Natural history and prognosis of hepatitis B

Quality of life in patients with HBV infection: A systematic review and meta-analysis

Background & Aims

Despite nearly 250 million people worldwide estimated to have chronic HBV infection, health-related quality of life (HRQOL) in HBV-related disease has not been well characterised. Here, we summarise existing data on HBV-related HRQOL and quantify summary utility values by stage of disease.

Methods

Embase, Global Health, PubMed, and Web of Science were searched for articles investigating HBV HRQOL. Meta-analyses for utility scores were pooled by stage of disease and utility instrument; meta-regression was further adjusted for the effect of current health expenditure as a percentage of gross domestic product (CHE/GDP), as a proxy of the importance of healthcare perceived by different countries.

Results

Twenty-two articles from 19 studies, comprising 10,311 patients, were included. Of these studies, 74% were performed in the Western Pacific Region, and 47% used the EuroQoL-5D-3L instrument. HRQOL was found to decrease with advancing stages of HBV-related disease. Meta-regression showed the following predicted mean utility scores for the different stages of chronic HBV infection: non-cirrhotic, 0.842; compensated cirrhosis, 0.820 (p = 0.474 compared with non-cirrhotic); decompensated cirrhosis, 0.722 (p = 0.001); and hepatocellular carcinoma, 0.749 (p = 0.008). The type of tool affected HRQOL and populations with a higher CHE/GDP were associated with higher predicted utility values.

Conclusions

Chronic HBV infection impairs the HRQOL of patients, even when there is no evidence of cirrhosis. HRQOL is particularly impaired in the advanced stages of decompensated cirrhosis and hepatocellular carcinoma. These results have important implications for global hepatitis elimination efforts and are useful for economic analyses. However, further research is needed, particularly in high-burden, low-income settings where data are lacking.

Impact and implications

This study, based on 22 articles and 10,311 patients, provides a comprehensive synthesis of data on the impact of chronic hepatitis B virus (HBV) infection on patients' health-related quality of life (HRQOL) worldwide. These findings, of how HRQOL is affected in people living with HBV, highlight the importance of patient-centred care and holistic approaches to management, even at the early stages of disease. These results are useful for cost-effectiveness analyses and may help inform decision-making in improving public health policy towards the elimination of viral hepatitis. The study also underscores the need for further data from low-to middle-income settings, and on the effects of treatment on HRQOL.

Global Epidemiology of Cirrhosis in Women

Recent epidemiological evidence indicates a significant rise in cirrhosis burden over the past 2 decades in all parts of the world, with cirrhosis incidence rates and related deaths escalating quickly. Women face unique risk factors and susceptibility to chronic liver diseases compared with men, underscoring the need for a sex-specific approach in early identification, reversal of causative factors, and complication prevention. This review aims to explore epidemiological trends and sex-specific factors contributing to the global epidemiology of cirrhosis among female patients today. While cirrhosis prevalence remains higher in male patients globally, the incidence rate from 2010 to 2019 grew faster among female patients. The female-to-male incidence ratio of metabolic dysfunction-associated steatotic liver disease-related cirrhosis globally in 2019 was 1.3, indicating a shifting trend toward new diagnoses among women now surpassing that of men. Alcohol-associated cirrhosis epidemiology is also changing, with trends toward an equal incidence of alcohol-associated cirrhosis between both sexes, particularly in industrialized nations with increased alcohol accessibility. Cirrhosis from viral hepatitis remains the main etiology among female patients in endemic regions. Sex differences in epidemiology are likely multifactorial, influenced by varying risk factors, susceptibility, and behaviors between sexes. Further research is necessary to better understand these disparities and to tailor sex-specific interventions toward improved management and treatment strategies, ultimately enhancing outcomes for women with cirrhosis and providing better patient-centered care.

Clinical and economic value of bulevirtide in the treatment of chronic hepatitis D

BACKGROUND/AIMS

Bulevirtide (Hepcludex®) is the first drug approved for the treatment of chronic hepatitis D (CHD), unlike the current off-label treatment (PEG-IFN-α), limited in clinical practice and associated with post-treatment relapses. In a hypothetical cohort of CHD patients in Spain, the study aim was to compare the efficiency of bulevirtide with PEG-IFN-α in terms of clinical events avoided and associated cost savings.

METHODS

A validated economic model reflecting the natural history of the disease was used to project lifetime liver complications and costs for two hypothetical cohorts treated with bulevirtide or PEG-IFN-α. The model considered progression to complications such as decompensated cirrhosis (DCC), hepatocellular carcinoma (HCC), liver transplantation (LT), and death. The efficacy rates used at 24 and 48 weeks were defined as the combined response rate for bulevirtide and undetectable HDV RNA to PEG-IFN-α. The numbers of clinic events and associated costs were evaluated from the perspective of the National Healthcare System.

RESULTS

In a hypothetical cohort of 3882 patients, bulevirtide reduced the numbers of complications events in comparison to PEG-IFN-α (152 DCC, 113 HCC, 11 LT, and 321 deaths over a lifetime). This was associated with a reduction of event-related costs of €11,837,044 (DCC €1,138,059; HCC €1,503,583; LT €7,834,291; and death €1,361,111).

CONCLUSION

In patients with CHD, bulevirtide could prevent a significant number of clinical events compared to PEG-IFN-α and contribute to cost savings through these reduction in liver complications. Further testing for hepatitis D virus is needed so that more patients can benefit from bulevirtide.

Combined impact of prognostic nutritional index, fibrinogen-to-albumin ratio, and neutrophil-to-lymphocyte ratio on surgical outcomes and prognosis in hepatocellular carcinoma

This study evaluated the predictive value of the prognostic nutritional index (PNI), fibrinogen-to-albumin ratio (FAR), and neutrophil-to-lymphocyte ratio (NLR) for overall survival in hepatocellular carcinoma (HCC) patients. A total of 283 HCC cases from Hunan Provincial People's Hospital were included in the analysis, with 45 additional patients as external validation. The relationship between these indices and patient prognosis was further evaluated using the Kaplan-Meier method and Cox regression analysis. Receiver operating characteristic (ROC) curve analysis was performed to assess the predictive performance of these indices for overall survival (OS) and to determine the optimal cutoff values. ROC curve analysis revealed that the area under the curve (AUC) for PNI, FAR, and NLR was 0.723, 0.857, and 0.872, respectively. Multivariate analysis identified hepatitis history, intraoperative blood transfusion, FAR, NLR, and PNI as independent prognostic factors (all P<0.05). The resulting prediction model demonstrated strong performance in both the training (C-index =0.917) and external validation (C-index =0.853) cohorts, with AUCs of 0.889 and 0.931 for 6-month and 1-year prediction in the validation set, respectively. These findings suggest that preoperative levels of peripheral blood PNI, FAR, and NLR are closely associated with the surgical prognosis of HCC patients. The prognostic prediction model developed based on these indices exhibits good predictive efficacy.

HBV Biomarkers and Their Role in Guiding Treatment Decisions

Over 300 million individuals worldwide are chronically infected with hepatitis B virus and at risk for progressive liver disease. Due to the lack of a therapy that reliably achieves viral elimination and the variability of liver disease progression, treatment decisions are guided by the degree of liver disease and viral biomarkers as the viral life-cycle is well characterized and largely conserved between individuals. In contrast, the immunological landscape is much more heterogeneous and diverse and the measurement of its components is less well standardized. Due to the lack of a universal and easily measurable set of biomarkers, clinical practice guidelines remain controversial, aiming for a balance between simplifying treatment decisions by reducing biomarker requirements and using all available biomarkers to avoid overtreatment of patients with low risk for disease progression. While approved therapies such as nucleos(t)ide analogs improve patient outcomes, the inability to achieve a complete cure highlights the need for novel therapies. Since no treatment candidate has demonstrated universal efficacy, biomarkers will remain important for treatment stratification. Here, we summarize the current knowledge on virological and immunological biomarkers with a specific focus on how they might be beneficial in guiding treatment decisions in chronic hepatitis B.

Predicting clinical outcomes in chronic hepatitis B patients receiving nucleoside analogues and pegylated interferon alpha: a hematochemical and clinical analysis

BACKGROUND

The best antiviral treatment for chronic hepatitis B (CHB) poses a complex challenge. The treatment effect of the combination of nucleoside analogues (NAs) and pegylated interferon alpha (PegIFN) was still in debate.

METHODS

We studied patients treated with NAs and PegIFN-2b at our institution from November 2019 to January 2022. Logistic regression identified independent factors influencing clinical cure. The predictive accuracy of the formula was assessed using the Receiver operating characteristic (ROC) curve at different time points (before therapy, 12 weeks, and 24 weeks into treatment).

RESULTS

A total of 120 patients were enrolled in the final analysis. Among the cohort of patients under study, 71 (59.1%) patients had clinical cure while 49 (40.9%) patients did not. Hepatitis B surface antigen (HBsAg) at baseline and age were the powerful variables predicting the clearance of HBsAg. The area under the ROC (AUC) was 0.907 for pre-treatment predictive model, 0.958 for 12-week predictive model and 0.747 for 24-week predictive model.

CONCLUSION

This study provided predictive formulas for clinical cure, offering valuable insights for CHB treatment. PegIFN and NAs exhibited efficacy. Future research that explores additional factors, such as HBV genotype, in a larger cohort study is needed.

A Chronic Hepatitis B Identification and Surveillance Program Improves Care in an Integrated Health Plan

INTRODUCTION

Optimal management of patients with chronic hepatitis B (CHB) requires surveillance for hepatocellular carcinoma (HCC) and identification of antiviral therapy candidates, but few dedicated CHB surveillance models have been described. Kaiser Permanente Northern California developed a systematic CHB surveillance and management program in 2012. We report the results of the program's performance over the initial 8-year period.

METHODS

We conducted a retrospective cohort study of all patients with CHB meeting guideline criteria for HCC surveillance. Eligible patients were invited into the Kaiser Permanente Northern California Liver Care Program (LCP), wherein patients receive reminders to obtain semiannual laboratory and imaging surveillance, which are reviewed by nurse practitioners. Treatment-eligible patients are provided with antiviral medications.

RESULTS

Since its inception, 14,630 patients met study criteria, and 9,373 (64.1%) enrolled in the LCP. Adherence to imaging recommendations was higher in the LCP-managed group (41.5% of patients in the LCP received ≥80% of recommended imaging compared with 10.9% among patients not enrolled [risk ratio = 3.8; P < 0.001]). Approximately 63% of treatment-eligible patients in both groups received medication, although full-adherence rates were higher in patients managed in the LCP (72.3% vs 63.4%, respectively, P < 0.001). Among the 197 patients who developed HCC, recommended surveillance imaging was performed more frequently among LCP-managed patients (71.4% vs 53.8%, respectively, P < 0.05) who were also significantly more likely to be diagnosed at Barcelona Clinic Liver Cancer Stage 0/A (95.9% vs 74.6%; P < 0.001).

DISCUSSION

In this integrated healthcare system, a systematic program for surveilling and managing patients with CHB seemed beneficial for both process and clinical endpoints.

Association Between Serum Levels of Anti-heat Shock Protein 27 Antibody and Liver Cell Injury in Chronic Hepatitis B

Heat Shock Protein 27 (HSP27), an anti-HBV factor, exists in the intracellular and extracellular spaces. As an inflammatory modulator, serum HSP27 (sHSP27) is associated with elevated pro-inflammatory cytokines and a higher likelihood of hepatocellular carcinoma in chronic hepatitis. SHSP27 results in natural antibody production (anti-HSP27-Ab) that is more stable and easily detectable compared to sHSP27. We aimed to investigate any potential association between anti-HSP27-Ab level and chronic hepatitis B (CHB) progression and inflammation indicated by liver cell injury and HBV replication. This cross-sectional study was conducted on 91 patients with CHB and 92 individuals without CHB. Following demographic data collection, anti-HSP27-Ab, serum lipids including total cholesterol, triglyceride, LDL-C, HDL-C, and aminotransferase levels were measured using enzymatic assays in participants' serum samples. HBV DNA was also measured by quantitative PCR in CHB patients. Bivariate and multivariate analyses showed a significantly higher mean level of anti-HSP27-Ab in CHB than in healthy individuals (0.304 vs. 0.256AU/ml, P value = 0.015). These levels held significant differences in the CHB subgroups of male patients, at the age of 50 years and above, with non-smoking status, elevated aminotransferase levels, and hypotriglyceridemia (P value < 0.05). However, no difference was found between the antibody levels and HBV DNA copies (P value > 0.05). This study provides evidence that anti-HSP27 antibody levels can reflect the degree of liver necrosis indicated by aminotransferase levels. Regarding the higher incidence rate of HBV-associated complications in 50 to 60-year-old men, monitoring the antibody can be beneficial in managing this group of CHB patients, which deserves further investigation.

Review of Related Factors for Persistent Risk of Hepatitis B Virus-Associated Hepatocellular Carcinoma

Chronic hepatitis B virus (HBV) infection is the largest global cause of hepatocellular carcinoma (HCC). Current HBV treatment options include pegylated interferon-alpha and nucleos(t)ide analogues (NAs), which have been shown to be effective in reducing HBV DNA levels to become undetectable. However, the literature has shown that some patients have persistent risk of developing HCC. The mechanism in which this occurs has not been fully elucidated. However, it has been discovered that HBV's covalently closed circular DNA (cccDNA) integrates into the critical HCC driver genes in hepatocytes upon initial infection; additionally, these are not targets of current NA therapies. Some studies suggest that HBV undergoes compartmentalization in peripheral blood mononuclear cells that serve as a sanctuary for replication during antiviral therapy. The aim of this review is to expand on how patients with HBV may develop HCC despite years of HBV viral suppression and carry worse prognosis than treatment-naive HBV patients who develop HCC. Furthermore, HCC recurrence after initial surgical or locoregional treatment in this setting may cause carcinogenic cells to behave more aggressively during treatment. Curative novel therapies which target the life cycle of HBV, modulate host immune response, and inhibit HBV RNA translation are being investigated.

HBV elimination in Africa-Current status and challenges

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Retrospective cohort study assessing coverage, uptake and associations with hepatitis B vaccination among females who engage in sex work attending sexual health services in England between 2015 and 2019

OBJECTIVES

Females who engage in sex work (FSW) are at high risk of hepatitis B virus (HBV) and are eligible for HBV vaccination. The objective of this analysis was to explore coverage, uptake and correlates of HBV vaccination among FSW who attend sexual health services (SHS) in England.

METHODS

Data on all attendances at SHS in England were obtained from the GUMCAD STI Surveillance System. Attendees were eligible for inclusion if they were female, had not been previously diagnosed with HIV and sex work was recorded between 2015 and 2019. Bivariable and multivariable logistic regression models were used to investigate sociodemographic factors (age, ethnicity, region of birth and region of residence) associated with having received an HBV vaccination on or after an attendance where sex work was reported.

RESULTS

There were 13 769 FSW attending SHS in England between 2015 and 2019 (median age 30 years, 71% white ethnicity). HBV vaccination coverage was 37% (n=5050/13 751, 95% CI 35.9%-37.5%). Among those that first reported sex work between 2015 and 2019, HBV vaccination uptake was 30% (n=3249/10 681, 95% CI 29.6%-31.3%). In multivariable analyses, HBV vaccination uptake was associated with younger age (5-year increase: OR=0.87, 95% CI 0.85, 0.89) and being born in South America (37%, adjusted OR (aOR)=1.40, 95% CI 1.18, 1.66) compared with being born in the UK. Being of Asian ethnicity (19%, aOR=0.63, 95% CI 0.45, 0.89) compared with white ethnicity was associated with reduced odds of HBV vaccination. Sixteen FSW were diagnosed with HBV after their first attendance where sex work was recorded.

CONCLUSIONS

To achieve the WHO goals of elimination of HBV as a public health threat by the year 2030, further research is needed to understand the individual and structural barriers to the offering and uptake of HBV vaccination among FSW, as well as using health promotion methods to improve uptake.

Economic Evaluation of Nucleic Acid Testing for Screening of Blood Donations for Thalassemia Patients (ECONAT) in Western India

Background

Transfusion Transmitted infections(TTI) are of significant concern for blood safety. The thalassemia patients who receive multiple transfusions are at an increased risk of TTIs and the Nucleic Acid Test (NAT ) has been advocated for safe blood. Though NAT can reduce the window period compared to serology, cost is a constraint.

Methods

The thalassemia patient and NAT yield data from the centralized NAT lab in AIIMS Jodhpur was evaluated for cost-effectiveness using the Markov model. The incremental cost-effectiveness ratio (ICER) was calculated by dividing the difference between the cost for NAT and the cost of medical management of TTI-related complications by the product of the difference in utility value of a TTI health state with time and Gross National Income(GNI) per capita.

Results

Out of the 48,762 samples tested by NAT, 43 samples were discriminated NAT yield all of which were reactive for Hepatitis B (NAT yield of 1:1134). There was no HCV and HIV NAT yield despite HCV being the most prevalent TTI in this population. The cost of this intervention was INR 5,85,14,400. The number of lifetime QALY saved was 1.38 years. The cost of medical management is INR 82,19,114. Therefore the ICER for intervention is INR 3,64,45,860 per QALY saved which is 274 times the GNI per capita of India.

Conclusions

The provision of IDNAT-tested blood for thalassemia patients in Rajasthan state was not found to be cost-effective. Measures to bring down the cost or alternative options to increase blood safety should be explored.

Does aspirin reduce the incidence, recurrence, and mortality of hepatocellular carcinoma? A GRADE-assessed systematic review and dose-response meta-analysis

PURPOSE

Aspirin has been suggested to reduce the risk of cancer. However, previous studies have been inconsistent regarding the relationship between aspirin use and the risk of occurrence of hepatocellular carcinoma (HCC). The purpose of this study was to assess the effect of aspirin on clinical outcomes in patients with HCC in a meta-analysis and to explore the possible dose-response relationship.

METHODS

A systematic literature search was conducted in 10 electronic databases and 4 registries. The combined hazard ratios (HRs) were calculated using a random-effects model with 95% confidence interval (CIs) to assess the effect of aspirin on the risk of HCC. Relevant subgroup analyses and sensitivity analyses were performed.

RESULTS

The results show that aspirin use correlated with lower incidence of HCC (HR: 0.75, 95% CI: 0.71-0.80), decreased risk of HCC recurrence (HR: 0.79, 95% CI: 0.65-0.96), and reduced mortality (HR: 0.72, 95% CI: 0.60-0.87). The results of the subgroup analysis showed that aspirin use was consistently associated with reduced incidence of HCC across different regions, study designs, and populations. A linear relationship was found for both dosage and duration of aspirin use. An increased of bleeding with aspirin use among patients was also observed (HR 1.10, 95% CI: 1.02-1.20).

CONCLUSIONS

This meta-analysis found that aspirin use was independently associated with a reduced risk of HCC incidence, recurrence, and death. Furthermore, aspirin use influenced HCC occurrence in a dose-dependent and duration-dependent manner. However, an increased risk of bleeding with aspirin use was noted.

HBcrAg Predicts Hepatocellular Carcinoma Development in Chronic B Hepatitis Related Liver Cirrhosis Patients Undergoing Long-Term Effective Anti-Viral

Hepatitis B core-related antigen (HBcrAg) is a predictor of hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients. Studies on anti-viral therapy have shown that the use of NUC therapy in HBV patients could reduce the incidence of HCC. However, the incidence of HCC continues to increase after long-term anti-viral therapy. The relationship between HBcrAg and HCC development in CHB-related liver cirrhosis (LC) patients undergoing long-term anti-viral therapy is still unclear. This study enrolled 1108 treatment-naïve CHB patients diagnosed with HBV-related LC receiving NUC therapy from April 1999 to February 2015. The baseline biomarkers, disease history, and following results were collected by the hospital. Among the 1108 patients, 219 developed HCC within a median follow-up period of 6.85 years. A multivariable Cox regression model was used, with adjustment for age, gender, FIB-4, DM, and HBsAg-HQ. The adjusted hazard ratios for the HBcrAg tertile levels were 1.70 (95%CI: 1.21, 2.39) and 2.14 (95%CI: 1.50, 3.05) for levels 3.4-4.9 and >4.9 logU/mL, respectively, compared with levels ≤3.4. The effect of the HBcrAg level on HCC incidence was found to be significantly modified by HBsAg-HQ, where lower HBsAg-HQ (≤ 3) values were associated with a significantly higher risk, but HBsAg-HQ levels >3 were not. Our results highlight that, after adjustment for potential confounding factors, patients with CHB-related LC and higher HBcrAg levels are at significant risk for HCC development, even while undergoing long-term effective anti-viral therapy. The HBcrAg level is therefore an independent risk factor for HCC development, especially for patients with HBsAg-HQ levels <3.

Effectiveness of antiviral treatment in HBeAg-negative chronic hepatitis B patients with normal or mildly elevated alanine aminotransferase: a retrospective study

Background

There are inadequate data and no histological evidence regarding the effects of antiviral treatment for hepatitis B e-antigen (HBeAg)-negative chronic hepatitis B (CHB) patients with normal or mildly elevated alanine aminotransferase (ALT). This study investigated the effects of antiviral treatment on these patients.

Methods

We retrospectively analysed the outcomes of antiviral treatment for HBeAg-negative CHB patients with normal or mildly elevated ALT who were treated with nucleoside/nucleotide analogues (NAs) for up to 96 weeks.

Results

A total of 128 patients were enrolled; 74 patients had normal ALT and 54 patients had mildly elevated ALT. The total cumulative rates of viral suppression were 64.06%, 81.97%, and 96.39%, at weeks 24, 48, and 96, respectively. The cumulative rates of viral suppression for the normal and mildly elevated ALT groups were 67.85% and 58.97%, 86.39% and 76.31%, and 93.13% and 97.04% at weeks 24, 48, and 96, respectively. The serum HBV DNA levels at week 12 and hepatitis B surface antigen (HBsAg) levels at week 24 were significant predictors of the 96-week virological response. Of the 128 patients, 54 with normal ALT and 33 with mildly elevated ALT underwent FibroScan at baseline. Significant fibrosis (F ≥ 2) was found in 44.4% (n = 24) and 51.5% (n = 17) of the patients in the normal ALT group and mildly elevated ALT group, respectively. Compared with the values at baseline, liver stiffness values significantly decreased at week 48 (8.12 kPa vs. 6.57 kPa; p < 0.001) and week 96 (8.87 kPa vs. 6.43 kPa; p < 0.001), respectively.

Conclusions

HBeAg-negative CHB patients with normal ALT could benefit from antiviral therapy with NAs, similar to patients with mildly elevated ALT. Antiviral treatment is strongly recommended for HBeAg-negative CHB patients with normal ALT. Additionally, significant liver fibrosis is not rare in HBeAg-negative CHB patients with ALT less than two-times the upper limit of normal, and FibroScan should be performed regularly for these patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02471-y.

Abbreviated magnetic resonance imaging vs ultrasound for surveillance of hepatocellular carcinoma in high-risk patients

BACKGROUND & AIMS

We aimed to compare the performance of gadoxetic acid-enhanced abbreviated MRI (AMRI)-based surveillance and ultrasound-only surveillance in high-risk patients for hepatocellular carcinoma (HCC).

METHODS

Prospectively recruited high-risk patients (>5% annual risk of HCC) who underwent one to three rounds of complete gadoxetic acid-enhanced MRI (CMRI) and ultrasound at 6-months intervals were retrospectively analysed. AMRI consisted of diffusion-weighted, T2-weighted, and hepatobiliary phase imaging. The sensitivity, specificity, and accuracy of CMRI followed by AMRI (CAA), AMRI-only (AAA), and ultrasound-only (US) were compared using generalized estimating equations. Image quality was assessed.

RESULTS

In 382 patients, HCC was diagnosed in 43 (11.3%), including 42 with early-stage HCCs. The sensitivities of CAA (90.7%, 39/43) and AAA (86.0%, 37/43) were higher than US (27.9% [12/43]; P < 0.001), whereas the sensitivities of the two MRI approaches did not significantly differ (P = 0.56). The specificity of CAA (97.1%, 983/1012) was higher than AAA (95.6% [967/1012]; P = 0.01) and not significantly different from US (96.3% [975/1012]; P = 0.59). The CAA approach had the best accuracy of 96.9% (1022/1055), higher than the AAA approach (95.2% [1004/1055]; P = 0.01) and the US approach (93.6% [987/1055]; P = 0.01). Image quality was inadequate in 33.7% (356/1055) of US examinations but in only 10.0% (105/1055) of the AAA and 11.1% (117/1055) of the CAA approach.

CONCLUSIONS

In high-risk patients, AMRI-based surveillance approaches had higher sensitivities than ultrasound-only surveillance for early-stage HCC. A sequential MRI approach of CMRI followed by AMRIs showed superior accuracy than the AMRI-only or ultrasound-only approach.

Economic Evaluation of Oral Nucleos(t)ide Analogues for Patients with Chronic Hepatitis B in Thailand

BACKGROUND

Nucleos(t)ide analogues (NAs) are the main drug category used in the treatment of chronic hepatitis B (CHB). There is a need to update the economic evaluation of CHB treatment.

OBJECTIVE

This study aimed to determine the cost effectiveness of NAs for CHB in Thailand.

METHOD

We used a lifetime Markov model undertaken from a societal perspective. Tenofovir disoproxil fumarate (TDF), tenofovir alafenamide fumarate (TAF), entecavir (ETV) with TDF or TAF as rescue medications, and lamivudine (LAM) with TDF or TAF rescue medications were compared with best supportive care (BSC). We performed a network meta-analysis to estimate the treatment effects of each NA on hepatitis B surface antigen (HBsAg) loss in an Asian population and performed an additional literature review to identify inputs. We calculated incremental cost-effectiveness ratios (ICERs) per quality-adjusted life-years (QALYs) and performed sensitivity analyses.

RESULTS

Compared with BSC, all NAs could improve patients' QALYs, with results ranging from 4.04 to 4.25 QALYs gained. TAF, TDF, LAM/TAF, and LAM/TDF yielded lower total lifetime costs than BSC, ranging from - $US1387 to - 814, whereas ETV/TAF and ETV/TDF yielded higher total lifetime costs than BSC, ranging from $US4965 to 4971. The ICER was $US1230/QALY for ETV/TDF and $US1228/QALY for ETV/TAF. Full incremental analysis showed that the ICER for LAM/TAF was $US1720/QALY compared with TAF.

CONCLUSION

At current prices, TAF, TDF, LAM/TAF, and LAM/TDF are dominant options, and ETV/TAF or ETV/TDF are cost-effective options. LAM/TAF is the most cost-effective option, followed by TAF.

Evaluation of HBsAg Seroclearance in Patients with Hepatitis B

Objective

Hepatitis B surface antigen (HBsAg) seroclearance/seroconversion is regarded as an indicator of the ultimate immune control of hepatitis B virus (HBV) infections. HBsAg loss is the most important endpoint, as it shows deep suppression of HBV replication and viral protein expression. This study was aimed to retrospectively evaluate the HBsAg seroclearance/seroconversion status in patients with acute or chronic hepatitis B (CHB) diagnosis.

Materials and methods

Patients diagnosed with acute or CHB at the Harran University Faculty of Medicine Department of Gastroenterology between January 2012 and December 2020 were included in this study. This study was designed as a retrospective historical cohort. Experimental analysis of the data was done with the help of the SPSS version 22.0 package program.

Results

Of 1,053 patients with positive HBsAg, 854 patients with sufficient data in their files were included in this study. There were 494 (57.8%) males and 360 (42.2%) females; the mean age was 42.71 ± 14.31 (range 18-88). The mean duration of illness was 86.13 ± 72.92 months. In the 9-year follow-up of 854 patients, 65 (7.9%) of the last HBsAg test were negative and seroclearance had developed. The last anti-HBs test was positive in 49 (75.4%) of 65 patients who developed seroclearance, and it was found that seroconversion had developed. Twenty-seven of 30 (90%) of the patients who developed seroclearance had liver transplantation. Sixteen of 19 (84.2%) of them had acute hepatitis B, 14 of 477 (2.9%) were hepatitis carriers, 5 of 201 (2.5%) had e-negative CHB, 2 of 36 (5.6%) had cirrhosis, and 1 of 43 (2.3%) of them were delta hepatitis who developed seroclearance disease; none of the 38 e-positive CHB patients developed seroclearance.

Conclusion

In the 9-year follow-up of patients who were positive for HBsAg at their first admission, approximately one-tenth (7.9%) developed seroclearance, and two-thirds also developed seroconversion. After liver transplantation and acute hepatitis B, almost all patients developed seroclearance, whereas, in approximately 3% of carriers (e-negative CHB and cirrhotic patients) seroclearance developed.

How to cite this article

Taşkın MC, Uyanikoglu A, Cindoglu C. Evaluation of HBsAg Seroclearance in Patients with Hepatitis B. Euroasian J Hepato-Gastroenterol 2022;12(2):65-68.

Trends in the disease burden of HBV and HCV infection in China from 1990 to 2019

OBJECTIVES

This study aims to reveal the 30-year dynamics of HBV and HCV disease burden in China from 1990 to 2019.

METHODS

HBV/HCV data were retrieved from the Global Burden of Disease database. Joinpoint regression was used to examine temporal trends. Age-period-cohort models were applied to evaluate effects of patient age, period, and cohort on HBV/HCV-associated mortality and incidences.

RESULTS

A dramatic decrease in the disease burden of HBV was found from 1990 to 2019, but the disease burden of HCV has remained stable since 2000. Patient age, period, and cohort exerted a significant effect on the diseases burden of HBV and HCV infection. Compared with females, males had a higher risk of HBV/HCV infections as well as HBV/HCV-associated mortality and liver cancer. Overweight, alcohol, tobacco and drug use were important risk factors associated with HBV/HCV-associated liver cancer. The incidences of HBV- and HCV-associated liver cancer from 2019 to 2044 are expected to decrease by 39.4% and 33.3%, respectively.

CONCLUSIONS

The disease burden of HBV/HCV infection has decreased in China over the past 30 years, but HBV incidences remain high, especially in males. Effective management of HBV and HCV infections is still needed for high-risk populations.

Identifying Potential New Gene Expression-Based Biomarkers in the Peripheral Blood Mononuclear Cells of Hepatitis B-Related Hepatocellular Carcinoma

OBJECTIVE

The analysis of the gene expression of peripheral blood mononuclear cells (PBMCs) is important to clarify the pathogenesis of hepatocellular carcinoma (HCC) and the detection of suitable biomarkers. The purpose of this investigation was to use RNA-sequencing to screen the appropriate differentially expressed genes (DEGs) in the PBMCs for the HCC.

METHODS

The comprehensive transcriptome of extracted RNA of PBMC (n = 20) from patients with chronic hepatitis B (CHB), liver cirrhosis, and early stage of HCC (5 samples per group) was carried out using RNA-sequencing. All raw RNA-sequencing data analyses were performed using conventional RNA-sequencing analysis tools. Next, gene ontology (GO) analyses were carried out to elucidate the biological processes of DEGs. Finally, relative transcript abundance of selected DEGs was verified using qRT-PCR on additional validation groups.

RESULTS

Specifically, 13, 1262, and 1450 DEGs were identified for CHB, liver cirrhosis, and HCC, when compared with the healthy controls. GO enrichment analysis indicated that HCC is closely related to the immune response. Seven DEGs (TYMP, TYROBP, CD14, TGFBI, LILRA2, GNLY, and GZMB) were common to HCC, cirrhosis, and CHB when compared to healthy controls. The data revealed that the expressions of these 7 DEGs were consistent with those from the RNA-sequencing results. Also, the expressions of 7 representative genes that had higher sensitivity were obtained by receiver operating characteristic analysis, which indicated their important diagnostic accuracy for HBV-HCC.

CONCLUSION

This study provides us with new horizons into the biological process and potential prospective clinical diagnosis and prognosis of HCC in the near future.

Innate and Adaptive Immunopathogeneses in Viral Hepatitis; Crucial Determinants of Hepatocellular Carcinoma

Viral hepatitis B (HBV) and hepatitis C (HCV) infections remain the most common risk factors for the development of hepatocellular carcinoma (HCC), and their heterogeneous distribution influences the global prevalence of this common type of liver cancer. Typical hepatitis infection elicits various immune responses within the liver microenvironment, and viral persistence induces chronic liver inflammation and carcinogenesis. HBV is directly mutagenic but can also cause low-grade liver inflammation characterized by episodes of intermittent high-grade liver inflammation, liver fibrosis, and cirrhosis, which can progress to decompensated liver disease and HCC. Equally, the absence of key innate and adaptive immune responses in chronic HCV infection dampens viral eradication and induces an exhausted and immunosuppressive liver niche that favors HCC development and progression. The objectives of this review are to (i) discuss the epidemiological pattern of HBV and HCV infections, (ii) understand the host immune response to acute and chronic viral hepatitis, and (iii) explore the link between this diseased immune environment and the development and progression of HCC in preclinical models and HCC patients.

Serum cadmium is associated with hepatic steatosis and fibrosis: Korean national health and nutrition examination survey data IV-VII

Although cadmium (Cd) is correlated with elevated levels of hepatic amino transferases, its influence on the degree of liver steatosis and fibrosis are unknown yet. We aimed to investigate the associations between the serum level of Cd and degree of liver steatosis/fibrosis.Clinical data were obtained from Korean National Health and Nutrition Examination Surveys IV-VII. Alanine aminotransferase (ALT) elevation was defined as ≥ 33 IU/L for men and ≥ 25 IU/L for women. Significant steatosis was defined as a hepatic steatosis index ≥ 36, while significant fibrosis was defined as a fibrosis index (FIB-4) ≥ 2.67 and as an aspartate aminotransferase and platelet ratio index ≥ 0.7. Adjusted odds ratios and 95% confidence intervals were calculated after adjustment.The levels of serum Cd were assessable in 15,783 subjects. The serum cadmium concentrations were significantly associated with ALT elevation, significant liver steatosis and fibrosis. Multivariate logistic regression analysis demonstrated serum Cd level in the forth quartile had a positive correlation with ALT elevation, hepatic steatosis index ≥ 36, FIB-4 ≥ 2.67 and aspartate aminotransferase-to-platelet ratio ≥ 0.7 using the first quartile of serum Cd level as the reference, (adjusted odds ratios 1.90, 1.26, 1.73, and 2.53, respectively; P values <.001).The serum level of Cd was associated with liver steatosis and fibrosis. The evaluation of serum Cd may help for assessing an unexplained liver steatosis and fibrosis, and further prospective studies are needed to confirm our findings.

Current Landscape and Future Perspectives of Abbreviated MRI for Hepatocellular Carcinoma Surveillance

While ultrasound (US) is considered an important tool for hepatocellular carcinoma (HCC) surveillance, it has limited sensitivity for detecting early-stage HCC. Abbreviated MRI (AMRI) has recently gained popularity owing to better sensitivity in its detection of early-stage HCC than US, while also minimizing the time and cost in comparison to complete contrast-enhanced MRI, as AMRI includes only a few essential sequences tailored for detecting HCC. Currently, three AMRI protocols exist, namely gadoxetic acid-enhanced hepatobiliary-phase AMRI, dynamic contrast-enhanced AMRI, and non-enhanced AMRI. In this study, we discussed the rationale and technical details of AMRI techniques for achieving optimal surveillance performance. The strengths, weaknesses, and current issues of each AMRI protocol were also elucidated. Moreover, we scrutinized previously performed AMRI studies regarding clinical and technical factors. Reporting and recall strategies were discussed while considering the differences in AMRI protocols. A risk-stratified approach for the target population should be taken to maximize the benefits of AMRI and the cost-effectiveness should be considered. In the era of multiple HCC surveillance tools, patients need to be fully informed about their choices for better adherence to a surveillance program.

Anti-HBc IgG Levels: A Predictor of HBsAg Seroclearance in Chronic Hepatitis B Patients with Nucleos(t)ide Analogue-Induced HBeAg Seroclearance

BACKGROUND/AIMS

We investigated the efficiency of the indirect ratio of anti-HBc IgG at predicting HBsAg seroclearance in patients with nucleos(t)ide analogue (NA)-induced HBeAg seroclearance.

METHODS

We performed a retrospective study that included 366 chronic hepatitis B patients (March 2007 to December 2016) at a single tertiary hospital. These patients were HBsAg seropositive, and experienced NA-induced HBeAg seroclearance. The indirect ratio of light absorbance of anti-HBc IgG levels were measured with chemiluminescent microparticle immunoassay using the Architect Anti-HBc assay (Abbott Laboratories, IL, USA) as a qualitative method prior to antiviral therapy. We calculated the cumulative incidences of HBsAg seroclearance based on the anti-HBc IgG levels.

RESULTS

After a 10-year follow-up, 48 patients experienced HBsAg seroclearance (13.1%). Thirty-three of 179 patients who had an indirect ratio of light absorbance of anti-HBc IgG < 11 RLU (relative light unit) showed HBsAg seroclearance (18.4%); 15 of 187 patients who had an indirect ratio of light absorbance of anti-HBc IgG ≥ 11 RLU showed HBsAg seroclerance (8.0%) (p = 0.003). In multivariate analysis, age, and ALT at the time of HBeAg seroclearance were predictors of HBsAg seroclearance. Especially, the relative risk of HBsAg seroclearance in patients with baseline anti-HBc IgG levels < 11 RLU was 2.213 (95% CI, 1.220-4.014), compared to that in patients with higher levels of anti-HBc IgG at baseline (p = 0.009).

CONCLUSION

Using an indirect method for anti-HBc IgG levels, baseline anti-HBc IgG levels (< 11RLU), age (≥ 50 years), and ALT (≥ 40 IU/L) might be associated with HBsAg seroclearance in patients with NA-induced HBeAg seroclearance.

Hepatocellular Carcinoma Tumor Microenvironment and Its Implications in Terms of Anti-tumor Immunity: Future Perspectives for New Therapeutics

PURPOSE

Hepatocellular cancer is an insidious tumor that is often diagnosed in a later stage of life. The tumor microenvironment is the key to tumorigenesis and progression. Many cellular and non-cellular components orchestrate the intricate process of hepatocarcinogenesis. The most important feature of hepatocellular cancer is the immune evasion process. The present review aims to summarize the key components of the tumor microenvironment in the immune evasion process.

METHODS

Google Scholar and PubMed databases have been searched for the mesh terms "Hepatocellular carcinoma" or "Liver Cancer" and "microenvironment." The articles were reviewed and the components of the tumor microenvironment were summarized.

RESULTS

The tumor microenvironment is composed of tumor cells and non-tumoral stromal and immune cells. HCC tumor microenvironment supports aggressive tumor behavior, provides immune evasion, and is an obstacle for current immunotherapeutic strategies. The components of the tumor microenvironment are intratumoral macrophages (tumor-associated macrophages (TAM)), bone marrow-derived suppressor cells, tumor-associated neutrophils (TAN), fibroblasts in the tumor microenvironment, and the activated hepatic stellate cells.

CONCLUSION

There are intricate mechanisms that drive hepatocarcinogenesis. The tumor microenvironment is at the center of all the complex and diverse mechanisms. Effective and multistep immunotherapies should be developed to target different components of the tumor microenvironment.

Is urinary β2-microglobulin a reliable marker for assessment of renal tubular dysfunction in chronic hepatitis B patients receiving tenofovir therapy?

BACKGROUND AND AIM

Urinary β2-microglobulin (β2-M) is a marker for renal tubular dysfunction. The current study aimed to assess urinary β2-M as a reliable marker for early prediction of tenofovir disoproxil fumarate (TDF)-related nephrotoxicity among hepatitis B virus (HBV) patients.

METHODS

Forty-two HBV patients who were a candidate for TDF therapy or have recently started it (for less than 6 months) were enrolled and subjected to demographic, clinical, laboratory assessment, abdominal ultrasound and transient elastography. The glomerular filtration rate (GFR) was estimated using the Cockcroft-Gault equation. Also, urinary β2-M was measured by the ELISA method within 6 months after the introduction of TDF treatment and 6 months later.

RESULTS

Mean age was 41.8 (9.55) years, 27 were males and 59.5% of patients have elevated urinary β2-M after 6 months follow-up of TDF therapy. Urinary β2-M was 0.07 ± 0.07 μg/ml at baseline and insignificantly increased up to 0.09 ± 0.08 μg/ml after 6 months follow-up. Despite the insignificant increase in serum creatinine from 0.85 ± 0.23 mg/dl at baseline to 0.9 ± 0.21 mg/dl after 6 months and the insignificant decrease in eGFR from 126.2 ± 39.72 ml/min at baseline and 117.64 ± 42.23 ml/min at 6 months follow-up. No correlation was found between the changes in urinary β2-M and the changes in other renal function indices at baseline and 6 months follow-up.

CONCLUSIONS

Short-term TDF therapy is associated with nonsignificant changes either in eGFR or urinary β2-M; these changes are not clinically relevant that indicates disease progression. Therefore, the suitability of urinary β2-M as a screening tool for tenofovir induced tubular dysfunction should be further.

Risk and Prevention of Hepatitis B Virus Reactivation during Immunosuppression for Non-Oncological Diseases

Reactivation of overt or occult HBV infection (HBVr) is a well-known, potentially life-threatening event which can occur during the course of immunosuppressive treatments. Although it has been described mainly in subjects receiving therapy for oncological or hematological diseases, the increasing use of immunosuppressant agents in non-oncological patients observed in recent years has raised concerns about the risk of reactivation in several other settings. However, few data can be found in the literature on the occurrence of HBVr in these populations, and few clear recommendations on its management have been defined. The present paper was written to provide an overview of the risk of HBV reactivation in non-neoplastic patients treated with immunosuppressive drugs, particularly for rheumatological, gastrointestinal, dermatological and neurological diseases, and for COVID-19 patients receiving immunomodulating agents; and to discuss the potential strategies for prevention and treatment of HBVr in these settings.

Guidelines for Prevention and Treatment of Chronic Hepatitis B

To achieve the goal of the World Health Organization to eliminate viral hepatitis as a major public health threat by 2030, the Chinese Society of Infectious Diseases and the Chinese Society of Hepatology convened an expert panel in 2019 to update the guidelines for the prevention and treatment of chronic hepatitis B (CHB). The current guidelines cover recent advances in basic, clinical, and preventive studies of CHB infection and consider the actual situation in China. These guidelines are intended to provide support for the prevention, diagnosis, and treatment of CHB.

EASL-ALEH 2015 algorithm for the use of transient elastography in treatment-naive patients with hepatitis B: An independent validation

Various non-invasive methods have been evaluated in chronic hepatitis B, but none of them have been fully validated for the assessment of liver fibrosis. The issued EASL-ALEH 2015 guidelines provide detailed algorithms based on LSM and ALT serum levels. The aim of our study was to validate the diagnostic accuracy of this algorithm and to better understand discrepancies. Four hundred and thirteen patients from 3 centres were retrospectively included. All included patients were classified for fibrosis stage according to results of a liver biopsy. The overall diagnostic value was expressed with AUROCs given with 95% confidence intervals for the diagnostic targets. For each diagnostic target, optimal cut-offs were determined according to the Youden method. For the population of patients with ALT<N (n = 65), the AUROCs of TE were 0.75 (0.62-0.88) and 0.72 (0.56-0.88) for F ≥ 2 and F ≥ 3 diagnostic targets. Taking the EASL cut-offs, the prevalence of significant fibrosis was 8%, 38% and 67% when LSM was <6kPa, between 6 and 9 kPa or >9 kPa, respectively. For patients with ALT>N but ≤5N (n = 306), AUROCs of transient elastography were 0.79 (0.73-0.84) and 0.84 (0.75-0.92) for F ≥ 2 and F ≥ 3 diagnostic targets. The prevalence of significant fibrosis was, respectively, 15%, 52% and 85% when LSM was <6kPa, between 6 and 12 kPa or >12 kPa. Our study independently validates the EASL-ALEH algorithm based on ALT levels and LSM assessed by transient elastography.

The role of hepatitis B virus core-related antigen in predicting hepatitis B virus relapse after cessation of entecavir in hepatitis B e antigen-negative patients

This study investigated the ability of hepatitis B core-related antigen (HBcrAg) to predict hepatitis B virus (HBV) relapse in HBeAg-negative patients after cessation of entecavir therapy. A total of 301 HBeAg-negative patients without cirrhosis who had stopped entecavir therapy for at least 12 months were recruited. All patients fulfilled the stopping criteria proposed by the APASL 2012 guidelines. The five-year cumulative rates of virological relapse, clinical relapse and HBsAg loss were 71.6%, 57.3% and 18.7%, respectively. Serum HBsAg at end of treatment (EOT) was an independent predictor of virological relapse, clinical relapse and HBsAg loss; an EOT HBsAg of 150 IU/ml was the optimal cut-off value. The 5-year virological relapse rates for patients with <150 and ≥150 IU/ml HBsAg at EOT were 43.3% and 82.2% (p < 0.001), clinical relapse rates were 32.3% and 66.3% (p < 0.001), and HBsAg loss rates were 46.1% and 5.2% (p < 0.001), respectively. A baseline HBcrAg of 4 IU/ml was the optimal cut-off value for predicting HBV relapse. Among patients with an EOT HBsAg <150 IU/ml, the five-year virological relapse rates for patients with baseline HBcrAg levels ≤4 and >4 log U/ml were 27.9% and 59.1% (p = 0.006) and the clinical relapse rates were 18% and 48.1% (p = 0.014), respectively. EOT HBcrAg was not a significant predictor of virological or clinical relapse after cessation of entecavir. In conclusion, the combination of an EOT HBsAg of 150 IU/ml and baseline HBcrAg of 4 log U/ml can effectively predict the risk of HBV relapse after stopping entecavir therapy.

Screening for Hepatocellular Carcinoma in Chronic Hepatitis B: An Update

(1) Background: Hepatocellular carcinoma (HCC) is an important cause of mortality in individuals with chronic hepatitis B infection, with screening of high-risk groups recommended in all major international guidelines. Our understanding of the risk factors involved has improved over time, encouraging researchers to develop models that predict future risk of HCC development. (2) Methods: A literature search of the PubMed database was carried out to identify studies that derive or validate models predicting HCC development in patients with chronic hepatitis B. Subsequently, a second literature search was carried out to explore the potential role of novel viral biomarkers in this field. (3) Results: To date, a total of 23 models have been developed predicting future HCC risk, of which 12 have been derived from cohorts of treatment-naïve individuals. Most models have been developed in Asian populations (n = 20), with a smaller number in Caucasian cohorts (n = 3). All of the models demonstrate satisfactory performance in their original derivation cohorts, but many lack external validation. In recent studies, novel viral biomarkers have demonstrated utility in predicting HCC risk in patients with chronic hepatitis B, amongst both treated and treatment-naïve patients. (4) Conclusion: Several models have been developed to predict the risk of HCC development in individuals with chronic hepatitis B infection, but many have not been externally validated outside of the Asian population. Further research is needed to refine these models and facilitate a more tailored HCC surveillance programme in the future.

Prevalence of chronic hepatitis B phases in Eritrean patients: a laboratory-based cross-sectional study

Background

Understanding the natural history of chronic hepatitis B (CHB) virus infection is important for determining optimal management and predicting prognosis in patients. The aim of this study was to determine the prevalence of different phases of CHB infection among Eritrean patients and to identify the proportion of patients who are eligible for treatment according to the latest American Association for the Study of Liver Diseases (AASLD) guidelines.

Methods

This cross-sectional study enrolled 293 CHB patients (213 males and 80 females) between Jan 2017 and Feb 2019. The patients were classified into immune-tolerant, immune-active, and inactive CHB phases of the infection, which is based on the results of Hepatitis B virus (HBV) serological panel (HBsAg, anti-HBc total, HBeAg, and anti-HBe), ALT levels, and HBV DNA viral load. The 2018 AASLD guidelines were also used to identify patients who needed treatment.

Results

The mean age of the patients was 41.66 ± 13.84 years. Of these, 3 (1.0%) were at the immune tolerant phase, 58 (19.8%) at the immune-active CHB phase, and 232 (79.2%) at the inactive CHB phase. As most subjects (93%) were HBeAg-negative, based on AASLD guidelines, only 5 (1.7%) were currently eligible for treatment.

Conclusions

Our data show that CHB patients in Eritrea were predominantly in the inactive CHB phase. Although initiating antiviral therapy is not recommended in these patients, periodic assessment of liver function and disease severity should be considered in patients older than 40 years. The immune-tolerant phase had the fewest patients, most of whom were aged above 20 years, attesting to the success of incorporating HBV vaccine in the national childhood immunization program since 2002. Our study shows that adopting AASLD treatment guidelines with adjustments to suit the local setting is a suitable option in the management of Eritrean CHB patients.

Ending risk-group HBV vaccination for MSM after the introduction of universal infant HBV vaccination: A mathematical modelling study

BACKGROUND

Risk-group HBV vaccination for men who have sex with men (MSM) was introduced in the Netherlands in 2002, followed by universal infant vaccination in 2011, that will enable termination of risk-group vaccination over time. The introduction of pre-exposure prophylaxis (PrEP) for HIV prevention might result in increased HBV testing and vaccination against HBV. The aim of this study was to investigate the impact of the transition from risk-group to universal HBV vaccination, accounting for improvements in HBV testing and treatment, as well as the introduction of PrEP.

METHODS

We developed a mathematical model for HBV transmission among MSM. Universal vaccination was modelled by assigning some MSM (5-15% in 2028 increasing to 80-90% in 2033 and thereafter) to be vaccinated when they become sexually active. We investigated different scenarios assuming 0.5% extra vaccination rate and 0.5% extra testing rate due to PrEP consultations; and 5% of HIV-negative MSM on PrEP, that will reduce the probability of HBV acquisition by 88%.

RESULTS

Universal vaccination resulted in a reduction of 24% (interquartile range; 22-25%) of the total number of HBV infections among MSM estimated to occur from 2020 to 2070. With universal vaccination, terminating risk-group vaccination in 2030 or 2040 resulted in 30% or 10% more HBV infections over 2020-2070, respectively, compared to continuation of risk-group vaccination until 2070. With PrEP and continued risk-group vaccination, the total number of HBV infections over 2020-2070 was reduced by 13%.

CONCLUSIONS

Universal HBV vaccination can lead to a major reduction in HBV incidence among MSM in the future. The reduction becomes smaller when ending risk-group HBV vaccination, but larger by PrEP use for HIV prevention. Efforts to keep high levels of HBV vaccination, testing, and treatment have to be continued in the coming decades in order to eliminate HBV as a health threat for MSM.

Evaluation of Chitinase 3-like 1 (CHI3L1) as a noninvasive biomarker of hepatic fibrosis in patients with Hepatitis B virus-related compensated chronic liver disease

BACKGROUND

Liver biopsy is the gold-standard method for diagnosing and staging liver fibrosis, but the procedure is invasive, not available in the primary health care facilities, and not free from complications. Noninvasive serum biomarkers of hepatic fibrosis are the current research focus.

OBJECTIVES

To assess the correlation between serum Chitinase 3-like 1 (CHI3L1) levels and histological severity in patients with Hepatitis B Virus (HBV)-related compensated chronic liver disease (CLD).

MATERIAL AND METHODS

This cross-sectional study evaluated 50 treatment-naïve patients with chronic hepatitis B with compensated CLD. Liver biopsy was done, and hepatic fibrosis was categorized using the METAVIR scoring system; we divided the study subjects into three groups; group 1 included subjects with F0 and F1, group 2 having F2 group 3 having F3 and F4. Serum CHI3L1 was measured in all by immunoassay.

RESULT

Among 50 patients, only one had METAVIR score F0, seven had F1, 33 had F2, nine had F3, and none had METAVIR score F4. The median value of CHI3L1 was 460.8 (IQR 340.1-570.3) in all study subjects; 359.5 (IQR 272.8-526.9) in group 1, 450.0 (IQR 307.75-5332.0) in group 2, and 1355.5 (IQR 530.75-1580.5) in the group 3. The difference in median CHI3L1 across the groups was statistically significant. Serum aspartate aminotransferase (AST) and the AST to Platelet Ratio Index (APRI) score had significant positive correlations with CHI3L1 levels. CHI3L1 also had significant positive correlations with METAVIR scores.

CONCLUSION

This study found a positive correlation between serum CHI3L1 level and hepatic histological severity in patients with HBV-related compensated CLD. Further larger-scale research is needed to establish the fact.

Risk Factors, Pathogenesis, and Strategies for Hepatocellular Carcinoma Prevention: Emphasis on Secondary Prevention and Its Translational Challenges

Hepatocellular carcinoma (HCC) is a leading cause of cancer-associated mortality globally. Given the limited therapeutic efficacy in advanced HCC, prevention of HCC carcinogenesis could serve as an effective strategy. Patients with chronic fibrosis due to viral or metabolic etiologies are at a high risk of developing HCC. Primary prevention seeks to eliminate cancer predisposing risk factors while tertiary prevention aims to prevent HCC recurrence. Secondary prevention targets patients with baseline chronic liver disease. Various epidemiological and experimental studies have identified candidates for secondary prevention-both etiology-specific and generic prevention strategies-including statins, aspirin, and anti-diabetic drugs. The introduction of multi-cell based omics analysis along with better characterization of the hepatic microenvironment will further facilitate the identification of targets for prevention. In this review, we will summarize HCC risk factors, pathogenesis, and discuss strategies of HCC prevention. We will focus on secondary prevention and also discuss current challenges in translating experimental work into clinical practice.

[Seroprevalence of viral hepatitis B and its associated factors determined based on data from a screening campaign targeting the general population in Benin]

INTRODUCTION

hepatitis B is a global public health problem. The purpose of this study was to determine the prevalence of hepatitis B virus (HBV) and its associated factors based on data from a mass screening in several localities across Benin.

METHOD

we conducted a cross-sectional descriptive and analytical study with prospective data collection. Data collection was carried out during voluntary free hepatitis B screening organized by the Rotary Club in 23 localities across Benin from the 20th to 28th July 2019. Rapid test for diagnostic orientation was used for the detection of HBs antigen.

RESULTS

a total of 9035 volunteers were included in the study. They were mostly of Benin origin (99%), with a mean age of 27 years; 51.1% of them were singles, mainly schoolchildren, pupils or students (37.9%). HBV seroprevalence was 6% (545/9035) [95%CI=5.5%-6.5%]. In univariate analysis, factors associated with HBs Ag colonization were: age, sex, marital status, education level, occupation and a history of diabetes, scarification and hepatitis C, while in multivariate analysis they were: sex, age and education level.

CONCLUSION

HBV seroprevalence is 6% in the study population. HBV infection mainly affects male subjects over 17 years of age with secondary-level education.

Analysis of antibody-negative medical students after hepatitis B vaccination in Japan

Hepatitis B virus (HBV) vaccination is recommended for health-care professionals because of their frequent contact with blood. At one medical school, new students undergo HBV antibody tests upon admission, and antibody-negative individuals receive the HBV vaccine. We aimed to characterize individuals who remained antibody negative after HBV vaccination. Between 2009 and 2017, we enrolled 1064 first-year students from a medical school where their HBV antibody test and vaccination records remained. We analyzed data regarding the hepatitis B surface antibody (anti-HBs) test record during admission, vaccination record for antibody-negative participants, anti-HBs test result after completing the three vaccination doses, drug name of the vaccine used, sex, body mass index (BMI), and age. We calculated the yearly percentage of antibody-negative individuals and analyzed the characteristics of vaccine-refractory cases by logistic regression analysis. Of the 1064 participants, 999 were initially antibody negative. They were vaccinated with HBV thrice and tested for antibodies after vaccination. The average age of participants was 20.1 y, with 677 males. Although the type of vaccine has been changed since 2016, the average rate of refractoriness from 2009 to 2015 was 6.9% per year and 18.6% after 2016. Logistic regression analyses showed that sex (male vs. female; OR, 1.787), BMI (OR. 1.171), and vaccine type (genotype A vs. genotype C: OR, 3.144) were significant factors associated with antibody-negative individuals. Vaccine type differences altered the proportion of antibody-refractory individuals, with no association with age. The data on vaccine refractoriness will be continuously analyzed in the future while considering other factors.

Global dynamics of a model of hepatitis B virus infection in a sub-Saharan African rural area

We formulate and systematically study a deterministic compartmental model of Hepatitis B. This model has some important and novel features compared with the well-known basic model in the literature. Specifically, it takes into account the differential susceptibility that follows the vaccine formulation employing three-doses schedule. It points up the HbeAg status of carriers, their levels of viral replication, the fact that treatment being not curative is recommended only to a small proportion of chronic carriers, and finally the fact that only inactive carriers are able to recover from disease. The model has simple dynamical behavior which has a globally asymptotically stable disease-free equilibrium when the basic reproduction number [Formula: see text] and an endemic equilibrium when [Formula: see text]. By the use of Lyapunov functions, when it exists, we prove the global asymptotic stability of the endemic equilibrium under some conditions. Using data from Tokombere, a rural area in Cameroon, numerical simulations are performed. These numerical simulations first confirm analytical results, second they suggest that a policy based on treatment could not significantly impact the course of the infection. Third, they show as it is well known that vaccination is a very effective measure to control the infection. Furthermore, they show that neonatal vaccination influences more the course of infection than mass vaccination strategy. Nevertheless, they picture how much loss between consecutive doses of vaccine could be harmful. Finally, it is suggested that for a Sub-saharan African rural area, two-thirds of expected incidence of Hepatitis B virus infection and one third of expected prevalence of chronic carriers could be averted by 2030 if the birth dose vaccination becomes systematic and if mass vaccination rate increases to up 10%.

[Natural History and Treatment Indications of Chronic Hepatitis B]

HBV is the most common etiology of both liver cirrhosis and hepatocellular carcinoma in Korea. Despite much progress made, the currently available antiviral therapies cannot eradicate or eliminate this virus. Hence, the benefits and risks of antiviral therapy should be carefully evaluated on an individual basis and within the context of the clinical situation. The ultimate goals of treatment are to decrease the mortality from liver disease. The benefits of antiviral therapy come from prevention of progression of liver disease. Understanding the natural history of chronic HBV infection is a key step in the decision making process to treat patients with chronic HBV infection. Generally, chronic hepatitis B patients in the immune tolerant phase and immune inactive phase are not recommended to undergo antiviral treatment, except for those patients in special conditions (e.g., immunosuppression or anticancer chemotherapy). Chronic hepatitis B patients in the immune active phase are recommended for antiviral therapy. For patients with liver cirrhosis, treatment should be considered when serum HBV DNA is detectable regardless of the serum level of ALT.

Prevalence and burden of HBV co-infection among people living with HIV: A global systematic review and meta-analysis

Globally, in 2017 35 million people were living with HIV (PLHIV) and 257 million had chronic HBV infection (HBsAg positive). The extent of HIV-HBsAg co-infection is unknown. We undertook a systematic review to estimate the global burden of HBsAg co-infection in PLHIV. We searched MEDLINE, Embase and other databases for published studies (2002-2018) measuring prevalence of HBsAg among PLHIV. The review was registered with PROSPERO (#CRD42019123388). Populations were categorized by HIV-exposure category. The global burden of co-infection was estimated by applying regional co-infection prevalence estimates to UNAIDS estimates of PLHIV. We conducted a meta-analysis to estimate the odds of HBsAg among PLHIV compared to HIV-negative individuals. We identified 506 estimates (475 studies) of HIV-HBsAg co-infection prevalence from 80/195 (41.0%) countries. Globally, the prevalence of HIV-HBsAg co-infection is 7.6% (IQR 5.6%-12.1%) in PLHIV, or 2.7 million HIV-HBsAg co-infections (IQR 2.0-4.2). The greatest burden (69% of cases; 1.9 million) is in sub-Saharan Africa. Globally, there was little difference in prevalence of HIV-HBsAg co-infection by population group (approximately 6%-7%), but it was slightly higher among people who inject drugs (11.8% IQR 6.0%-16.9%). Odds of HBsAg infection were 1.4 times higher among PLHIV compared to HIV-negative individuals. There is therefore, a high global burden of HIV-HBsAg co-infection, especially in sub-Saharan Africa. Key prevention strategies include infant HBV vaccination, including a timely birth-dose. Findings also highlight the importance of targeting PLHIV, especially high-risk groups for testing, catch-up HBV vaccination and other preventative interventions. The global scale-up of antiretroviral therapy (ART) for PLHIV using a tenofovir-based ART regimen provides an opportunity to simultaneously treat those with HBV co-infection, and in pregnant women to also reduce mother-to-child transmission of HBV alongside HIV.

Hepatitis B Virus: Advances in Prevention, Diagnosis, and Therapy

Currently, despite the use of a preventive vaccine for several decades as well as the use of effective and well-tolerated viral suppressive medications since 1998, approximately 250 million people remain infected with the virus that causes hepatitis B worldwide. Hepatitis C virus (HCV) and hepatitis B virus (HBV) are the leading causes of liver cancer and overall mortality globally, surpassing malaria and tuberculosis. Linkage to care is estimated to be very poor both in developing countries and in high-income countries, such as the United States, countries in Western Europe, and Japan. In the United States, by CDC estimates, only one-third of HBV-infected patients or less are aware of their infection. Some reasons for these low rates of surveillance, diagnosis, and treatment include the asymptomatic nature of chronic hepatitis B until the very late stages, a lack of curative therapy with a finite treatment duration, a complex natural history, and a lack of knowledge about the disease by both care providers and patients. In the last 5 years, more attention has been focused on the important topics of HBV screening, diagnosis of HBV infection, and appropriate linkage to care. There have also been rapid clinical developments toward a functional cure of HBV infection, with novel compounds currently being in various phases of progress. Despite this knowledge, many of the professional organizations provide guidelines focused only on specific questions related to the treatment of HBV infection. This focus leaves a gap for care providers on the other HBV-related issues, which include HBV's epidemiological profile, its natural history, how it interacts with other viral hepatitis diseases, treatments, and the areas that still need to be addressed in order to achieve HBV elimination by 2030. Thus, to fill these gaps and provide a more comprehensive and relevant document to regions worldwide, we have taken a global approach by using the findings of global experts on HBV as well as citing major guidelines and their various approaches to addressing HBV and its disease burden.

Albumin-Bilirubin Score Differentiates Liver Fibrosis Stage and Hepatocellular Carcinoma Incidence in Chronic Hepatitis B Virus Infection: A Retrospective Cohort Study

The albumin-bilirubin (ALBI) score was originally established to stratify prognosis in patients with cirrhosis. The diagnostic accuracy of ALBI score in liver fibrosis staging in patients with chronic hepatitis B remains to be investigated. The present retrospective study, therefore, aimed to evaluate the ability of this score to stage liver fibrosis in these patients. Briefly, consecutive patients with hepatitis B virus (HBV) infection who underwent liver biopsy examinations in Kagawa University Hospital were enrolled. Liver fibrosis stage was assessed using a modified Meta-Analysis of Histological Data in Viral Hepatitis score. Albumin-bilirubin scores were calculated according to the following equation: (log₁₀ total bilirubin [T-Bil] × 0.66) + (albumin [Alb] × -0.085). A total of 91 patients were enrolled in this study. Albumin-bilirubin score was able to differentiate stage 4 from stage 3 fibrosis (P < 0.05). When an ALBI score of -2.190 was adopted as the cutoff value for differentiating stage 4 from stages 1-3, the sensitivity, specificity, and positive likelihood ratio were 85.7%, 74.0%, and 3.300, respectively. Kaplan-Meier analysis showed that baseline ALBI scores < -2.190 correlated with better hepatocellular carcinoma (HCC)-free survival (P < 0.05). In conclusion, ALBI score can be used for liver fibrosis staging in Japanese chronic hepatitis B patients and can help distinguish cirrhotic from non-cirrhotic status. Furthermore, ALBI score was useful as a prognosis biomarker in our patients, with smaller ALBI scores predicting better HCC-free survival. Because calculating ALBI score is easy using serum T-Bil and Alb alone, ALBI score will help clinicians with decision-making in management of HBV-infected patients.

Liver Stiffness Measurement Can Reflect the Active Liver Necroinflammation in Population with Chronic Liver Disease: A Real-world Evidence Study

Background and Aims: Non-invasive evaluation of liver necroinflammation in patients with chronic liver disease is an unmet need in clinical practice. The diagnostic accuracy of transient elastography-based liver stiffness measurement (LSM) for liver fibrosis could be affected by liver necroinflammation, the latter of which could intensify stiffness of the liver. Such results have prompted us to explore the diagnosis potential of LSM for liver inflammation. Methods: Three cross-sectional cohorts of liver biopsy-proven chronic liver disease patients were enrolled, including 1417 chronic hepatitis B (CHB) patients from 10 different medical centers, 106 non-alcoholic steatohepatitis patients, and 143 patients with autoimmune-related liver diseases. Another longitudinal cohort of 14 entecavir treatment patients was also included. The receiver operating characteristic (ROC) curve was employed to explore the diagnostic value of LSM. Results: In CHB patients, LSM value ascended with the increased severity of liver necroinflammation in patients with the same fibrosis stage. Such positive correlation between LSM and liver necroinflammation was also found in non-alcoholic steatohepatitis and autoimmune-related liver diseases populations. Furthermore, the ROC curve exhibited that LSM could identify moderate and severe inflammation in CHB patients (area under the ROC curve as 0.779 and 0.838) and in non-alcoholic steatohepatitis patients (area under the ROC curve as 0.826 and 0.871), respectively. Such moderate diagnostic value was also found in autoimmune-related liver diseases patients. In addition, in the longitudinal entecavir treated CHB cohort, a decline of LSM values was observed in parallel with the control of inflammatory activity in liver. Conclusions: Our study implicates a diagnostic potential of LSM to evaluate the severity of liver necroinflammation in chronic liver disease patients.

Anti-PD-1 blockade with nivolumab with and without therapeutic vaccination for virally suppressed chronic hepatitis B: A pilot study

BACKGROUND & AIMS

To evaluate the hypothesis that increasing T cell frequency and activity may provide durable control of hepatitis B virus (HBV), we administered nivolumab, a programmed death receptor 1 (PD-1) inhibitor, with or without GS-4774, an HBV therapeutic vaccine, in virally suppressed patients with HBV e antigen (HBeAg)-negative chronic HBV.

METHODS

In a phase Ib study, patients received either a single dose of nivolumab at 0.1 mg/kg (n = 2) or 0.3 mg/kg (n = 12), or 40 yeast units of GS-4774 at baseline and week 4 and 0.3 mg/kg of nivolumab at week 4 (n = 10). The primary efficacy endpoint was mean change in HBV surface antigen (HBsAg) 12 weeks after nivolumab. Safety and immunologic changes were assessed through week 24.

RESULTS

There were no grade 3 or 4 adverse events or serious adverse events. All assessed patients retained T cell PD-1 receptor occupancy 6-12 weeks post-infusion, with a mean total across 0.1 and 0.3 mg/kg cohorts of 76% (95% CI 75-77), and no significant differences were observed between cohorts (p = 0.839). Patients receiving 0.3 mg/kg nivolumab without and with GS-4774 had mean declines of -0.30 (95% CI -0.46 to -0.14) and -0.16 (95% CI -0.33 to 0.01) log₁₀ IU/ml, respectively. Patients showed significant HBsAg declines from baseline (p = 0.035) with 3 patients experiencing declines of >0.5 log₁₀ by the end of study. One patient, whose HBsAg went from baseline 1,173 IU/ml to undetectable at week 20, experienced an alanine aminotransferase flare (grade 3) at week 4 that resolved by week 8 and was accompanied by a significant increase in peripheral HBsAg-specific T cells at week 24.

CONCLUSIONS

In virally suppressed HBeAg-negative patients, checkpoint blockade was well-tolerated and led to HBsAg decline in most patients and sustained HBsAg loss in 1 patient.

LAY SUMMARY

Chronic hepatitis B virus infection (CHB) is characterized by a dysfunctional immune response. In patients with CHB, inhibitory receptors, such as programmed death receptor 1 (PD-1) are overexpressed on T cells, leading to an ineffective immune response in the liver. Herein, we show that the PD-1 inhibitor, nivolumab, is safe and effective for the treatment of virally suppressed patients with CHB. Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au/) number: ACTRN12615001133527.

Population-based study of Entecavir and long-term mortality in chronic hepatitis B-related decompensated liver cirrhosis

BACKGROUND AND AIMS

We lack population-based studies that identify the role of entecavir (ETV) in extending long-term survival in chronic hepatitis B (CHB)-related decompensated liver cirrhotic patients. Since 2010, National Health Insurance in Taiwan has covered long-term medical payment for antiviral therapy in CHB-related cirrhotic patients whose HBV DNA is ≥ 2000 IU/mL. We studied the effect of ETV on the mortality of CHB-related decompensated cirrhosis patients compared with patients who did not receive antiviral agents at baseline.

METHODS

From the Taiwan National Health Insurance Database, we collected 758 CHB-related decompensated cirrhosis patients with elevated viral loads (HBV DNA ≥ 2000  IU/mL) using ETV and discharged between January 1, 2010, and December 31, 2013. The comparison group consisted of 1516 selected CHB-related decompensated cirrhotic patients without antiviral therapy at baseline using propensity score matching analysis.

RESULTS

The 1-, 2-, and 3-year mortality probabilities were 34.7%, 42.5%, and 48.5 % in the ETV group and 21.1%, 37.8% and 51.3 % in the non-ETV group, respectively. Based on a Cox proportional hazards regression model adjusted by patients' sex, age, and comorbid disorders, the hazard ratios (HR) in the ETV group for 1-year, 1-2-year, and 2-3-year mortalities were 1.22 (95% confidence interval [CI] 1.05-1.43, P = .010), 1.02 (0.86-1.20, P = .866), and 0.59 (0.38-0.90, P = .016), compared with the non-ETV group.

CONCLUSIONS

Even in CHB-related decompensated cirrhotic patients, higher initial viral loads were correlated with poor outcomes. However, the long-term usage of ETV can decrease long-term mortality in these patients.

Treg/Th17 imbalance and its clinical significance in patients with hepatitis B-associated liver cirrhosis

BACKGROUND

Recent studies have shown that T cell-mediated cellular immune mechanisms play important roles in the progression of hepatitis B to liver cirrhosis, but the underlying mechanisms remain unclear. This present study was aimed to determine the relationship between Treg/Th17 and hepatitis B-associated liver cirrhosis.

METHODS

The Treg and Th17 cell frequencies in the peripheral blood of all participants, including 93 patients with hepatitis B-associated liver cirrhosis and 40 healthy subjects, were measured by flow cytometer. Cox regression model and receiver operating characteristic(ROC) curves were applied to investigate the prognostic significance of Treg/Th17 ratio in decompensated liver cirrhosis.

RESULTS

We observed the Treg/Th17 imbalance was present in patients with hepatitis B-associated liver cirrhosis, with reduced Treg cells in their peripheral blood, increased Th17 cells and decreased Treg/Th17 ratio. Treg and Th17 cells were negatively correlated. Treg/Th17 imbalance was closely related to the clinical stage of hepatitis B-associated liver cirrhosis. The Virus load, Treg frequencies and the Treg/Th17 ratio were independent factors predicting decompensated liver cirrhosis from a Cox regression model. The ROC analysis showed that the Treg/Th17 ratio was the best marker for predicting decompensated liver cirrhosis.

CONCLUSIONS

Treg/Th17 imbalance is involved in the pathogenesis of hepatitis B-associated liver cirrhosis and the Treg/Th17 ratio can be used as a potential marker for predicting decompensated liver cirrhosis.

Reactivation of hepatitis B virus infection in patients with hemo-lymphoproliferative diseases, and its prevention

Reactivation of hepatitis B virus (HBV) replication is characterized by increased HBV-DNA serum values of about 1 log or by HBV DNA turning positive if previously undetectable in serum, possibly associated with liver damage and seldom life-threatening. Due to HBV reactivation, hepatitis B surface antigen (HBsAg)-negative/anti-HBc-positive subjects may revert to HBsAg-positive. In patients with hemo-lymphoproliferative disease, the frequency of HBV reactivation depends on the type of lymphoproliferative disorder, the individual's HBV serological status and the potency and duration of immunosuppression. In particular, it occurs in 10%-50% of the HBsAg-positive and in 2%-25% of the HBsAg- negative/anti-HBc-positive, the highest incidences being registered in patients receiving rituximab-based therapy. HBV reactivation can be prevented by accurate screening of patients at risk and by a pharmacological prophylaxis with anti-HBV nucleo(t)sides starting 2-3 wk before the beginning of immunosuppressive treatment and covering the entire period of administration of immunosuppressive drugs and a long subsequent period, the duration of which depends substantially on the degree of immunodepression achieved. Patients with significant HBV replication before immunosuppressive therapy should receive anti-HBV nucleo(t)sides as a long-term (may be life-long) treatment. This review article is mainly directed to doctors engaged every day in the treatment of patients with onco-lymphoproliferative diseases, so that they can broaden their knowledge on HBV infection and on its reactivation induced by the drugs with high immunosuppressive potential that they use in the care of their patients.