Assessment and treatment of liver disease in Japanese haemophilia patients

Human pegivirus type 1 infection in Asia-A review of the literature

The human pegivirus type 1 (HPgV-1)-as known as hepatitis G virus and GB virus C-is a common single-stranded RNA flavivirus. Because few studies have demonstrated an association between HPgV-1 infection and disease, screening for HPgV-1 is not performed routinely. Nonetheless, a beneficial impact of HPgV-1 infection on HIV disease progression has been reported in multiple studies. Given the burden of HIV in Asia and the complex interactions between viral co-infections and the host, we provide a comprehensive overview of the existing data from Asia on HPgV-1 infection, including the prevalence and circulating genotypes in all Asian countries with data reported. This review highlights the research conducted thus far and emphasizes the need for additional studies on HPgV-1 across the Asian continent.

Features of hepatitis C virus infection, current therapies and ongoing clinical trials in ten Asian Pacific countries

Estimated hepatitis C virus (HCV) infection rates in the general populations were 1.3, 0.9, 0.4-1.0, 14.7, 0.1-0.3, 0.9-1.9, 1.0-2.0, 5, 4.4-8.6 and 0.5-1.3 % in Australia, Bangladesh, Mainland China, Egypt, Hong Kong, India, Japan, Pakistan, Taiwan and Turkey, respectively. The main HCV genotypes (Gs) are G1, G3, G1b, G4, G1b, G3, G1b, G3, G1b and G2, and G1 in Australia, Bangladesh, Mainland China, Egypt, Hong Kong, India, Japan, Pakistan, Taiwan and Turkey, respectively. Of IL28B genotypes, favorable alleles are ~50 % in Australia and Turkey, but 60-70 % in most of the other Asian countries. Peginterferon plus ribavirin is available in all ten Asian Pasific countries. In addition, HCV NS3/4A protease inhibitors with peginterferon plus ribavirin are currently available in several countries. Clinical trials of interferon-free regimens for HCV are ongoing in most of the ten Asian Pacific countries.

Deconvoluting the composition of low-frequency hepatitis C viral quasispecies: comparison of genotypes and NS3 resistance-associated variants between HCV/HIV coinfected hemophiliacs and HCV monoinfected patients in Japan

Pre-existing low-frequency resistance-associated variants (RAVs) may jeopardize successful sustained virological responses (SVR) to HCV treatment with direct-acting antivirals (DAAs). However, the potential impact of low-frequency (∼0.1%) mutations, concatenated mutations (haplotypes), and their association with genotypes (Gts) on the treatment outcome has not yet been elucidated, most probably owing to the difficulty in detecting pre-existing minor haplotypes with sufficient length and accuracy. Herein, we characterize a methodological framework based on Illumina MiSeq next-generation sequencing (NGS) coupled with bioinformatics of quasispecies reconstruction (QSR) to realize highly accurate variant calling and genotype-haplotype detection. The core-to-NS3 protease coding sequences in 10 HCV monoinfected patients, 5 of whom had a history of blood transfusion, and 11 HCV/HIV coinfected patients with hemophilia, were studied. Simulation experiments showed that, for minor variants constituting more than 1%, our framework achieved a positive predictive value (PPV) of 100% and sensitivities of 91.7–100% for genotyping and 80.6% for RAV screening. Genotyping analysis indicated the prevalence of dominant Gt1a infection in coinfected patients (6/11 vs 0/10, p = 0.01). For clinical samples, minor genotype overlapping infection was prevalent in HCV/HIV coinfected hemophiliacs (10/11) and patients who experienced whole-blood transfusion (4/5) but none in patients without exposure to blood (0/5). As for RAV screening, the Q80K/R and S122K/R variants were particularly prevalent among minor RAVs observed, detected in 12/21 and 6/21 cases, respectively. Q80K was detected only in coinfected patients, whereas Q80R was predominantly detected in monoinfected patients (1/11 vs 7/10, p < 0.01). Multivariate interdependence analysis revealed the previously unrecognized prevalence of Gt1b-Q80K, in HCV/HIV coinfected hemophiliacs [Odds ratio = 13.4 (3.48–51.9), p < 0.01]. Our study revealed the distinct characteristics of viral quasispecies between the subgroups specified above and the feasibility of NGS and QSR-based genetic deconvolution of pre-existing minor Gts, RAVs, and their interrelationships.

Acute kidney injury in a diabetic haemophiliac: one step at a time

We present a young man with type 1 diabetes mellitus and haemophilia A; who presented with oliguric acute kidney injury (AKI). He is also known to have chronic hepatitis C virus infection. On presentation, he had an active urinary sediment warranting a renal biopsy for definitive diagnosis and management. Although he was at high risk for bleeding we elected for renal biopsy with appropriate factor VIII supplementation and monitoring. Ultrasound-guided percutaneous renal biopsy was successful with no immediate or long-term complications. Biopsy revealed advanced diabetic glomerulosclerosis with mild chronic interstitial inflammation.

Renal biopsy in a patient with haemophilia A and cryoglobulinaemic membranoproliferative glomerulonephritis associated with hepatitis C virus infection

A renal biopsy was performed in a 47-year-old man with haemophilia A. Thirty minutes after administration of an intravenous bolus of 4000 units of recombinant factor VIII, which increased the activity to 74–91%, a needle renal biopsy was successfully performed, followed by administration of 3000 units of factor VIII in the evening, and then the subsequent morning and evening. The patient was diagnosed with hepatitis C virus-associated membranoproliferative glomerulonephritis. Treatment with interferon, ribavirin, prednisolone and cyclosporine A improved the nephrotic syndrome. This is the first report of a successful renal biopsy in a patient with haemophilia A after factor VIII injection.

Feasibility, safety and cost-effectiveness of transjugular liver biopsy following major surgery in patients with haemophilia

Prior to the introduction of virally inactivated clotting factor concentrates, the majority of patients with haemophilia became infected with the hepatitis C virus. Although transjugular liver biopsy can be safely performed in these patients, the procedure is associated with a significant financial burden mainly related to replacement therapy with clotting factor. The purpose of this study was to evaluate the feasibility and safety of transjugular liver biopsy in patients with haemophilia substituted with clotting factor concentrates for major surgical procedures. Over the last 5 years, transjugular liver biopsy was performed in nine patients with haemophilia within 1-10 days after orthopaedic (7), thoracic (1) or abdominal surgery (1). All patients had abnormal liver function tests and persistent hepatitis C viraemia. At the time of the biopsy, patients received recombinant factor VIII delivered by dose-adjusted continuous infusion through a central catheter inserted preoperatively in the left internal jugular (n = 8) or in an ante-cubital vein (n = 1). Before the biopsy, basal FVIII levels were raised to 80-100% by a bolus infusion and maintained above 80% for 24 h. The biopsy was informative in all cases. Only one patient developed an episode of supraventricular dysrhythmia. No bleeding or infectious complications were observed. When compared with elective liver biopsy performed outside the postsurgical period, the cost-savings per biopsy were 19 875 +/- 2660 euro. This study shows that intensive replacement therapy required by surgical procedures provides a safe and cost-effective opportunity for transjugular liver biopsy in patients with haemophilia and active hepatitis C.

Hepatitis C virus genotypes among patients with thalassemia and inherited bleeding disorders in Markazi province, Iran

Hepatitis C virus (HCV) genotypes, multiple genotypes infection and HCV seroprevalence were investigated among 98 thalassemia patients and 76 haemophiliacs in Markazi province, Iran. HCV antibody was detected in 5 (5.1%) of the first group and 33 (43.4%) of the latter. Risk factors associated with anti-HCV antibody were also determined. Anti-HCV positivity in thalassemiacs were related to the number of blood transfusion units, splenectomy and duration of thalassemia. Analysis of risk factors in haemophiliacs revealed that seropositivity was significantly associated with duration of transfusion (P =0.009) and severity of disease (P = 0.000). The prevalence of HCV antibody in thalassemia subjects dropped from 8.1% to 0% after implementation of anti-HCV screening (1996). It was found that higher prevalence of HCV antibody in haemophiliacs (43.4%) compared with thalassemia patients (5.1%) correlated with clotting factor concentrates. Of the 34 seropositive haemophilia patients, HCV RNA was detected in 23 (67.7%). HCV genotype distribution was one in 50%, three in 18.2%, two in 4.54% and mixed in 27.3% (1 + 2 in 9.1%, 1 + 3 in 4.54%, 1 + 4 in 9.2% and 2 + 3a in 4.54%) cases. Among the five anti-HCV-positive thalassemiacs, two (40%) were positive for HCV RNA and one sample was found to be subtype 3a. This study confirms that multitransfused patients in Markazi province had similar genotype distribution as those previously reported form some other regions of Iran. Considering the possibilities of HCV mixed genotype among patients with haemophilia and thalassemia, accuracy and precision should be highly concerned in the detection of genotypes and their subsequent treatment.

Treatment of chronic hepatitis C in patients with haemophilia: a review of the literature

Chronic hepatitis C is a major cause of morbidity and mortality in haemophilia patients. In contrast to studies in the general population, the studies of antiviral therapy in haemophilia patients are limited and often include small numbers of patients. A review of the literature was performed to assess the efficacy of interferon (IFN)-based therapy for patients with haemophilia chronically infected with hepatitis C virus (HCV). Studies were identified by electronic searches (Medline, Embase) and hand searches in references of key articles. Data of the included studies were pooled, and responses to therapy were stratified according to treatment regimen, HIV co-infection status, and treatment history. The main outcome was a sustained virological response (SVR) defined as absence of HCV RNA both at the end of treatment and 24-week post-treatment. Thirty-five studies were identified that included 1151 patients. After pooling the data of included patients, the SVR in HIV-negative treatment naïve patients was 22% for IFN monotherapy, 43% for IFN and ribavirin, and 57% for pegylated IFN and ribavirin, respectively. Re-treatment with IFN and ribavirin of those who failed to respond to previous IFN monotherapy was successful in 33%. In HCV/HIV-coinfected patients, response to IFN monotherapy was 8% and to IFN combined with ribavirin 39%. Responses to IFN-based therapy in patients with haemophilia have been improved over time and are nowadays approximately 50-60%. However, data on haemophilic HCV/HIV-coinfected patients and in patients who failed to respond to previous therapy are limited and future studies in these specific patient population are necessary.

Update on Liver Disease in Hemophilia Patients

Prior to the introduction of viral inactivation techniques in the mid-1980s, the vast majority of patients with hemophilia who received plasma-derived clotting factor concentrates were exposed to and infected with the hepatitis C virus (HCV), a lipid-enveloped bloodborne pathogen. Hemophilia patients may also have been co-infected with the human immunodeficiency virus (HIV) after receiving contaminated blood products. HCV mono-infection has a very slow progression, but patients with hemophilia who are co-infected with HCV and HIV can exhibit a comparatively rapid progression of liver disease. Potential complications of chronic HCV infection are subsequent cirrhosis with hepatic failure and the ultimate onset of hepatocellular carcinoma. The treatment of either of these may involve orthotopic liver transplantation. Liver biopsy and morphologic evaluation of tissue remain the current "gold standard" by which the severity of HCV-induced liver disease can be reliably assessed. Although there has been a reluctance to perform invasive percutaneous liver biopsies in patients with hemophilia, available evidence suggests that they appear to be safe and they certainly provide greater specificity and sensitivity than radiographic techniques such as computerized tomography or magnetic resonance imaging. Treatment of HCV-infected patients is targeted towards preventing the progression of early cirrhosis and end-stage liver disease. The current standard of care for individuals with hemophilia has generally been considered to be the combination of standard interferon-alpha (IFN-alpha) with ribavirin for at least 6 months. Data concerning the use of PEGylated IFN, substituting for standard IFN-alpha, are now emerging, although relatively little of this information relates specifically to hemophilia patients with liver disease. Nevertheless, the favorable data from large non-hemophilia-related HCV disease with early cirrhosis have been extrapolated to the hemophilia scenario, and there has been no evidence in the limited number of hemophiliacs treated in this way to refute this conclusion.

A Canadian multicenter retrospective study evaluating transjugular liver biopsy in patients with congenital bleeding disorders and hepatitis C: is it safe and useful?

Prior to the introduction of virally inactivated clotting factor concentrates, the majority of individuals with congenital bleeding disorders became infected with the hepatitis C virus. Although liver biopsy is valuable in prognosis and guiding antiviral therapy, there is a reluctance to perform biopsies in this population because of the risk of hemorrhage. The purpose of this study was to evaluate the safety of transjugular liver biopsy, and the usefulness of evaluating liver histology in this patient population. Liver histopathology was assessed by the METAVIR index and compared with corrected sinusoidal pressures, platelet counts, and abdominal ultrasonography. Liver biopsy was performed at seven Canadian centers in 65 patients with hemophilia or von Willebrand's disease. Biopsies were done on an outpatient basis, followed by a 4-hr observation period in hospital. Normal hemostasis was maintained during the peribiopsy period, with follow-up doses of factor concentrate self administered by the patient at home. One patient (1.4%) had significant bleeding leading to readmission and red cell transfusion. Liver histology showed 14 patients (22%) had cirrhosis. Ten patients had elevated corrected sinusoidal pressures; 7 of these (70%) had cirrhosis on biopsy, and the other 3 (30%) likely had cirrhosis although histology showed stage 3 fibrosis. This series represents the largest reported experience of transjugular biopsy in individuals with congenital bleeding disorders. We conclude that this procedure can be safely performed on an outpatient basis. The diagnosis of cirrhosis and/or portal hypertension was made in a substantial proportion of individuals (26%), all of whom had asymptomatic liver disease.

Liver biopsy in patients with inherited disorders of coagulation and chronic hepatitis C

Liver biopsy plays a pivotal role in the management of patients with a variety of liver diseases, including chronic hepatitis C virus. The major risk of the procedure is the potential for significant haemorrhagic complications. Although the data are limited, the procedure does not appear to pose excessive risk to the patient with inherited disorders of coagulation, provided that adequate haemostasis can be achieved prior to the liver biopsy. This requires close coordination of care between the hepatologist and the haematologist. Indications for liver biopsy should be the same in patients with haemophilia as in other populations.

Role of liver biopsy in management of chronic hepatitis C: a systematic review

This systematic review addresses 2 questions pertinent to the need for pretreatment liver biopsy in patients with chronic hepatitis C: how well do liver biopsy results predict treatment outcomes for chronic hepatitis C? How well do biochemical blood tests and serologic measures of fibrosis predict the biopsy findings in chronic hepatitis C? Medline and other electronic databases were searched from January 1985 to March 2002. Additional articles were sought in references of pertinent articles and recent journals and by querying experts. Articles were eligible for review if they reported original human data from a study that used virological, histological, pathologic, or clinical outcome measures. Paired reviewers assessed the quality of each eligible study and abstracted data. Studies suggested that advanced fibrosis or cirrhosis on initial liver biopsy is associated with a modestly decreased likelihood of a sustained virological response (SVR) to treatment. Also, studies relatively consistently showed that serum aminotransferases have modest value in predicting fibrosis on biopsy; that extracellular matrix tests hyaluronic acid and laminin may have value in predicting fibrosis, and that panels of tests may have the greatest value in predicting fibrosis or cirrhosis. Biochemical and serologic tests were best at predicting no or minimal fibrosis, or at predicting advanced fibrosis/cirrhosis, and were poor at predicting intermediate levels of fibrosis. Thus, evidence suggests that liver biopsy may have some usefulness in predicting efficacy of treatment in patients with chronic hepatitis C, and biochemical blood tests and serologic tests currently have only modest value in predicting fibrosis on liver biopsy.

Role of liver biopsy in management of chronic hepatitis C: a systematic review

This systematic review addresses 2 questions pertinent to the need for pretreatment liver biopsy in patients with chronic hepatitis C: how well do liver biopsy results predict treatment outcomes for chronic hepatitis C? How well do biochemical blood tests and serologic measures of fibrosis predict the biopsy findings in chronic hepatitis C? Medline and other electronic databases were searched from January 1985 to March 2002. Additional articles were sought in references of pertinent articles and recent journals and by querying experts. Articles were eligible for review if they reported original human data from a study that used virological, histological, pathologic, or clinical outcome measures. Paired reviewers assessed the quality of each eligible study and abstracted data. Studies suggested that advanced fibrosis or cirrhosis on initial liver biopsy is associated with a modestly decreased likelihood of a sustained virological response (SVR) to treatment. Also, studies relatively consistently showed that serum aminotransferases have modest value in predicting fibrosis on biopsy; that extracellular matrix tests hyaluronic acid and laminin may have value in predicting fibrosis, and that panels of tests may have the greatest value in predicting fibrosis or cirrhosis. Biochemical and serologic tests were best at predicting no or minimal fibrosis, or at predicting advanced fibrosis/cirrhosis, and were poor at predicting intermediate levels of fibrosis. Thus, evidence suggests that liver biopsy may have some usefulness in predicting efficacy of treatment in patients with chronic hepatitis C, and biochemical blood tests and serologic tests currently have only modest value in predicting fibrosis on liver biopsy.

Infection of hepatitis A virus in Japanese haemophiliacs

OBJECTIVES

Outbreaks of hepatitis A virus (HAV) infection in haemophiliacs have been reported from many countries. The aim of this study was to determine the prevalence of hepatitis A virus antibody (HAVAb) in Japanese haemophiliacs.

METHODS

Sixty-seven male haemophiliacs were recruited for this study of HAV infection. We also compared the rate of HAV infection with that of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis G virus (HGV).

RESULTS

Fifteen of 67 haemophiliacs (22.4%) were positive for HAVAb. Prevalence of HAVAb was significantly higher in haemophiliacs than in Japanese normal subjects previously reported (P= 0.0001). Age, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin and prevalence of HIV, HCV, and HGV were not statistically different between HAVAb positive and HAVAb negative haemophiliacs. We suggest that the use of clotting factor concentrates is closely associated with HAV infection, but HAV infection does not have an effect on clinical course.

CONCLUSIONS

Administration of clotting factor concentrates may increase risk of HAV infection in haemophiliacs.

Incidence and treatment of hepatitis C virus infection in children with haemophilia in Poland

In 80% of children with haemophilia treated in our department, screening tests showed the presence of antibodies against the hepatitis C virus (HCV). HCV RNA was detected in serum in 41% of cases. In 20% of cases there were periodic increases in the level of alanine aminotransferase (ALT) activity, and in these cases liver biopsy was performed after factor concentrate replacement. No haemorrhagic complications or pain complaints were reported either during the biopsy or immediately afterwards. In all cases histopathological examination revealed chronic hepatitis type C - chronic mild hepatitis and chronic minimal hepatitis. Eight boys were treated with interferon (INF) alpha. In two cases this therapy was successful. No HCV RNA was detected in serum and transaminase activity was normal during the year following interferon treatment.