Natural history of chronic hepatitis B virus infection

Risk factors of hepatitis B virus infection between vaccinated and unvaccinated groups among spouses in 2006 and 2014: a cross-sectional study in Beijing

Objectives: To assess the prevalence of hepatitis B virus (HBV) infection among married individuals and to analyze the associated risk factors of HBV infection in vaccinated and unvaccinated groups in 2006 and 2014.

Methods: Information of married individuals aged over 16 y with a clear HBV vaccination status was extracted from the database constructed by the Beijing Center for Disease Prevention and Control from population-based investigation.

A structured questionnaire was employed to collect demographic information, vaccinated history, and other related influence information of HBV of participants. Pearson chi-square test, Fisher's test, and logistic regression were used to explore the risk factors of HBV infection.

Results: A total of 2874 individuals in 2006 and 1622 individuals in 2014 were enrolled in our study. The mean age of individuals was 49.30 and 46.68 y in 2006 and 2014, respectively. The overall positive rates of HBsAg, anti-HBc, and single anti-HBs were 4.80%, 43.01%, and 5.78% in 2006, which were 4.69%, 38.22%, and 14.18% in 2014, respectively. For vaccinated individuals, age was significantly correlated with anti-HBc in 2014 (40 < age ≤50 versus age ≤30, relative risk (RR) = 3.03, 95% confidence interval (95%CI) = 1.04–8.84). Gender [male versus female, RR = 0.60, 95%CI = 0.36–1.00 (2006); RR = 0.71, 95%CI = 0.52–0.97 (2014)] and age (in 2006) were found to be significantly associated with single anti-HBs.

For unvaccinated individuals, HBsAg positivity was statistically significant correlated with gender [RR = 1.47, 95%CI = 1.04–2.06, in 2006], residence (urban versus rural, RR = 0.40, 95%CI = 0.24–0.67, in 2006; RR = 0.58, 95%CI = 0.34–0.99, in 2014), sharing syringes [RR = 3.75, 95%CI = 1.33–10.63 (in 2006); RR = 2.07, 95%CI = 1.26–3.41 (in 2014)], infected wives (RR = 1.97, 95%CI = 1.28–3.05, in 2006), and infected husbands (RR = 2.19, 95%CI = 1.25–3.82, in 2006). Anti-HBc positivity was significantly associated with gender [RR = 1.19, 95%CI = 1.10–1.30 (in 2006); RR = 1.24, 95%CI = 1.09–1.40 (in 2014)], age (in 2006 and 2014), endoscopic medicine treatment [RR = 1.16, 95%CI = 1.03–1.32 (in 2006), RR = 1.21, 95%CI = 1.01–1.45 (in 2014)], sharing syringes (RR = 1.43, 95%CI = 1.25–1.64, in 2014), body piercing (RR = 0.84, 95%CI = 0.75–0.93, in 2006), infected wives (RR = 1.32, 95%CI = 1.18–1.47, in 2006), and infected husbands (RR = 1.39, 95%CI = 1.22–1.59, in 2006). Anti-HBs positivity was associated with age (in 2006 and 2014).

Conclusions: Prevalence of HBV infection was lower in 2014 than in 2006 according to HBsAg and anti-HBc positivity. Unvaccinated individuals faced much more risk of HBV infection than those of vaccinated.

Clinical features of HBsAg seroclearance in hepatitis B virus carriers in South Korea: A retrospective longitudinal study

AIM

To investigate the characteristic features of hepatitis B surface antigen (HBsAg) seroclearance among Korean hepatitis B virus (HBV) carriers.

METHODS

Carriers with HBsAg seroclearance were selected by analyzing longitudinal data collected from 2003 to 2015. The period of time from enrollment to the negative conversion of HBsAg (HBsAg-NC) was compared by stratifying various factors, including age, sex, hepatitis B e antigen (HBeAg), HBV DNA, sequential changes in the signal-to-cutoff ratio of HBsAg (HBsAg-SCR), as measured by qualitative HBsAg assay, and chronic liver disease on ultrasonography (US-CLD). Quantification of HBV DNA and HBsAg (HBsAg-QNT) in the serum was performed by commercial assay.

RESULTS

Among the 1919 carriers, 90 (4.7%) exhibited HBsAg-NC at 6.2 ± 3.6 years after registration, with no differences observed among the different age groups. Among these carriers, the percentages of those with asymptomatic liver cirrhosis (LC) and hepatocellular carcinoma (HCC) at registration were 31% and 7.8%, respectively. The frequency of HBsAg-NC significantly differed according to the HBV DNA titer and US-CLD. HBeAg influenced HBsAg-NC in the 40-50 and 50-60 year age groups. HBsAg-SCR < 1000 was correlated with an HBsAg-QNT < 200 IU/mL. A gradual decrease in the HBsAg-SCR to < 1000 predicted HBsAg-NC. Six patients developed HCC after registration, including two before and four after HBsAg-NC. The rate at which the patients developed new HCC after HBsAg seroclearance was 4.8%. LC with excessive drinking and vertical infection were found to be risk factors for HCC in the HBsAg-NC group.

CONCLUSION

HCC surveillance should be continued after HBsAg seroclearance. An HBsAg-SCR < 1000 and its decrease in sequential testing are worth noting as predictive markers of HBsAg loss.

Distribution and epidemiologic trends of HBV genotypes and subtypes in 14 countries neighboring china

BACKGROUND

The number of cases of HBV infection reported by the WHO for each district and country is positively correlated with the number of HBV sequences in the database isolated from the corresponding district and country.

OBJECTIVES

This study determined distribution characteristics of HBV genotypes and subtypes in 14 countries neighboring China. The progress made in genomic research involving HBV was also reviewed.

MATERIALS AND METHODS

Nine hundred fifty-one complete genome sequences of HBV from 14 countries neighboring China were selected from NCBI. The sequence-related information was analyzed and recorded. One hundred seventy-two sequences of HBV genotype B were screened for alignment using DNA star and MEGA 5.1.

RESULTS

Dominant HBV genotypes in the countries neighboring China were genotypes B, C and D and dominant subtypes were adw2 and adrq+. The association between genotype and serotype of HBV in these countries was shown to differ from previous research results. As shown by sequence alignment, the sequence divergence between five subgenotypes (B3, B5, B7, B8 and B9) was below 4%. The B subgenotypes shared six common specific amino acid sites in the S region.

CONCLUSIONS

The B3, B5, B7, B8 and B9 subgenotypes can be clustered into quasi-sub-genotype B3 and the open reading frame of HBV has a start codon preference; however, whether a mutation in the start codon in the pre-S2 region has an impact on survival and replication of HBV remains to be determined.

What evidence exists to support antiviral treatment in children with chronic hepatitis B?

Many questions are unanswered on the optimal management of chronically HBV-infected children. Chronic hepatitis B is generally a mild disease in children; however, response to therapy is partial and limited to specific subgroups, and available drugs have no proven advantage on long-term course of disease versus no treatment, and are hampered by numerous limitations. Studies on the natural history of chronic hepatitis B and the long-term results of the therapeutic schedules adopted so far should be critically appraised. A balance between the potential benefits of the treatment and its side effects, and the spontaneous course of the disease left untreated should be made.

Prediction of early HBeAg seroconversion by decreased titers of HBeAg in the serum combined with increased grades of lobular inflammation in the liver

Background

Hepatitis B e antigen (HBeAg) seroconversion is an important hallmark in the natural course of chronic hepatitis B. This study was designed to predict early HBeAg seroconversion within 1 year, by not only biochemical and virological markers, but also pathological parameters in patients with chronic hepatitis B.

Material/Methods

In a retrospective cohort study, 234 patients with HBeAg were reviewed for demographic, biochemical, virological and pathological data at the time of liver biopsy. Then, the patients who accomplished HBeAg seroconversion within 1 year thereafter were compared with those who did not, for sorting out factors predictive of early HBeAg seroconversion.

Results

Early HBeAg seroconversion occurred in 58 (24.8%) patients. In univariate analysis, factors predictive of early HBeAg seroconversion were: alanine aminotransferase (ALT) (p=0.002), IP-10 (p=0.029), HBsAg (p=0.003), HBeAg (p<0.001), HBV DNA (p=0.001), HBcrAg (p=0.001), core-promoter mutations (p=0.040), fibrosis (p=0.033) and lobular inflammation (p=0.002). In multivariate analysis, only serum HBeAg levels <100 Paul Ehrlich Institute (PEI) U/ml and grades of lobular inflammation ≥2 were independent factors for early HBeAg seroconversion (odds ratio 8.430 [95% confidence interval 4.173–17.032], p<0.001; and 4.330 [2.009–9.331], p<0.001; respectively).

Conclusions

HBeAg levels < 100 PEIU/ml combined with grades of lobular inflammation ≥2 are useful for predicting early HBeAg seroconversion. In patients without liver biopsies, high ALT levels (≥200 IU/L) can substitute for lobular inflammation (grades ≥2).

B alert: hepatitis B virus infection in children in Victoria

AIM

The aim of this study is to determine the demographic, clinical and serological patterns of hepatitis B in children in Victoria over a 17-year period.

METHODS

Retrospective analysis of medical records of all patients <18 years of age with positive hepatitis B surface antigen referred to the Gastroenterology, Immigrant Health and Infectious Diseases clinics between 1992 and 2009.

RESULTS

Of the 164 children identified, 76% were born overseas, with vertical transmission the most likely source in 84%. Most were asymptomatic, with no signs of chronic liver disease. Forty children infected with hepatitis B virus (HBV) were born in Australia prior to universal vaccination. There was poor documentation of vaccination or response to vaccination in siblings at risk within families where at least one child was infected. An increasing number of referrals was noted from 2006 to 2009 compared with the preceding 4 years (P < 0.001). Of an expected 200 follow-up visits from new referrals, 78% were attended.

CONCLUSION

These findings suggest that the number of children with HBV in our population is increasing and that models of health care designed to integrate primary with specialist care are required to minimise the overall health care burden of this chronic infection.

Hepatitis B surface antigen prevalence among 12,393 rural women of childbearing age in Hainan Province, China: a cross-sectional study

Background

Hepatitis B virus (HBV) infection is highly endemic in China and it threats human health seriously. The hepatitis B surface antigen (HBsAg) prevalence among women of childbearing age plays an important role in mother to child transmission of HBV, as 30% ~50% of chronic carriers can be attributed to maternal-infantile transmission. However, there are few studies which have reported on the prevalence of HBsAg among women of childbearing age in China. This study aimed to determine the prevalence of HBsAg and its associated risk factors among rural women of childbearing age in Hainan, which is the highest hepatitis B virus endemic province in China.

Methods

A cross-sectional, population-based study, which included 12393 rural women aged 15 ~ 49 years, enrolled by a multistage stratified cluster sampling, was carried out in Hainan province, China, from November 2007 to December 2008. Blood samples were obtained from each study participant, and screened for HBsAg.

Results

The overall HBsAg prevalence of childbearing age women was 9.51%. Risk factors for HBsAg positivity among rural women were: lower education level (OR=1.206), lower family monthly income (OR=1.233), having an HBsAg-positive family member (OR=1.300), without an immunization history (OR=1.243), tattooing (OR=1.190), body piercing (OR=1.293), vaginoscopy history (OR=1.103) and history of induced abortion (OR=1.142).

Conclusions

There is a high HBsAg seroprevalence rate among rural women of childbearing age in Hainan province. Hence, it is necessary to take preventive measures to reduce the seroprevalence of HBsAg and to control its associated risk factors.

Prevention of hepatitis B virus-related hepatocellular carcinoma with antiviral therapy

Chronic hepatitis B (CHB) infection is the major cause of hepatocellular carcinoma (HCC). Primary prevention of hepatitis B infection by vaccination is effective in reducing the incidence of HCC. In persons with CHB infection, the two accepted treatment modalities are interferon alpha (IFN-α) given subcutaneously for a limited period and nucleoside/nucleotide analogs given orally on a long-term basis. These treatments are effective in suppressing viral activity and improving disease markers in short-term studies. The long-term effect on the development of liver cancers with these two forms of treatment appears to be different. However, there are no studies directly comparing IFN-α and nucleoside/nucleotide analogs. Comparisons across studies are inevitably limited by differences in the baseline characteristics of the study cohorts. Long-term follow-up studies of IFN-α therapy show inconsistent results. The beneficial effect in reducing the development of liver cancer is observed mainly in treatment responders who have preexisting cirrhosis of the liver. The long-term studies of lamivudine (and adefovir) show a consistent reduction in the development of liver cancers in patients with, and without, cirrhosis. This beneficial effect is blunted by the development of resistance. The effects of the newer nucleoside/nucleotide analogs, with higher potency and minimal risk of resistance development, are, as yet, unknown.

An intronic variant in the GRP78, a stress-associated gene, improves prediction for liver cirrhosis in persistent HBV carriers

BACKGROUND

Our previous study indicated that a common variant (rs430397 G>A) in the intron 5 of glucose-regulated protein 78 (GRP78) gene was associated with risk and prognosis of primary hepatocellular carcinoma (HCC), including HBV- and cirrhosis-related HCC. rs430397 polymorphism may be a contributing factor or biomarker of HBV infection or HBV-related cirrhosis.

METHODOLOGY/PRINCIPAL FINDINGS

539 non-HBV-infected individuals, 205 self-limited infection and 496 persistent HBV infection were recruited between January 2001 and April 2005 from the hospitals in Southern China. Genomic DNA was genotyped for rs430397. The associations between the variation and susceptibility to liver cirrhosis (LC) in persistent HBV infection were examined. We observed that individuals carrying allele rs430397A were more likely to become HBV-related LC. When persistently infected patients were divided into four subgroups, patients with phase IV had an increased allele A and genotype AG compared with phase I and/or phase III. Decreased serum albumin and prolonged plasma prothrombin time (PT) were showed in LC patients carrying genotype AA. Furthermore, rs430397 genotype had an increased susceptibility to LC with dose-dependent manners (P-trend = 0.005), and the genotype did constitute a risk factor for the development of advanced LC (Child-Pugh classification C and B, P-trend = 0.021).

CONCLUSIONS/SIGNIFICANCE

rs430397 polymorphism may be a contributing factor to LC in persistent HBV carriers.

Effect of alcohol on the development of hepatocellular carcinoma in patients with hepatitis B virus-related cirrhosis: a cross-sectional case-control study

Background/Aims

Whether alcohol intake increases the risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B virus (HBV) infection remains controversial. The aim of this study was to determine the effect of alcohol intake on the development of HCC.

Methods

Between January 2006 and August 2008, 146 patients with an initial diagnosis of HCC who were hospitalized in 3 major hospitals in the Incheon area were enrolled as cases. Another 146 cirrhotic patients, who matched the cases by age and sex, were enrolled as controls. All cases and controls were HBsAg positive, and had a history of lifetime alcohol intake.

Results

The cases and controls were aged 53±8 and 53±9 years (mean±SD), respectively, with each group comprising 118 males and 28 females. The basal laboratory data, distribution of Child-Pugh class, HBeAg positivity (31.5% vs. 37.7%), HBV DNA level (5.74±2.35 vs. 5.98±2.29 log₁₀ copies/mL), and proportion with a lifetime alcohol intake of more than 292 kg (30.8% vs. 34.9%) did not differ between cases and controls. The cumulative alcohol intake and the proportion of heavy drinkers did not differ between the two groups in male patients.

Conclusions

Alcohol intake might not increase the risk of HCC in patients with HBV infection.

Precore and core promoter mutations of the hepatitis B virus gene in chronic genotype C-infected children

The precore (G1896A) and core promoter (A1762T, G1764A) mutations of the hepatitis B virus gene are known to be associated with changes in immunologic phase or the progression to complicated liver disease in adults. We analyzed these mutations in chronically HBV-infected children. Serum was collected from 37 children with chronic HBV infection from March 2005 to September 2008. HBV DNA extraction and nested PCR were followed by sequencing of the PCR products. The children were 6.7 ± 4.6 yr old. All of 37 children had HBV genotype C. Of the cohort, 31 (83.8%) were HBeAg-positive and 6 (16.2%) were HBeAg-negative; the former group comprised 18 (48.6%) who were in the immune-tolerance phase (ITP) and 13 (35.2%) in the immune-clearance phase (ICP). Most of the patients had HBV DNA levels of > 1.0 × 10(8) copies/mL. In the ITP group, only 1 (5.5%) had core promoter mutations, and none had the precore mutation. In the ICP group, only 2 (15.4%) had core promoter mutations; the remaining 6 patients had HBV DNA levels of < 2.0 × 10(3) copies/mL and no core promoter/precore mutations. The very low incidence of the precore/core promoter gene mutation, in children, suggests that these mutations may be the result of life-long chronic HBV infection.

Natural history of hepatitis B virus infection: pediatric perspective

Hepatitis B virus (HBV) infection is an important disease globally. Chronic HBV infection may result in serious complications. Its transmission may be either perinatal or horizontal. Perinatal transmission is particularly important after the implementation of a universal vaccination program. Through either route, chronic carrier status is usually established in early childhood. The course of the disease course is determined by the host-virus interaction. The host's immune system initially tolerates the virus, and then gradually attempts to clear it. The virus, on the other hand, tries to avoid host immune system attack by a strategy involving targeted epitope mutations. By generating mutants, the virus can survive attacks from the host's immune system, enabling the infection to persist. Different individuals have different responses to HBV infection; genetic polymorphisms in cytokines, hormones, and other immune modulators may affect the final outcome of chronic HBV infection. Due to the implementation of a universal infant HBV vaccination program, HBV infection is now under control. Unfortunately, there still are some cases of vaccination failure. Very high maternal viremia, in utero infection, or escape mutants are possible reasons for vaccination failure. Immunocompromised hosts also risk vaccination failure. Blood or organ donors with occult HBV infection are possible sources for immunocompromised hosts. These victims of vaccination failure may exhibit a different disease course due to chronic HBV infection from those who acquired the infection before the universal vaccination era. The achievement of our ultimate goal of HBV elimination depends on a globally effective universal vaccination program, as well as the application of some novel successful medications to control those who are already infected.

Incidence and determinants of spontaneous hepatitis B surface antigen seroclearance: a community-based follow-up study

BACKGROUND & AIMS

Seroclearance of hepatitis B surface antigen (HBsAg) is one of the most important clinical outcomes for chronic hepatitis B treatment trials. Few studies have explored the incidence and determinants of spontaneous seroclearance using a long-term follow-up study. This study aimed to examine the natural history and predictors of HBsAg seroclearance.

METHODS

A total of 3087 individuals with chronic hepatitis B virus infection were enrolled between 1991 and 1992 in this community-based study. Serum samples collected at baseline and follow-up examinations were tested for HBsAg, hepatitis B e antigen (HBeAg), serum hepatitis B virus (HBV)-DNA levels, and anti-hepatitis C virus serostatus. Cox proportional hazards models were used to estimate HBsAg seroclearance rate ratios associated with various determinants.

RESULTS

HBsAg seroclearance occurred in 562 participants during 24,829 person-years of follow-up evaluation, giving a 2.26% annual seroclearance rate. HBV-DNA levels at baseline and follow-up evaluation were the most significant predictor of seroclearance. Higher HBV viral loads conferred lower HBsAg seroclearance rates (P<.001). A spontaneous decrease in follow-up HBV-DNA level (>or=3 log) was associated significantly with seroclearance, showing an adjusted odds ratio of 4.17 (95% confidence interval, 2.55-6.82). Among those with seroclearance, 95.8% had undetectable HBV-DNA levels before seroclearance. Cumulative incidence of HBsAg seroclearance at 60 and 100 months after serum HBV-DNA level decreased to undetectable was 25.8% and 51.3%, respectively.

CONCLUSIONS

This study reveals determinants of HBsAg seroclearance, and suggests that a low viral load is an important factor affecting the natural seroclearance of HBsAg, indicating significant clinical implications for the treatment of chronic HBV.

Influence of transforming growth factor-beta1 gene polymorphism at codon 10 on the development of cirrhosis in chronic hepatitis B virus carriers

Transforming growth factor (TGF)-beta1 is a key cytokine producing extracellular matrix. We evaluated the effect of TGF-beta1 gene polymorphism at codon 10 on the development of cirrhosis in patients with chronic hepatitis B. One hundred seventy eight patients with chronic hepatitis (CH, n=57) or liver cirrhosis (LC, n=121), who had HBsAg and were over 50 yr old, were enrolled. The genotypes were determined by single strand conformation polymorphism. There were no significant differences in age and sex ratio between CH and LC groups. HBeAg positivity and detection rate of HBV DNA were higher in LC than in CH groups (P=0.055 and P=0.003, respectively). There were three types of TGF-beta1 gene polymorphism at codon 10: proline homozygous (P/P), proline/leucine heterozygous (P/L), and leucine homozygous (L/L) genotype. In CH group, the proportions of P/P, P/L, and L/L genotype were 32%, 51%, and 17%, respectively. In LC group, the proportions of those genotypes were 20%, 47%, and 33%, respectively. The L/L genotype was presented more frequently in LC than in CH groups (P=0.017). Multivariate logistic regression analysis confirms that detectable HBV DNA (odds ratio [OR]: 3.037, 95% confidence interval [CI]: 1.504-6.133, P=0.002) and L/L genotype (OR: 3.408, 95% CI: 1.279-9.085, P=0.014) are risk factors for cirrhosis.

Chinese medicines as a resource for liver fibrosis treatment

Liver fibrosis is a condition of abnormal proliferation of connective tissue due to various types of chronic liver injury often caused by viral infection and chemicals. Effective therapies against liver fibrosis are still limited. In this review, we focus on research on Chinese medicines against liver fibrosis in three categories, namely pure compounds, composite formulae and combination treatment using single compounds with composite formulae or conventional medicines. Action mechanisms of the anti-fibrosis Chinese medicines, clinical application, herbal adverse events and quality control are also reviewed. Evidence indicates that some Chinese medicines are clinically effective on liver fibrosis. Strict quality control such as research to identify and monitor the manufacturing of Chinese medicines enables reliable pharmacological, clinical and in-depth mechanism studies. Further experiments and clinical trials should be carried out on the platforms that conform to international standards.

Predictive factors for early HBeAg seroconversion in acute exacerbation of patients with HBeAg-positive chronic hepatitis B

BACKGROUND & AIMS

This study aimed to identify the predictors for early hepatitis B e antigen (HBeAg) seroconversion following acute exacerbation (AE) in patients with HBeAg-positive chronic hepatitis B (CHB).

METHODS

A total of 151 patients with HBeAg-positive CHB and AE were consecutively enrolled. AE was defined as an elevation of alanine aminotransferase level to more than 5 times the upper limit of normal and more than twice the patients' baseline value. Early HBeAg seroconversion was defined as HBeAg loss and the appearance of hepatitis B e antibody within 6 months of AE. Clinical and laboratory data were compared between an early HBeAg seroconversion group and a nonearly HBeAg seroconversion group.

RESULTS

All patients had genotype C hepatitis B virus (HBV). Early HBeAg seroconversion occurred in 35.5% (39/110). Under univariate analysis, age, transmission mode, disease status, and serum HBV DNA level were associated with early HBeAg seroconversion. Multivariate analysis showed that nonvertical transmission mode (RR, 3.681; 95% CI, 1.279-10.592; P = .016) and low serum HBV DNA levels (< or = log [copies/mL]; RR, 6.891; 95% CI, 2.165-21.935; P = .001) were independent predictors.

CONCLUSIONS

Patients with CHB with genotype C may have a higher chance of early HBeAg seroconversion after AE in the context of nonvertical transmission and/or had low serum HBV DNA levels (< or = 7 log [copies/mL]) at AE. Therefore, we should take into account transmission modes and serum HBV DNA levels when choosing appropriate management strategies for patients who exhibit AE of HBeAg-positive CHB with genotype C.

The role of serial measurement of serum HBV DNA levels in patients with chronic HBeAg(-) hepatitis B infection: association with liver disease progression. A prospective cohort study

BACKGROUND/AIMS

To evaluate the fluctuating course of serum HBV-DNA levels during the natural history of chronic HBV infection in the general population of North-Eastern Greece, in association with liver disease progression.

METHODS

Two hundred and sixty-three adults with chronic HBV, median 34 years of age, were randomly selected and prospectively followed-up for a maximum period of 12 years. Viral markers, liver biochemistry and physical examination were performed every 6 months, and liver biopsy/abdominal ultrasound every 2-4 years.

RESULTS

At entry, 195/263 (76%) were HBeAg (-)/anti-HBe (+) inactive carriers: (a) almost all 195 individuals with undetectable or HBV-DNA levels <2000IU/ml had no liver disease at entry and at follow-up period by imaging or liver histology evaluation (b) only 4/195 (2%) showed HBV reactivation with HBV-DNA >2000IU/ml. At entry, 48/263 (18%) patients were chronic HBeAg(-); (a) 1/3 patients had intermittently HBV-DNA <2000IU/ml for at least one occasion and were misclassified as inactive carriers (b) 22/48 (46%) had moderate/severe histology at entry and 5/48 (10%) showed liver disease progression during follow-up. Logistic regression analysis was used to derive OR (95%CI) for factors associated with liver disease progression.

CONCLUSIONS

Close monitoring of serum HBV-DNA levels is useful in the management of chronic HBeAg(-) patients, as associated with liver disease progression.

Estimates and projections of hepatitis B-related hepatocellular carcinoma in Australia among people born in Asia-Pacific countries

BACKGROUND AND AIM

Australia has increasing immigration from hepatitis B virus (HBV) endemic countries of the Asia-Pacific region (APR). This study estimates immigration-related chronic HBV cases, chronic HBV prevalence, and HBV-related hepatocellular carcinoma (HCC) from 1960 to 2005 and projects HBV-related HCC to 2025 in Australia among people born in the APR.

METHODS

The populations of APR origin for the period 1960-2005 were derived from Australian census data. HBV prevalence from population-based sero surveys in the APR countries was used to estimate new chronic HBV cases (immigrant arrivals per year with chronic HBV). Age-specific incidence rates of HCC derived from a Taiwanese population-based study were used to estimate and project HBV-related HCC.

RESULTS

Chronic HBV cases among APR-born population increased rapidly from the late 1970s reaching a peak of 4182 in 1990. Chronic HBV prevalence increased to >53 000 in 2005. Estimates of HBV-related HCC increased linearly from one in 1960 to 140 in 2005, with a projected increase to 250 in 2025. Universal HBV vaccination programs in countries of origin had limited impact on projected HBV-related HCC to 2025.

CONCLUSION

The burden of chronic HBV including HBV-related HCC among APR-born Australians has increased over the past three decades and is projected to increase further during the next two decades.

Clinical trial: effects of adefovir dipivoxil therapy in Asian and Caucasian patients with chronic hepatitis B

BACKGROUND

Two-thirds of the 350 million people infected with chronic hepatitis B virus live in the Asia-Pacific region. AIM To compare the effects of adefovir dipivoxil therapy between Asian and Caucasian patients with chronic hepatitis B.

METHODS

The safety and efficacy of 10 mg of adefovir dipivoxil was compared to placebo in 501 Asian (n = 259) or Caucasian (n = 242) HBeAg+ and HBeAg- chronic hepatitis B virus patients treated for 48 weeks in two randomized, double-blind, placebo-controlled studies.

RESULTS

At week 48, histological improvement was observed in 60% and 56% of Caucasian and Asian patients, respectively. Change in serum hepatitis B virus DNA from baseline to week 48 for the adefovir dipivoxil-treated patients was -3.89 and -3.70 log(10) copies/mL in Caucasian and Asian patients, respectively, while 34 per cent of Caucasian patients and 39 per cent of Asian patients had undetectable serum hepatitis B virus DNA (<400 copies/mL) at week 48. The percentage of patients achieving alanine aminotransferase (ALT) normalization at week 48 was similar in both groups (Caucasian 64 per cent, Asian 63 per cent). No patients developed resistance through week 48. No differences in adverse events or grade 3 or 4 laboratory abnormalities were observed between groups.

CONCLUSIONS

There were no significant differences in treatment response between Asians and Caucasians. Adefovir dipivoxil was well tolerated and no resistance developed up to week 48 in both racial groups.

Revisiting the natural history of chronic hepatitis B: impact of new concepts on clinical management

Appropriate treatment for chronic hepatitis B (CHB) to prevent disease progression and clinical complications requires an accurate knowledge of the natural history of this disorder. In patients who acquire the disease in early life, as is the situation in Asian CHB patients, complications of CHB continue to develop because of the prolonged insidious damage to the liver, even in the low viremic phase. Hepatitis B e antigen seroconversion with hepatitis B virus (HBV) DNA levels just below 10(5) copies/mL may not be an adequate treatment endpoint for Asian CHB patients. Furthermore, it has been shown that patients with mild elevation of alanine aminotransferase (ALT) levels are already at considerable risk of development of complications. More recent studies have shown that in order to move towards a better disease outcome, CHB patients should have HBV DNA levels at least less than 10(3) copies/mL, with ALT levels preferably in the range of less than 0.5 times the upper limit of the normal range. Therefore, prolonged, adequate suppression of viral replication should be the practical goal for the treatment of CHB disease in the Asian population.

Viremia profiles in children with chronic hepatitis B virus infection and spontaneous e antigen seroconversion

BACKGROUND & AIMS

This study investigated the viremia profiles in children with chronic hepatitis B virus (HBV) infection and spontaneous hepatitis B e antigen (HBeAg) seroconversion.

METHODS

Fifty-eight children with chronic HBV infection met the following criteria: normal alanine aminotransferase (ALT) level at enrollment, followed up for more than 10 years, no antiviral treatment, and having undergone spontaneous HBeAg seroconversion during follow-up evaluation. They were grouped according to the post-HBeAg seroconversion HBV-DNA levels: (1) low viremia: transient or never 10(4) copies/mL or greater (n=35) (2) fluctuating high viremia: 10(4) copies/mL or greater at least twice at intervals more than 1 year apart (n=23). Abdominal sonography, ALT, and HBV-DNA levels were assessed annually. Another 14 nonseroconverted children served as controls. The precore mutant (nt1896) and genotypes were examined.

RESULTS

The initial HBV-DNA level of the 58 seroconverters was 10(8.4+/-1.0) copies/mL and decreased to 10(2.9+/-2.0) copies/mL at the end of follow-up period. Their mean ages at enrollment, at peak HBV-DNA, at peak ALT, at HBeAg seroconversion, and at final follow-up were 7.0 +/- 3.7, 13.4 +/- 5.8, 16.3 +/- 6.0, 17.2 +/- 5.8, and 23.7 +/- 4.1 years, respectively. The precore mutant appeared more often in the fluctuating-high-viremia group than in the low-viremia group (60.9% vs 22.9%, P=.004). HBV genotypes had no effect on the viremia profiles. After HBeAg seroconversion, none had persistent abnormal ALT levels.

CONCLUSIONS

Generally, these young seroconverters had decreased viral loads, normal ALT levels, and uneventful courses after HBeAg seroconversion. A longer follow-up period is necessary to elucidate the significance of HBeAg seroconversion occurring in childhood and young adulthood.

High levels of subgenomic HCV plasma RNA in immunosilent infections

A genetic analysis of hepatitis C virus (HCV) in rare blood donors who remained HCV seronegative despite long-term high-level viremia revealed the chronic presence of HCV genomes with large in frame deletions in their structural genes. Full-length HCV genomes were only detected as minority variants. In one immunodeficiency virus (HIV) co-infected donor the truncated HCV genome transiently decreased in frequency concomitant with delayed seroconversion and re-emerged following partial seroreversion. The long-term production of heavily truncated HCV genomes in vivo suggests that these viruses retained the necessary elements for RNA replication while the deleted structural functions necessary for their spread in vivo was provided in trans by wild-type helper virus in co-infected cells. The absence of immunological pressure and a high viral load may therefore promote the emergence of truncated HCV subgenomic replicons in vivo.

Chronic hepatitis B virus infection acquired in childhood: special emphasis on prognostic and therapeutic implication of delayed HBeAg seroconversion

In high endemic areas of hepatitis B virus (HBV) infection, the vast majority of infection is acquired perinatally or during early childhood. The age of the patient is, therefore, almost equivalent to the duration of HBV infection. The natural history of chronic HBV infection consists of three chronological phases: immune tolerance, immune clearance and low replicative phases. The prevalence of hepatitis B e antigen (HBeAg) in asymptomatic HBV carriers is around 90% before 15 years of age, and decreases remarkably to less than 10% after 40 years of age. The immune clearance phase is characterized by a series of hepatitis flares and remissions. These will be followed eventually by HBeAg seroconversion, which is usually accompanied by remission of liver disease and confers favourable outcome. However, patients with persistent HBeAg seropositivity over 40 years of age are associated with a significantly higher risk for progression to cirrhosis than those with HBeAg seroconversion before 40 years of age, and thus should be considered as patients with 'delayed' HBeAg seroconversion. Antiviral or immunomodulatory therapy should be considered seriously for these patients.

Predicting cirrhosis risk based on the level of circulating hepatitis B viral load

BACKGROUND & AIMS

Cirrhosis develops as a result of hepatic inflammation and subsequent fibrosis in chronic hepatitis B infection. We report on the relationship between hepatitis B viremia and progression to cirrhosis in chronic hepatitis B infection.

METHODS

This was a population-based prospective cohort study of 3582 untreated hepatitis B-infected patients established in Taiwan from 1991 to 1992. Serum samples were tested for HBV DNA on cohort entry serum samples and the diagnosis of cirrhosis was by ultrasound.

RESULTS

During a mean follow-up time of 11 years, the 3582 patients contributed 40,038 person-years of follow-up evaluation and 365 patients were newly diagnosed with cirrhosis. The cumulative incidence of cirrhosis increased with the HBV-DNA level and ranged from 4.5% to 36.2% for patients with a hepatitis B viral load of less than 300 copies/mL and 10(6) copies/mL or more, respectively (P < .001). In a Cox proportional hazards model adjusting for hepatitis B e-antigen status and serum alanine transaminase level among other variables, hepatitis B viral load was the strongest predictor of progression to cirrhosis relative risk [95% confidence interval] was 2.5 [1.6-3.8]; 5.6 [3.7-8.5]; and 6.5 [4.1-10.2] for HBV-DNA levels >/=10(4) - <10(5); >/=10(5) - <10(6); >/=10(6) copies/mL, respectively.

CONCLUSIONS

These data show that progression to cirrhosis in hepatitis B-infected persons is correlated strongly with the level of circulating virus. The risk for cirrhosis increases significantly with increasing HBV-DNA levels and is independent of hepatitis B e-antigen status and serum alanine transaminase level.

Introduction to chronic hepatitis B infection

Chronic hepatitis B virus (HBV) infection affects over 350 million people worldwide and over 1 million die annually of HBV-related chronic liver disease. Although many individuals eventually achieve a state of nonreplicative infection, the prolonged immunologic response to infection leads to the development of cirrhosis, liver failure, or hepatocellular carcinoma (HCC) in up to 40% of patients. In endemic areas, where carrier rates are >5%, most individuals are infected perinatally, by vertical transmission, or in early childhood. In the United States, where prevalence is low except in particular areas and populations (e.g., Alaskan natives, immigrants from highly endemic areas), transmission is generally horizontal, percutaneous, or via sexual contact in adulthood. A variety of host (age at infection, gender, immune status); viral (viral load, genotype, mutation); and external (concurrent viral infections, alcohol consumption, chemotherapy) factors influence disease progression. Several variables (age at infection, gender, ethnicity, immune status) also influence the risk of chronic infection. Perinatal transmission, the most common mode of infection worldwide, can be reduced by appropriate prophylaxis (vaccination of the infant at birth together with hepatitis B immune globulin); anti-viral therapy in late pregnancy may also be beneficial. Five drugs are now FDA-approved for the treatment of HBV (interferon, lamivudine, adefovir, entecavir, and peginterferon alfa-2a), and suppressive anti-viral therapy improves the natural history of HBV. Patients with decompensated cirrhosis or HCC are highly likely to die unless they successfully undergo liver transplantation. While novel anti-viral drugs have improved the management of cirrhosis, strategies to prevent and treat HCC remain inadequate.

Relative predictive factors for hepatocellular carcinoma after HBeAg seroconversion in HBV infection

AIM: To determine the predictive factors for hepatocellular carcinoma (HCC) development in patients after spontaneous or therapeutic HBeAg seroconversion.

METHODS: In 48 patients who seroconverted to anti-HBe positive during follow-up, the background factors for HCC development were analyzed.

RESULTS: HCC was developed in six patients during follow-up (average follow-up after HBeAg seroconversion: 10.9±5.4 years). The incidence of HCC evaluated by Kaplan–Meier analysis was significantly higher in patients with abnormal aspartate aminotransferase (AST> 40 IU/L) level, lower platelet counts (PLT<10×10⁴/µL), lower albumin level (Alb<30 g/L), positive HBV-DNA or older age at seroconversion (>40 years). However, lower platelet count was the only predictive factor for HCC development shown by multivariate proportional-hazard analysis.

CONCLUSION: Active hepatitis or advanced hepatitis at HBeAg seroconversion or progressive hepatitis even after HBeAg seroconversion would be the risk factors for HCC development. These predictive factors should be taken into account in determining the frequency of biochemical study or imaging studies for HCC surveillance.

Genotype C hepatitis B virus infection is associated with a higher risk of reactivation of hepatitis B and progression to cirrhosis than genotype B: a longitudinal study of hepatitis B e antigen-positive patients with normal aminotransferase levels at baseline

BACKGROUND/AIMS

Longitudinal studies on the relationship between hepatitis B virus (HBV) genotypes and reactivation of hepatitis B and progression to cirrhosis were very rare.

METHODS

Liver biochemistry, virological markers and ultrasound were monitored in 202 hepatitis B e antigen (HBeAg)-positive patients with normal alanine aminotransferase (ALT) at baseline for 3-20 (average 10.8) years, and the outcome was correlated with HBV genotypes.

RESULTS

There were 150 genotype B and 52 genotype C patients. Hepatitis activity during the HBeAg-positive phase showed no significant difference. However, genotype B was associated with a significantly earlier and higher rate of HBeAg seroconversion. HBeAg seroconversion correlated with age at entry for genotype B and with ALT levels for genotype C. Reactivation of hepatitis B was significantly more common in genotype C patients. Five genotype B and 10 genotype C patients progressed to cirrhosis. Multivariate analysis revealed that genotype C (P = 0.03) and reactivation of hepatitis B (P = 0.0004) were independent factor predictive of cirrhosis.

CONCLUSIONS

Rate and factors of HBeAg seroconversion, and rate of reactivation of hepatitis B differed between genotype B and genotype C patients. Genotype C and reactivation of hepatitis B were associated with increased risk of cirrhosis.

The relationship between HBV-DNA levels and cirrhosis-related complications in Chinese with chronic hepatitis B

We studied the hepatitis B virus (HBV)-DNA levels below which the development of cirrhosis-related complications became unlikely in chronic hepatitis B (CHB). Seventy-nine Chinese CHB patients with cirrhosis-related complications and 158 age-, sex- and HBeAg status-matched patients without complications were enrolled. The precore and core promoter mutations were detected by the Line Probe assay (LiPA). HBVDNA levels were determined by Digene assay and Cobas Amplicor Monitor test. Patients with complications had higher HBVDNA levels than those without complications (P = 0.02). HBeAg-positive patients with complications had similar alanine transferase (ALT) and HBVDNA levels and frequency of precore mutations, but higher frequency of core promoter mutations (P = 0.003), compared with those without complications. Anti-HBe-positive patients with complications had higher ALT and HBVDNA levels (P < 0.01) but similar frequency of precore and core promoter mutations, compared with those without complications. Anti-HBe patients (24.5%) with complications had HBVDNA levels <10(4) copies/mL. The major factor for the development of cirrhotic complications was viral loads but cirrhotic complications continued to develop in patients with HBVDNA levels below 10(4) copies/mL.

Determinants for the occurrence of acute exacerbation of hepatitis B virus infection in Chinese patients after HBeAg seroclearance

This study was performed to determine the factors for predicting the occurrence of acute exacerbation of hepatitis B virus infection in HBeAg-negative patients. Two hundred and sixteen patients with known times of HBeAg seroclearance were recruited. Liver biochemistry and virologic markers were monitored. Precore and core promoter mutations were determined by a line probe assay. The median age at HBeAg seroclearance was 34.5 years. The median follow-up duration was 26.4 months. Fifty-six (27.9%) patients had acute exacerbations. By Cox regression analysis, male gender, older age, and core promoter mutations at the time of HBeAg seroclearance were independently associated with the occurrence of acute exacerbation after HBeAg seroclearance (P = 0.025, 0.018, and 0.001, respectively). Fourteen (7.0%) patients had HBeAg seroreversion within a median follow-up period of 11.6 months after HBeAg seroclearance. By Cox regression analysis, older age at HBeAg seroclearance was independently associated with the chance of HBeAg seroreversion (P = 0.01). We concluded that male patients with core promoter mutations and delayed HBeAg seroclearance had a higher cumulative chance of acute exacerbation in the HBeAg-negative phase. Patients with delayed HBeAg seroclearance had a higher frequency of HBeAg seroreversion.

Detection of intrahepatic hepatitis B virus DNA and correlation with hepatic necroinflammation and fibrosis

Assessment of intrahepatic hepatitis B virus (HBV) DNA levels in patients with chronic hepatitis B is important in understanding the natural history of the disease and designing antiviral therapy regimens. However, there is no standardized method for the measurement of intrahepatic HBV DNA levels. We describe a convenient novel method for the measurement of intrahepatic HBV DNA levels based on a modified COBAS Amplicor HBV Monitor test for HBV DNA measurement and real-time PCR beta-actin gene detection for human genomic DNA (hgDNA) quantitation. Fifteen hepatitis B e antigen (HBeAg)-positive patients, 26 patients positive for antibody to HBeAg (anti-HBe), and 8 control patients were recruited. The mean between-run coefficient of variation for the beta-actin real-time PCR assay was 15.4%. All eight control patients had undetectable intrahepatic and serum HBV DNA levels. All chronic hepatitis B patients had detectable intrahepatic HBV DNA levels, and all but one anti-HBe-positive patient had detectable serum HBV DNA levels. HBeAg-positive patients had higher median intrahepatic and serum HBV DNA levels than anti-HBe-positive patients (6,950 versus 676 HBV DNA copies/ng of hgDNA, respectively [P < 0.001] and 184 x 10(6) versus 6.65 x 10(6) copies/ml, respectively [P < 0.001]). The intrahepatic HBV DNA levels correlated strongly with the serum HBV DNA levels (r = 0.842; P < 0.001) and with the degree of fibrosis (P = 0.014). We conclude that the method that we describe is reliable and convenient for the measurement of intrahepatic HBV DNA levels and has potential clinical significance.

Benefit of Lamivudine Therapy and Factors Associated with Clinical Outcome in Spontaneous Severe Acute Exacerbation of Chronic Hepatitis B Virus Infection

OBJECTIVE

During the course of chronic hepatitis B virus (HBV) infection, severe acute exacerbations of the infection often occur spontaneously and follow a fulminating progression to fatal hepatic failure. The aim of this study was to clarify potential factors, including benefit of lamivudine therapy, which could influence clinical course of the serious disease in an area of intermediate HBV endemicity.

METHODS AND RESULTS

Using a database of 3,163 chronically HBV-infected patients, 418 (13.2%) developed acute exacerbation of hepatitis B. Of the 418 patients, 52 (12.4%) spontaneously developed severe acute exacerbation and were included in this study. Of the 52 patients, 23 were treated with lamivudine. In multivariate analyses, fulminating progression to hepatic failure (odds ratio, 15.45; 95% confidence interval, 3.71-64.41; p = 0.0002) was a significantly independent predictor of patient survival. Three variables were independently associated with fulminating development of hepatic failure: presence of cirrhosis (29.06, 1.74-85.56, 0.019, respectively), higher baseline bilirubin level (14.89, 1.31-52.91, 0.029, respectively), and genotype B (22.14, 1.59-29.68, 0.021, respectively). Treatment lacking lamivudine was a significant factor that contributed to shorter survival time, development of hepatic failure, and progression to cirrhosis in univariate analyses (p = 0.014, 0.012 and 0.0030, respectively).

CONCLUSION

In an area of intermediate HBV endemicity, certain proportion of chronic hepatitis B patients could spontaneously develop the serious disease. Factors influencing clinical course of the disease should be identified to improve prognosis and establish more rational and effective therapeutic strategies. Lamivudine therapy could potentially benefit the serious disease, although larger series of patients and longer follow-up periods are needed.

Natural history of hepatitis B in perinatally infected carriers

OBJECTIVES

To establish natural seroconversion rates and incidence of hepatic pathology in perinatally infected hepatitis B carriers.

METHODS

Seventy three perinatally infected hepatitis B carriers identified through maternal screening were evaluated. Fifty three were born to parents from the Indian subcontinent, nine were Oriental, six were Afro-Caribbean, and five were white. Median follow up was 10.24 (range 2.02-20.16) years.

RESULTS

Only three of the children followed up had cleared hepatitis B surface antigen during this period, and 30% of the children had seroconverted to anti-HBe. Seroconversions to anti-HBe were observed in Asian (18/50) and white (4/5) children, but not in Oriental or Afro-Caribbean children. More girls (40%) than boys (23%) had seroconverted, but the difference was not significant. All children were asymptomatic with normal physical examination, growth, and development. Almost half (48%) of the hepatitis B e antigen (HBeAg) positive children had normal hepatic transaminases and liver function. Thirty five liver biopsies were performed in children with active virus replication (HBeAg or hepatitis B virus DNA positive) who were being considered for antiviral treatment as part of a clinical trial and were scored using the Ishak method. Two thirds (62%) of the children had mild hepatitis, 60% had mild fibrosis, and 18% had moderate to severe fibrosis. There was a weak correlation between histological evidence of hepatitis and hepatic transaminase activity, implying that biochemical monitoring of hepatic disease activity may be ineffective.

CONCLUSIONS

These asymptomatic hepatitis B virus carrier children remain infectious in the medium to long term with notable liver pathology. They should receive antiviral treatment to reduce infectivity and to prevent further progression of liver disease. Hepatic transaminases alone are not a reliable marker of liver pathology, and liver histology is essential before consideration for antiviral treatment.

Screening for hepatocellular carcinoma: survival benefit and cost-effectiveness

BACKGROUND

The prognosis for patients with hepatocellular carcinoma (HCC) is poor by the time they present with symptoms. This review examines the usefulness of screening programs from the perspectives of survival benefit and of cost-effectiveness.

MATERIALS AND METHODS

Articles were searched through Medline for screening, HCC, treatment and cost-effectiveness.

RESULTS

Both ultrasonography and alpha-fetoprotein testing have a low sensitivity for detecting HCC, although a combination of the two investigations can increase sensitivity. They remain the main screening methods because they are convenient, non-invasive and easily assessable. Though earlier studies fail to show improvement in patient management and survival by screening, more recent studies demonstrate that screening can increase the chance of curative treatment and, more importantly, improve survival even after the adjustment of lead-time bias. This is probably due to the improvement in medical treatment and technology. The cost per tumor detected for a region is inversely proportional to the tumor incidence of that region.

CONCLUSIONS

In countries with a low prevalence of HCC, screening for HCC is not cost-effective. But in countries with a high prevalence of HCC, especially when screening is directed at older patients with a high risk of HCC, screening programs for HCC become much more cost-effective.

Viral hepatitis B

More than 400 million people worldwide are chronically infected by the hepatitis B virus. The virus is responsible for more than 300000 cases of liver cancer every year and for similar numbers of gastrointestinal haemorrhage and ascites. Major breakthroughs have been achieved in diagnosis and treatment of this virus. Hepatitis B vaccine reduces incidence of liver cancer. As with hepatitis C, advances have been made in molecular virology, especially for naturally occurring and treatment-induced mutant viruses. The clinical significance of low viral load and genotypes are also under investigation. Currently available monotherapies-interferon, lamivudine, and adefovir dipivoxil-very rarely eradicate the virus, but greatly reduce its replication, necroinflammatory histological activity, and progression of fibrosis. Lamivudine, and presumably other nucleoside analogues, can reverse cirrhosis of the liver.

Chronic hepatitis B: a long-term retrospective cohort study of disease progression in Shanghai, China

BACKGROUND AND AIMS

The present study aimed to describe the disease progression of chronic hepatitis B patients without or with compensated cirrhosis at baseline, to estimate the risk of progression to decompensated cirrhosis, hepatocellular carcinoma and death, and to determine prognostic factors of disease progression in patients in Shanghai, China.

METHODS

Stored medical records from 322 biopsy-confirmed chronic hepatitis B cases diagnosed between 1981 and 1993 were selected, and the status of patients was tracked in 1999-2000. Among consenting patients, ultrasound examination and laboratory tests were conducted. Person-year incidence rates, Kaplan-Meier analysis, log-rank tests, and Cox regression analysis were conducted.

RESULTS

Among chronic hepatitis B patients without compensated cirrhosis, the incidence rates of decompensated cirrhosis, hepatocellular carcinoma, and death were 6.3, 2.8, and 7.6 per 1000 person-years, respectively, while for patients with compensated cirrhosis, the rates were 35.6, 8.2, and 35.2 per 1000 person-years, respectively. The 15-year survival rate was 88% for patients without compensated cirrhosis, compared with 56% for patients with compensated cirrhosis (P < 0.001). Cox regression analysis demonstrated that increased alpha-fetoprotein (AFP) (P < 0.01), gamma-globulin (P < 0.05), and high-level severity of hepatic fibrosis (P < 0.01) at baseline were risk factors of decompensated cirrhosis. Factors associated with a high risk of death included elevated AFP at baseline (P < 0.01), severity of hepatic fibrosis (P < 0.003), and sustained positivity for hepatitis B surface antigen (P < 0.004).

CONCLUSION

Increased AFP and severity of hepatic fibrosis at baseline were associated with higher risk of decompensated cirrhosis and death. These data provide rare empirical estimates of the negative long-term outcomes for patients with chronic hepatitis B in Shanghai, China.

Clinical outcome and virologic profiles of severe hepatitis B exacerbation due to YMDD mutations

BACKGROUND/AIMS

To study the outcome and the virologic profiles of severe hepatitis exacerbations due to YMDD mutants in lamivudine-treated patients.

METHODS

Eighteen lamivudine-treated patients with severe hepatitis exacerbations due to YMDD mutants were recruited. Laboratory and clinical parameters were monitored. Viral genotypes and YMDD mutations were determined.

RESULTS

None of the 18 patients had YMDD wild-type during exacerbations. Three (17%) and 15 (83%) patients had genotypes B and C, respectively. Elevated bilirubin levels and prolonged prothrombin time were found in 11 (61%) and six patients (33%) respectively. Three patients (17%) had adverse outcome with the development of ascites and/or encephalopathy. One of these patients required liver transplantation and one died. Both patients had evidence of cirrhosis before treatment and hepatitis B e antigen (HBeAg) seroreversion from anti-HBe positivity. The remaining 16 patients (89%) have no evidence of pre-existing cirrhosis. Thirty seven percent of patients had normal alanine aminotransferase levels at the last follow-up. The median HBV DNA level at the last follow-up was significantly lower than the pre-treatment level (P=0.009).

CONCLUSIONS

Though the majority of patients with severe hepatitis exacerbations due to YMDD mutants had uneventful course, early liver transplantation should be considered in patients with pre-existing cirrhosis and HBeAg seroreversion.

Cholangiocarcinoma in liver cirrhosis

BACKGROUND AND AIM

Hepatocellular carcinoma (HCC) is usually associated with chronic liver diseases and liver cirrhosis, while conversely, cholangiocarcinoma (CC) usually occurs in a non-cirrhotic liver. The purpose of the present study was to evaluate CC in liver cirrhosis.

METHODS

Between January 1998 and December 1999, 26 patients with CC were retrospectively reviewed. The occurrence of CC in chronic hepatitis B infection-related liver cirrhosis, portal vein thrombosis (PVT) and survival were analyzed.

RESULTS

Twenty-six patients with CC (19 with a non-cirrhotic liver and seven with chronic hepatitis B infection-related liver cirrhosis) were included in the present study. All cases of CC in the cirrhotic group were incidentally discovered during routine screening for HCC. The mean age (+/- SD) was 58.8 +/- 14 years in the cirrhotic group and 73.2 +/- 15.9 years (P = 0.001) in the non-cirrhotic group. When compared to the cirrhotic group, the non-cirrhotic group had a higher median level of albumin (42 compared to 30 g/L, P = 0.005), bilirubin (117.5 compared to 18 micro mol/L, P = 0.01), alkaline phosphatase (291.5 compared to 100 U/L, P = 0.001) and gamma glutamyl transpeptidases (215.5 compared to 31 U/L, P = 0.001). In contrast, the cirrhotic group had a higher median prothrombin time (PT) compared to the non-cirrhotic group (18.2 compared to 12 s, P = 0.05). In the non-cirrhotic group, only one patient (5.3%) showed evidence of PVT on a computerized tomography and Doppler ultrasound, while in the cirrhotic group six patients (85.7%) had PVT (P < 0.001). The median survival period in the cirrhotic group was six months (range 2-24 months) compared to 16 months (range 6-41 months) in the non-cirrhotic group (P = 0.036).

CONCLUSION

CC in cirrhotic liver presented at a younger age and patients who developed CC were prone to PVT. The survival period was also shorter in comparison to that of non-cirrhotic liver patients.

In situ expression of Granzyme B and Fas-ligand in the liver of viral hepatitis

BACKGROUND/AIMS

The molecular mechanism involved in hepatocellular injury in viral hepatitis remains to be clarified.

METHODS

We investigated the in situ expression of effector molecules of cytotoxic T lymphocytes such as Fas-ligand (Fas-L), perforin and Granzyme B (Gr-B) immunohistochemically in liver tissues from 20 patients with chronic hepatitis B (CHB) and C (CHC). The degree of cell infiltration was analysed semi-quantitatively and compared with the histological activity index (HAI). Fas-L was expressed in both CD4 and CD8 T-cells in the portal tract as well as in the parenchyma.

RESULTS

Immunostaining of serial sections demonstrated that mononuclear cells at interface hepatitis and focal necrosis were mainly Fas-L positive CD8 T-cells. On the other hand, the expression of perforin or Gr-B was limited to a few mononuclear cells in the portal tract and parenchyma. Semi-quantitative analysis showed a positive correlation between HAI and the grade of infiltration of CD8 T-cells or Fas-L-positive cells, while the correlation was not apparent between HAI and the number of Gr-B positive cells. The expression of these molecules was not different between types of viruses.

CONCLUSIONS

These results suggest that Fas-L-positive CD8 T-cells play a major role in the pathogenesis of liver cell injury in chronic hepatitis.

Introduction of lamivudine for the treatment of chronic hepatitis B: expected clinical and economic outcomes based on 4-year clinical trial data

BACKGROUND

Chronic hepatitis B (CHB) is associated with a significant burden of illness and treatment involves substantial health-care costs. This study estimates clinical outcomes and cost-effectiveness of lamivudine compared with other treatment scenarios for CHB, from an Australian health-care provider perspective.

METHODS

A two-step modeling approach depicted clinical progression of hepatitis B in hypothetical patient cohorts using three different treatment scenarios: scenario A, lamivudine and alpha-interferon (IFN-alpha) available; scenario B, IFN-alpha available only; and scenario C, no treatment available. Assumptions were based on clinical trials, published studies, a hepatologist's questionnaire and an expert panel follow up. One-year clinical outcomes and costs were estimated using a decision tree, while lifetime costs and outcomes were estimated using available clinical trial data for lamivudine (up to 4 years therapy duration) and a Markov model.

RESULTS

The analysis considered only patients with pretreatment elevated alanine aminotransferase levels > or = 2 x upper limit of normal. In the short term, the introduction of lamivudine is expected to result in almost 3.5 times more CHB patients receiving therapy (lamivudine or IFN-alpha) compared to IFN-alpha only (67% compared to 20%, respectively). Hence, scenario A subsequently doubled the seroconversion rate. The incremental cost-effectiveness ratio was $3341 Australian per additional seroconversion. Also, non-seroconverted lamivudine patients are less likely to progress to cirrhosis than those receiving IFN-alpha/no treatment. One-year progression to cirrhosis was estimated at 5.1% with scenario A, compared to 12.2% and 12.7%, scenarios B and C, respectively. From the long-term analysis, lamivudine is expected to increase life expectancy by years and reduce the lifetime risk of compensated cirrhosis, decompensated cirrhosis and hepatocellular carcinoma by 6%, 12% and 12%, respectively. Additionally, the introduction of lamivudine decreases lifetime costs by $548, thus making it a cost-saving and life-extending strategy. In both short- and long-term models, worst case scenarios in sensitivity analyses still associate lamivudine with a favorable cost-effectiveness ratio.

CONCLUSION

Introduction of lamivudine is expected to improve health outcomes in CHB patients, resulting in overall savings in health-care costs. In this model, compared with IFN-alpha only and no treatment, lamivudine allowed more CHB patients to be treated, increased the seroconversion rate, delayed disease progression and prolonged life expectancy.