Post-transfusional anti-HCV-negative, non-A, non-B hepatitis. (I) a prospective clinical and epidemiological survey

Comparison of long-term effects of lymphoblastoid interferon alpha and recombinant interferon alpha-2a therapy in patients with chronic hepatitis B

To compare the long-term effect of natural lymphoblastoid interferon-alpha (IFN-alpha nl) and recombinant IFN-alpha 2a therapy in patients with chronic hepatitis B, 210 patients in two trials were followed-up for 1.1-15.5 years following the end of therapy. They included 34 patients who received placebo (control), 67 treated with IFN-alpha nl (36 after prednisolone priming) and 109 treated with IFN-alpha 2a (56 after prednisolone priming). The cumulative sustained response was higher in patients who had been treated with IFN-alpha nl after prednisolone priming than was exhibited using IFN-alpha nl alone, IFN-alpha 2a alone or the placebo (P < 0.05), or IFN-alpha 2a following prednisolone priming (P = 0.052) at the end of 11 years. Hepatocellular carcinoma (HCC) was detected in 1.5% of the IFN-alpha nl group, 3.7% of the IFN-alpha 2a group and 14.7% of the control group (control vs IFN-alpha nl or IFN-alpha 2a, P < 0.05). The cumulative HCC development was higher in the control group than in the IFN-alpha nl group (P < 0.002) and the IFN-alpha 2a group (P = 0.06). The cumulative survival rate was lower in the control group than in the IFN-alpha nl group (P < 0.01) and the IFN-alpha 2a group (P = 0.02). Multivariate analysis revealed that IFN-alpha nl therapy and female gender are significant predictors of sustained response; preexisting cirrhosis, age at entry and IFN therapy are significant factors in both HCC development and survival. In conclusion, IFN-alpha nl treatment may have a better long-term effect on hepatitis B virus (HBV) clearance than IFN-alpha 2a and placebo, and IFN therapy may provide better long-term beneficial effects than placebo in terms of HBV clearance, reduction of HCC and prolonged survival.

Isolation, characterization and biological significance of hepatitis B virus mutants from serum of a patient with immunologically negative HBV infection

BACKGROUND/AIM

A low-titered hepatitis B virus infection without immunological markers was identified in a prospective study in the serum of a kidney transplant recipient by PCR. The aim of this study was to analyze HBV genomes and their biological significance.

METHODS

The genome was amplified in two overlapping fragments A and B. Sequencing of 22 clones of the A- and 12 clones of the B-fragment revealed a heterogeneous virus population. A consensus and a mutant sequence were computed, representing the complete sequence of the virus population. The two sequences were compared with 41 published genomes of the different HBV geno- and serotypes.

RESULTS

Ninety-five point mutations and two deletions were identified. Two mutations were observed in all clones and 17 other mutations in three or more clones. The deletions were found in ten and seven of 22 clones. They were located in the C-gene and led to stop codons yielding truncated e- and/or core proteins. In vitro transfection of DNA constructs containing these deletions demonstrated a stop of HBV replication and of HBeAg expression. Cotransfection experiments demonstrated a dominant negative effect of the mutants containing the deletions. In addition, we describe new variants of naturally occurring HBsAg mutants that may cause HBV infection less detectable by standard HBsAg measurement assays. They were characterized by two point mutations which were observed in 9 of 12 and 13 of 22 clones of the S-gene. They significantly reduced the HBsAg expression in in vitro transfection experiments.

CONCLUSION

We found a patient with low-titered HBV infection, with mutations of the 'a' epitope of the Santigen as well as with mutations leading to truncated core proteins which may cause a dominant negative effect.

Impact of TT virus infection in acute and chronic, viral- and non viral-related liver diseases

BACKGROUND/AIMS

The prevalence and pathogenicity of TT virus, recently identified in patients with non A-non G post-transfusional hepatitis, are questioned.

METHODS

We investigated the impact of this new viral infection in a large series of patients with non A-non G, cryptogenic, non-viral and viral-related, acute and chronic liver diseases (n=577) and blood donors (n=300). TTV DNA was detected in serum by hemi-nested polymerase chain reaction. Phylogenetic analysis was performed in 13 isolates.

RESULTS

TTV DNA was detected in 6/25 and 15/127 patients with cryptogenic non A-non G acute and chronic liver disease, respectively. TTV DNA positive subjects with post-transfusional acute hepatitis scored negative before transfusion. TTV prevalence was increased in patients with cryptogenic non A-non G acute and chronic liver disease compared to blood donors (6/300; p<0.001) and non-viral-related chronic liver diseases (6/137; p<0.05). TTV/HBV coinfection was frequently identified (35/147), but this was not the case for HCV-infected subjects (4/77). Transaminase activity or liver histological score was not significantly increased among TTV positive, HBV infected or non A-non G patients. The HBV infection and Mediterranean origin were the risk factors associated with TTV infection. The majority of analysed sequences clustered in genotype 1 (8=1b; 3=1a). Two isolates showed homology to genotype 2.

CONCLUSIONS

These results support the view that TTV is a widely spread infectious agent with a weak pathogenicity. It raises the possibility, however, that TTV might be implicated in a few cases of acute and chronic non A-non G hepatitis. TTV-DNA-analysed sequences are related to genotypes 1 and 2 described in Europe.

Transfusion-associated or nosocomial hepatitis G virus infection in patients undergoing surgery

BACKGROUND

Despite blood donor screening, there are still cases of transfusion-associated hepatitis. From 1988 to 1992, a prospective study was conducted on the incidence of non-A, non-B posttransfusion hepatitis (PTH).

STUDY DESIGN

The present investigation was designed to determine if transfusion recipients with PTH who are negative for hepatitis C virus (HCV) were positive for hepatitis G virus (HGV). Patients admitted for surgery who had normal liver tests and no transfusions during the previous 6 months were enrolled. Alanine amino transferase levels were determined monthly for 6 months after surgery and for 1 year in the case of PTH (defined as alanine aminotranferase twice the upper limit of normal in two consecutive assays). HGV RNA and E2 antibodies were tested for in samples from transfusion recipients with or without PTH and from nontransfused patients.

RESULTS

Of the 308 blood recipients who were enrolled in the study, 21 (6.8%) had PTH. HGV RNA was detected at the onset of hepatitis in 3 patients with PTH (14%), 2 of whom were also anti-HCV and HCV RNA positive. One patient developed E2 antibodies without detectable HGV RNA. Three (10.7%) of 28 recipients of an allogeneic transfusion without PTH developed HGV infection. HGV RNA was also found in two nontransfused patients, which suggests nosocomial transmission of HGV.

CONCLUSION

Some cases of PTH are associated with HGV; most cases of postoperative HGV infection are not associated with liver abnormalities; and most PTH cases are not associated with known hepatotropic viruses.

[Feasibility of following up transfused patients]

The aim of this study was to assess the natural history of patients after transfusion and the acceptability of a standardized biological follow-up. In 1995, during 1 month, in 13 French hospitals, a follow-up at 3 and 6 months after blood transfusion was proposed to all blood recipients who had not received any blood transfusion within the past 6 months (eligible patients): screening for red cell antibodies, alanine aminotransferase (ALT) activity and specific viral markers of hepatitis B (hepatitis B surface antigen and antibody to hepatitis virus core antigen), of hepatitis C (antibodies) and of Human Immunodeficiency Virus (antibodies). At the beginning of the study, 296 patients were followed for 6 months. A complete follow-up was available at 3 months for 183 patients (62%), at 6 months for 168 (57%) and after 6 months, 198 patients (67%) have been once followed. Of eligible patients, 76% were alive at six months. After transfusion, the incidence of red cell alloantibodies and elevated ALT concentration were respectively 4% and 17%. At 6 months, one patient had Hepatitis B surface antigen; the responsibility of blood transfusion was excluded. Within the first 24 hours, 68 patients (23%) required another blood transfusion and 42% of units were transfused to patients with malignant disease. Our study quantifies in real conditions the difficulty of a biological follow-up in a transfused population, mostly composed of patients that could not be followed in the hospital where they were transfused.

Chronic non-A, non-B, non-C hepatitis: is hepatitis G/GBV-C involved?

BACKGROUND

Hepatitis G virus/GBV-C is a recently discovered virus, and its relevance in chronic hepatitis is still debated.

METHODS

We have previously described 127 long-term-studied and well-characterized patients with chronic non-A, non-B hepatitis (NANBH). Ninety-one (71.7%) were positive for hepatitis C virus antibodies (anti-HCV) in a first-generation anti-HCV enzyme-linked immunosorbent assay (ELISA). We now reanalyzed the same group of patients and added a third-generation anti-HCV ELISA and recombinant immunoblot assay and, in negative patients, also polymerase chain reactions for hepatitis C virus RNA, hepatitis GBV-C RNA, and hepatitis B virus DNA. Additional tests for autoimmune hepatitis types 2 and 3 were also included.

RESULTS

Anti-HCV were detected in 114 of the 123 evaluable patients (92.7%). Of the remaining nine anti-HCV-negative patients one had misdiagnosed primary biliary cirrhosis, and two had autoimmune hepatitis type 3. None of the anti-HCV-negative patients were hepatitis GBV-C RNA-, HCV RNA-, or HBV DNA-positive. Thus, 114 of 120 NANBH patients (95.0%) had chronic hepatitis C. None of the remaining six patients had received blood transfusions or was a drug addict, and two of them were successfully treated with steroids.

CONCLUSIONS

Hepatitis G/GBV-C as a single cause of chronic non-A, non-B hepatitis is uncommon, and in all patients with parenteral risk factors hepatitis C was detected.

Response of patients with dual hepatitis B virus and C virus infection to interferon therapy

Patients with dual infection with hepatitis B virus (HBV) and delta virus (HDV) responded poorly to interferon (IFN) therapy. Little is known about the effect of IFN therapy in patients with HBV and hepatitis C virus (HCV) dual infection. The patients in two randomized controlled trials with chronic HBV infection were retrospectively assayed for HCV markers. The HBV responses to IFN therapy in patients with and without HCV markers were compared. An open trial was conducted in 4 patients who had lost their serum HBV surface antigen (HBsAg) but had continuing HCV viremia and hepatitis. Of the 15 patients seropositive for HCV marker(s), only 1 (6.7%) responded with seroclearance of HBV DNA and HBV e antigen, as compared with 46 (28%) of 164 HCV-negative patients (p = 0.058). Icteric hepatitis developed in 1 patient on emergence of serum HCV RNA in association with seroclearance of HBV DNA. In contrast, good response was demonstrated in 3 of the 4 patients who had lost serum HBsAg before therapy. The results suggest that IFN therapy is not only of limited value in patients with dual infection with HBV and HCV but also has a potential risk of severe hepatitis if the clearance of one virus removes its suppressive effect on and facilitates the emergence of the other. However, patients with continuing HCV hepatitis after termination of the chronic HBsAg carrier state responded well to IFN therapy.

[Screening and early detection in blood transfusion: when are they indicated?]

Screening is proposed to allow an early intervention concerning a diseased individual, but its public health consequences are seldom considered. We propose criteria to judge whether a screening program can be associated to a benefit to patients or society. These criteria refer to the magnitude of disease, the characteristics of the pre-clinical stage, the availability of reliable and valid tests, the effectiveness and risk for all individuals, whether they are diseased or not, and acceptability to the health-care system and to individuals. We illustrate the application of these criteria to screening of human immunodeficiency virus among blood donors, hepatitis among recipients of labile blood products, and bacterial contaminations among febrile recipients. These criteria should be considered in decision analyses including alternatives to screening and all aspects of safety regarding patients and population.

Cost-effectiveness of screening blood donors for hepatitis C and non-A, non-B, non-C hepatitis. The EATHIS Eco Research Group. European Acute Transfusion Hepatitis Interferon Study

The current approach to screening for hepatitis C and non-A, non-B, non-C hepatitis in French blood transfusion centers involves a combination of a transaminase assay and tests for antibodies to hepatitis B core antigen (anti-HBc) and antibodies to hepatitis C virus (anti-HCV). A decision-analysis model was used to assess the cost-effectiveness ratio of this approach compared to the former approach, which included only transaminase and anti-HBc screening. Cost data were collected by a questionnaire sent to 26 centers throughout France. The average costs of diagnostic kits, equipment, staff, and administration were calculated. Estimates of prevalence and sensitivity values came from the medical literature. The cost-effectiveness ratio was expressed in French francs per infected donor detected. A sensitivity analysis of the variables in the model was performed to estimate the validity of the cost-effectiveness ratio. For 100,000 donations the incremental cost of the current approach reached FrF 2,566,111 (about US $500,000), with a marginal effectiveness of 180 donations detected. The sensitivity analysis showed the effect of prevalence on the incremental cost-effectiveness ratio. Transfusion centers may change their screening approach in areas of high or low prevalence of hepatitis C in France.

Donor levels of serum alanine aminotransferase activity and antibody to hepatitis B core antigen associated with recipient hepatitis C and non-B, non-C outcomes

BACKGROUND

Hepatitis virus(es) that are neither hepatitis B (HBV) nor hepatitis C (HCV) (non-B, non-C [NBNC]) may be transmitted by transfusion. The present study assessed donor values for alanine aminotransferase (ALT) and antibody to hepatitis B core antigen (anti-HBc) for their association with HCV and NBNC hepatitis outcomes among allogeneic blood recipients.

STUDY DESIGN AND METHODS

Data on blood donors and recipients enrolled in the Transfusion- Transmitted Viruses Study in four United States cities from 1974 through 1980 were supplemented by anti-HBc testing of donors and anti-HCV evaluation of recipients. Two statistical approaches estimated the value of these indirect tests in detecting donors associated with HCV seroconversion and NBNC hepatitis in recipients.

RESULTS

For HCV cases, donor ALT alone (at > or = 60 IU/L) had a sensitivity and a specificity of 30 and 96 percent, respectively, and anti-HBc alone (at > or = 60% inhibition) had a sensitivity and specificity of 53 and 86 percent, respectively. The two markers combined had a sensitivity and a specificity of 69 and 83 percent. For NBNC hepatitis cases, each measure had low sensitivity (20%) that was not improved by using both (28%) [corrected].

CONCLUSION

The indirect tests proved to be equal in sensitivity to the first-generation anti-HCV tests. The positive predictive power of these indirect tests in the 1980s was sufficient to affect HCV incidence in studies during that period. Improved anti-HCV assays, however, replaced the need for indirect tests. The sensitivity of indirect tests for NBNC hepatitis contributed little.

Incidence of post-transfusion hepatitis in Taiwan before and after introduction of anti-HCV testing

The effectiveness of second-generation anti-hepatitis C virus antibody (anti-HCV) screening of blood donations for the prevention of non-A, non-B post-transfusion hepatitis (NANB PTH) was assessed. A prospective study of 192 transfusion recipients was performed to compare the incidence of NANB PTH after the introduction of the second-generation anti-HCV test with the incidence before its introduction. We used a polymerase chain reaction to detect HCV-RNA and HBV-DNA in the sera of patients with NANB PTH. The incidence of acute post-transfusion hepatitis C was 11% (8 of 71) before the screening for anti-HCV as compared with 2.5% (3 of 121) after the screening (p < 0.05). Viremia was detected within the first five weeks of infection in 10 patients with acute post-transfusion hepatitis C. However, there was no significant difference in the incidence of non-A, non-B, non-C (NANBNC) PTH before screening (3 of 71, 4.2%) compared with after screening (3 of 121, 2.5%). Usually, NANBNC PTH was not clinically important. Anti-HCV screening of blood donors significantly reduces the incidence of post-transfusion hepatitis C, but not the incidence of NANBNC PTH.

Severe clinical rebound upon withdrawal of corticosteroid before interferon therapy: incidence and risk factors

To analyse the incidence and risk factors of clinical rebound and hepatic decompensation during or upon withdrawal of prednisolone pretreatment before interferon (IFN) therapy, two series of Taiwanese patients with chronic viral hepatitis from two independent randomized controlled trails were compared. Group 1 included 41 patients with chronic hepatitis B who were pretreated with daily prednisolone (30 mg) for 3 weeks, 15 mg for 1 week and no prednisolone for 2 weeks prior to lymphoblastoid IFN therapy. Group 2 consisted of 59 patients with chronic hepatitis B who were pretreated with daily prednisolone (40 mg) for 2 weeks, 30 mg prednisolone for 2 weeks, 20 mg prednisolone for 2 weeks and no prednisolone for 2 weeks prior to INF alpha-2a therapy. Clinical rebound developed more frequently in group 2 (67.8%) than in group 1 patients (41.5%; P < 0.01). The peak serum transaminase levels of group 1 and 2 patients during clinical rebound were similar. Icteric and symptomatic clinical rebound occurred in four (one cirrhotic) group 2 patients. The incidence of hepatic decompensation was 3.4% in group 2 patients, or 5.0% in group 2 patients with clinical rebound. Patients pretreated with a higher dose (40 mg) of prednisolone (odds ratio 3.0; 95% CI 1.3-6.6; P < 0.01) and non-cirrhotic patients (odds ratio 6.2; 95% CI 1.2-32.1; P < 0.02) tended to suffer from clinical rebound more frequently. However, once clinical rebound develops in cirrhotic patients, the relative risk of decompensation is 16 times that of non-cirrhotic patients. These results suggest that clinicians should be cautious in prescribing a short course of corticosteroids for patients with chronic viral hepatitis, because hepatic decompensation might occur in Oriental people with or without cirrhosis.

Hepatitis B virus infection without immunological markers after open-heart surgery

Post-transfusion hepatitis is still an important problem, despite the screening of blood donors for hepatitis B (HBV) and C virus infections. We assessed whether HBV DNA might be detected by PCR in prospectively collected serum samples of patients with unexplained post-transfusion hepatitis but no immunological HBV markers. We found HBV DNA in 4 (20%) of 20 patients with unexplained post-transfusion hepatitis and in 5 patients with mildly increased aminotransferases. The clinical course of these HBV infections was usually mild and self-limiting. Thus we found that low-titre, immunologically negative HBV infections do exist and might represent a significant cause of post-transfusion hepatitis.