Detection of serum HBV-DNA by molecular hybridisation. Correlation with HBeAg/anti-HBe status, racial origin, liver histology and hepatocellular carcinoma

HBeAg-Negative/Anti-HBe-Positive Chronic Hepatitis B: A 40-Year-Old History

Hepatitis B “e” antigen (HBeAg) negative chronic hepatitis B (CHB), 40 years since discovery in the Mediterranean area, has become the most prevalent form of HBV-induced liver disease worldwide and a major health care burden caused by HBV infection. A great deal of knowledge accumulated over the last decades provides consistent evidence on the bimodal dynamics of the expression of structural and non-structural forms of the viral core proteins which associate with different virologic and clinic–pathologic outcomes of HBV infection. In absence of serum HBeAg, the presence and persistence of HBV replication causes and maintains virus-related liver injury. Thus, in clinical practice it is mandatory to screen HBV carriers with HBeAg-negative infection for the early diagnosis of HBeAg-negative CHB since antiviral therapy can cure HBV-induced liver disease when started at early stages.

Potential of diterpene compounds as antivirals, a review

Viruses cause widely transmitted diseases resulting in pandemic conditions. Currently, the world is being hit by the Covid-19 pandemic caused by the SAR-CoV-2 infection. Countries in the world are competing to develop antivirals to overcome this problem. Diterpene compounds derived from natural ingredients (plants, corals, algae, fungi, sponges) and synthesized products have potential as antivirals. This article summarizes the different types of diterpenes such as daphnane, tiglilane, kaurane, abietane, pimarane, labdane, dollabelane, jatrophane, dolastane, prenylated guaiane, tonantzitlolone, casbane, have antivirals activity such as targeting HIV, Coxsackie virus, herpes virus, hepatitis virus, influenza virus, Chikungunya virus, Zika virus, dengue virus, and SARS-CoV. Some compounds such as andrographolide and its derivatives show promising activity in inhibiting the influenza virus. Additionally, compounds such as pineolidic acid, forskolin, sugiol, and many other diterpene compounds showed anti-SAR-CoV activity. The diterpene compound class's high antivirals potential does not rule out the possibility that these compounds can also act as anti-SAR-CoV-2 drugs in the future.

Viral Biomarkers in Chronic HBeAg Negative HBV Infection

Viral biomarkers are important tools for monitoring chronic hepatitis B virus (HBV) hepatitis B early antigen (HBeAg) negative infection, both in its natural course as well as during and after treatment. The biomarkers consist of antibodies against viral epitopes, viral proteins, and molecular surrogate markers of the quantity and transcriptional activity of the stable episomal HBV covalently closed circular DNA (cccDNA) which is located in the nuclei of the infected hepatocytes. HBV deoxyribonucleic acid (DNA) or else viral load measurement in plasma or serum is a marker of HBV replication of major clinical importance. HBV DNA is used for staging and treatment monitoring as described in international scientific guidelines. Quantification of HBV antigens, mainly hepatitis B surface antigen (HBsAg) as well as Hepatitis B core related antigen (HBcrAg), play an important yet secondary role, especially in cases of low or undetectable HBV DNA and has been evaluated for the classification of the inactive carrier state, as a predictor of subsequent HBsAg clearance, treatment outcome, and development of hepatocellular carcinoma (HCC). The measurement of the replicative intermediate HBV RNA in serum is currently evaluated and may also prove to be a significant biomarker particularly in patients treated with nucleot(s)ide analogs. This review focuses on the viral biomarkers mentioned above and their role in HBV, HBeAg negative, infection.

Successful withdrawal of antiviral treatment in kidney transplant recipients with chronic hepatitis B viral infection

BACKGROUND

The optimal duration of antiviral therapy for kidney transplant recipients (KTR) with chronic hepatitis B virus (HBV) infection remains unclear. We reported the long-term outcomes after withdrawal of antiviral agent in KTR with chronic HBV infection.

METHODS

We retrospectively investigated the hepatitis B surface antigen (HBsAg)-positive KTR with antiviral agents between January 2002 and January 2012. Antiviral treatments were withdrawn in patients who met all of the following 7 criteria: (i) no clinical and histologic evidence of cirrhosis, (ii) normal liver biochemistry, (iii) negative for both HBV DNA and hepatitis B envelope antigen (HBeAg), (iv) no resistance to antiviral agent, (v) antiviral therapy > 9 months, (vi) maintenance dosage of immunosuppressant for > 3 months, and (vii) no history of acute rejection during recent 6 months. All patients were followed regularly at approximately 3-6 months for liver enzyme, viral markers, and HBV DNA level after antiviral withdrawal.

RESULTS

Among a total of 445 KTR, 14 HBsAg-positive patients were included in this study. Antiviral agents were used, with lamivudine in 11 patients, and with adefovir, entecavir, and telbivudine in 3 patients, respectively. Discontinuation of antiviral agent was attempted in 6 (42.9%) of 14 patients who satisfied the criteria. The median duration of antiviral therapy before withdrawal was 14.3 months (range, 9-24 months). Four (66.7%) of 6 patients were successfully withdrawn and remained negative for HBV DNA for a median 60.5 months (range, 47-82 months). The baseline HBV DNA level was not related to maintenance of remission after withdrawal. Two reactivated patients resumed antiviral treatment immediately, with subsequent normalization of HBV DNA. During the follow-up, 1 patient developed hepatocellular carcinoma; however, no patient death or graft failure was reported for all HBsAg-positive KTR.

CONCLUSIONS

Antiviral therapy can be discontinued successfully and safely in selected KTR with chronic HBV infection, after complete suppression of HBV and sufficient duration of antiviral therapy.

Direct acting antivirals for the treatment of chronic viral hepatitis

The development and evaluation of antiviral agents through carefully designed clinical trials over the last 25 years have heralded a new dawn in the treatment of patients chronically infected with the hepatitis B and C viruses, but not so for the D virus (HBV, HCV, and HDV). The introduction of direct acting antivirals (DDAs) for the treatment of HBV carriers has permitted the long-term use of these compounds for the continuous suppression of viral replication, whilst in the case of HCV in combination with the standard of care [SOC, pegylated interferon (PegIFN), and ribavirin] sustained virological responses (SVRs) have been achieved with increasing frequency. Progress in the case of HDV has been slow and lacking in significant breakthroughs.This paper aims to summarise the current state of play in treatment approaches for chonic viral hepatitis patients and future perspectives.

KASL Clinical Practice Guidelines: Management of chronic hepatitis B

The guideline on the management of chronic hepatitis B (CHB) was first developed in 2004 and revised in 2007 by the Korean Association for the Study of the Liver (KASL). Since then there have been many developments, including the introduction of new antiviral agents and the publications of many novel research results from both Korea and other countries. In particular, a large amount of knowledge on antiviral resistance--which is a serious issue in Korea--has accumulated, which has led to new strategies being suggested. This prompted the new guideline discussed herein to be developed based on recent evidence and expert opinion.

TARGET POPULATION

The main targets of this guideline comprise patients who are newly diagnosed with CHB and those who are followed or treated for known CHB. This guideline is also intended to provide guidance for the management of patients under the following special circumstances: malignancy, transplantation, dialysis, coinfection with other viruses, pregnancy, and children.

Correlation between intrahepatic hepatitis B virus cccDNA levels and other activity markers in patients with HBeAg-negative chronic hepatitis B infection

OBJECTIVE

The aim of this study was to demonstrate the relation between intrahepatic (IH) hepatitis B virus (HBV) covalently closed circular DNA (cccDNA) levels and the other HBV replicative intermediates and hepatocyte expression of HBV antigens.

PATIENTS AND METHODS

Patients with hepatitis B surface antigen (HBsAg) positivity, hepatitis B early antigen negativity, serum HBV DNA levels 10 copies/ml or more, and constantly or intermittently increased alanine aminotransferase levels were included.

RESULTS

Fifty-nine patients were included. There was a good correlation between the levels of IH HBV cccDNA and serum HBV DNA (P<0.001). Serum HBsAg levels were weakly correlated with IH HBV cccDNA levels and moderately correlated with serum HBV DNA (r=0.322, P=0.017; r=0.489, P=0.001, respectively). There were no significant correlation between serum HBsAg level and histologic activity index groups (P=0.691), but stage 0, 1, and greater than 2 fibrosis groups were positively correlated with serum HBsAg levels (P=0.019). IH cccDNA and serum HBV DNA were significantly different in hepatitis B core antigen staining groups (P=0.008 and <0.001, respectively) but there was no significant correlation between HBsAg staining groups and HBV replication markers. There was a weak correlation between serum HBsAg levels and IH HBsAg and hepatitis B core antigen levels (r=0.333, P=0.012; r=0.366, P=0.006, respectively). In multivariate analysis, alanine aminotransferase, age, fibrosis stage, and serum HBsAg quantitation were the most important factors predicting IH HBV cccDNA level.

CONCLUSION

Histopathologic damage, serum HBV DNA levels, and IH HBV replication markers have a more complex and dynamic process. However, both serum and IH HBV replication markers provide important knowledge about the activity of the disease.

Chronic hepatitis B: past, present, and future

There have been major advances in the field of hepatitis B (HBV) over the last few decades. These advances have resulted in the understanding of the natural history of chronic HBV infection, effective vaccines against the virus, sensitive assays for screening and monitoring of treatment, and effective treatments for viral suppression, all leading to improved outcomes. Debates and controversies remain, however, over the ideal management strategies of patients with chronic hepatitis B. To eradicate HBV, the global community needs to improve current preventive, screening, and treatment strategies.

The degrees of hepatocyte cytoplasmic expression of hepatitis B core antigen correlate with histologic activity of liver disease in the young patients with chronic hepatitis B infection

Subcellular localizaton of HBcAg have been found to be related to the activity of liver disease and HBV replication. The aim of this study was to determine whether the degree of expression of HBcAg in the hepatocyte nucleus and cytoplasm reflects the level of viral replication and histological activity in chronic HBV infection. A total of 102 patients with biopsy proven chronic hepatitis B were included. There was a highly significant correlation between the levels of HBV DNA in serum and the degree of expression of HBcAg in the nucleus for HBeAg-positive(p=0.000) and negative patients(p=0.04). There was a highly significant, correlation between the degrees of expression of HBcAg in hepatocyte cytoplasm and histologic activities (p<0.01) for HBeAg-positive patients. The degrees of expression of HBcAg in the hepatocyte cytoplasm correlated positively with the lobular activities (p<0.01), but not correlated with the portal activity and fibrosis for HBeAg-negative patients. In conclusion, in the young patients with chronic B viral hepatitis, the degree of expression of HBcAg in the hepatocyte nucleus may affect viral load, and the degree of expression of HBcAg in the hepatocyte cytoplasm may affect histologic activities of liver disease.

Histopathology and clinical correlates of end-stage hepatitis B cirrhosis: a possible mechanism to explain the response to antiviral therapy

In chronic liver disease associated with histological necroinflammation, clinical severity is frequently greater in those with higher grades of activity. Conventional wisdom assumes that necroinflammation is mild or absent in patients with end-stage hepatitis B virus (HBV) cirrhosis due to the frequent presence of mildly elevated aminotransferase levels, the absence of hepatitis B e antigen (HBeAg), and low or undetectable HBV deoxyribonucleic acid (DNA) levels. However, a histopathologic analysis of such patients has not been undertaken. The aims of this study were 1) to assess severity and histological features of inflammation, 2) to correlate the severity of inflammation with biochemical and virologic parameters, and 3) to define the relationship between inflammation and clinical severity in explanted livers from patients undergoing liver transplantation for HBV cirrhosis. Characteristics of 34 consecutive patients undergoing liver transplantation for HBV cirrhosis were correlated with inflammation and immunohistological findings in the explanted livers. High-grade inflammation (grades 3 and 4) was found in many cases (47.1% interface hepatitis; 14.8% lobular inflammation; and 20.6% portal inflammation). The presence of positive cytoplasmic staining for hepatitis B core antigen (HBcAg) was associated with grade 3 or 4 interface hepatitis (P = .046) and lobular hepatitis (P = .005). There was no correlation between inflammatory activity and age, Asian ethnicity, aminotransferase levels, total bilirubin levels, HBeAg seropositivity, and detectable HBV DNA level. Patients with high-grade inflammation had greater degrees of hepatic decompensation. In conclusion, high-grade inflammation is common in end-stage HBV cirrhosis, but it is not readily detected by biochemical and virologic parameters. High-grade inflammation is associated with a greater degree of hepatic decompensation.

Significance of HBV DNA levels in liver histology of HBeAg and Anti-HBe positive patients with chronic hepatitis B

OBJECTIVE

To determine the relationship between hepatitis B virus (HBV) DNA levels and total histologic activity index (HAI), necroinflammation (HAI-NI), and fibrosis (HAI-F) scores.

PATIENTS AND METHODS

Liver histology and HBV DNA levels were determined in 94 patients with chronic hepatitis B.

RESULTS

There was no association between HBV DNA levels and liver histology in hepatitis-B-e antigen-positive patients (n = 43). In anti-HBe-positive patients (n = 51), HBV DNA levels correlated positively with HAI-NI (r = 0.31, p= 0.014) and HAI-F (r = 0.33, p= 0.017) scores. Though the majority of anti-HBe-positive patients with HBV DNA levels <10(5) copies/ml had mild necroinflammation and no fibrosis, 14.3% had established fibrosis. Anti-HBe-positive patients with core promoter mutations had a poorer histology compared to those without. There was no difference in the histology between anti-HBe-positive patients with and without precore mutations. Alanine aminotransferase (ALT) level correlated positively with HAI-NI score. Patients with persistently normal ALT levels had a significantly lower median HAI-NI score compared to patients with either persistently or intermittently elevated ALT levels.

CONCLUSIONS

In anti-HBe-positive patients, though HBV DNA level <10(5) copies/ml was associated with better histology, 14.3% patients had established fibrosis. Further studies to define a better cut-off HBV DNA level to differentiate low- and high-risk patients for disease progression are required.

Detection of hepatitis B virus in seropositive and seronegative patients with chronic liver disease using DNA amplification by PCR

BACKGROUND

The aim of this study was to detect DNA of hepatitis B virus (HBV) for reliable diagnosis of HBV infection in sera by means of a validated polymerase chain reaction (PCR) using a 5' oligonucleotide (primer) previously described and a 3' primer designed by our investigation group.

METHODS

Sera samples collected from patients with chronic liver disease (CLD) related to HBV infection and negative to hepatitis C virus (HCV) infection were analyzed. Patients were both positive and negative to HBV by serum markers detected by ELISA immunoassay. A 146-base pair (bp) fragment was amplified from highly conserved precore-core region. This procedure enabled us to search for DNA HBV-positive cases.

RESULTS

Viral replicative state in negative hepatitis B e antigen (HBeAg) (15.7%) cases was verified by PCR technique. This detected infection by HBV in 100% of immunoassay-positive samples. Additionally, sequences of expected size in patients bearing atypical markers in their sera (7.1%) and those with negative serology (4.8%) for HBV markers were detected.

CONCLUSIONS

In this study we have improved a PCR technique successfully applied in hepatitis B prevalence studies in northeastern Mexico. Prevalence of hepatitis B in this region of Mexico is intermediate compared to countries of the northern hemisphere where prevalence is lower, and to countries of Southeast Asia and the Mediterranean region where it is highly endemic.

Natural history of chronic hepatitis B virus infection: an immunopathological study

Three clinicopathological phases of chronic hepatitis B virus (HBV) infection are identified. First, is immune tolerance of HBV. High levels of viraemia are associated with normal alanine aminotransferase (ALT) levels and minimal histological lesions. More than 30-40% of hepatocytes have the hepatitis B core antigen (HBcAg), predominantly in their nuclei. Maternally derived hepatitis B e antigen (HBeAg) crossing the placenta may result in the elimination of T helper cells responsive to HBeAg/HBcAg. This phase can last for periods ranging from a few weeks to 10 or more years until the immune tolerance is lost. Second, is the immune clearance of HBV. Intermediate levels of viraemia are associated with fluctuating ALT levels and active and ongoing hepatitis. Approximately 20-30% of hepatocytes have HBcAg, predominantly in their cytoplasm. Expression of pre-core defective HBV mutants during chronic HBV infection may lead to a reduction in the secretion of HBeAg and may trigger the beginning of the immuno-elimination phase. The mechanism of intrahepatic shift of HBcAg from the nucleus to the cytoplasm and the decreased levels of viraemia in this phase may be, at least in part, secondary to liver damage and regeneration. Third, is latent infection with residual integrated HBV. Undetectable viraemia is associated with normal ALT levels and no virus-induced liver damage. With regard to hepatocyte expression of HBsAg in chronic HBV infection, membrane staining of HBsAg on hepatocytes has been shown to correlate well with the presence of viraemia. The degree of cytoplasmic hepatitis B surface antigen (HBsAg) expression inversely correlates with the level of viraemia. Therefore, HBsAg carriers with high levels of viraemia have low levels of cytoplasmic hepatitis B surface antigen (HBsAg) expression, while those with low levels of viraemia have high levels of cytoplasmic HBsAg expression. However, several exceptions have been identified. High levels of viraemia associated with high levels of cytoplasmic HBsAg expression were recognized in patients with fibrosing cholestatic hepatitis. In contrast, low levels of viraemia associated with low levels of cytoplasmic HBsAg expression were recognized in patients with hepatitis C virus but not hepatitis D virus superinfection.

What technique should be used for routine detection and quantification of HBV DNA in clinical samples?

Detection of hepatitis B virus (HBV) DNA in serum allows monitoring of HBV replication and assessing responses to antiviral treatment. HBV DNA quantification measures virus replication and can be used as a prognosis indicator of liver disease and an index of response to antiviral drugs. The aim of this study was to compare the performances of three HBV DNA detection and/or quantification techniques for assessing HBV replication. Three hundred unselected sera with a request for HBV DNA detection and quantification were tested with a molecular hybridisation technique without amplification (Digene Hybrid-Capture, Murex Diagnostics Ltd), a signal amplification assay based on branched DNA technology (Quantiplex HBV DNA, Chiron diagnostics), and an 'in-house' qualitative, non quantitative target amplification assay based on the polymerase chain reaction (PCR) with primers located in the S gene of the HBV genome. Hybrid-capture and branched DNA gave concordant results in 278 cases (93%). In the 128 samples positive by both assays, DNA titres in pg/ml were related significantly (r = 0.70, P < 0.0001). but branched DNA titres increased more rapidly than hybrid-capture titres when the amount of HBV DNA in the sample increased. Twenty-two sera (7%) were negative by hybrid-capture, but positive in branched DNA (detection rate gain: 15%). In these 22 patients, DNA titres were low, HBsAg was present in all instances and alanine aminotransferase activity was elevated in 18 patients (82%); HBeAg was present in seven patients (32%) and anti-HBe antibodies in 18 patients (82%); liver biopsy, undertaken in 18 patients, revealed chronic active hepatitis in all instances, associated with cirrhosis in eight cases. Qualitative, non-quantitative HBV DNA PCR was positive in 75 (50%) of the 150 hybrid-capture-negative, branched DNA-negative samples, including a significant proportion of patients without evidence of ongoing HBV-related liver disease. The results show that in general, the branched DNA assay detects HBV DNA in more patients than hybrid-capture and that this improved detection rate is relevant clinically and genome equivalents/ml are preferred to pg/ml to quantify HBV DNA in clinical specimens and finally qualitative, non-quantitative polymerase chain reaction can detect HBV DNA in patients without evidence of active HBV-related liver disease. This study emphasizes the need for more sensitive, university standardised quantitative HBV DNA assays and for the definition of clinically relevant cutoffs with these assays.

The expression of hepatitis B virus polymerase in hepatocytes during chronic HBV infection

A recombinant protein corresponding to part of the amino-terminal domain of hepatitis B virus (HBV) polymerase was expressed in Escherichia coli. Antisera raised against this protein stained hepatocytes, from human liver biopsies, predominantly in the nucleus but some cytoplasmic staining was also observed. No staining was observed in hepatocytes from uninfected patients. Liver biopsies, taken from patients who were infected with human immunodeficiency virus (HIV) as well as HBV showed more intense staining with these antisera than that seen in patients who were infected with HBV alone. The staining pattern suggests that either the whole HBV polymerase protein, or a portion encoding the amino-terminal domain, is translocated to the nucleus. This event may be an important early step in replication of the HBV genome.

Quantitative detection of hepatitis B virus DNA in human sera by branched-DNA signal amplification

Serum samples from 116 patients with hepatitis B surface antigen (HBsAg), from 7 patients without detectable HBsAg and from 71 healthy blood donors were tested by a branched DNA signal amplification (bDNA) method. Hepatitis B virus (HBV) DNA was detected in 39 (34%) of the 116 samples with HBsAg, including 19 (70%) of the 27 patients who were also positive for hepatitis B e antigen (HBeAg). In contrast, one of the 7 patients without HBsAg and none of the 71 blood donors were positive for HBV DNA. The titers of serum HBV DNA did not correlate with the serum alanine aminotransferase levels. All the samples positive by the bDNA assay were positive by the polymerase chain reaction (PCR). However, 59% of the PCR-positive samples were bDNA-negative. None of the PCR-negative samples was positive by the bDNA method. Although the sensitivity of bDNA method is not entirely satisfactory, it showed excellent specificity and reproducibility. Thus it may be considered as an alternative for quantitative detection of HBV DNA in serum samples of patients with relatively high titers of HBV viremia.

Membrane staining for hepatitis B surface antigen on hepatocytes: a sensitive and specific marker of active viral replication in hepatitis B

AIMS--To test the hypothesis that membranous staining of hepatitis B surface antigen (HBsAg) on the hepatocyte is a marker of active viral replication in chronic hepatitis B virus (HBV) infection. METHODS--Intrahepatic expression of HBsAg and hepatitis B core antigen (HBcAg) was studied by indirect immunofluorescence on frozen sections of liver specimens from 75 patients with chronic hepatitis B, and the results were correlated with serum levels of HBV-DNA assayed by spot hybridisation. RESULTS--Hepatocyte HBcAg was detected in all of 20 patients with serum levels of HBV-DNA > 1000 pg/ml, 18 (75%) of 24 patients with levels of HBV-DNA < or = 1000 pg/ml, and two (6.5%) of 31 patients without detectable serum HBV-DNA. The concordance between hepatocyte HBcAg and serum HBV-DNA was 89.3% (67/75). There were six patients (8%) who had detectable serum HBV-DNA but without hepatocyte HBcAg, and two patients (2.7%) who had detectable hepatocyte HBcAg but without serum HBV-DNA. Membranous staining of HBsAg associated with variable degrees of cytoplasmic HBsAg was found in all but one of 44 patients with serum HBV-DNA, irrespective of the levels, but in none of the 31 patients without serum HBV-DNA. Of the latter, HBsAg was distributed solely in the cytoplasm. In addition, there is an inverse correlation between serum levels of HBV-DNA and the degrees of cytoplasmic staining of HBsAg. The concordance between membranous staining fo HBsAg and serum HBV-DNA was 98.7% (74/75), significantly higher than that between hepatocyte HBcAG and serum HBV-DNA. CONCLUSIONS--Membranous staining of HBsAg on the hepatocyte correlated excellently with serum HBV-DNA and thus can be recognised as a sensitive and specific marker of active hepatitis B virus replication.

The role of interferon in the treatment of viral hepatitis

Chronic viral hepatitis, frequently an asymptomatic disease, can persist for decades. Despite the lack of symptoms, prolonged infection can lead to the complications of cirrhosis, liver failure and hepatocellular carcinoma. The goal of therapy is to reduce the risk of developing these complications and to eradicate the infectious pool. Patients with ongoing viral replication appear to be at greatest risk for developing complications. These patients have been targeted for treatment. Numerous randomized studies of interferon treatment of chronic hepatitis B and C have been published in the last 8 years. The experience from these studies and more recent developments will be reviewed.

Perinatal transmission of hepatitis B virus in Senegal, west Africa

We studied 152 healthy pregnant women and their 156 newborns for markers of hepatitis B virus (HBV) infection in Dakar, Senegal. Of these, 120 mothers (79%) had antibodies to the hepatitis B core antigen (anti-HBc), 21 (13.8%) were hepatitis B surface antigen (HBs Ag) positive, including 2/21 (9.5%) hepatitis B core-associated antigen (HBe Ag) positive and 1/21 (4.7%) HBV DNA positive. At birth, 11 (7%) infants were HBs Ag positive; 9/11 had an HBs Ag positive mother. Ten of these HBs Ag positive-born infants were investigated at 6-7 months: 5 were strongly HBs Ag positive and developed antibodies to HBs Ag, HBc Ag or HBe Ag; these 5 (3.2% of the total) probably became chronic carriers of HBV. The 5 others were HBs Ag negative and 4/5 did not develop antibodies against HBV Ag; HBs Ag positivity at birth was likely due to contamination of the mother's blood. Thirty-one of the 145 HBs Ag negative-born infants were studied at 6-7 months and remained HBs Ag negative. However, 5 (16%) showed evidence of HBV infection occurring between 0 and 6 months, as shown by the development of antibodies to HBs Ag, HBc Ag, and/or HBe Ag. Despite the low prevalence of HBV DNA and HBe Ag in HBs Ag positive African mothers, this study shows the occurrence of perinatal transmission of HBV in West Africa, in contrast with previous studies. Perinatal HBV transmission could explain the HBV vaccination failure recently reported in children in Senegal.

Interferon therapy is effective in treatment of hepatitis B-induced polyarthritis

A patient with acute hepatitis B developed significant polyarthritis. After 10 months of observation he had not cleared the virus and continued to have symptomatic joint problems, with migratory polyarthralgia, tenosynovitis of the left wrist, and a large knee effusion. Hepatitis B surface antigen (HBsAg) and hepatitis B virus (HBV) DNA levels were measured in the synovial fluid and were found to be virtually identical to serum levels, indicating the potential infectivity of this fluid. The patient was treated with 14 weeks of thrice-weekly lymphoblastoid interferon and cleared all markers of viral replication. The arthritis resolved with the disappearance of measurable HBsAg. Interferon may be effective therapy for this disorder.

Mutation of the core region of HBV-DNA and submassive hepatic necrosis in patients with anti-HBe-positive chronic hepatitis B

Three patients with submassive hepatic necrosis developed acute liver failure during the severe reactivation of chronic hepatitis B. The activity of hepatitis B virus (HBV) DNA polymerase increased in all three patients immediately before the onset of hepatic failure. Liver biopsy specimens obtained before and after the episode of submassive hepatic necrosis showed progression to advanced liver cirrhosis. The nucleotide sequences of the precore and core regions of HBV-DNA were investigated in two of the three patients and in another two patients with piecemeal and bridging necrosis. The nucleotide and amino acid sequences of the HBV-DNA core region changed after reactivation in the the two patients with submassive hepatic necrosis, while the sequences in the other two patients with piecemeal necrosis remained unchanged before and after reactivation. These results suggest that the antigenicity of the HBV-DNA core region may have been changed before and after severe reactivation. Due to mutation at the core region, a different type of epitope would be expressed on the hepatocytes after submassive hepatic necrosis, which would not be a target for the cytotoxic T cell. This was evident by the continuation of the normal serum GPT for 5 and 9 years, respectively.

Blood-borne Infections Associated with Transfusion

The epidemic of acquired immunodeficiency syndrome (AIDS) and the realization that transmission of human immunodeficiency virus is caused by homologous blood transfusion have changed the way physicians and their patients view the safety of hemotherapy. Considering that nearly four million patients receive the lifesaving benefits of blood transfusions every year in the United States, we need to recognize and reduce the inherent biological complications of this therapy. Currently, a major concern is the transmission of blood-borne infectious agents and the establishment of persistent infection in transfusion recipients, which is apparently facilitated by suppression of the recipient's hematopoietic and immune systems. Education of blood donors, patients, and attending physicians regarding infectious complications of transfusion is essential and remains the most effective procedure for making rational decisions. Before giving blood transfusions, astute physicians should calculate a risk/benefit ratio and communicate it to the patient or family. Potential recipients of transfusions can be assured that the blood supply is safer now than at any time in the past, although there is still a very small risk for the transmission of infectious agents that cause chronic diseases, such as hepatitis, AIDS, neuropathies, and leukemias. It is essential that everyone understands that the goal of a zero-risk blood supply is not attainable. Recent developments in molecular biology and biotechnology, however, provide opportunities for further reduction of infectious complications of blood transfusions.

Isolated hepatitis B core antibody--can response to hepatitis B vaccine help elucidate the cause?

The finding of a positive hepatitis B core antibody (anti-HBc) in the absence of hepatitis B surface antigen (HBsAg) or hepatitis B surface antibody (anti-HBs) is relatively uncommon. This finding is known to occur during the 'window period' of acute hepatitis B between loss of HBsAg and the appearance of anti-HBs. It may also occur with active infection or following resolution. The aim of this study was to determine if response to hepatitis B vaccination would allow the separation of these subgroups of patients with isolated anti-HBc. Seventeen patients with persistent isolated core antibody were vaccinated and serum obtained at 2, 4 and 8 weeks. Results were compared with a seronegative control group. Six subjects (35%) but no control patients (p = 0.016) responded with a titre of greater than 50mIU/mL at two weeks, suggesting an anamnestic response due to prior infection and immunity. A further seven subjects (41%) finally seroconverted (anti-HBs titre greater than 10mIU/mL) thus excluding chronic infection and suggesting initial false positive results. Only two subjects did not respond to a full course of vaccination, but neither they nor any other subjects were positive for HBV DNA. These results indicate that hepatitis B vaccination and subsequent measurement of anti-HBs will identify evidence of past infection in the form of an anamnestic response in up to one third of the patients and will also exclude chronic infection on the grounds of a normal vaccine response in a majority of the remainder.

Comparison of hepatitis B virus subtyping ofd/y determinants by radioimmunoprecipitation assay and the polymerase chain reaction

Using a double polymerase chain reaction a method was devised for detecting and subtyping hepatitis B virus DNA in serum samples. Primers from the S-gene were selected from the sequence analyses of five HBV HBsAg subtypes, to amplify HBV DNA and subtype for y specific DNA. Thirty-eight samples were subtyped for d and y determinants by radioimmunoprecipitation assay (RIPA) and the polymerase chain reaction (PCR). Subtyping by PCR and RIPA was in agreement in 100% of subtype y samples and 83.3% of subtype d, giving an overall correlation of 92.1%. As a third comparison, 12 amplified samples were digested by the restriction enzyme Sau 3A, which differentiates between subtypes y and d. The digest results agreed with PCR in 83.3% of the samples. In addition, we compared our standard phenol/chloroform extraction against a rapid one step method. The phenol/chloroform stage was found to be essential for the removal of nucleases and polymerase inhibitors present in sera.

Expression of hepatitis B surface antigen subtypes in liver of patients with hepatocellular carcinoma; comparison of subtypes in serum and liver

To clarify the discrepancy in hepatitis B surface antigen (HBsAg) subtypes present in the serum and liver, as well as among hepatocytes, liver specimens which were resected from 37 HBsAg-positive patients with hepatocellular carcinoma (HCC) were examined. We evaluated HBsAg and the subtypic determinants of HBsAg and hepatitis B core antigen (HBcAg) using the peroxidase-antiperoxidase (PAP) staining method. Hepatitis B antigens were more frequently detected in small tumors (HBsAg in 67%. HBcAg in 40%) than in large ones (HBsAg in 36%, HBcAg in 14%). The prevalence of each subtypic determinant in the HBsAg positive non-tumorous vs. tumorous areas was 100% vs. 67% in a, 100% vs. 57% in d, 100% vs. not tested in y, 100% vs. 53% in r and 25% vs. 0% in w (a, d, y, r and w represent subtypic determinants). There was virtually no difference in a set of subtypic determinants between the serum and liver. However, there were some variations in a set of subtypic determinants among the hepatocytes. On the other hand, liver tissue of compound subtype adyr in serum contained both cells with a,d,r and with a,y,r as well as a few cells with a,d,y,r. These findings suggest that HBV genomes in hepatocytes of type B chronic liver disease may differ genetically among cells even in the same liver tissue.

Age- and sex-related study of HBV-DNA in HBsAg asymptomatic children from an endemic area (Cameroon)

A sero-epidemiological survey was carried out in Cameroon in January 1989 on a sample of 702 children of primary school age. A high HBV endemicity level was observed: 60.3% of the sera were positive to any HBV marker, 23.2% (163 sera) were HBsAg-positive. HBV-DNA positivity was observed in 38/163 (23.3%), thus showing a high level of infectivity among these carriers. Seventy-seven HBsAg-positive sera were tested for HBeAg/anti-HBe: 20 (26%) were HBeAg-positive 31 (40%) anti-HBe-positive, and 26 (34%) were negative for both. All sera were anti-HD-negative. Twenty-five per cent of HBeAg-positive sera were HBV-DNA-negative. This finding could be explained by a delayed HBeAg/anti-HBe seroconversion phase with fluctuant HBV-DNA. Only one case of HBV-DNA-positive anti-HBe-positive serum was observed. This study showed that HBV-DNA prevalence was significantly higher in boys (31.8%) than in girls (14.1%) (p less than 0.02). This difference was not observed for any HBV marker. We therefore conclude that in boys a prolonged HBV replicative phase might explain the observed high chronicity rate.

Correlation between HBV DNA detection by polymerase chain reaction and Pre-S1 antigenemia in symptomatic and asymptomatic hepatitis B virus infections

The presence of hepatitis B virus (HBV) genome in sera from 73 symptomatic and asymptomatic HBsAg carriers was studied by the polymerase chain reaction (PCR) with primers specific for the S and C regions. Pre-S proteins of the HBV envelope were detected in serum by a specific monoclonal antibody in a double immunoradiometric assay. Out of twenty-five symptomatic patients with chronic active hepatitis (14 with HBeAg and 11 with anti-HBe), all were positive for HBV DNA by PCR, while 14/14 HBeAg and 2/11 (18%) of the anti-HBe patients were positive by dot blot hybridization. All but one anti-HBe patient (96%) carried Pre-S1 proteins. Among the asymptomatic HBsAg carriers, HBV DNA was detected by PCR in 14/14 (100%) HBeAg positive patients and in 25/34 (73%) anti-HBe positive patients. Pre-S1 proteins were found, respectively, in 14/14 (100%) and 11/22 (50%) of the same cases tested in parallel. The 20 healthy blood donors devoid of HBV markers and with normal transaminases tested were found negative for HBV DNA using PCR. Out of 12 patients who recovered from acute hepatitis B, all were found negative by PCR analysis after a mean follow up of 1 year after seroconversion to anti-HBs. When serial samples from 2 patients (one with acute hepatitis B, the other with chronic hepatitis B) were tested for the presence of HBV DNA and of Pre-S1 proteins, both markers showed parallel development.(ABSTRACT TRUNCATED AT 250 WORDS)

Discordance of hepatitis B e antigen and hepatitis B viral deoxyribonucleic acid

Sera from 899 hepatitis B surface antigen (HBsAg) carriers from four separate ethnic groups (Caucasian, Australian Aboriginal, Melanesian, and Asian) were studied for their correlation for hepatitis B virus deoxyribonucleic acid (HBV DNA) and hepatitis B e antigen (HBeAg). Discordance, as signified by the absence of HBV DNA despite the presence of HBeAg, was unusual in Caucasians but frequently occurred in the other three ethnic groups (11-25%). Analysis by age showed that it occurred occasionally during childhood and, in this age group, may simply be part of the process of seroconversion with impending loss of HBeAg, whereas its greater prevalence in patients with liver disease may have a different mechanism. In sera obtained from Melanesians with hepatocellular carcinoma and Asians with chronic hepatitis, discordance was a common feature with HBV DNA being undetectable in those with HBeAg in 87% and 72%, respectively. A number of important implications flow from these observations pertinent to the use of HBeAg to detect replicating virus and the prognostic significance of HBeAg in HBsAg carriers when HBV DNA is undetectable.

A precore-defective mutant of hepatitis B virus associated with e antigen-negative chronic liver disease

The pathogenesis of chronic liver disease (CLD) due to persistent hepatitis B virus (HBV) infection has not been defined, but the disease activity is believed to correlate with the presence of hepatitis B e-antigen (HBeAg) antigenemia and high viremia. The molecular characterization of an HBV mutant isolated from an HBeAg-negative patient with severe CLD required amplification of the circulating HBV DNA (2 pg/ml) by the polymerase chain reaction (PCR). Direct sequencing of the nucleotides from five independent amplifications of the conserved precore region consistently revealed a G to A mutation in each of the two terminal codons of the precore region. Codon 28 was mutated from tryptophan-encoding TGG to a translational stop codon, TAG; codon 29 preceding the core initiation codon was changed from GGC to GAC. For biologic evaluation of these mutations on HBV replication and expression of HBeAg in vitro, HepG2 cells were transfected with cloned, recircularized mutant HBV DNA. The transfected cells contained subviral core particles in the cytoplasm and secreted mature HBV, without HBeAg, into the medium. The findings present the first evidence that complete HBV genomes can be amplified by PCR and are replication-competent in vitro. The data also indicate that HBeAg is not necessary for replication of HBV and furthermore suggest that HBeAg is not required for the progression of HBV-induced CLD.

Hepatitis B virus replication in Chinese patients with hepatocellular carcinoma

We studied the frequency of hepatitis B virus replication in Chinese patients with hepatocellular carcinoma. Hepatitis B e antigen and hepatitis B virus DNA could be detected in the sera of 28% and 47% of 116 HBsAg-positive patients, but not in the sera of 15 HBsAg-negative patients. Replicative forms of hepatitis B virus DNA were detected in the neoplastic and nonneoplastic liver tissues from 34% and 62% of 29 HBsAg-positive patients and 0% and 20% of five HBsAg-negative patients by Southern blot hybridization analysis. Of the 10 patients with chronic hepatitis B virus infection in whom hepatocellular carcinoma developed during follow-up, hepatitis B e antigen and hepatitis B virus DNA were detected in the sera of seven and eight patients, respectively, at presentation, 13 to 43 mo before the diagnosis of hepatocellular carcinoma. In nine patients, hepatitis B virus DNA was persistently or intermittently detected in the serum during follow-up. Five patients remained hepatitis B e antigen-positive and seven were detectable for hepatitis B virus DNA in serum when hepatocellular carcinoma was diagnosed. Four patients had one or more episodes of exacerbations before the diagnosis of hepatocellular carcinoma; in three, the exacerbations were associated with changes in level of hepatitis B virus replication. Our study demonstrated that despite the long interval between the onset of hepatitis B virus infection and the development of hepatocellular carcinoma, hepatitis B virus replication persisted in most patients with hepatocellular carcinoma, albeit at a low level.

Delta infection in chronic HBs Ag carriers in Tunisia: high prevalence in chronic asymptomatic HBs Ag carriers and in HBs Ag positive cirrhosis

The presence of hepatitis B virus DNA, delta antigen and anti-delta antibodies was examined in 159 Tunisian chronic HBs Ag carriers: 45 were asymptomatic and 114 suffered from cirrhosis. Serum hepatitis B virus DNA was detected in two (4.5%) asymptomatic HBs Ag carriers and in 11 (10%) HBs Ag positive cirrhosis patients. The prevalence of HDV infection determined by the presence of anti-delta was relatively high in asymptomatic HBs Ag carriers (33%) and in HBs Ag positive cirrhosis patients (21%). Active ongoing HDV infection, detected by serum HD Ag and anti-delta IgM, was shown in five patients with cirrhosis and active hepatitis B virus replication. We conclude that hepatitis delta virus may be endemic in Tunisia and does not always inhibit hepatitis B virus replication.

HBV-DNA, HBeAg/anti-HBe serological status in hepatitis B chronic individuals from central Italy

A population of 488 HBsAg carrier individuals, from central Italy, classified on the basis of biochemical, clinical and histological parameters, was analysed for the presence of HBV-DNA in serum and its relationship with HBeAg/anti-HBe markers. The prevalence of HBV-DNA was 32.8% in chronic patients with biopsy-proven liver disease, and 20 and 4.3% respectively in asymptomatic carriers with and without altered ALT levels. The values in chronic patients were correlated with the histological activity. Concordance of HBV-DNA presence and HBeAg positivity was observed in only 61.4% of cases. However HBV-DNA prevalence in sera of anti-HBe positive individuals was very low in asymptomatic carriers with normal ALT levels (2.5%). Higher values were observed in anti-HBe positive chronic patients (15.8%) and in carriers occasionally found with changes in ALT without any other clinical sign of illness (16.7%). These data would indicate that HBV-DNA is the serological marker which is most closely related to liver disease.

Hepatitis B virus replication in patients with chronic liver diseases

One hundred and seventy five subjects with chronic liver diseases which included patients with chronic active hepatitis (90), liver cirrhosis (31) and asymptomatic hepatitis B carriers (54), were included in the study. Hepatitis B virus (HBV) specific DNA-polymerase activity and HBe-markers were tested as markers of HBV-multiplication. In HBsAg positive samples, DNA-P activity was positive in 44.4% of the HBV carriers, 52.9% of the patients with chronic active hepatitis and 81.8% of the patients with liver cirrhosis. The corresponding figures for the presence of HBeAg in these groups were 18.5, 26.5 and 45.5% respectively. Virus multiplication was also observed in 41.1 and 44.4% patients with chronic active hepatitis and liver cirrhosis respectively, in the absence of HBsAg. The results of the present study show that hepatitis B virus is the most important etiological factor of chronic liver diseases in India. Most of our patients of chronic liver diseases seems to have contacted HBV infection as young adults and the mode of transmission is likely to be horizontal rather than vertical. The virus replicating markers correlate well with the severity of the liver injury and decreased with the age. DNA-P activity is a more sensitive marker of viral multiplication than HBeAg. Viral multiplication was also found to occur in the absence of the usual HBV markers. Continued viral multiplication in patients with chronic active hepatitis and liver cirrhosis is implicated in continued liver injury and progressive liver disease.

Detection of hepatitis B viral DNA by polymerase chain reaction in patients with hepatitis B surface antigen

Hepatitis B virus (HBV) DNA was assayed using the polymerase chain reaction in serum samples of 116 hepatitis B surface antigen (HBsAg) carriers, including 30 positive for hepatitis B e antigen (HBeAg) and 86 negative for HBeAg. In the HBeAg-positive group, all were positive for HBV DNA. In the HBeAg-negative group, 80.2% were positive for HBV DNA (80.0% in the healthy carrier group, 90.0% in the chronic active liver disease group, and 69.2% in patients with cirrhosis). This study indicated that every HBeAg-positive carrier as well as the majority of HBeAg-negative carriers were infectious and, in the latter group, that viral replication is most active in patients with chronic active liver disease.

The absence of hepatitis B virus DNA in hepatitis B e antigen positive sera from chronic hepatitis B surface antigen carriers in China

Sera from 20 Chinese patients with chronic hepatitis B were examined for hepatitis B e antigen and hepatitis B virus (HBV) DNA. There was considerable discordance with HBV DNA not being detectable in 10 out of 13 (77%) patients who were hepatitis B e antigen positive. Further testing for anti-HBe and HBV-DNA polymerase activity confirmed the results. Possible reasons for this discordance are discussed but neither hepatitis D (delta) infection nor the acquired immunodeficiency syndrome (AIDS) could be implicated.

Prevalence of HBeAg, anti-HBe serological markers and HBV-DNA in asymptomatic carriers in Ethiopia

Data on the distribution of HBV-DNA and other serological markers of hepatitis B virus infection in a population of asymptomatic carriers in Ethiopia are reported. As compared to data from other countries of similar or lower levels of endemicity, it has been found that HBV-DNA prevalence and its correlation with HBeAg/anti-HBe status is similar to that of northern Europe. HBV-DNA is present in 84% of HBe Ag-positive sera but in only 4% of anti-HBe-positive sera, where the lowest concentration of DNA (less than 5 pgr/20 microliters) was found. The trend of increasing prevalence of serological markers with age seems to indicate a considerable horizontal transmission still present in this age range (18-30). In keeping with data of other authors a 3% of HBV-DNA positivity in anti HBc only positive sera was found. No regional or ethnical differences of HBV-DNA positive sera across the country were observed. There is also no evidence of any correlation between HBV-DNA prevalence and HBsAg subtypes ad and ay.

Mutation preventing formation of hepatitis B e antigen in patients with chronic hepatitis B infection

Some patients with chronic hepatitis B virus (HBV) infection are HB e antigen (HBeAg) negative, have circulating HBV particles, and often have especially severe chronic hepatitis. To test the hypothesis that the absence of HBeAg production may be due to a change in the nucleotide sequence of the pre-core region of the genome, 18 Greek and 3 non-Greek patients positive for HB surface antigen underwent direct sequencing of HBV-DNA amplified from sera. In 7 out of 8 HBeAg negative patients, two mutations (guanosine to adenosine) were found in the terminal two codons of the pre-core region, giving the sequence TAGGACATG. The remaining patient had the first mutation only. The sequence TGGGGCATG was found in 4 of 5 of the HBeAg positive patients. The first mutation results in a translational stop codon that is predicted to result in failure to produce HBeAg. The rest of the pre-core region in the HBeAg negative patients was otherwise homologous to that of the HBeAg positive patients and to known sequences.

Clearance of hepatitis B virus DNA and pre-S surface antigens in patients with markers of acute viral replication

To clarify the relationship between the pre-S antigens and other serological markers of hepatitis B virus (HBV) replication, we followed up 27 patients: 21 presented with symptoms of acute hepatitis (two progressed to chronicity) and six suffered from chronic hepatitis. Pre-S1, pre-S2, HBV DNA, IgM antihepatitis core antigen (HBc), hepatitis B e antigen (HBeAg), and anti-HBe were detected in about 200 sera serially collected at different times for at least 6-12 months from the onset of clinical observation. In the early symptomatic phase of acute hepatitis, the pre-S1 and pre-S2 antigens were present in 95% of the cases and correlated well with high levels of alanine-transferase (ALT) and IgM anti-HBc, while HBV DNA was present in the sera of only six (28.6%) patients (P less than 0.0001). This was the first marker to disappear (1 month after the initial stage). All of the HBV DNA-positive patients were also HBeAg positive, whereas no HBeAg-negative subjects were found with serum HBV DNA. In the six chronic patients, pre-S antigens were always present independently of the HBeAg/anti-HBe status; HBV DNA was detected in three of them, even if transiently, and in two of these it reappeared together with pre-S2 epitope. The follow-up data suggest that, in acute hepatitis, the clearance of pre-S antigens can be considered as a prognostic index of clinical resolution and that, in chronic hepatitis, the persistence of pre-S antigens seems to indicate progression of the disease. In particular, pre-S2, in patients in whom it is intermittent, can be considered as an index of reactivation.

Chronic hepatitis B in male and female children of HBsAg carrier mothers

We have studied a group of children born to HBsAg+ mothers, resident in the English West Midlands; none of the children had sought medical attention for hepatitis B-related problems. Forty-two out of 48 children born to HBeAg+ mothers were HBsAg+. Among these children, the mean age of the HBeAg+ girls was significantly lower than that of the HBeAg+ boys (P = 0.05), suggesting that girls eradicate HBeAg at a younger age than boys. Among all children born to HBsAg+ mothers, liver function tests were normal except in 2 HBsAg+ boys who had elevated serum aminotransferase activities. Excluding these boys, serum alanine aminotransferase activity, while within the normal range, was significantly higher in HBeAg+ and anti-HBe+ children than in their immune (anti-HBs+) and non-infected siblings (P less than 0.01 and P less than 0.05). Waning infectivity was observed in many HBsAg+ mothers, giving rise to a typical pattern of infection within a family: older children, born to the still HBeAg+ mother, being HBeAg+ carriers, while younger siblings, born when the mother had become anti-HBe+, had no markers of infection. These younger children are vulnerable to 'horizontal' transmission.

Acute and chronic hepatitis delta virus infection: direct or indirect effect on hepatitis B virus replication?

In a large population of patients, chronic hepatitis delta virus (HDV) infection was usually associated with absence of hepatitis B virus (HBV) replication. However, acute HDV superinfection progressing to chronic HDV infection in two hepatitis B e antigen (HBeAg)-positive HBV carriers and coinfection in two other patients who progressed to chronic HBV (HBeAg-positive) and HDV infection was associated with continuing high-level HBV replication for several years. Thus HDV infection does not always inhibit HBV replication. The hypothesis that the different effects of HDV coinfection and superinfection on HBV replication may stem from variability in the capacity of the host to produce and respond to interferon is discussed.

The prevalence of serological markers, hepatitis B virus DNA and elevated serum amino transferase values in institutionalized mentally handicapped males and females: an epidemiological study of HBV infection in residents with Down's syndrome or other forms of mental deficiency

Conventional HBV serological markers, as well as serum alanine amino transferase and hepatitis B virus DNA (HBV DNA) were studied in a population of 667 institutionalized mentally handicapped males and females and in 676 staff members. The role of Down's syndrome (DS), sex and age-related factors with respect to the prevalence of these markers was analyzed. A young age at admission was found as one of the important factors in the development of the chronic HBsAg carrier state in females. The well-known higher prevalence of HBsAg carriership in DS patients appeared to be restricted to males. Markers indicative of viral replication, HBeAg and HBV DNA, were also more prevalent in male than in female DS residents, or OMR residents. These findings indicate that the phase of active viral replication is prolonged in male HBsAg carriers with DS. However, only 66.7 per cent of HBV DNA-positive and 26.2 per cent of HBsAg-positive residents had abnormal serum alanine aminotransferase (ALT) values. In addition, more than 50 per cent of residents with elevated serum alanine amino transferase values were negative for HBV serological markers. We conclude that male DS residents are the main source of HBV infection in institutions for the mentally handicapped and that determination of ALT values is not very useful in identifying those HBsAg carriers capable of transmission the infection.

Screening for hepatitis B virus in healthy blood donors by molecular DNA hybridization analysis

A DNA molecular hybridization technique employing a purified adw subtype hepatitis B virus (HBV) cloned DNA of 3.2 kilobase pairs as a probe was used to screen for the presence of HBV DNA in blood samples collected from 486 apparently healthy blood donors. Eighteen of 104 (17.3%) hepatitis B surface antigen (HBsAg) carriers and 7 of 382 (1.8%) HBsAg-negative individuals had circulating HBV DNA in their sera. Among the seven individuals who were positive for HBV DNA but negative for HBsAg, three had antibodies against both HBsAg (anti-HBsAg) and hepatitis B core antigen, one had only anti-HBsAg, one had both anti-hepatitis B core antigen and anti-hepatitis B e antigen and two were negative for all the above HBV markers. The results suggest that the absence of HBsAg in otherwise apparently healthy individuals may not be enough to ensure lack of circulating HBV.

Symptomatic anti-HBe positive chronic hepatitis B in Taiwan with special reference to persistent HBV replication and HDV superinfection

Ninety-four patients, who were admitted with symptoms of liver disease and found to be positive for hepatitis B surface antigen and antibody to hepatitis B e antigen (anti-HBe), were examined for hepatitis B virus (HBV) DNA in serum and immunoglobulin antibody to hepatitis B core antigen and liver biopsies were stained for hepatic hepatitis B core antigen. Of 94 patients, 34 (36%) had evidence of HBV replication and 35 (37%) evidence of hepatitis D virus (HDV) superinfection. Most of the latter two groups of patients (greater than 70%) had evidence of chronic active hepatitis or active cirrhosis in their liver biopsies. The majority of these patients (greater than 80%) also had high levels of serum alanine aminotransferase (greater than 200 U/L) during the acute stage of their illness, and suffered from prolonged hepatic inflammation (greater than 1 year). Many of the patients (59%) also experienced frequent (1-6 episodes) relapsing exacerbations during a two-year follow-up period. Thus, persistent replication or reactivation of HBV and HDV superinfection were the two major causes of clinical exacerbations in anti-HBe-positive chronic HBV carriers in Taiwan, and also played an important role in the progression of their liver diseases and unfavorable outcomes.

Chronic hepatitis: pathogenesis and treatment

Current therapies for chronic viral hepatitis, autoimmune "lupoid" chronic active hepatitis, and drug-induced chronic hepatitis are discussed in the context of recent advances in our understanding of the pathophysiology of chronic active liver disease. Accurate diagnosis is the cornerstone of proper treatment; the limitations and pitfalls of conventional techniques are discussed. Current theories of the pathogenesis of chronic hepatitis B are reviewed to provide a framework for the use of antiviral drugs. Data from the early results of therapy with adenine arabinoside, acyclovir, and immunomodulatory agents are reviewed, and the theoretical basis for the use of alpha-interferon as well as preliminary data supporting its efficacy is presented. Strategies for the treatment of chronic delta hepatitis and chronic non-A, non-B viral hepatitis are discussed as well. The immunological changes associated with autoimmune chronic active hepatitis are described to help define those patients with chronic active hepatitis who are likely to respond to immunosuppressive therapy. The recognized hazards of long-term corticosteroid therapy are indicated and guidelines for the management of these patients are suggested. Chronic drug-induced liver disease will usually improve with cessation of the offending agent. An approach to the patient with suspected drug-induced chronic hepatitis is indicated. Finally, the role of liver transplantation is mentioned as the ultimate treatment modality available for endstage liver disease.