HCV). A total of 74.8% and 82.20% of HBV- and HCV-positive patients had hepatomegaly with an average increase in liver size of 4.17 and 4.33 cm, respectively. Splenomegaly was observed in 64.9% and 67.12% of HBV- and HCV-positive patients with an average increase in spleen size of 4 and 4.46 cm, respectively. Splenectomy was observed among 14.50% and 15.75% of HBV- and HCV-infected thalassemia patients. There is a strong need to properly screen blood before transfusions to reduce the future load of viral hepatitis from Pakistan.

Role of maternal viremia and placental infection in hepatitis B virus intrauterine transmission

The mechanism of intrauterine hepatitis B virus infection has not been established. In this study, venous blood, cord blood, and placental tissues from 171 chronic hepatitis B virus infected pregnant women were tested for hepatitis B surface antigen, hepatitis B core antigen, and hepatitis B virus DNA. We found that residence, mode of delivery, age, and number of gestational weeks of pregnant women were not correlated with intrauterine hepatitis B virus infection, while neonates of mothers who were hepatitis B s antigen positive and hepatitis B e antigen positive (P < 0.01) or who had high hepatitis B virus DNA levels (≥10(6) copies/ml) were more likely to get an intrauterine infection (P < 0.01). The hepatitis B virus infection rate in placental cell layers gradiently decreased from the mother's side to the fetus's side of the placenta, but the odds ratio value of correlation between placental hepatitis B virus infection and intrauterine infection gradiently increased. The way of intrauterine hepatitis B virus infection may be through a layer-layer transmission pathway, although the possibility of placental leakage cannot be excluded.

The HepaRG cell line: a valuable in vitro tool for hepatitis virus infection studies

Hepatitis virus infections, mainly hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, constitute a major problem for public health since they have a worldwide distribution and because they are associated with hepatocellular carcinoma and death. Current anti-HBV vaccines seem to be effective in the majority of people. However, an important issue waiting to be tackled nowadays is how to cure patients with chronic hepatitis B. Moreover, no vaccine is available today for the prevention of HCV infection. Therefore, the use of adequate in vitro infection systems is a prerequisite for the molecular understanding of the infection events of these viruses, which could result in the development of novel powerful therapeutics. In this respect, the HepaRG cell line exhibits a hepatocyte-like morphology and displays drug metabolism capacity similar to that of primary hepatocytes. HepaRG cells have yet been proven to be a useful tool in the study of viral infections, particularly for deciphering the mechanism of HBV entry into hepatocytes.

Discrepancy of potential antiviral resistance mutation profiles within the HBV reverse transcriptase between nucleos(t)ide analogue-untreated and -treated patients with chronic hepatitis B in a hospital in China

Little is known about the discrepancy of the potential antiviral resistance mutation profiles within the hepatitis B virus (HBV) reverse transcriptase (RT) between nucleos(t)ide analogue (NA)-untreated and -treated patients with chronic hepatitis B. Full-length HBV RT sequences from 59 NA-treated and 105 NA-untreated Chinese patients were amplified and sequenced. Forty-two potential NA resistance (NAr) mutation sites were screened within these 164 RT sequences. The NAr mutation prevalence and frequency in the NA-treated group were significantly higher than those in the NA-untreated one (P < 0.001, respectively). The classical primary drug resistance and secondary/compensatory mutations were only detected at seven sites (rtL80, rtI169, rtL180, rtA181, rtT184, rtM204, and rtN236) in NA-treated patients. The non-classical putative NAr and pre-treatment mutations were observed at 22 sites (rtT38, rtN/S53, rtL82, rtL/I91, rtN/Y124, rtH126, rtT128, rtN/D134, rtN139, rtR153, rtV191, rtV207, rtS213, rtV214, rtE218, rtY/F221, rtV/I224, rtL229, rtI233, rtN/H238, rtR242, and rtS/C256) in both groups. Substitutions at seven non-classical mutation sites were of interest due to either detection only in patients with virologic breakthrough (rtL82 and rtV214), or potential ties with HBV genotypes (rtV191 and rtL229), or coexistence with rtM204I/V (rtL229), or increased mutation trends after NA-treatment (rtT128, rtV207, and rtN/H238). In conclusion, NA treatment not only constitutes a major selection factor for the primary and secondary/compensatory NAr mutations but also drives the changes of some of the putative NAr mutation sites, most of which are the genotype-independent RT sites (rtL82, rtT128, rtV191, rtV207, rtV214, rtL229, and rtN/H238). Their antiviral resistance potential calls for further investigations.

Immune response and immunologic memory in medical personnel vaccinated with hepatitis B vaccine

The occupation-related nature of Hepatitis B viral infection in medical personnel has been well documented in a lot of studies. The only reliable way of prevention of this infection is immunisation with hepatitis B vaccine.

AIM

To follow-up the primary immune response after immunisation with recombinant vaccine and its duration in adult immunocompetent subjects.

MATERIALS AND METHODS

One hundred sixty-five health-care workers working at St. George University Hospital, Plovdiv in 2009/2010 were included in the study and allocated to two groups. Group 1 (N1 = 70) was followed up for the primary immune response after immunization; group 2 (N2 = 95) was with documented immunization in 1998/1999 (n = 81) and in 1994/1995 (n = 14). Tests based on ELISA for quantitative determination of anti-HBs in mIU/ml were used. The measurement were performed at the National Reference Laboratory of Viral Hepatitis at the NCIPD, Sofia. Descriptive statistics, non-parametric and parametric tests, qualitative correlation were used to analyse data.

RESULTS

Group 1 mean age was 40.3 +/- 2.6 years; anti-HBs concentration of > or = 10 mIU/ ml was found in 92.8%. No association between the immune response and the commonly involved factors such as gender, age, overweight, smoking, etc., was found. In group 2, anti-HBs concentration of > or = 10 mIU/ml was found in 77.9%: it was in 75.3% in those immunized 10 years before, and in 92.9% in those immunized 15 years before (t = 0.24, p > 0.05). A booster dose of the vaccine was received by 15/21 subjects from group 2 (those immunized 10 years before that) with anti-HBs < 10 mIU/ml. After the booster, 9/15 produced anti-HBs in protective concentrations (anamnestic immune response). The actual level of seroprotection among the immunized more than 10 years ago was 92%.

CONCLUSION

This study and the documentation of the primary postvaccinal immunity in high-risk medical personnel will help specify if additional hepatitis B vaccine shots are needed.

Hepatitis B virus infection and pregnancy

Pregnancy only mildly affects that natural progression of acute and chronic infection by the hepatitis B virus (HBV) but it does bring to light three important questions. Mother to child (vertical) transmission risk is best prevented by mandatory HBs antigen testing in all pregnant women in their second trimester and by systemic serovaccination of newborns of infected mothers. In mothers with high viral load, vertical infection in utero could be prevented by lamivudine, telbivudine or tenofovir treatment. Invasive obstetric or gynecological procedures (such as amniocentesis, forceps, etc.) do not seem to increase the risk of vertical infection. Breastfeeding is not contraindicated in maternal HBV infection after serovaccination of the newborn. This holds true for mothers on active treatment with tenofovir which is not absorbed into breast milk. When it comes to managing active antiviral treatment, in absence of virosuppression with lamivudine, tenofovir remains a logical step-up treatment; in absence of virosuppression with adefovir, tenofovir also remains a logical step-up choice as do tenofovir/emtricitabine combinations or lamivudine in absence of preexisting resistance which may have been induced during combination treatment of adefovir and lamivudine. In cases of effective virosuppression with treatment by analogues, lamivudine should be continued and entecavir should eventually be replaced by lamivudine, telbivudine or tenofovir; adefovir should be replaced by tenofovir or lamivudine in absence of resistance (which would require tenofovir therapy) or adefovir which would restrict lamivudine therapy.

Burden of disease related to hepatitis C and hepatitis B in Spain: a methodological challenge of an unfolding health problem

Most previous studies of burden of disease (BoD) in the area of transmissible diseases have assessed the burden of hepatitis C and B without including the end stages of the disease and using an incident approach. We aimed to assess the disability-adjusted life years (DALYs) related to hepatitis C and B in Spain in 2006 taking into account related cirrhosis and liver cancer. A prevalence approach was used to estimate current years lived with disability (YLD) because of viral hepatitis contracted years/decades before. We added years of life lost (YLL) to obtain DALYs. Around 76,000 DALYs were attributed to hepatitis C virus (HCV) and 15,323 to hepatitis B virus (HBV) when calculated without applying social values. Applying the discount rate and age-weighting used in the Global Burden Disease study, the BoD nearly halved. In any case, the burden related to hepatitis C including long-term outputs becomes the leading cause of DALYs among transmissible diseases in Spain. The mortality component (YLL) represents more than 90% of the BoD in both HCV and HBV. The findings emphasize the need to provide good surveillance systems not only concerning acute viral hepatitis, but also chronic and end-stage consequences to allow a reliable assessment of the prevention and public health control policies.

Antiviral treatment of hepatitis B virus and hepatitis C virus co-infection

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are among the most common causes of advanced chronic liver disease worldwide. HBV/HCV co-infection is not uncommon with an estimated 7-20 million individuals affected worldwide. Patients with HBV/HCV co-infection have an increased risk of cirrhosis, hepatocellular carcinoma (HCC), and even death. The pathophysiology of HBV/HCV co-infection is complex, as different patterns of virological dominance may occur, which can even fluctuate over time. Recently, combination of pegylated interferon (PEG-IFN) plus ribavirin has been explored in HBV/HCV-coinfected patients who are positive for HCV-RNA. In this paper, we summarize the epidemiology, viral interaction and clinical features of HBV/HCV co-infection and the available treatment options. Detailed serological and virological evaluations are required for HBV/HCV-co-infected patients before initiation of antiviral therapy. At present, PEG-IFN-a plus ribavirin should be the treatment of choice in patients with dominant HCV replication. However, HBV rebound may occur after elimination of HCV, and thus close monitoring for both viruses is recommended even for patients with initially suppressed HBV DNA.

Evaluation of current treatment recommendations for chronic hepatitis B: a 2011 update

BACKGROUND AND AIM

Guidelines for the treatment of chronic hepatitis B have been recently updated in the 2009 European Association for the Study of the Liver consensus statement, the 2008 US Panel, the 2008 Asian-Pacific consensus statement, and the 2009 American Association for the Study of Liver Disease practice guidelines. We sought to determine whether these guidelines identified patients who developed hepatocellular carcinoma (HCC) or who died of non-HCC liver-related deaths for antiviral therapy.

METHODS

The criteria described in the new treatment guidelines were matched to the database of 369 hepatitis B surface antigen-positive patients, in whom 30 developed HCC and 37 died of non-HCC liver-related deaths during a mean follow up of 84 months.

RESULTS

Using criteria for antiviral therapy as stated by the four current guidelines, 19-30% of patients who died of non-HCC liver-related complications, and 23-53% of patients who developed HCC, would have been excluded for antiviral therapy. If baseline serum albumin levels of ≤ 3.5 g/dL or platelet counts of ≤ 130,000 mm(3) were included into the treatment criteria, then 85-94% of patients who developed liver-related complications would have been recommended for antiviral therapy. Also, the addition of precore A1896 mutants and basal core promoter T1762/A1764 mutants would have identified 98.5-100% of these patients.

CONCLUSION

The updated treatment guidelines for hepatitis B still excluded patients who developed serious liver-related complications. The inclusion of baseline serum albumin and platelet counts to current criteria would have identified a majority of these patients for antiviral therapy. These tests should be included into hepatitis B treatment strategies.

Mean platelet volume as a fibrosis marker in patients with chronic hepatitis B

INTRODUCTION

Many noninvasive tests have been studied for the diagnosis and determining the liver fibrosis score (LFS). In this study, we aimed to research the correlation of mean platelet volume (MPV) and stage of liver fibrosis in patients with chronic hepatitis B (CHB).

PATIENTS AND METHODS

Fifty-nine patients with CHB were enrolled retrospectively into the study. Age-sex matched 25 healthy subjects were used as control group. The following data were obtained from computerized patient registry database: HBV-DNA level, hepatitis B e-antigen seropositivity, liver enzymes and function tests, white blood cell count, platelet count, hemoglobin, histological activity index, LFS, and MPV. Patients were divided into two groups: patients without significant fibrosis (F0, F1, or F2) (Group 1) and patients with advanced fibrosis (F3, F4) (Group 2).

RESULTS

A statistically significant increase in MPV was seen in patients with CHB compared with healthy controls (8.49±0.84 fl vs.7.65±0.42 fl, P<0.001). Receiver operating characteristic curve analysis suggested that the optimum MPV level cut-off points for CHB was 8.0 fl, with sensitivity, specificity, PPV, and NPV of 68, 76, 86, and 50%, respectively. MPV levels were significantly higher in Group 2 (8.91±0.94 fl, P: 0.009) compared with Group 1 (8.32±0.74 fl). ROC curve analysis suggested that the optimum MPV level cut-off points for Group 2 was 8.45 fl, with sensitivity, specificity, positive and negative predictive value of 77, 59, 45, and 85%, respectively. Multivariable logistic regression model, which consisted of HAI, ALT, HBV-DNA, platelet count, and MPV, was performed. We showed that MPV was independently associated with advanced fibrosis (P: 0.031).

CONCLUSION

We suggest that MPV might help in the assessment of fibrosis in CHB. It should not be considered a stand-alone test for this use owing to nonspecificity with other diseases.

Caspase-cleaved fragments of cytokeratin 18 in patients with chronic hepatitis B

BACKGROUND

During hepatocyte apoptosis, intermediate filament protein cytokeratin 18 is cleaved by caspases at Asp396 which can be specifically detected by the monoclonal antibody M30 (M30-antigen). In this study, we sought to determine whether serum M30-antigen levels can serve as a useful biomarker of liver injury in the clinical spectrum of HBV infection.

METHODS

Serum M30-antigen levels were measured in inactive HBV carriers (n=54), patients with HBeAg-negative chronic hepatitis B (CHB, n=47), patients with HBeAg-positive CHB (n=42) and healthy controls (n=29). All subjects were treatment-naïve.

RESULTS

There were significant differences in serum M30-antigen levels across the study groups (P<0.001; Kruskal-Wallis test). Post hoc analyses revealed that M30-antigen levels did not differ significantly between inactive HBV carriers (median 109.6 U/L) and healthy controls (median 106.1 U/L). However, both patients with HBeAg-negative (CHB, median 182.9 U/L, P<0.001) and HBeAg-positive CHB (median 158.3 U/L, P<0.001) had significantly higher levels of M30-antigen compared with inactive HBV carriers.

CONCLUSIONS

Hepatocyte apoptotic activity--as reflected by serum M30-antigen levels--is increased in chronic active hepatitis B, but is not associated with the HBeAg status. In contrast, apoptosis does not appear to be a prominent feature of inactive HBV carriers.

Factors that predict response of patients with hepatitis B e antigen-positive chronic hepatitis B to peginterferon-alfa

BACKGROUND & AIMS

Therapy with pegylated interferon (PEG-IFN)-alfa results in sustained response in a minority of patients with chronic hepatitis B virus (HBV) infection and has considerable side effects. We analyzed data from the 2 largest global trials of hepatitis B e antigen (HBeAg)-positive patients with chronic hepatitis B to determine which are most likely to respond to PEG-IFN-alfa therapy.

METHODS

The study included 542 patients treated with PEG-IFN-alfa-2a (180 microg/wk, 48 wk) and 266 patients treated with PEG-IFN-alfa-2b (100 microg/wk, 52 wk). Eighty-seven patients were excluded, leaving 721 patients for analysis. A sustained response was defined as HBeAg loss and HBV-DNA level less than 2.0 x 10(3) IU/mL 6 months after treatment. Logistic regression analysis was used to identify predictors of sustained response and a multivariable model was constructed.

RESULTS

HBV genotype, high levels of alanine aminotransferase (ALT; >or=2 x upper limit of normal), low levels of HBV DNA (<2.0 x 10(8) IU/mL), female sex, older age, and absence of previous IFN therapy predicted a sustained response. Genotype A patients with high ALT and/or low HBV-DNA levels had a high predicted probability (>30%) of a sustained response. The strongest predictors of response were a high level of ALT in genotype B patients and a low level of HBV DNA in genotype C patients. Genotype D patients had a low chance of sustained response, irrespective of ALT or HBV-DNA levels.

CONCLUSIONS

The best candidates for a sustained response to PEG-IFN-alfa are genotype A patients with high levels of ALT or low levels of HBV DNA, and genotypes B and C patients who have both high levels of ALT and low HBV DNA. Genotype D patients have a low chance of sustained response.

T3098C and T53C mutations of HBV genotype C is associated with HBV infection progress

OBJECTIVE

To analyze the association between mutation(s) in preS region of HBV and hepatitis B disease progress in Chinese patients with genotype C chronic HBV infection.

METHODS

Ninety-three patients with chronic genotype C HBV infection, including 24 asymptomatic carriers (ASC), 26 patients with chronic hepatitis B (CHB), 22 patients with liver cirrhosis (LC) and 21 HCC patients were investigated. Levels of HBV DNA, HBeAg, alanine aminotransferase (ALT), asparate transaminase (AST) were measured. HBV preS region was analyzed by PCR direct sequencing.

RESULTS

The prevalence of preS T3098C and T53C mutations of genotype C HBV was significantly higher in LC and HCC patients than ASC and CHB patients. The rate of T3098C mutation in ASC, CHB, LC, and HCC patients were 0.00% (0/24), 3.85% (1/26), 9.09% (2/22), and 30.77% (8/22), respectively (P=0.0015), while the rate of T53C mutation was 12.50% (3/24), 3.85% (1/26), 40.91% (9/22), and 42.31% (11/26), respectively (P=0.0012).

CONCLUSION

The frequency of genotype C HBV preS T3098C and T53C mutations is associated with hepatitis B infection progression

Meta-analyses on viral hepatitis

This article summarizes the meta-analyses of interventions for viral hepatitis A, B, and C. Some of the interventions assessed are described in small trials with unclear bias control. Other interventions are supported by large, high-quality trials. Although attempts have been made to adjust for unclear bias control, analysis of publication bias and other biases is difficult when only few trials are available. It is possible that some of the meta-analyses presented in this article are biased. Furthermore, performing updated cumulative meta-analyses also may introduce random error.3,4 The extent and direction of bias may vary. On average, however, bias leads to overestimated intervention benefits.1 Accordingly, the benefit of some of the interventions suggested in this article may be exaggerated by systematic and random errors. Additional research including large, randomized trials is necessary to clarify the true intervention effects.

Hepatitis B virus surface antigen levels: a guide to sustained response to peginterferon alfa-2a in HBeAg-negative chronic hepatitis B

We investigated the relationship between hepatitis B virus surface antigen (HBsAg) serum level decline and posttreatment response in patients with hepatitis B e antigen (HBeAg)-negative chronic hepatitis B from a large multinational study of pegylated interferon alfa-2a (peginterferon alfa-2a), with or without lamivudine, versus lamivudine alone. Serum HBsAg was quantified using the Architect assay (Abbott Diagnostics) at pretreatment, end of treatment (week 48), and 6 months after the end of treatment (week 72) in sera from 386 of the 537 patients who participated in the multinational study (peginterferon alfa-2a, 127; peginterferon alfa-2a plus lamivudine, 137; lamivudine monotherapy, 122). Pretreatment HBsAg levels varied according to genotype, with the highest levels present in patients infected with genotypes A (median, 4.11 log(10) IU/mL) and D (median, 3.85 log(10) IU/mL). Significant on-treatment decline in HBsAg was observed during treatment with peginterferon alfa-2a (alone or combined with lamivudine; mean decline at week 48, -0.71 and -0.67 log(10) IU/mL, respectively, P < 0.001), but not during treatment with lamivudine alone (-0.02 log(10) IU/mL). Significantly more patients treated with peginterferon alfa-2a (21%) or peginterferon alfa-2a plus lamivudine (17%) achieved HBsAg levels <100 IU/mL at the end of treatment compared with lamivudine (1%) (both P < 0.001 versus lamivudine). End-of-treatment HBsAg level correlated strongly with HBV DNA suppression to <or=400 copies/mL 6 months posttreatment. An HBsAg level <10 IU/mL at week 48 and on-treatment decline >1 log(10) IU/mL were significantly associated with sustained HBsAg clearance 3 years after treatment (both P < 0.0001).

CONCLUSION

On-treatment quantification of HBsAg in patients with HBeAg-negative chronic hepatitis B treated with peginterferon alfa-2a may help identify those likely to be cured by this therapy and optimize treatment strategies.

Hepatitis B and hepatitis C in 2009

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are among the most frequent viral infections in humans, and represent a major global public health problem. HBV- and HCV-related chronic hepatitis are the main causes of cirrhosis and hepatocellular carcinoma (HCC) that are responsible for a high rate of morbidity and mortality. End-stage HBV- and HCV-related liver disease and HCC are the main causes of liver transplantation. In the last few years, knowledge of the epidemiology and the natural history of HBV and HCV infection has markedly improved. Furthermore, considerable progress has been made in the efficacy of therapy. New drugs and new therapeutic strategies that are currently under evaluation could further improve the efficacy of therapy in the near future.

[Nucleoside and nucleotide analogs in the treatment of chronic hepatitis B]

At least 4 nucleos(t)ide analogs have been approved for the treatment of chronic hepatitis B: lamivudine, adefovir dipivoxil, entecavir, and telbivudine. The introduction of these drugs has radically changed the treatment of this disease. The advantages of these drugs are their oral administration, excellent tolerability and efficacy in all types of chronic hepatitis B (compensated and decompensated disease). The limitations are the need for prolonged treatments, which hampers adherence and can cause selection of HBV strains resistant to distinct drugs. The resistance rate differs for each of the drugs. Nucleotide analogs such as adefovir and tenofovir are useful in patients resistant to nucleoside analogs such as lamivudine, entecavir and telbivudine and vice versa. In cases of resistance to one of these drugs, combined treatment is advised.

A treatment algorithm for the management of chronic hepatitis B virus infection in the United States: 2008 update

Chronic HBV infection is an important public health problem worldwide and in the United States. A treatment algorithm for the management of this disease, published previously by a panel of U.S. hepatologists, has been revised on the basis of new developments in the understanding of the disorder, the availability of more sensitive molecular diagnostic tests, and the licensure of new therapies. In addition, a better understanding of the advantages and disadvantages of new treatments has led to the development of strategies for reducing the rate of resistance associated with oral agents and optimizing treatment outcomes. This updated algorithm was based primarily on available evidence by using a systematic review of the literature. Where data were lacking, the panel relied on clinical experience and consensus expert opinion. The primary aim of antiviral therapy is durable suppression of serum HBV DNA to low or undetectable levels. Assays can now detect serum HBV DNA at levels as low as 10 IU/mL and should be used to establish a baseline level, monitor response to antiviral therapy, and survey for the development of drug resistance. Interferon alfa-2b, lamivudine, adefovir, entecavir, peginterferon alfa-2a, telbivudine, and tenofovir are approved as initial therapy for chronic hepatitis B and have certain advantages and disadvantages. Although all of these agents can be used in selected patients, the preferred first-line treatment choices are entecavir, peginterferon alfa-2a, and tenofovir. Issues for consideration for therapy include efficacy, safety, rate of resistance, method of administration, and cost.

Liver stiffness in the hepatitis B virus carrier: A non-invasive marker of liver disease influenced by the pattern of transaminases

AIM: To investigate the usefulness of transient elastography by Fibroscan (FS), a rapid non-invasive technique to evaluate liver fibrosis, in the management of chronic hepatitis B virus (HBV) carriers.

METHODS: In 297 consecutive HBV carriers, we studied the correlation between liver stiffness (LS), stage of liver disease and other factors potentially influencing FS measurements. In 87 chronic hepatitis B (CHB) patients, we monitored the FS variations according to the spontaneous or treatment-induced variations of biochemical activity during follow-up.

RESULTS: FS values were 12.3 ± 3.3 kPa in acute hepatitis, 10.3 ± 8.8 kPa in chronic hepatitis, 4.3 ± 1.0 kPa in inactive carriers and 4.6 ± 1.2 kPa in blood donors. We identified the cut-offs of 7.5 and 11.8 kPa for the diagnosis of fibrosis ≥ S3 and cirrhosis respectively, showing 93.9% and 86.5% sensitivity, 88.5% and 96.3% specificity, 76.7% and 86.7% positive predictive value (PPV), 97.3% and 96.3% negative predictive value (NPV) and 90.1% and 94.2% diagnostic accuracy. At multivariate analysis in 171 untreated carriers, fibrosis stage (t = 13.187, P < 0.001), active vs inactive HBV infection (t = 6.437, P < 0.001), alanine aminotransferase (ALT) (t = 4.740, P < 0.001) and HBV-DNA levels (t = -2.046, P = 0.042) were independently associated with FS. Necroinflammation score (t = 2.158, > 10/18 vs≤ 10/18, P = 0.035) and ALT levels (t = 3.566, P = 0.001) were independently associated with LS in 83 untreated patients without cirrhosis and long-term biochemical remission (t = 4.662, P < 0.001) in 80 treated patients. During FS monitoring (mean follow-up 19.9 ± 7.1 mo) FS values paralleled those of ALT in patients with hepatitis exacerbation (with 1.2 to 4.4-fold increases in CHB patients) and showed a progressive decrease during antiviral therapy.

CONCLUSION: FS is a non-invasive tool to monitor liver disease in chronic HBV carriers, provided that the pattern of biochemical activity is taken into account. In the inactive carrier, it identifies non-HBV-related causes of liver damage and transient reactivations. In CHB patients, it may warrant a more appropriate timing of control liver biopsies.

New antiviral choice for chronic hepatitis B: tenofovir disoproxil fumarate

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

Entecavir therapy for lamivudine-refractory chronic hepatitis B: improved virologic, biochemical, and serology outcomes through 96 weeks

In hepatitis B e antigen (HBeAg)-positive chronic hepatitis B patients who were refractory to current lamivudine therapy, switching to entecavir was superior to continued lamivudine at week 48 for histologic improvement, viral load reduction by polymerase chain reaction and alanine aminotransferase normalization. We assessed the efficacy, safety, and resistance profile of entecavir through 96 weeks of treatment. A total of 286 patients were randomized and treated with entecavir 1 mg (n = 141) or continued lamivudine 100 mg (n = 145). At week 52, 77 entecavir-treated patients who had a protocol-defined virologic response (HBV branched DNA [bDNA] < 0.7 MEq/mL but HBeAg-positive) continued blinded therapy for up to 96 weeks. Patients were assessed for efficacy, safety, and emerging resistance. Cumulative proportions of all treated patients who achieved confirmed efficacy endpoints were also analyzed. Between week 48 and the end of dosing, the proportions of patients with HBV DNA <300 copies/mL by polymerase chain reaction increased from 21% to 40%, and alanine aminotransferase normalization (< or =1x upper limit of normal) increased from 65% to 81%. In the second year, HBeAg seroconversion was achieved by 10% of patients. Of the 77 patients in the second year treatment cohort, entecavir resistance emerged in six patients, and seven experienced virologic breakthrough (five with genotypic resistance acquired before year 2). The safety profile of entecavir in the second year of therapy was consistent with that reported during year 1.

CONCLUSION

Through 96 weeks of treatment, 1 mg entecavir resulted in continued clinical benefit in lamivudine-refractory HBeAg-positive chronic hepatitis B patients with a safety profile comparable to lamivudine.

Etiology and clinical character of liver cirrhosis: an analysis of 178 cases

AIM: To investigate the etiology and clinical characteristics of liver cirrhosis in the Northeast of China.

METHODS: We retrospectively analyzed the clinical data and laboratory test results of 178 patients with liver cirrhosis admitted to our hospital from January to October 2007.

RESULTS: Of the 178 patients, 31 cases (34.3%) had simple hepatitis B virus infection; 11 cases (6.2%) had simple hepatitis C virus infection; 3 (1.7%) cases had overlapping infection of hepatitis B and C virus; 39 cases (21.9%) had simple alcoholic cirrhosis; 27 (15.2%) cases had co-injury caused by alcohol and hepatitis virus; the rest included 8 (4.5%) cases with primary biliary cirrhosis and 29 (16.3%) cases with cryptogenic cirrhosis. In addition to spider telangiectasia (χ² = 4.503, P = 0.034), other signs and symptoms had no significant differences between viral infection patients and heavy drinker. Upper gastrointestinal bleeding (42.0%), primary hepatic carcinoma (28.7%), secondary infection (16.1%) and hepatic encephalopathy were main complications in liver cirrhosis.

CONCLUSION: Hepatitis B virus infection is still the main cause of liver cirrhosis in the Northeast of China. Portal hypertension often happens in simple viral infection, and liver function injury usually happens in simple alcoholism. Hepatocellular carcinoma occurs more frequently in the cases with overlapping infection of hepatitis virus and concurrent of alcohol-drinking and hepatitis viral infection.

The use of molecular assays in the management of viral hepatitis

Molecular assays are instrumental in the clinical management of viral hepatitis. During the past years, a wide variety of molecular assays have been developed and implemented. This considerably improved the understanding of the natural history and pathogenesis of Hepatitis B virus (HBV), Hepatitis C virus (HCV) or Hepatitis delta virus (HDV) hepatitis, but also caused uncertainties in the selection of the most appropriate assays for clinical requirements. Indeed, a rational choice and application of these assays requires adequate knowledge of the performance of the single test. Moreover, the choice of the most accurate assay for patients' needs and physicians' objectives, needs to be oriented to specific contexts, such as diagnosis, management or treatment. In the past, a hurdle in the routine use of assays for hepatitis viruses nucleic acid quantification was represented by the availability of only "home brew" methods which lacked standardization. Major improvement in addressing the use of molecular assays for viral hepatitis has been derived from recent standardization procedures that allowed a comparison between different tests after results were given as International Units. In addition, it should be reminded that, before getting into the market, molecular assays should be approved by European regulation authorities and validated using internationally recognized standards. A subsequent clinical validation should address the diagnostic accuracy of the assay. These proceedings have the aim of identifying which molecular tests, among those currently available, meet clinical requirements for each specific application.

96 weeks combination of adefovir dipivoxil plus emtricitabine vs. adefovir dipivoxil monotherapy in the treatment of chronic hepatitis B

BACKGROUND/AIMS

In order to prevent the occurrence of drug-resistant mutants associated with treatment for chronic hepatitis B virus (HBV) infection, combination therapy is being developed. To determine the efficacy of adefovir dipivoxil (ADV) plus emtricitabine (FTC) combination therapy in chronic HBV infection.

METHODS

Thirty treatment-nai ve, HBeAg-positive patients were randomized to combination ADV plus FTC (n=14) or ADV plus placebo monotherapy (n=16) for 96 weeks. HBV DNA was measured by polymerase chain reaction. Treatment was stopped in those with HBeAg seroconversion.

RESULTS

The median decrease in HBV DNA at week 96 was higher in the combination group (-5.30 vs. -3.98 log(10)copies/ml, p=0.05). More patients in the combination group had normalization of alanine aminotransaminase and HBV DNA<300 copies/ml at week 96 when compared with the monotherapy group [11 of the 14 patients (78.6%) vs. 6 of the 16 patients (37.5%), p=0.03]. However, HBeAg seroconversion at week 96 was similar in the 2 groups [2/14 (14.3%) vs. 4/16 (25.0%), p=NS]. No ADV or FTC resistance was detected at week 96. In those with HBeAg seroconversion, 50.0% had post-treatment relapse.

CONCLUSIONS

Combination ADV plus FTC resulted in more potent suppression of HBV DNA over 96 weeks of therapy.

[Molecular virology of the hepatitis B virus]

The hepatitis B virus (HBV) belongs to the hepadnavirus family. The genome of the virus, formed by a small DNA molecule with 3,200 base pairs, has 4 strongly overlapping protein coding regions: ORF preS/S, corresponding to the envelope proteins that constitute the HBV surface antigen (HBsAg); ORF preC/C, which encodes the viral capsid component (core antigen or HBcAg) and a non-structural protein that, after postranslation modification, is secreted and constitutes the "e" antigen (HBeAg); ORF P, which encodes the viral polymerase (polyprotein with DNA polymerase activity, reverse transcriptase and RNAase), and ORF X, which encodes a protein that acts as a multifunctional regulator for both the viral and cell cycles. HBV has a mutation rate of 1.4-3.2 x 105 substitutions/nucleotide/year. As a result of this variability, the virus circulates as a complex mixture of genetic variants, constituting a semi-species, that evolves throughout the infection depending on the evolutionary pressure of factors such as the immune response and antiviral treatments. Based on this variability, HBV has been classified into 8 genotypes (A-H) defined by a difference of more than 8% in the sequences of the complete viral genome. This variability is also responsible for HBV resistance to antiviral treatments with nucleotide and nucleoside analogs. Diagnosis of HBV infection includes determination of virological markers: viral antigens (HBsAg, HBeAg), specific antibodies (anti-HBc, anti-HBe, anti-HBs) and study of HBV-DNA for its detection and quantification and determination of genotypes and viral variants.

Aging liver and hepatitis

Chronic liver disease and cirrhosis are the tenth leading causes of death in the United States and results in approximately 25,000 deaths annually. As life expectancy in developed countries has increased, so has the number of elderly patients who have liver disease. With an aging population and chronic liver disease becoming an increasingly significant cause of morbidity and mortality, the various causes for hepatitis will need to be evaluated and available treatments considered, even in elderly population. Common causes for hepatitis in elderly individuals include viral, autoimmune, and drug-induced hepatitis, but evidence for treatment of this population is limited. This article reviews the likely causes of hepatitis in elderly individuals and discusses evidence for treating this population.

Cost-effectiveness analysis of entecavir versus lamivudine in the first-line treatment of Australian patients with chronic hepatitis B

BACKGROUND

Chronic hepatitis B (CHB) virus infection is a major global healthcare problem. The recent introduction of entecavir in Australia for the treatment of CHB patients in the naive treatment setting has triggered significant optimism with regards to improved clinical outcomes for CHB patients.

OBJECTIVE

To estimate, from an Australian healthcare perspective, the cost effectiveness of entecavir 0.5 mg/day versus lamivudine 100 mg/day in the treatment of CHB patients naive to nucleos(t)ide therapy.

METHODS

A cost-utility analysis to project the clinical and economic outcomes associated with CHB disease and treatment was conducted by developing two decision-tree models specific to hepatitis B e antigen-positive (HBeAg+ve) and HBeAg-ve CHB patient subsets. This analysis was constructed using the Australian payer perspective of direct costs and outcomes, with indirect medical costs and lost productivity not being included. The study population comprised a hypothetical cohort of 1000 antiviral treatment-naive CHB patients who received either entecavir 0.5 mg/day or lamivudine 100 mg/day at model entry. The population of patients used in this analysis was representative of those patients likely to receive initial antiviral therapy in clinical practice in Australia. The long-term cost effectiveness of entecavir compared with lamivudine in the first-line treatment of CHB patients was expressed as an incremental cost per life-year gained (LYG) or QALY gained.

RESULTS

Results revealed that the availability of entecavir 0.5 mg/day as part of the Australian hepatologist's treatment armamentarium should result in significantly lower future rates of compensated cirrhosis (CC), decompensated cirrhosis (DC), and hepatocellular carcinoma (HCC) events (i.e. 54 fewer cases of CC, seven fewer cases of DC, and 20 fewer cases of HCC over the model's timeframe for HBeAg+ve CHB patients, and 69 fewer cases of CC, eight fewer cases of DC and 25 fewer cases of HCC over the model's timeframe for HBeAg-ve CHB patients). Compared with lamivudine 100 mg/day, entecavir 0.5 mg/day generated an estimated incremental cost per LYG of Australian dollars ($A, year 2006 values) 5046 and an estimated incremental cost per QALY of $A5952 in the HBeAg+ve CHB patient population, an estimated incremental cost per LYG of $A7063 and an estimated incremental cost per QALY of $A8003 in the HBeAg-ve CHB patient population, and an overall estimated incremental cost per LYG of $A5853 and an estimated incremental cost per QALY of $A6772 in the general CHB population.

CONCLUSION

The availability of entecavir in Australian clinical practice should make long-term suppression of hepatitis B virus replication increasingly attainable, resulting in fewer CHB sequelae, at an acceptable financial cost.

Lamivudine/pegylated interferon alfa-2b sequential combination therapy compared with lamivudine monotherapy in HBeAg-negative chronic hepatitis B

BACKGROUND AND AIM

Monotherapy has been proven insufficient in achieving sustained control of chronic hepatitis B. We aimed to assess the efficacy of combined sequential administration of lamivudine and pegylated interferon alfa-2b in patients with hepatitis Be antigen (HBeAg)-negative chronic hepatitis B.

METHODS

Eighteen patients were given sequential combination treatment starting with 3 months of lamivudine monotherapy followed by 9 months of pegylated interferon alfa-2b (after a 3-month period of concomitant administration of the two drugs) and 24 patients received lamivudine monotherapy.

RESULTS

At the end of treatment, 88.9% of the patients who received sequential combination treatment and 70.8% of those who received lamivudine monotherapy had hepatitis B virus (HBV) DNA levels below 400 copies/mL (P = not significant). At the end of treatment, 72.2% of the patients who received sequential combination treatment and 70.8% of those who received lamivudine monotherapy achieved alanine aminotransferase normalization (P = not significant). After 12 months of follow up, 33.3% of the patients who received sequential combination treatment and 16.7% of those who received lamivudine monotherapy had HBV-DNA levels below 400 copies/mL (P = 0.4). After 12 months of follow up, 72.2% of the patients who received sequential combination treatment and 25.0% of those who received lamivudine monotherapy had normal alanine aminotransferase levels (P < 0.01). Twenty-five percent of the patients in the lamivudine monotherapy group had virological breakthrough compared to none in the sequential combination treatment group (P = 0.06).

CONCLUSIONS

Sequential combination treatment is able to improve sustained biochemical response rates and prevent the emergence of lamivudine-resistant mutants in patients with HBeAg-negative chronic hepatitis B.

Barriers to care of chronic hepatitis patients in Latin America

Delay in diagnosis of chronic hepatitis due to HCV or HBV is mainly caused by lack of information about these prevalent and life-threatening disorders. Diagnostic tests are either not easily available or not requested by primary care physicians. When cases positive for hepatitis-B markers or anti-HCV are found, misleading guidance may be given to patients. Absence of symptoms associated with lack of information is another barrier to the care of chronic hepatitis patients. Management of these diseases is not simple, and treatment options and schedules are in rapid and continuous evolution. Surveillance of patients with chronic hepatitis before, during and after antiviral therapy is mandatory. For patients with no indication for therapy, identification of optimal follow-up frequency constitutes a problem, as does determination of the correct amount and type of diagnostic tests to be used. Another important barrier to care of patients with chronic hepatitis is the absence of an ideal drug, namely, one that is inexpensive, does not have collateral effects, and has very high percentages of cure or resolution. Access to therapy is uncertain, and the side effects of interferon frighten some patients and physicians. Lack of adherence to the medication, early interruption, and the need for other supportive therapies are frequent barriers to successful treatment.

Comparison of Versant HBV DNA 3.0 and COBAS AmpliPrep-COBAS TaqMan assays for hepatitis B DNA quantitation: Possible clinical implications

We compared two commercial assays for HBV DNA quantitation, Versant HBV 3.0, System 340 (bDNA; Bayer Diagnostics) and COBAS AmpliPrep-COBAS TaqMan HBV Test (TaqMan; Roche Diagnostics). Analytical sensitivity, calculated on WHO International Standard, predicted 95% detection rate at 11.4 and 520.2IU/ml for TaqMan and bDNA, respectively. Specificity, established on 50 blood donor samples, was 100% and 84% for TaqMan and bDNA, respectively. When using clinical samples, HBV DNA was detected by TaqMan in 21/55 samples negative to bDNA. Mean values of HBV DNA obtained with bDNA were higher than those obtained with TaqMan (4.09log(10)+/-1.90 versus 3.39log(10)+/-2.41, p<0.001), and 24.4% of samples showed differences in viral load values >0.5log(10), without association with HBV genotype. There was a good correlation for HBV DNA concentrations measured by the two assays (r=0.94; p<0.001) within the overlapping range, and the distribution of results with respect to relevant clinical threshold recently confirmed (20,000 and 2000IU/ml) was similar. Approximately 50% of samples with low HBV DNA, appreciated by TaqMan but not by bDNA, were successfully sequenced in pol region, where drug resistance mutations are located.

Defining Optimal Therapeutic Outcomes in Chronic Hepatitis

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

Report of an international workshop: Roadmap for management of patients receiving oral therapy for chronic hepatitis B

An international group of experienced hepatologists and virologists conducted a single-day workshop to review the management of patients with chronic hepatitis B receiving treatment with oral nucleosides or nucleotides. Guidelines regarding on-treatment management and available published data on the importance of serum hepatitis B virus (HBV) DNA as a marker of outcomes were reviewed. On-treatment monitoring strategies to define early virologic responses that might be predictive of better outcomes and a reduced risk of viral resistance were proposed for further study. This treatment plan, labeled the roadmap concept, recommends monitoring of serum HBV DNA levels to identify outcomes of therapy. Primary treatment failure was defined as a reduction of serum HBV DNA levels by less than 1 log10 IU/mL from baseline at week 12. Measurement of the HBV DNA level at week 24 was considered essential to characterize virologic responses as complete, partial, or inadequate. Complete virologic response was defined as negative HBV DNA by a sensitive assay (<60 IU/mL or <300 copies/mL); partial virologic response was defined as HBV DNA levels less than 2000 IU/mL (4 log10 copies/mL), and inadequate virologic response was defined as HBV DNA levels of 2000 IU/mL or greater (4 log10 copies/mL). Strategies are proposed for managing patients in each of these categories, depending in part on the rapidity with which HBV DNA suppression is achieved and the emergence of genotypic mutations that reduce the effectiveness of a specific drug. Future studies of the use of the roadmap concept in improving outcomes of chronic hepatitis B are warranted.

Outcomes of Chronic Hepatitis B Infection in Oriental Patients with Rheumatic Diseases

Introduction: The aim of this study was to ascertain the outcomes of chronic hepatitis B (CHB) infection following immunosuppressive therapy in 38 consecutive oriental patients with systemic rheumatic diseases. Materials and Methods: This is a retrospective consecutive, non-comparative study. Results: The majority of patients were female (26, 68.4%), predominantly Chinese (92.1%), with a mean age 54 ± 14 years (range, 16 to 87). The mean duration of rheumatic disease was 9 ± 11 years (range, 0.1 to 48), with rheumatoid arthritis (52.6%) and systemic lupus erythematosus (23.7%) being the most common. The mean duration of CHB infection was 6 ± 5 years (range, 0.1 to 17), with the majority diagnosed during pre-methotrexate screening (50.0%) and asymptomatic transaminitis following initiation of immunosuppressive therapy (23.7%). Upon diagnosis of rheumatic disease, all patients had normal alanine aminotransferase (ALT). Of these, 18.2% were positive for hepatitis B e antigen (HBeAg) and 78.1% were positive for anti-HBe antibody. Twenty (52.6%) developed ALT elevation, which was more than twice the upper limit of normal in 12 patients. ALT normalised spontaneously in 12 patients without hepatic decompensation or change in therapy. Seven (18.4%) patients received lamivudine for 18 ± 22 months (range, 2 to 61). Two patients developed YMDD mutation subsequently treated with adefovir (1) and adefovir/lamivudine (1). There were 3 (7.9%) hepatitis B virus (HBV)-unrelated deaths [infection (2), genitourinary malignancy (1)], and 1 from HBV-reactivation complicated by septicaemia. None have developed hepatocellular carcinoma. Conclusion: Elevated ALT occurred in 52.6% of patients, with only 18.4% requiring anti-viral therapy for HBV reactivation. HBV-related mortality was low. With the appropriate precautionary measures, prednisolone and immunosuppressants (except methotrexate and leflunomide) may be used safely in patients where clinically indicated. Key words: Ankylosing spondylitis, Lamivudine, Rheumatoid arthritis, Spondyloarthropathies

Chronic Hepatitis B and C--current treatment and future therapeutic prospects

In chronic hepatitis B treatment with pegylated interferon can now be considered as therapy of choice in both HBeAg positive and HBeAg negative patients and seems to be more effective than lamivudine monotherapy. Alternatively, treatment with lamivudine is able to suppress HBV DNA and to induce HBeAg conversation in up to 30 % of the patients. In HBeAg negative chronic hepatitis B lamivudine has a similar efficiency in suppressing HBV DNA as in HBeAg positive patients. The frequently developing lamivudine resistant HBV variants can now be successfully be treated with adevofir dipivoxil in both forms of chronic hepatitis B. These nucleosides analogues are generally better tolerated than interferon and can also be given in patients with HBV related liver cirrhosis. Our therapeutic armamentarium will be expanded in the near future by other nucleoside analogues such as entecavir, emtricitapine, telbivudine or clevudine. The treatment of choice in chronic hepatitis C currently is pegylated interferon plus ribavirin. This regimen is able to induce a sustained virologic response in 50 % of treatment naïve cases. The limited effectiveness of this therapeutic approach makes additional drugs highly warranted and inhibitors of the NS3-4a protease region or the NS5B polymerase region of the viral genome are under development. In addition, HCV replication inhibitors based on RNA interference (siRNA) or agonists of toll like receptors (TLR), which are part of the inborn immune system recognizing the presence of invading microorganisms, are currently explored as agents active in inhibiting HCV replication. Although none of these drugs are currently licensed for HCV treatment they are promising antiviral candidates for the future.