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KASL clinical practice guidelines for management of chronic hepatitis B. Clin Mol Hepatol 2022; 28:276-331. [PMID: 35430783 PMCID: PMC9013624 DOI: 10.3350/cmh.2022.0084] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 01/10/2023] Open
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Wu F, Lu R, Liu Y, Wang Y, Tian Y, Li Y, Li M, Wang W, Zhang X, Jia X, Dang S. Efficacy and safety of peginterferon alpha monotherapy in Chinese inactive chronic hepatitis B virus carriers. Liver Int 2021; 41:2032-2045. [PMID: 33896094 DOI: 10.1111/liv.14897] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/27/2021] [Accepted: 03/31/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The effectiveness and safety of peginterferon alpha (peg-IFN-α) monotherapy in inactive hepatitis B virus (HBV) carriers (IHCs) have not been fully evaluated. METHODS This observational study prospectively enrolled 298 IHCs in China from 2015 to 2019. Participants were given the right to choose to either receive peg-IFN-α monotherapy (treatment group, n = 142) or be monitored without treatment (control group, n = 156) according to their wishes. The scheduled treatment duration was 48 weeks. All participants were followed up to 72 weeks. The main efficacy endpoint was hepatitis B surface antigen (HBsAg) clearance at 72 weeks. RESULTS Baseline characteristics were similar between both groups. At 72 weeks, intention-to-treat analysis showed that the rates of HBsAg clearance and seroconversion of the treatment group were 47.9% (68/142) and 36.6% (52/142), respectively, which were significantly higher than the HBsAg clearance rate of 1.9% (3/156) and the seroconversion rate of 0.6% (1/156) in the control group (both P < .001). Baseline HBV DNA < 20 IU/mL, lower HBsAg levels at baseline, 12 and 24 weeks, alanine aminotransferase elevation at 12 weeks, and greater HBsAg reduction from baseline to 12 and 24 weeks were independent predictors of HBsAg clearance. Generally, the therapy was well tolerated. Only five participants discontinued therapy as a result of peg-IFNα-related adverse events. CONCLUSIONS Peg-IFN-α monotherapy results in high rates of HBsAg clearance and seroconversion and the treatment is safe for IHCs.
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Affiliation(s)
- Fengping Wu
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Rui Lu
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yixin Liu
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yikai Wang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yan Tian
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yaping Li
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Mei Li
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wenjun Wang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xin Zhang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaoli Jia
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shuangsuo Dang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Toka B, Koksal AS, Eminler AT, Tozlu M, Uslan MI, Parlak E. Comparison of Tenofovir Disoproxil Fumarate and Entecavir in the Prophylaxis of HBV Reactivation. Dig Dis Sci 2021; 66:2417-2426. [PMID: 32729014 DOI: 10.1007/s10620-020-06506-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 07/19/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Current guidelines recommend starting antiviral prophylaxis to prevent hepatitis B virus (HBV) reactivation in patients receiving immunosuppressive treatments (IST). The aim of this study was to compare the efficacy of entecavir (ETV) and tenofovir disoproxil fumarate (TDF) for prophylaxis. METHODS Patients, who were HBsAg and/or anti-HBc IgG positive and scheduled to receive IST for oncologic and hematologic diseases, were enrolled into the study. Those who were already receiving an antiviral treatment for HBV or had an associated HIV, hepatitis C, D were excluded. The remaining patients with a prophylaxis indication according to the AGA guideline were randomized to receive either ETV (0.5 mg/day) or TDF (245 mg/day). Prophylaxis was continued for 6-12 months after completion of IST. Patients were followed up for 1 year after completion of prophylaxis. The HBV reactivation rates and side effects of the drugs were compared. RESULTS The study group included 120 patients. There was no significant difference between the demographic data, viral serologic parameters and reactivation risk profiles of the ETV (n = 60) and TDF (n = 60) groups. Forty-one patients in the ETV and 36 in the TDF group completed the antiviral prophylaxis, and no HBV reactivation was observed. HBV reactivation was observed in 4 of 37 patients (10.8%) in the ETV group and 5 of 35 (14.3%) patients in the TDF group (including one with flare) during the follow-up after completion of prophylaxis. Ten patients in the ETV group (16.7%) and 14 patients (23.3%) in the TDF group experienced side effects (p = 0.77). One patient in the TDF group had to switch to ETV due to severe itchy, maculopapular rash-like lesions. CONCLUSIONS ETV and TDF had a similar efficacy in the prophylaxis of HBV reactivation in patients undergoing IST, with none of the patients experiencing reactivation.
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Affiliation(s)
- Bilal Toka
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Korucuk Campus, Sakarya, Turkey.
| | - Aydin Seref Koksal
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Korucuk Campus, Sakarya, Turkey
| | - Ahmet Tarik Eminler
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Korucuk Campus, Sakarya, Turkey
| | - Mukaddes Tozlu
- Department of Gastroenterology, Sakarya Eğitim ve Araştırma Hastanesi, Sakarya, Turkey
| | - Mustafa Ihsan Uslan
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Korucuk Campus, Sakarya, Turkey
| | - Erkan Parlak
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Korucuk Campus, Sakarya, Turkey
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Cam S, Yoruk MA. Alteration in Hepatitis B Serology in Children Receiving Chemotherapy. Viral Immunol 2020; 33:628-633. [PMID: 33090085 DOI: 10.1089/vim.2020.0194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Chemotherapy-induced immunosuppression can lead to hepatitis B virus (HBV) reactivation in cancer patients. Both HBV carriers and individuals with serological signs of previously resolved HBV exposure are under the risk of severe hepatitis and liver failure during and after chemotherapy. The objective of this largest retrospective study was to analyze the consequences of HBV status in children receiving chemotherapy. A total of 479 patients (273 boys and 206 girls) aged 1-211 months diagnosed with acute hematologic malignancies and solid tumors were included in the study. Serological markers for HBV before and after chemotherapy and clinical data of the patients were evaluated retrospectively. Two hundred thirty-four of the participants were found to have protective antibody titers to HBV at admission. Five children were carrying HBV before chemotherapy. They received antiviral therapy during treatment and no reactivation was detected. Antibody against hepatitis B surface antigen (antiHBs) remained positive in 194 patients after chemotherapy. However, 17.09% (40/234) lost antiHBs positivity. In this group, three patients (1.28%) who initially had positive antiHBs and antihepatitis B core antibody experienced HBV reactivation and lost their protective antiHBs at the end of the therapy. Median antiHBs titer significantly decreased after chemotherapy (213.14 [range: 24-888] vs. 180.85 [range: 0-850]) (p = 0.0094). The current relatively large trial demonstrated that protective antibody titers remarkably altered after chemotherapy, and at least 17% of the pediatric oncology cases lost antiHBs positivity. Therefore, vaccine prevention and close monitoring of serology should be considered during chemotherapy.
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Affiliation(s)
- Sebahat Cam
- Division of Pediatric Gastroenterology, Department of Pediatrics, School of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Mustafa Asim Yoruk
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Yeditepe University Hospital, Istanbul, Turkey
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Park EJ, Kim H, Jung SM, Sung YK, Baek HJ, Lee J. The Use of Biological Disease-modifying Antirheumatic Drugs for Inflammatory Arthritis in Korea: Results of a Korean Expert Consensus. JOURNAL OF RHEUMATIC DISEASES 2020. [DOI: 10.4078/jrd.2020.27.1.4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Eun-Jung Park
- Division of Rheumatology, Department of Medicine, National Medical Center, Seoul, Korea
| | - Hyungjin Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Han Joo Baek
- Division of Rheumatology, Department of Internal Medicine, Gachon University College of Medicine Gil Medical Center, Incheon, Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
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Park EJ, Kim H, Jung SM, Sung YK, Baek HJ, Lee J. The use of biological disease-modifying antirheumatic drugs for inflammatory arthritis in Korea: results of a Korean Expert Consensus. Korean J Intern Med 2020; 35:41-59. [PMID: 31935319 PMCID: PMC6960050 DOI: 10.3904/kjim.2019.411] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/23/2019] [Indexed: 12/17/2022] Open
Abstract
Biological disease-modifying antirheumatic drugs (bDMARDs) are highly effective agents for the treatment of inf lammatory arthritis; however, they also possess a potential risk for serious infection. Recently, with the rapid expansion of the bDMARDs market in Korea, reports of serious adverse events related to the agents have also increased, necessitating guidance for the use of bDMARDs. Current work entitled, "Expert consensus for the use of bDMARDs drugs for inflammatory arthritis in Korea," is the first to describe the appropriate use of bDMARDs in the management of inflammatory arthritis in Korea, with an aim to provide guidance for the local medical community to improve the quality of clinical care. Twelve consensus statements regarding the use of bDMARDs for the management of rheumatoid arthritis and ankylosing spondylitis were generated. In this review, we provide detailed guidance on bDMARDs use based on expert consensus, including who should prescribe, the role of education, indications for use, and monitoring strategies for safety.
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Affiliation(s)
- Eun-Jung Park
- Division of Rheumatology, Department of Medicine, National Medical Center, Seoul, Korea
| | - Hyungjin Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Min Jung
- Division of Rheumatology, Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Han Joo Baek
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
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Wani MA, Sodhi JS, Yatoo GN, Shah A, Geelani S, Zargar SA, Gulzar GM, Khan M, Aziz SA. Clinical Profile and Efficacy of Antivirals in Hepatitis B Virus Reactivation, in Patients With Cancer Receiving Chemotherapy. J Clin Exp Hepatol 2020; 10:590-598. [PMID: 33311896 PMCID: PMC7719970 DOI: 10.1016/j.jceh.2020.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/22/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/PURPOSE Hepatitis B virus reactivation (HBVR) is common in patients withcancer. The aim of the present study was to find out clinical profile of patients with cancer receiving chemotherapy with HBVR and to study the efficacy of entecavir (ETV) and tenofovir in the treatment of HBVR. METHODS This is a prospective study in which all consecutive patients with cancer with evidence of HBVR were included. HBVR was defined as: New onset transaminitis with alanine aminotransferase (ALT) >3 times upper limit of normal and >10 fold increase in HBV DNA levels from baseline levels or detection of HBV DNA ≥100,000 IU/ml in patients with no baseline HBV DNA. Patients with HBVR were put on ETV or tenofovir and were closely monitored for efficacy and safety for minimum of 1 year. RESULTS Of 204 Hepatitis B surface antigen (HBsAg)-positive patients with different cancers, 92 met the inclusion criteria. Of 92, 46 received ETV 0.5 mg/day and 46 received tenofovir disoproxil fumarate (TDF) 300 mg/day. At 6 months, there was 4.7 log reduction in HBV DNA level in the ETV group and 5.2 log reduction in the TDF group (P = 0.029). Proportion of patients with undetectable HBV DNA (75.7% vs 87.5%), ALT normalization (89.2% Vs 87.5%), HBsAg negativity (25% vs 28.1%), and seroconversion (2.8% vs 3.1%) at 1 year were almost similar in both groups with P value > 0.05 for all efficacy end points. There was no HBVR-related mortality in any group. CONCLUSION Both ETV and tenofovir are very effective in the treatment of HBVR and reduce the liver-related mortality and morbidity in such patients.
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Key Words
- AASLD, American Association of Study of Liver Diseases
- ADR, Adverse Drug Reaction
- ALT, Alanine Aminotransferase
- ANOVA, Analysis of Variance
- CHB, Chronic Hepatitis B
- CT, Chemotherapy
- CXR, Chest X-ray
- EASL, European Association of Study of Liver
- ETV, Entecavir
- HBV, Hepatitis B Virus
- HBVR, Hepatitis B Virus reactivation
- HCC, Hepatocellular Carcinoma
- INASL, Indian National Association of Study of Liver
- PCR, Polymerase Chain Reaction
- TAF, Tenofovir Alafenamide
- TDF, Tenofovir Disoproxil Fumarate
- USG, Ultrasonography
- cancer
- chemotherapy
- reactivation
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Affiliation(s)
- Manzoor A. Wani
- Jawahar Lal Nehru Memorial Hospital(JLNMH), Srinagar, J&K, India
- Address for correspondence. Manzoor Ahmad Wani (MD, DM Gastroenterology and Hepatology), Consultant Gastroenterology and Hepatology, Jawahar Lal Nehru Memorial hospital(JLNMH) 584, lane 5, Umer Colony B,Lalbazar, Srinagar,J&K, India. 190023.
| | - Jaswinder S. Sodhi
- Department of Gastroenterology and Hepatology, Sheri Kashmir Institute of Medical Sciences (SKIMS), India
| | - Ghulam N. Yatoo
- Department of Gastroenterology and Hepatology, Sheri Kashmir Institute of Medical Sciences (SKIMS), India
| | - Altaf Shah
- Department of Gastroenterology and Hepatology, Sheri Kashmir Institute of Medical Sciences (SKIMS), India
| | | | - Showkat A. Zargar
- Department of Gastroenterology and Hepatology, Sheri Kashmir Institute of Medical Sciences (SKIMS), India
| | - Ghulam M. Gulzar
- Department of Gastroenterology and Hepatology, Sheri Kashmir Institute of Medical Sciences (SKIMS), India
| | - Mushtaq Khan
- Department of Gastroenterology and Hepatology, Sheri Kashmir Institute of Medical Sciences (SKIMS), India
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KASL clinical practice guidelines for management of chronic hepatitis B. Clin Mol Hepatol 2019; 25:93-159. [PMID: 31185710 PMCID: PMC6589848 DOI: 10.3350/cmh.2019.1002] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023] Open
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Su J, Long L, Zou K. Antiviral prophylaxis for preventing reactivation of hepatitis B virus in rheumatic patients: a systematic review and meta-analysis. Clin Rheumatol 2018; 37:3201-3214. [PMID: 29637482 DOI: 10.1007/s10067-018-4096-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/26/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023]
Abstract
To estimate the risk of reactivation of hepatitis B virus (HBV) and evaluate the effectiveness of antiviral prophylaxis (AVP) in patients with different status of HBV infection undergoing antirheumatic therapies. We searched Cochrane Library, Medline, and EMBASE for randomized controlled trials (RCTs), quasi-RCTs, non-RCTs, cohort studies, or case series studies examining reactivation of HBV in patients undergoing antirheumatic therapy with or without AVP. We estimated the HBV reactivation rate (HRR) and its 95% confidence interval (CI) among different patient groups (indirect comparison). We also calculated rate ratio (RR), rate difference (RD) with their 95% CIs, and the number needed to treat (NNT) of AVP (direct comparison). Fifty-three case series studies with 2162 patients were included. The RD of AVP was - 0.13 (95% CI - 0.21 to - 0.05) for all patients, - 0.16 (95% CI - 0.26 to - 0.06) for rheumatic patients with chronic HBV infection, but not statistically significant for patients with other status of HBV infection. Lamivudine (RD - 0.10, 95% CI - 0.25 to 0.05) was less effective than other prophylactic antiviral drugs (RD - 0.31, 95% CI - 0.52 to - 0.11). The HHR varied from 55 to 5% by HBV status and treatment. There is limited evidence that AVP was effective for preventing reactivation of HBV in patients undergoing antirheumatic therapy. The effectiveness varies by patient HBV status and antiviral regimens. Rheumatic HBV carriers may be more beneficial from AVP, and lamivudine may be inferior to other AVP regimens. Findings in this study warrant further investigation in rigorous RCTs.
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Affiliation(s)
- Jiang Su
- Department of Rheumatology and Immunology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Affiliated Hospital of the University of Electronic Science and Technology, Chengdu, China
| | - Li Long
- Department of Rheumatology and Immunology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Affiliated Hospital of the University of Electronic Science and Technology, Chengdu, China
| | - Kun Zou
- Department of Medical Records and Statistics, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Affiliated Hospital of the University of Electronic Science and Technology, No. 32, West Second Section, First Ring Road, Chengdu, China.
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Wu YT, Li X, Liu ZL, Xu Z, Dai W, Zhang K, Wu JS, Arshad B, Wu KN, Kong LQ. Hepatitis B virus reactivation and antiviral prophylaxis during lung cancer chemotherapy: A systematic review and meta-analysis. PLoS One 2017. [PMID: 28640902 PMCID: PMC5480953 DOI: 10.1371/journal.pone.0179680] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Antiviral drugs have been recommended as prophylaxis for the reactivation of hepatitis B virus (HBV) infection in cancer patients undergoing chemotherapy. However, screening and antiviral prophylaxis for lung cancer remain controversial because of insufficient evidence. Purpose In this study, we investigate the absolute risk for HBV reactivation and the prophylactic effects of antiviral drugs in hepatitis B surface antigen (HBsAg)-positive lung cancer patients during chemotherapy. Methods We searched Pubmed, Embase, Cochrane, Web of Science and SinoMed from inception until 28 November 2016, and identified all potential relevant references with or without prophylactic use of antiviral therapy in HBsAg-positive lung cancer patients during chemotherapy. The primary outcome was the incidence of HBV reactivation, the secondary outcomes were the incidence of hepatitis, chemotherapy disruption and mortality. Results Eleven studies involving 794 patients were analyzed. The incidences of HBV reactivation in control group and antiviral prophylaxis group ranged from 0% to 38% (median, 21%, 95% CI: 0.17–0.25) and 0% to 7% (median, 4%, 95% CI: 0.02–0.06), respectively. Antiviral prophylaxis had significantly reduced the risk for HBV reactivation (RR, 0.22 [95% CI: 0.13–0.37], p< 0.0001), hepatitis (RR, 0.35 [95% CI: 0.22–0.56], p<0.0001) and chemotherapy disruption (RR: 0.29 [95% CI, 0.15–0.55], p<0.0002) compared to those without antiviral prophylaxis. There was no significant heterogeneity in the comparisons, and a fixed-model was used. Conclusion The risks of HBV reactivation and relevant complications are high in HBsAg-positive lung cancer patients receiving chemotherapy, and available evidences support HBV screening for antiviral prophylaxis before initiation of chemotherapy for lung cancer patients.
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Affiliation(s)
- Yu-tuan Wu
- Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin Li
- Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zi-li Liu
- Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhou Xu
- Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Dai
- Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ke Zhang
- Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiu-song Wu
- Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bilal Arshad
- Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kai-nan Wu
- Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ling-quan Kong
- Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- * E-mail:
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García-Marco JA, Delgado J, Hernández-Rivas JA, Ramírez Payer Á, Loscertales Pueyo J, Jarque I, Abrisqueta P, Giraldo P, Martínez R, Yáñez L, Terol MJ, González M, Bosch F. Update of the Grupo Español de Leucemia Linfocítica Crónica clinical guidelines of the management of chronic lymphocytic leukemia. Med Clin (Barc) 2017; 148:381.e1-381.e9. [PMID: 28236475 DOI: 10.1016/j.medcli.2016.12.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/20/2016] [Accepted: 12/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE The broad therapeutic arsenal and the biological heterogeneity of patients with chronic lymphocytic leukemia (CLL) makes it difficult to standardize treatment for CLL patients with specific clinical settings in routine clinical practice. These considerations prompted us to elaborate the present consensus document, which constitutes an update of the previous version published in 2013, mainly focusing on novel treatment strategies that have been developed over last 5 years, namely B-cell receptor inhibitors (ibrutinib and idelalisib), anti-CD20 monoclonal antibodies (ofatumumab and obinutuzumab), and Bcl-2 inhibitors (venetoclax). MATERIAL AND METHODS A group of experts from the Spanish Chronic Lymphocytic Leukemia Group reviewed all published literature from January 2010 to January 2016, in order to provide recommendations based on clinical evidence. For those areas without strong scientific evidence, the panel of experts established consensus criteria based on their clinical experience. RESULTS The project has resulted in several practical recommendations that will facilitate the diagnosis, treatment, and follow-up of patients with CLL. CONCLUSIONS There are many controversial issues in the management of CLL with no appropriate studies for making consensus recommendations.
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Affiliation(s)
- José A García-Marco
- Servicio de Hematología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España.
| | - Julio Delgado
- Servicio de Hematología, Hospital Clínic i Provincial, Barcelona, España
| | | | - Ángel Ramírez Payer
- Servicio de Hematología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | | | - Isidro Jarque
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Pau Abrisqueta
- Servicio de Hematología, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Pilar Giraldo
- Servicio de Hematología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - Rafael Martínez
- Servicio de Hematología, Hospital Clínico Universitario San Carlos, Madrid, España
| | - Lucrecia Yáñez
- Servicio de Hematología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Mª José Terol
- Servicio de Hematología, Hospital Clínico Universitario, Valencia, España
| | - Marcos González
- Servicio de Hematología, Hospital Clínico Universitario-Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, España
| | - Francesc Bosch
- Servicio de Hematología, Hospital Universitario Vall d'Hebron, Barcelona, España
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YOUNG SHIHHAO, WEI TIENHSIN, LIN CHUNGCHI, CHU CHIJEN, LEE FAYAUH, YU MAYING, LU REIHWA, CHANG CHIAOYU, YANG PEILING, WANG MEIHUI, LIN HANCHIEH. Analysis of baseline hepatitis B virus DNA levels in chronic hepatitis B patients with non-hematological malignancies prior to the initiation of cancer chemotherapy. Mol Clin Oncol 2016; 5:165-170. [DOI: 10.3892/mco.2016.857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 04/01/2016] [Indexed: 11/05/2022] Open
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Chen J, Yi H, Cen H, Yan W. Hepatitis B Virus Infection in B-Cell Non-Hodgkin’s Lymphoma, and Effect of Entecavir in Prophylactic Antiviral Therapy. Health (London) 2016. [DOI: 10.4236/health.2016.85053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Preemptive antiviral therapy is recommended for chronic hepatitis B virus (HBV)-infected patients receiving cytotoxic chemotherapy. However, little data are available for the stopping therapy. AIMS We evaluated clinical outcome and predictors of off-treatment virological response of patients who discontinued therapy. METHODS Ninety-five adult patients who discontinued therapy were enrolled. They were analyzed for sustained off-treatment virological response, defined as HBV DNA levels below 2000 IU/ml for at least 12 months after the end of therapy. RESULTS Sustained off-treatment virological response was seen in 52 patients (54.7%). The baseline HBV DNA level was an independent factor associated with sustained off-treatment virological response, and the rate was 72.1 and 23.5% for those with HBV DNA < 2000 IU/ml and ≥ 2000 IU/ml, respectively (P < 0.001). The duration of consolidation treatment showed marginal association with sustained off-treatment virological response [odd ratio (95% confidence interval) 1.20 (0.98-1.47), P = 0.069] for those with baseline HBV DNA < 2000 IU/ml, but not for those with ≥ 2000 IU/ml. The sustained off-treatment virological response rate was 54.5, 71.4, 73.9, and 100% for consolidation treatment duration of <3, 3-6, 6-12, and ≥ 12 months, respectively, among those with baseline HBV DNA < 2000 IU/ml. CONCLUSIONS The baseline HBV DNA level was indicator for sustained off-treatment virological response after stopping preemptive antiviral therapy. Consolidation treatment duration showed association with sustained off-treatment virological response only for those with low baseline HBV DNA levels.
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Tang W, Chen L, Zheng R, Pan L, Gao J, Ye X, Zhang X, Zheng W. Prophylactic Effect of Lamivudine for Chemotherapy-Induced Hepatitis B Reactivation in Breast Cancer: A Meta-Analysis. PLoS One 2015; 10:e0128673. [PMID: 26057738 PMCID: PMC4461354 DOI: 10.1371/journal.pone.0128673] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 04/29/2015] [Indexed: 01/02/2023] Open
Abstract
Background Three strategies using lamivudine have been proposed to prevent chemotherapy-induced HBV (hepatitis B virus) reactivation in the clinical setting. The purpose of this meta-analysis is to evaluate the efficacy of the early preemptive strategy, deferred preemptive strategy and therapeutic strategy in patients with HBsAg-positive breast cancer during chemotherapy. Methods Clinical studies published from database inception until Nov 1, 2014, were included for analysis. The primary outcomes were overall survival, rate of chemotherapy disruption and virological and clinical reactivation. The secondary outcomes were the rates of HBV-related chemotherapy disruption, HBV-related mortality, YMDD mutations and withdrawal hepatitis. Results Four hundred and thirty patients in four studies that compared the early preemptive strategy with a therapeutic strategy were included. Application of early preemptive lamivudine was superior in reducing HBV recurrence (pooled OR: 0.12, 95% CI, 0.04 to 0.31, P< 0.0001), the incidence of HBV-related hepatitis (pooled OR: 0.13, 95% CI, 0.04 to 0.37, P< 0.0001) and the rate of chemotherapy disruption (pooled OR: 0.37, 95% CI, 0.23 to 0.60, P< 0.0001). In these two groups, no significant difference was found in overall mortality (P = 0.32), YMDD mutant rate (P = 0.13) or incidence of withdrawal hepatitis (P = 0.38). Of the two studies that compared the efficacy of an early and a deferred preemptive strategy, one showed that an early preemptive strategy significantly reduced the incidence of hepatitis (P = 0.046), whereas the other showed no significant difference (P = 0.7). Conclusions An early preemptive strategy is superior to a therapeutic strategy in decreasing the incidence of HBV reactivation, incidence of HBV-related hepatitis and rate of chemotherapy disruption in patients with breast cancer. A deferred preemptive strategy might be an alternative approach to controlling viral replication.
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Affiliation(s)
- Wei Tang
- Department of Breast Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, People’s Republic of China
| | - Lun Chen
- Department of Breast Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, People’s Republic of China
| | - Ruohui Zheng
- Department of Breast Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, People’s Republic of China
- Department of Biotechnology, School of Life Science, Sun Yat-sen University, Guangzhou, 510275, People’s Republic of China
| | - Lingxiao Pan
- Department of Breast Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, People’s Republic of China
| | - Jin Gao
- Department of Breast Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, People’s Republic of China
| | - Xigang Ye
- Department of Breast Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, People’s Republic of China
| | - Xiaoshen Zhang
- Department of Breast Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, People’s Republic of China
| | - Wenbo Zheng
- Department of Breast Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, People’s Republic of China
- * E-mail:
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Lim S, Han J, Kim GM, Han KH, Choi HJ. Hepatitis B viral load predicts survival in hepatocellular carcinoma patients treated with sorafenib. J Gastroenterol Hepatol 2015; 30:1024-31. [PMID: 25611175 DOI: 10.1111/jgh.12898] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM Sorafenib is now considered as a standard treatment for advanced hepatocellular carcinoma (HCC). We evaluated the effect of hepatitis B virus (HBV) DNA titers on prognosis in HCC patients treated with sorafenib. METHODS From 2008 to 2012, 78 HBV-related HCC patients who received sorafenib treatment at Severance Hospital were included in our analysis. The effect of pretreatment HBV-DNA levels on clinical outcomes for use in predicting prognosis after treatment with sorafenib was examined by univariate and multivariate analysis. RESULTS Median overall survival and median progression-free survival were 5.2 months (95% confidence interval: 4.0-6.4) and 3.5 months (95% confidence interval: 2.3-4.7), respectively. Multivariate analysis revealed high levels of HBV-DNA (> 2000 IU/mL) to be an independent risk factor for worse overall survival (P=0.005; hazard ratio, 2.85) and disease progression among patients who did not receive concomitant prophylactic antiviral therapy during sorafenib treatment (P=0.008; hazard ratio, 87.4). Moreover, viral reactivation occurred more frequently in patients who did not receive concomitant prophylactic antiviral therapy than in those who did (4/38 vs 0/40; P=0.025). CONCLUSION Higher HBV-DNA levels prior to sorafenib treatment were associated with poorer prognosis and increased viral reactivation thereafter. These results suggest the potential usefulness of prophylactic antiviral therapy when treating HBV-related HCC patients with sorafenib.
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Affiliation(s)
- Seungtaek Lim
- Department of Internal Medicine, Konyang University Hospital, Daejon, Korea
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Preemptive adefovir versus lamivudine for prevention of hepatitis B reactivation in chronic hepatitis B patients undergoing chemotherapy. Hepatol Int 2015; 9:224-30. [PMID: 25788197 DOI: 10.1007/s12072-015-9612-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 02/10/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND This proof-of-concept study compared lamivudine (LAM) with a newer antiviral agent, adefovir dipivoxil (ADF), in preventing hepatitis B virus (HBV) reactivation in chronic HBV patients undergoing chemotherapy. METHODS Hepatitis B surface antigen (HBsAg) positive patients intended to undergo chemotherapy were randomized to receive either LAM 100 mg daily or ADF 10 mg daily. Anti-viral therapy was started 1 week prior to chemotherapy and until 6 months after completing chemotherapy. The primary outcome was HBV reactivation rate. All patients with viral breakthrough were screened for resistance mutations by direct sequencing. RESULTS Seventy treatment-naïve patients were consecutively randomized 1:1 to LAM or ADF. The median baseline HBV DNA levels were similar (LAM 3.36 vs. ADF 3.17 log10 copies/mL, p = 0.860). The median duration was 8.3 months on LAM and 10.6 months on ADF (p = 0.220). HBV reactivation was observed in 13/35 (37.1%) on LAM compared with 10/35 (28.6%) on ADF (p = 0.611). The median time to HBV reactivation was 4.6 and 8.1 months, on LAM and ADF respectively. Among these 13 patients, 8/13 (61.5%) on LAM had developed drug resistance mutations but none on ADF had developed drug resistance mutations to ADF (p = 0.003). Both drugs were well tolerated and no severe drug-related toxicities were reported. CONCLUSION In this randomized clinical study, adefovir and lamivudine demonstrated similar efficacy in preventing hepatitis B reactivation in HBsAg-positive patients undergoing chemotherapy. In patients whose hepatitis B reactivated, adefovir was associated with a lower resistance profile.
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Lee JI. Reactivation of Hepatitis B Virus in Patients with Rheumatologic Disease Treated with Biologic Disease Modifying Anti-rheumatic Drugs: Screening and Treatment. JOURNAL OF RHEUMATIC DISEASES 2015. [DOI: 10.4078/jrd.2015.22.5.282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jung Il Lee
- Division of Gastroenterology, Deparmtment of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Entecavir as a first-line treatment for hepatitis B virus reactivation following polychemotherapy for chronic lymphocytic leukemia and invasive ductal carcinoma: a report of two cases and review of the literature. Eur J Gastroenterol Hepatol 2015; 27:39-45. [PMID: 25076063 DOI: 10.1097/meg.0000000000000115] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Hepatitis B reactivation has been reported in chronic carriers of hepatitis B [hepatitis B surface antigen (HBsAg)] or in patients with prior hepatitis B virus (HBV) infection who are HBsAg-negative and have antibodies against hepatitis B core antigen (anti-HBc) with or without antibodies to HBsAg (anti-HBs). Lamivudine has been the first and commonly used nucleoside analog to inhibit HBV replication; however, prolonged therapy has been associated with an increased risk for drug-resistant mutations and mortality rates. Entecavir, a deoxyguanosine analog, offers several advantages over lamivudine for the treatment of HBV reactivation following chemotherapy while exhibiting more potent antiviral activity and a lower resistance rate. METHODS Herein, we report rapid and sustained suppression of polychemotherapy-related HBV reactivation by entecavir administered as a prompt antiviral therapy in the cases of two patients with chronic lymphocytic leukemia and invasive ductal carcinoma. A review of the literature is discussed. RESULTS Entecavir produced a rapid and sustained suppression of polychemotherapy-related HBV reactivation as a prompt antiviral therapy in the cases of two patients with chronic lymphocytic leukemia and invasive ductal carcinoma. CONCLUSION Allowing a rapid and sustained control of HBV replication, entecavir seems to be a promising drug for first-line prompt treatment of HBV reactivation in patients undergoing chemotherapy for hematological as well as solid organ malignancies, with safe long-term use enabling maintenance of resolved hepatitis.
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Xu X, Huang P, Tian H, Chen Y, Ge N, Tang W, Yang B, Xia J. Role of lamivudine with transarterial chemoembolization in the survival of patients with hepatocellular carcinoma. J Gastroenterol Hepatol 2014; 29:1273-8. [PMID: 24955456 DOI: 10.1111/jgh.12554] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The purpose of the present study was to determine whether lamivudine in combination with transarterial chemoembolization (TACE) could reduce hepatitis B virus (HBV) activation and improve the survival of patients with hepatocellular carcinoma (HCC). METHODS From July 2008 to October 2011, a total of 181 consecutive HBV-related HCC patients undergoing TACE were randomized to two groups (92: lamivudine, 89: control). Follow up was every 3 months. Primary and secondary end-points were time to progression (TTP) and overall survival (OS), respectively, both of which were evaluated by the Kaplan Meier technique and summarized by the hazard ratio. RESULTS The level of HBV-DNA became undetectable in 42 (45.6%) patients in the lamivudine group, compared with 10 (11.2%) in the control group (P < 0.001). The median TTP was 8.2 months in lamivudine group and 4.3 months in control group (P = 0.005), and lamivudine therapy was an independent protective factor related to TTP (P = 0.006). Moreover, 1-, 2-, and 3-year survival rates were 83%, 69%, and 58% in lamivudine group and 60%, 48%, and 48% in control group, respectively (P = 0.002). With multivariate Cox regression model, lamivudine therapy (P = 0.002) and α-fetoprotein (AFP) level (P = 0.003) were two independent predictors for OS. CONCLUSION Lamivudine therapy could reduce HBV activation and improve survival of HCC patients treated with TACE. Lamivudine therapy and AFP level are two independent factors affecting OS.
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García Marco JA, Giraldo Castellano P, López Jiménez J, Ríos Herranz E, Sastre Moral JL, Terol Casterá MJ, Bosch Albareda F. [National guidelines for the management of patients with chronic lymphocytic leukemia. Sociedad Espan˜ola de Hematologı´a y Hemoterapia and Grupo Espan˜ol de Leucemia Linfocı´tica Cro´ nica]. Med Clin (Barc) 2013; 141:175.e1-8. [PMID: 23830547 DOI: 10.1016/j.medcli.2013.04.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 04/23/2013] [Accepted: 04/25/2013] [Indexed: 12/21/2022]
Abstract
Chronic lymphocytic leukemia is the most common chronic lymphoproliferative disorder in Spain. The clinical management of this entity varies widely. Currently, in Spain, there are no national consensus guidelines, such as those published in other countries, to guide the diagnosis and treatment of this malignancy and the use of prognostic scores. This article reviews the current scientific literature and addresses issues on the diagnosis of chronic lymphocytic leukemia, the spread of the disease, the presence of comorbidities, the classification of prognostic scores, the common treatment regimens stratified by risk factors, and the management of complications associated with both the disease and its treatment, as well as the various controversies related to this entity. This document was drafted with the collaboration of national experts and aims to establish practical guidelines with their corresponding levels of evidence and grades of recommendation to guide the diagnosis, treatment and follow-up of patients with chronic lymphocytic leukemia.
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Affiliation(s)
- José A García Marco
- Servicio de Hematología, Hospital Puerta de Hierro, Majadahonda, Madrid, España
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23
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Idilman R, Arat M. Evaluation and management of hepatitis B virus infection in hematopoietic stem cell transplantation: before and after transplantation. Expert Rev Anti Infect Ther 2013; 9:641-52. [PMID: 21819330 DOI: 10.1586/eri.11.79] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
HBV infection remains a major global health problem and continues to be a common cause of liver-related morbidity and mortality in both immunocompetent and immunosuppressed individuals. Reactivation of HBV is a serious complication of chemotherapy/immunosuppressive therapy in patients with HBV infection. In this article, we aim to describe the diagnosis, prevention and management of HBV infection in allogeneic hematopoietic stem cell transplant candidates, from the pre- to post-transplant period. The data currently available suggest that all individuals with hemato-/onco-logical malignancies who undergo chemotherapy/immunosuppressive therapy should be screened for hepatotropic viruses such as HBV and HCV. HBV surface antigen-positive individuals who receive chemotherapy/immunosuppressive therapy are at considerable risk of HBV reactivation. Antiviral prophylaxis prevents HBV reactivation, decreases reactivation-related morbidity and mortality, and prevents interruptions in chemotherapy/immunosuppressive therapy in such individuals. The optimal duration of antiviral prophylaxis remains to be elucidated. The vaccination of HBV-naive recipients and their donors against HBV infection prior to transplantation plays an important role in preventing acquired HBV infection. The presence of hepatitis B surface antigen positivity is not an absolute contraindication for allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Ramazan Idilman
- Ankara University Faculty of Medicine, Department of Gastroenterology, Ibn-i Sina Hospital, Sihhiye, Ankara 06100, Turkey.
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Long-term effects of prophylactic and therapeutic lamivudine treatments in hepatitis B surface antigen-positive renal allograft recipients. Clin Exp Nephrol 2013; 18:144-50. [DOI: 10.1007/s10157-013-0807-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 04/07/2013] [Indexed: 01/07/2023]
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Yeo W, Chan HLY. Hepatitis B virus reactivation associated with anti-neoplastic therapy. J Gastroenterol Hepatol 2013; 28:31-7. [PMID: 23020594 DOI: 10.1111/j.1440-1746.2012.07280.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2012] [Indexed: 02/06/2023]
Abstract
Reactivation of hepatitis B virus (HBV) infection is a known complication during and after anti-cancer therapy. This condition can affect two patient populations: it is most commonly seen in patients who are seropositive for hepatitis B surface antigen (HBsAg), but it is also being increasingly reported among patients who are HBsAg-negative but who have prior infection, as evident by seropositive status for antibody to hepatitis B core antigen (anti-HBc), irrespective of their anti-HBs (antibody to HBsAg) status. The clinical course can vary from asymptomatic hepatitis to fulminant hepatic failure that can be potentially fatal. With the increasing use of biological agents in addition to potent cytotoxic chemotherapy in the armamentarium of anti-cancer treatments, reactivation of hepatitis B has become a common clinical situation that is faced by both oncologists and hepatologists especially in HBV endemic areas. In this review, we discuss the clinical course of reactivation in the two HBV-infected sub-populations, and the role of anti-virals in the prevention and management of HBV reactivation in association with cytotoxic chemotherapy and biological therapies.
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Affiliation(s)
- Winnie Yeo
- Department of Clinical Oncology, Sir Y.K. Pao Centre for Cancer, Faculty of Medicine, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
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Wu XY, Li X, Chen ZH, Wen JY, Lin Q, Xing YF, Dong M, Wei L, Wang TT, Chen J, Lin ZX, Wan XB, Ruan DY, Ma XK. An optimized antiviral modification strategy for prevention of hepatitis B reactivation in patients undergoing prophylactic lamivudine and chemotherapy: a pilot study. Tumour Biol 2012; 34:909-18. [DOI: 10.1007/s13277-012-0626-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 12/10/2012] [Indexed: 02/07/2023] Open
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27
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Liu JY, Sheng YJ, Ding XC, Tang H, Tong SW, Zhang DZ, Zhou Z, Hu P, Liao Y, Ren H, Hu HD. The efficacy of lamivudine prophylaxis against hepatitis B reactivation in breast cancer patients undergoing chemotherapy: a meta-analysis. J Formos Med Assoc 2012; 114:164-73. [PMID: 25678179 DOI: 10.1016/j.jfma.2012.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 10/11/2012] [Accepted: 10/11/2012] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND/PURPOSE Lamivudine has been recommended as prophylaxis for the reactivation of hepatitis B virus (HBV) infection in patients undergoing chemotherapy. However, information on breast cancer patients in particular has been lacking. The purpose of this meta-analysis was to assess the overall efficacy of lamivudine prophylaxis compared to untreated patients with hepatitis B S-antigen (HBsAg) seropositive breast cancer who had undergone chemotherapy. METHODS Studies that compared the efficacy of treatment with lamivudine prophylaxis versus no prophylaxis in HBsAg seropositive breast cancer patients were identified through Medline, Cochrane, and Embase databases. RESULTS Six studies involving 499 patients were analyzed. The rates of HBV reactivation in patients with lamivudine prophylaxis were significantly lower than those with no prophylaxis (risk ratio [RR] = 0.23, 95% confidence interval [CI]: 0.13-0.39, p < 0.00001). Patients given lamivudine prophylaxis had significant reductions in the rates of hepatitis attributable to HBV compared with those not given treatment (RR = 0.20, 95% CI: 0.08-0.47, p = 0.002). The rates of moderate and severe hepatitis in patients with lamivudine prophylaxis were significantly lower compared with those patients who had not received prophylaxis (RR = 0.25, 95% CI: 0.10-0.62, p < 0.003; RR = 0.25, 95% CI: 0.10-0.59, p = 0.002). Patients given lamivudine prophylaxis had significantly fewer disruptions of chemotherapy (RR = 0.36, 95% CI: 0.21-0.64, p = 0.0004). There was no significant heterogeneity in the comparisons. CONCLUSION Lamivudine prophylaxis in HBsAg seropositive breast cancer patients undergoing chemotherapy is effective in reducing HBV reactivation and HBV-associated morbidity and mortality.
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Affiliation(s)
- Jun-Ying Liu
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; Department of the Digestive System, Zhou Kou Central Hospital, Zhou Kou, China
| | - Yun-Jian Sheng
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; Department of Infectious Diseases, The Affiliated Hospital of LuZhou Medical College, LuZhou, China
| | - Xiang-Chun Ding
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; Department of Infectious Diseases, General Hospital of NingXia Medical University, NingXia, China
| | - Hui Tang
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shi-Wen Tong
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Da-Zhi Zhang
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhi Zhou
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peng Hu
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yong Liao
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hong Ren
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huai-Dong Hu
- Department of Infectious Diseases, Institute for Viral Hepatitis, Key Laboratory of Molecular Biology for Infectious Diseases, Ministry of Education, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Mahale P, Kontoyiannis DP, Chemaly RF, Jiang Y, Hwang JP, Davila M, Torres HA. Acute exacerbation and reactivation of chronic hepatitis C virus infection in cancer patients. J Hepatol 2012; 57:1177-85. [PMID: 22871500 DOI: 10.1016/j.jhep.2012.07.031] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 06/25/2012] [Accepted: 07/16/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Data on acute exacerbation and reactivation of chronic hepatitis C virus (HCV) infection following chemotherapy are very limited. We sought to characterize the episodes of acute exacerbation and viral reactivation of HCV infection in cancer patients. METHODS The medical records of HCV-infected patients seen at our institution (2008-2009) were analyzed retrospectively. Acute exacerbation was defined as greater than 3-fold increase in serum level of alanine aminotransferase, and viral reactivation as ≥ 1 log(10) IU/ml increase of HCV viral load following chemotherapy. RESULTS Acute exacerbation occurred in 33 (11%) of 308 patients with proven HCV infection. Patients with acute exacerbation more often had underlying hematological malignancies (73% vs. 29%; p<0.001) and lymphopenia (6% vs. 0%; p=0.01) than patients without it. In multivariate analysis, underlying hematological malignancies (p=0.02; odds ratio, 3.2; 95% confidence interval, 1.2-8.7) and use of rituximab (p=0.004; odds ratio, 4.2; 95% confidence interval, 1.6-10.9) were associated with acute exacerbation. Patients with acute exacerbation received higher median cumulative dose of rituximab than those without exacerbation. Discontinuation of chemotherapy due to liver dysfunction was more common in patients with acute exacerbation than in patients without it (45% vs. 11%; p<0.001). Eight (36%) of 22 patients with known pre- and post-chemotherapy viral load had viral reactivation. CONCLUSIONS Acute exacerbation and reactivation of chronic HCV infection occur often after chemotherapy. Liver dysfunction can lead to discontinuation of potentially life-saving chemotherapy in nearly one-half of the patients with exacerbation of HCV infection.
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Affiliation(s)
- Parag Mahale
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Yang F, Zhu HL, He C, Li JJ, Xiang B, Cui X, Huang J, Ji J, Ma HB, Liu T. Effect of Antiviral Prophylaxis Strategy for Chemotherapy-Associated Hepatitis B Reactivation in Non-Hodgkin's Lymphoma Patients with Hepatitis B Virus Infection: A Retrospective Cohort Study. Indian J Hematol Blood Transfus 2012; 30:97-104. [PMID: 24839363 DOI: 10.1007/s12288-012-0195-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Accepted: 08/31/2012] [Indexed: 02/05/2023] Open
Abstract
Recent data indicates that nucleoside/nucleotide analogue (NUC) is effective in preventing and controlling hepatitis B virus (HBV) reactivation in HBV-carrying cancer patients who undergo chemotherapy, but the ideal antiviral agent and optimal application protocol still needs to be determined. Meanwhile, it is uncertain whether those with past HBV infection require antiviral prophylaxis during chemotherapy. This report retrospectively analyzed non-Hodgkin's lymphoma (NHL) patients seen from January, 2004 to June, 2009 in West China Hospital. We found that the prevalence of chronic HBV infection in our NHL patients was 20.7 % while that of past HBV infection was 21.05 %. Compared with the high rate (25.6 %) of HBV reactivation in patients with chronic HBV infection, none of those with past HBV infection in fact had occult HBV infection thus none experienced reactivation. Of the 82 patients with chronic HBV infection who received chemotherapy, antiviral prophylaxis could significantly reduce the incidence of HBV reactivation (5.0 vs. 45.2 % in the control group) and the incidence of liver function damage (32.5 vs. 73.8 % in the control group). The results of the current study confirmed previous reports that prophylactic NUCs administration can effectively prevent HBV reactivation and significantly reduce the incidence of HBV reactivation especially for patients receiving rituximab-containing regimens. Due to the fact that none of individuals who had past HBV infection developed HBV reactivation reported in our study, antiviral prophylaxis may not be required for patients with past HBV infection. Close observation of alanine aminotransferase and HBV-DNA contributes to early diagnosis and timely treatment of HBV reactivation.
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Affiliation(s)
- Fan Yang
- West China School of Clinical Medicine, Sichuan University, No. 37 Guoxue Alley, Chengdu, China
| | - Huan-Ling Zhu
- Department of Haematology, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, China
| | - Chuan He
- Department of Haematology, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, China
| | - Jian-Jun Li
- Department of Haematology, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, China
| | - Bing Xiang
- Department of Haematology, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, China
| | - Xu Cui
- Department of Haematology, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, China
| | - Jie Huang
- Department of Haematology, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, China
| | - Jie Ji
- Department of Haematology, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, China
| | - Hong-Bing Ma
- Department of Haematology, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, China
| | - Ting Liu
- Department of Haematology, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, China
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Abstract
Hepatitis B virus (HBV) reactivation is well documented in previously resolved or inactive HBV carriers who receive cancer chemotherapy. The consequences of HBV reactivation range from self-limited conditions to fulminant hepatic failure and death. HBV reactivation also leads to premature termination of chemotherapy or delay in treatment schedules. This review summarizes current knowledge of management of HBV reactivation in patients receiving cancer chemotherapy. HBV surface antigen (HBsAg) testing should be performed in patients who require cancer chemotherapy. Four meta-analyses support lamivudine prophylaxis for HBV reactivation during chemotherapy in HBsAg-positive patients. Randomized controlled trials to compare different HBV antiviral agents are needed to define optimal regimens for the prevention and treatment of HBV reactivation in patients receiving cancer chemotherapy.
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Affiliation(s)
- Yi-Wen Huang
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Zurawska U, Hicks LK, Woo G, Bell CM, Krahn M, Chan KK, Feld JJ. Hepatitis B Virus Screening Before Chemotherapy for Lymphoma: A Cost-Effectiveness Analysis. J Clin Oncol 2012; 30:3167-73. [DOI: 10.1200/jco.2011.40.7510] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose Hepatitis B virus (HBV) reactivation is a potentially fatal complication of chemotherapy that can be largely prevented with antiviral prophylaxis. It remains unclear whether HBV screening is cost effective. Methods A decision model was developed to compare the clinical outcomes, costs, and cost effectiveness of three HBV screening strategies for patients with lymphoma before R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy: screen all patients for hepatitis B surface antigen (HBsAg; Screen-All), screen patients identified as being at high risk for HBV infection (Screen-HR), and screen no one (Screen-None). Patients testing positive were administered antiviral therapy until 6 months after completion of chemotherapy. Those not screened were initiated on antiviral therapy only if HBV hepatitis occurred. Probabilities of HBV and lymphoma outcomes were derived from systematic literature review. A third-party payer perspective was adopted, costs were expressed in 2011 Canadian dollars, and a 1-year time horizon was used. Results Screen-All was the dominant strategy. It was least costly at $32,589, compared with $32,598 for Screen-HR and $32,657 for Screen-None. It was also associated with the highest 1-year survival rate at 84.99%, compared with 84.96% for Screen-HR and 84.86% for Screen-None. The analysis was sensitive to the prevalence of HBsAg positivity in the low-risk population, with Screen-HR becoming least costly when this value was ≤ 0.20%. Conclusion In patients receiving R-CHOP for lymphoma, screening all patients for HBV reduces the rate of HBV reactivation (10-fold) and is less costly than screening only high-risk patients or screening no patients.
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Affiliation(s)
- Urszula Zurawska
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Lisa K. Hicks
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Gloria Woo
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Chaim M. Bell
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Murray Krahn
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Kelvin K. Chan
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Jordan J. Feld
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
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32
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Huang YW, Chung RT. Management of hepatitis B reactivation in patients receiving cancer chemotherapy. Therap Adv Gastroenterol 2012; 5:359-70. [PMID: 22973419 PMCID: PMC3437537 DOI: 10.1177/1756283x12450245] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Hepatitis B virus (HBV) reactivation is well documented in previously resolved or inactive HBV carriers who receive cancer chemotherapy. The consequences of HBV reactivation range from self-limited conditions to fulminant hepatic failure and death. HBV reactivation also leads to premature termination of chemotherapy or delay in treatment schedules. This review summarizes current knowledge of management of HBV reactivation in patients receiving cancer chemotherapy. HBV surface antigen (HBsAg) testing should be performed in patients who require cancer chemotherapy. Four meta-analyses support lamivudine prophylaxis for HBV reactivation during chemotherapy in HBsAg-positive patients. Randomized controlled trials to compare different HBV antiviral agents are needed to define optimal regimens for the prevention and treatment of HBV reactivation in patients receiving cancer chemotherapy.
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Affiliation(s)
- Yi-Wen Huang
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Liver Center, Cathay General Hospital Medical Center, Taipei, Taiwan,School of Medicine, Taipei Medical University, Taipei, Taiwan,Division of Gastroenterology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Raymond T. Chung
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Warren 1007, 55 Fruit Street, Boston, MA 02114, USA
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33
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Clinical prediction of failure of Lamivudine prophylaxis for hepatitis B virus-infected patients undergoing cytotoxic chemotherapy for malignancy. Antimicrob Agents Chemother 2012; 56:5511-9. [PMID: 22890764 DOI: 10.1128/aac.00821-12] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Although lamivudine (LAM) prophylaxis is recommended for patients infected with hepatitis B virus (HBV) undergoing chemotherapy for malignant disease, HBV reactivation sometimes occurs during or after LAM administration. The aim of this study was to determine predictors of LAM prophylactic failure in patients with malignancies. Patients with malignancies were routinely screened for serum hepatitis B surface antigen (HBsAg) from June 2002 to August 2008. All consecutive, HBsAg-positive patients received LAM prophylaxis during and after completion of chemotherapy. We assessed risk factors for virologic breakthrough and withdrawal hepatitis. Death without HBV reactivation was regarded as a competing risk event, which was adjusted by Fine and Gray's model. A total of 110 patients were included in this study. They received LAM prophylaxis for a median of 9.2 months. Virologic breakthrough occurred in 15 patients at a median of 10.9 months from the initiation of LAM prophylaxis. Withdrawal hepatitis occurred in 15 patients at a median of 2.4 months after cessation of LAM prophylaxis. Multivariable analysis showed that high baseline HBV DNA titer (≥2,000 IU/ml) (hazard ratio [HR], 9.94; P = 0.0063) and the use of rituximab (HR, 3.19; P = 0.027) were significant predictors of virologic breakthrough and that high baseline HBV DNA titer (HR, 5.90; P = 0.007), liver cirrhosis (HR, 10.4; P = 0.002), and distant metastasis (HR, 5.14; P = 0.008) were independent risk factors for withdrawal hepatitis. Patients with high viremia, liver cirrhosis, rituximab treatment, and distant metastasis are at high risk of prophylactic failure and need antiviral agents with a greater barrier to resistance.
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Abramson A, Menter A, Perrillo R. Psoriasis, hepatitis B, and the tumor necrosis factor-alpha inhibitory agents: a review and recommendations for management. J Am Acad Dermatol 2012; 67:1349-61. [PMID: 22727462 DOI: 10.1016/j.jaad.2012.04.036] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 04/04/2012] [Accepted: 04/11/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tumor necrosis factor inhibitory agents are currently considered to be contraindicated in psoriatic patients with hepatitis B. OBJECTIVE We aim to provide guidance to dermatologists on the use of tumor necrosis factor inhibitor therapy in these patients. METHODS The current literature was reviewed regarding the use of tumor necrosis factor-alpha inhibitory agents (etanercept, adalimumab, and infliximab) in psoriatic patients with particular reference to hepatitis B infection. RESULTS Tumor necrosis factor-alpha inhibitor therapy may result in reactivated hepatitis B in hepatitis B surface antigen-positive patients with psoriasis. This also occurs, although less frequently in patients with an isolated positive hepatitis B core antibody. Thus, all psoriasis patients should be screened for hepatitis B surface antigen plus hepatitis B core antibody prior to the initiation of tumor necrosis factor-alpha inhibitor therapy. Infliximab has been associated with more reactivation cases than the other 2 agents and fatalities have been reported with this agent. Evidence is presented that the risk of reactivation can be greatly minimized or eliminated by early or pre-emptive antiviral therapy. LIMITATIONS The data is largely based on small case series that are retrospective in nature. CONCLUSIONS Hepatitis B screening is essential prior to the initiation of tumor necrosis factor-alpha inhibitor therapy. Psoriatic patients found to be hepatitis B surface antigen or hepatitis B core antibody-positive should be referred to an appropriate specialist for evaluation and therapy. This would allow for the safe use of tumor necrosis factor-alpha inhibitors in psoriatic patients despite recently published guidelines to the contrary.
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Affiliation(s)
- Amanda Abramson
- Division of Dermatology, Baylor University Medical Center, Dallas, Texas, USA
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35
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Abstract
UNLABELLED 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.
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MESH Headings
- Acute Disease
- Adolescent
- Adult
- Aged
- Alanine Transaminase/blood
- Antiviral Agents/therapeutic use
- Asian People
- Aspartate Aminotransferases/blood
- Carcinoma, Hepatocellular/diagnosis
- Carcinoma, Hepatocellular/etiology
- Child
- Child, Preschool
- Coinfection/drug therapy
- DNA, Viral/blood
- Drug Resistance, Viral
- Drug Therapy, Combination
- Female
- Hepatitis B Surface Antigens/blood
- Hepatitis B e Antigens/blood
- Hepatitis B virus/genetics
- Hepatitis B, Chronic/complications
- Hepatitis B, Chronic/diagnosis
- Hepatitis B, Chronic/drug therapy
- Humans
- Immunosuppression Therapy
- Infectious Disease Transmission, Vertical/prevention & control
- Liver/pathology
- Liver/physiology
- Liver Cirrhosis/physiopathology
- Liver Neoplasms/diagnosis
- Liver Neoplasms/etiology
- Liver Transplantation
- Male
- Middle Aged
- Pregnancy
- Renal Dialysis
- Republic of Korea
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36
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Abstract
Chronic hepatitis B virus (HBV) infection is a complex clinical entity frequently associated with cirrhosis and hepatocellular carcinoma (HCC). The persistence of HBV genomes in the absence of detectable surface antigenemia is termed occult HBV infection. Mutations in the surface gene rendering HBsAg undetectable by commercial assays and inhibition of HBV by suppression of viral replication and viral proteins represent two fundamentally different mechanisms that lead to occult HBV infections. The molecular mechanisms underlying occult HBV infections, including recently identified mechanisms associated with the suppression of HBV replication and inhibition of HBV proteins, are reviewed in detail. The availability of highly sensitive molecular methods has led to increased detection of occult HBV infections in various clinical settings. The clinical relevance of occult HBV infection and the utility of appropriate diagnostic methods to detect occult HBV infection are discussed. The need for specific guidelines on the diagnosis and management of occult HBV infection is being increasingly recognized; the aspects of mechanistic studies that warrant further investigation are discussed in the final section.
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37
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Abstract
Chronic hepatitis B virus (HBV) infection is a complex clinical entity frequently associated with cirrhosis and hepatocellular carcinoma (HCC). The persistence of HBV genomes in the absence of detectable surface antigenemia is termed occult HBV infection. Mutations in the surface gene rendering HBsAg undetectable by commercial assays and inhibition of HBV by suppression of viral replication and viral proteins represent two fundamentally different mechanisms that lead to occult HBV infections. The molecular mechanisms underlying occult HBV infections, including recently identified mechanisms associated with the suppression of HBV replication and inhibition of HBV proteins, are reviewed in detail. The availability of highly sensitive molecular methods has led to increased detection of occult HBV infections in various clinical settings. The clinical relevance of occult HBV infection and the utility of appropriate diagnostic methods to detect occult HBV infection are discussed. The need for specific guidelines on the diagnosis and management of occult HBV infection is being increasingly recognized; the aspects of mechanistic studies that warrant further investigation are discussed in the final section.
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38
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Prevention of hepatitis B virus reactivation in immunosuppressive therapy or chemotherapy. Clin Exp Nephrol 2011; 15:634-640. [DOI: 10.1007/s10157-011-0464-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 05/11/2011] [Indexed: 01/16/2023]
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39
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Liu CJ, Chen PJ, Chen DS, Kao JH. Hepatitis B virus reactivation in patients receiving cancer chemotherapy: natural history, pathogenesis, and management. Hepatol Int 2011; 7:316-26. [DOI: 10.1007/s12072-011-9279-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 05/27/2011] [Indexed: 12/13/2022]
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40
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Long M, Jia W, Li S, Jin L, Wu J, Rao N, Feng H, Chen K, Deng H, Liu F, Su F, Song E. A single-center, prospective and randomized controlled study: Can the prophylactic use of lamivudine prevent hepatitis B virus reactivation in hepatitis B s-antigen seropositive breast cancer patients during chemotherapy? Breast Cancer Res Treat 2011; 127:705-12. [PMID: 21445574 DOI: 10.1007/s10549-011-1455-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 03/11/2011] [Indexed: 12/14/2022]
Abstract
Over the past four decades, chemotherapy has played an important role in prolonging survival in breast cancer patients. However, it may also result in undesirable side effects such as hepatitis B virus (HBV) reactivation seen in this study. With the increasing use of chemotherapy paralleling the rise in breast cancer incidence, the occurrence of HBV reactivation is likely to further increase. Several strategies use lamivudine to deal with this problem. Initially, lamivudine had been used to treat patients who developed alanine transaminase elevation attributable to HBV reactivation during chemotherapy. However, using this strategy, fatal reactivation has also been reported. Later studies have suggested that prophylactic lamivudine significantly reduces HBV reactivation and its associated morbidity. However, these studies were based mainly on patients with lymphoma, whereas studies on breast cancer patients were few. Moreover, these studies were retrospective. Recently, a prospective study has recommended that deferred preemptive lamivudine could be a comparable alternative to the prophylactic strategy. However, it was not a randomized controlled study. In this study, it was examined the efficacy of the prophylactic strategy in hepatitis B s-antigen seropositive breast cancer patients during chemotherapy using a prospective, randomized controlled study. Two groups were studied. One group consisted of 21 patients who were treated with prophylactic lamivudine, the other group consisted of 21 patients who were not treated with prophylactic lamivudine. The results showed that the prophylactic lamivudine strategy significantly decreased the incidence of HBV reactivation (0 vs. 28.6%, P = 0.021). It was conclude that the prophylactic lamivudine strategy significantly reduces the incidence of HBV reactivation for hepatitis B s-antigen seropositive breast cancer undergoing chemotherapy.
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Affiliation(s)
- Meijun Long
- Department of Breast Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
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41
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Prophylactic use of lamivudine for hepatitis B exacerbation in post-operative breast cancer patients receiving anthracycline-based adjuvant chemotherapy. Br J Cancer 2011; 104:559-63. [PMID: 21285992 PMCID: PMC3049600 DOI: 10.1038/bjc.2011.4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: With the increasing incidence of breast cancer worldwide, in particular in southeast Asia (including Korea), and the common use of anthracyclines in the adjuvant and metastatic settings, the occurrence of Hepatitis B virus (HBV) reactivation may develop in this patient population. The use of prophylactic antiviral agents in cancer patients may result in a reduced HBV exacerbation. The purpose of the current study was to assess the efficacy of prophylactic lamivudine in reducing the incidence and severity of HBV reactivation in post-operative breast cancer patients undergoing adjuvant doxorubicin-containing chemotherapy. Methods: The medical records of patients undergoing anthracycline-based adjuvant chemotherapy at Samsung Medical Center between January 2001 and September 2008 were reviewed. Results: From the database, 1912 breast cancer patients who had received anthracycline-based adjuvant chemotherapy were identified. Of 131 patients who were HBV surface antigen positive, 55 and 76 did and did not receive prophylactic lamivudine, respectively. In all, 30 patients (23%) developed hepatitis during doxorubicin-containing adjuvant chemotherapy. Of the 30 patients, 5 (9%) were in the prophylactic lamivudine group and 25 (33%) in the control group (P=0.001). In the prophylactic lamivudine group, there was significantly less HBV reactivation (1 patient (2%) vs 20 patients (16%); P=0.002), less disruption of chemotherapy (7 vs 14% P=0.04), and less severe hepatitis (0 vs 17% P=0.002). Conclusion: Prophylactic lamivudine significantly reduced the incidence and severity of HBV reactivation in breast cancer patients undergoing anthracycline-based adjuvant chemotherapy.
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42
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Yağci M, Ozkurt ZN, Yeğin ZA, Aki Z, Sucak GT, Haznedar R. Hepatitus B virus reactivation in HBV-DNA negative and positive patients with hematological malignancies. ACTA ACUST UNITED AC 2010; 15:240-4. [PMID: 20670484 DOI: 10.1179/102453309x12583347114059] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Reactivation of hepatitis B virus (HBV) is a frequent complication of chemotherapy (CT) in patients with HBsAg carriers. In this prospective study, we documented CT induced HBV reactivation risk in patients with hematological malignancies. HBV reactivation risk is influenced by baseline viral load. Therefore, we divided our study population into two groups according to HBV-DNA status. HBV-DNA negative patients (n=18) were treated with nucleoside analogues once HBV reactivation was observed. HBV-DNA positive patients (n=12) commenced lamivudine before the initiation of the CT. In HBV-DNA negative patients HBV reactivation was found in 10 patients (55.5%). HBV reactivation was significantly more frequent in chronic lymphocytic leukemia (CLL) patients (P=0.008) and in patients receiving rituximab containing chemotherapy regimens (P=0.06). Eight patients (80.0%) responded to antiviral treatment after HBV reactivation. Two CLL patients experienced a flare-up after the withdrawal of antiviral therapy. In HBV-DNA positive patients, HBV reactivation was observed in four patients (33.3%) during lamivudine treatment and in two patients after lamivudine withdrawal. This study demonstrated the increased risk of CT-induced HBV reactivation in CLL patients, for the first time.
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Affiliation(s)
- Münci Yağci
- Department of Hematology, Faculty of Medicine, Gazi University, Ankara, Turkey
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43
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Villadolid J, LaPlant KD, Markham MJ, Nelson DR, George TJ. Hepatitis B reactivation and rituximab in the oncology practice. Oncologist 2010; 15:1113-21. [PMID: 20930099 PMCID: PMC3227895 DOI: 10.1634/theoncologist.2010-0106] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Accepted: 08/24/2010] [Indexed: 12/19/2022] Open
Abstract
Rituximab use in hematology and oncology practice has significantly and positively improved the clinical outcomes in patients with a wide variety of B-cell lymphoproliferative disorders. However, emerging data reveal that there is a risk of viral hepatitis B reactivation in some patients treated with rituximab. Many of these cases result in treatment delays, inferior oncologic outcomes, increased morbidity, and more rarely fulminant hepatic decompensation and death. Indeed, the rituximab package insert and many clinical practice guidelines have been modified to reflect these concerns. The true incidence and mechanism of reactivation are still being elucidated. This article focuses on the current evidence that supports these recently revised clinical recommendations along with a review of the risk factors for reactivation, suggested monitoring, and preventative interventions.
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Affiliation(s)
| | | | | | - David R. Nelson
- Gastroenterology, Hepatology, and Nutrition, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
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44
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Affiliation(s)
- Lindsay Y King
- Gastrointestinal Unit, Massachusetts General Hospital, Warren 1007C, 55 Fruit Street, Boston, Massachusetts 02114, USA
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45
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Lubel JS, Angus PW. Hepatitis B reactivation in patients receiving cytotoxic chemotherapy: diagnosis and management. J Gastroenterol Hepatol 2010; 25:864-71. [PMID: 20546439 DOI: 10.1111/j.1440-1746.2010.06243.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Nearly one third of the world's population have been infected with hepatitis B and the virus is endemic in many Asian countries. With increasing life expectancy and the expected global increase in cancer, chemotherapy induced reactivation of hepatitis B is likely to become an increasing problem. Patients with significant levels of hepatitis B virus (HBV) DNA in serum prior to chemotherapy and patients receiving intensive chemotherapy for hematological malignancies appear particularly at risk. Most patients who suffer reactivation of hepatitis B are positive for hepatitis B surface antigen (HBsAg) prior to chemotherapy and are therefore easily identifiable by routine screening. In addition, the very large population of patients who have been exposed to the virus and have apparently cleared the virus as assessed by serological testing (HBsAg negative/hepatitis B core antibody [HBcAb] positive) may also be at risk of reactivation. These patients should be monitored and in some cases receive prophylaxis during chemotherapy. Published experience with antiviral prophylaxis has largely been limited to the nucleoside analogue, lamivudine. The commencement of antiviral prophylaxis prior to chemotherapy and its continuation until restitution of normal host immunity is the cornerstone to effective prevention of hepatitis B reactivation. This review summarizes the important issues related to HBV reactivation and suggests an algorithm for managing these patients in the clinical setting.
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Affiliation(s)
- John S Lubel
- Department of Hepatology, Box Hill Hospital, Box Hill, Melbourne, Victoria, Australia.
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46
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[Requirements for hygiene in the medical care of immunocompromised patients. Recommendations from the Committee for Hospital Hygiene and Infection Prevention at the Robert Koch Institute (RKI)]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2010; 53:357-88. [PMID: 20300719 PMCID: PMC7095954 DOI: 10.1007/s00103-010-1028-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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47
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Acar K, Göktepe MH, Polat İ, Atalay H. Hepatitis B Reactivation with Fulminant
Hepatitis During Rituximab Chemotherapy
in a Patient with Follicular Lymphoma. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2010. [DOI: 10.29333/ejgm/82823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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48
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Coiffier B. Hepatitis B Virus Reactivation in Patients Receiving Chemotherapy for Cancer Treatment: Role of Lamivudine Prophylaxis. Cancer Invest 2009; 24:548-52. [PMID: 16939967 DOI: 10.1080/07357900600815232] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatitis B virus (HBV) reactivation is a frequent complication in inactive HBV carriers at time of chemotherapy or following this chemotherapy. This complication appeared during or after chemotherapy and was not increased by the use of rituximab alone or combined with chemotherapy. This is a severe complication most frequently seen in lymphoma patients. Lamivudine have efficacy to treat the patients once the clinical disease is present. However, lamivudine prophylaxis beginning before chemotherapy and until at least 6 months after the end of chemotherapy is recommended for all HBV carriers. Hepatitis C virus is usually not associated with reactivation and prophylaxis should not be used.
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49
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Hayashi K, Katano Y, Ishigami M, Itoh A, Hirooka Y, Nakano I, Goto H. Successful cessation of lamivudine using interferon in a patient with chronic hepatitis B who received prophylactic lamivudine treatment during chemotherapy. Clin J Gastroenterol 2009; 2:210-213. [PMID: 26192298 DOI: 10.1007/s12328-009-0065-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Accepted: 12/12/2008] [Indexed: 11/28/2022]
Abstract
Lamivudine (LMV) prophylaxis is effective in preventing hepatitis B virus (HBV) reactivation in patients with chronic hepatitis B undergoing chemotherapy. However, the optimal duration of LMV prophylaxis remains unclear. We report herein the case of a woman with localized follicular B-cell lymphoma who received chemotherapy with LMV prophylaxis. She achieved complete response to lymphoma, and LMV treatment was continued for 8 months after completion of chemotherapy. HBV status was still inactive. LMV was then stopped, but reactivation of hepatitis developed 1 month after cessation of LMV. LMV was restarted, resulting in successful treatment of reactivated hepatitis. Interferon (IFN) was used for 6 months before withdrawal of LMV, which was successfully ceased without flare hepatitis. This report describes the utility of sequential therapy with LMV and IFN to treat flare after withdrawal of LMV in hepatitis B carriers who receive LMV prophylaxis during chemotherapy and to prevent flare after withdrawal of LMV.
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Affiliation(s)
- Kazuhiko Hayashi
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yoshiaki Katano
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Masatoshi Ishigami
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Akihiro Itoh
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Isao Nakano
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hidemi Goto
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
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Ziakas PD, Karsaliakos P, Mylonakis E. Effect of prophylactic lamivudine for chemotherapy-associated hepatitis B reactivation in lymphoma: a meta-analysis of published clinical trials and a decision tree addressing prolonged prophylaxis and maintenance. Haematologica 2009; 94:998-1005. [PMID: 19454492 DOI: 10.3324/haematol.2009.005819] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Lamivudine prophylaxis is an effective strategy in HbSAg-positive patients receiving cancer chemotherapy. Recent data indicate that a lamividune-prophylaxis strategy results in a decrease of hepatitis B virus (HBV) reactivation rates, though its effect on HBV-mortality remains equivocal. This report evaluates the benefits from this strategy among lymphoma patients and develops a management approach for patients with prolonged immunosuppression. A Medline search was conducted to retrieve published trials on HBsAg-positive lymphoma patients receiving prophylactic lamivudine during chemotherapy. Basic inclusion criterion was to report HBV-reactivation rates with and without lamivudine prophylaxis. A meta-analysis of the risk of HBV-reactivation and HBV-related mortality was conducted, and the pooled effect was calculated as risk ratio (RR). We found that lamivudine prophylaxis is associated with a significant reduction in hepatitis B virus reactivation (RR 0.21, 95%CI 0.13-0.35) and a trend in reducing HBV-related mortality (RR 0.68, 95%CI 0.19-2.49). In order to study the long-term effects of anti-HBV prophylaxis when prolonged immunosuppression is needed, we used our findings to model a decision tree. Overall survival was the main outcome used in the analysis. Rituximab maintenance in B-cell lymphomas was used as a paradigm of prolonged immunosuppression. We found that extended anti-HBV prophylaxis can improve survival rates by 2.4% in HBsAg-positive patients. If 1,000 HBsAg-positive lymphoma patients receive prophylaxis, one will die from hepatitis B virus reactivation versus 25/1,000 if no prophylaxis is administered. This effect is probably mediated through a reduction of hepatitis B virus reactivation and HBV-related mortality. The ideal antiviral agent needs to be determined.
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Affiliation(s)
- Panayiotis D Ziakas
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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