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Li X, Gu Y, Liao C, Ma X, Bi Y, Lian Y, Huang Y. A comprehensive model to better screen out antiviral treatment candidates for chronic hepatitis B patients. Int Immunopharmacol 2024; 140:112848. [PMID: 39096876 DOI: 10.1016/j.intimp.2024.112848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 04/03/2024] [Accepted: 07/29/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Chronic hepatitis B virus (HBV) infection is a serious human health threat given its high morbidity and mortality. Timely and effective antiviral treatment can postpone liver disease progression and reduce the occurrence of HBV-related end-stage liver disease. At present, the antiviral treatment criteria are mainly based on alanine transaminase (ALT) levels, HBV DNA levels and HBV e antigen levels according to the American Association for the Study of Liver Diseases treatment guidelines. However, some chronic hepatitis B (CHB) patients not meeting the above criteria still experience liver disease progression without antiviral treatment. It is urgent to identify a more comprehensive tool to screen out more antiviral treatment candidates as soon as possible. METHODS Considering the vital role of the immune response in the development of HBV infection and CHB cure, we collected data from 335 treatment-naïve CHB patients and comprehensively analysed their clinical and immune traits (including innate and adaptive responses). The immune parameters were obtained by flow cytometry. Finally, we established a model that can better distinguished CHB patients who need treatment through machine learning and LASSO regression of serological and immune parameters. RESULTS Through a series of analyses, we selected four important clinical parameters (ALT, HBV DNA, the Fibroscan value, and the A/G ratio) and four immune indicators (NKbright + NKp44+, NKbright + NKG2A+, NKT+GranzymeB+, and CD3 + CD107a + ) from more than 200 variables and then successfully established a mathematical model with high sensitivity and specificity to better screen out antiviral treatment candidates from all CHB patients. CONCLUSIONS Our results developed a refined model to better screen out antiviral treatment candidates from all CHB patients by combining common clinical parameters and important immune indicators, including innate and adaptive immunity. These findings provide more information for improving treatment guidelines and have potential implications for the timing of antiviral therapy to achieve better virus control and reduce the occurrence of end-stage liver disease.
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Affiliation(s)
- Xiaoyan Li
- Department of Infectious Diseases, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yurong Gu
- Department of Infectious Diseases, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Chunhong Liao
- Guangdong Provincial Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xinyi Ma
- Department of Infectious Diseases, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yanhua Bi
- Guangdong Provincial Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yifan Lian
- Guangdong Provincial Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Yuehua Huang
- Department of Infectious Diseases, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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2
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Duan M, Xiao H, Shi M, Xie Y, Zhao P, Li S, Chi X, Liu X, Zhuang H. Significant liver histological change is common in HBeAg-positive chronic hepatitis B with normal ALT. BMC Infect Dis 2024; 24:723. [PMID: 39044129 PMCID: PMC11264461 DOI: 10.1186/s12879-024-09617-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 07/15/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND AND AIMS Numerous HBeAg-positive chronic hepatitis B (CHB) patients with persistently normal ALT have significant liver histopathology. It is imperative to identify true "immune tolerant" patients. We aimed to evaluate the liver histopathology features of HBeAg-positive CHB patients with normal ALT and the incidence of liver cirrhosis and HCC in CHB patients during follow-up. METHODS 179 HBeAg-positive CHB patients with normal ALT who performed liver biopsy from 2009 to 2018 were retrospectively analyzed. Liver necroinflammation ≥ G2 and/or liver fibrosis ≥ S2 was defined as significant liver histopathological change. RESULTS 57.5% patients were in the indeterminate phase with significant liver histological changes. The proportion of the patients with evident liver necroinflammation was higher in the high-normal ALT group (21-40U/L) when compared with the low-normal ALT group (≤ 20 U/L) (51.3% vs. 30.0%, p < 0.05), and patients aged ≥ 40 years had a higher proportion of significant fibrosis than those aged < 40 years (64.5% vs. 39.9%, p < 0.05). The percentages of patients with ≥ S2 and ≥ G2/S2 in the HBV DNA < 107 IU/mL group were higher than those in the HBV DNA ≥ 107 IU/mL group (72.7% vs. 40.1%, p < 0.01; 81.8% vs. 54.1%, p < 0.05). During follow-up, two of immune tolerant patients and four of indeterminate patients developed into cirrhosis, and one of immune tolerant patients and one of indeterminate patients developed into HCC, respectively. CONCLUSIONS HBeAg-positive CHB patients with high-normal ALT or HBV DNA < 107 IU/mL were tend to be indeterminate. Liver biopsy or noninvasive approaches are recommended to evaluate liver histopathology, and antiviral therapy is recommended for patients with significant liver histopathology.
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Affiliation(s)
- Menghui Duan
- Department of Microbiology and Center of Infectious Diseases, School of Basic Medical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing, 100191, China
- The Clinical Laboratory of Tianjin Chest Hospital, Tianjin, China
| | - Huanming Xiao
- Hepatology Department, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Guangzhou, Guangdong Province, 510120, China
| | - Meijie Shi
- Hepatology Department, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Guangzhou, Guangdong Province, 510120, China
| | - Yubao Xie
- Hepatology Department, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Guangzhou, Guangdong Province, 510120, China
| | - Pengtao Zhao
- Hepatology Department, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Guangzhou, Guangdong Province, 510120, China
| | - Sheng Li
- Hepatology Department, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Guangzhou, Guangdong Province, 510120, China
| | - Xiaoling Chi
- Hepatology Department, Guangdong Provincial Hospital of Chinese Medicine, 111 Dade Road, Guangzhou, Guangdong Province, 510120, China.
| | - Xueen Liu
- Department of Microbiology and Center of Infectious Diseases, School of Basic Medical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing, 100191, China.
| | - Hui Zhuang
- Department of Microbiology and Center of Infectious Diseases, School of Basic Medical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing, 100191, China.
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Huang D, Lai H, Zhu Z, Yu H, Peng J, Chen Y, Liao X, Chen J. Inverse relationship between HBV DNA levels and liver histopathological changes in immune-tolerant CHB patients. J Viral Hepat 2024; 31:363-371. [PMID: 38581159 DOI: 10.1111/jvh.13940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/21/2024] [Accepted: 03/23/2024] [Indexed: 04/08/2024]
Abstract
Limited data exist regarding the association between hepatitis B virus (HBV) DNA levels and liver histopathological changes in patients with chronic hepatitis B (CHB) during the immune tolerant (IT) phase. In this study, we retrospectively analysed liver biopsy results from 150 adult IT-CHB patients. The liver tissue necroinflammation and fibrosis were evaluated by the Scheuer scoring system. Multivariate logistic regression, smooth curve fitting, and segmented regression models were used to examine the association between HBV DNA levels and liver histopathological changes. A total of 26%, 30.67% and 42% of IT patients had significant necroinflammation (≥G2), significant fibrosis (≥S2) and significant histopathological changes (≥G2 and/or ≥S2), respectively. HBV DNA levels were independently and non-linear inversely associated with significant necroinflammation and histopathological changes in IT-CHB patients. Patients with HBV DNA levels <107 IU/mL had a higher risk of significant histopathological changes compared to those with levels >107 IU/mL. The findings were further confirmed by smooth curve fitting analyses, subgroup and sensitivity analyses. In segmented regression model analyses, the optimal DNA value for the lowest odds ratio of significant histopathological changes was 7.26 log10 IU/mL. A non-linear inverse association between HBV DNA levels and significant histopathological changes in IT-CHB patients. DNA 7.26 log10 IU/mL may serve as a potential cut-off point to define a 'true immune tolerant phase' with minimal liver histopathological changes.
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Affiliation(s)
- Deliang Huang
- Department of Liver Diseases, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Huiyi Lai
- Department of Liver Diseases, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Zhibin Zhu
- Department of Liver Diseases, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Hong Yu
- Department of Pathology, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Jinghan Peng
- Department of Liver Diseases, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Yuanyuan Chen
- Department of Liver Diseases, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Xuejiao Liao
- Department of Liver Diseases, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Jun Chen
- Department of Liver Diseases, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
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Liang YJ, Chiou YW, Chiu APT, Shiao MS, Teng W, Lin CW, Cheng ML, Huang YH, Liang KH, Su CW, Lai CY, Chen CL, Wu JC. Antiviral therapy reduces hepatocellular carcinoma through suppressing hepatitis B virus replication may improve ER stress, mitochondrial and metabolic dysfunctions and decrease p62 in hybridized mice with single HBV transgene and miR-122. J Med Virol 2023; 95:e29325. [PMID: 38108211 DOI: 10.1002/jmv.29325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
Hepatitis B virus (HBV) hijacks autophagy for its replication. Nucleos(t)ide analogs (NUCs) treatment suppressed HBV replication and reduced hepatocellular carcinoma (HCC) incidence. However, the use of NUCs in chronic hepatitis B (CHB) patients with normal or minimally elevated serum alanine aminotransferase (ALT) levels is still debated. Animal models are crucial for studying the unanswered issue and evaluating new therapies. MicroRNA-122 (miR-122), which regulates fatty acid and cholesterol metabolism, is downregulated during hepatitis and HCC progression. The reciprocal inhibition of miR-122 with HBV highlights its role in HCC development as a tumor suppressor. By crossbreeding HBV-transgenic mice with miR-122 knockout mice, we generated a hybrid mouse model with a high incidence of HCC up to 89% and normal ALT levels before HCC. The model exhibited early-onset hepatic steatosis, progressive liver fibrosis, and impaired late-phase autophagy. Metabolomics and microarray analysis identified metabolic signatures, including dysregulation of lipid metabolism, inflammation, genomic instability, the Warburg effect, reduced TCA cycle flux, energy deficiency, and impaired free radical scavenging. Antiviral treatment reduced HCC incidence in hybrid mice by approximately 30-35% compared to untreated mice. This effect was linked to the activation of ER stress-responsive transcription factor ATF4, clearance of autophagosome cargo p62, and suppression of the CHOP-mediated apoptosis pathway. In summary, this study suggests that despite minimal ALT elevation, HBV replication can lead to liver injury. Endoplasmic reticulum stress, reduced miR-122 levels, mitochondrial and metabolic dysfunctions, blocking protective autophagy resulting in p62 accumulation, apoptosis, fibrosis, and HCC. Antiviral may improve the above-mentioned pathogenesis through HBV suppression.
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Affiliation(s)
- Yuh-Jin Liang
- Translational Research Division, Medical Research Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Cancer Progression Research Center, National Yang Ming Chiao Tung University, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yu-Wei Chiou
- Translational Research Division, Medical Research Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Abby Pei-Ting Chiu
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
- Department of Biology, University of Washington, Seattle, Washington, USA
| | - Ming-Shi Shiao
- Metabolomics Core Laboratory, Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan, ROC
- Department of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
| | - Wei Teng
- Department of Gastroenterology & Hepatology, Chang Gung Memorial Hospital, Linkou, Taiwan, ROC
| | - Chin-Wei Lin
- Translational Research Division, Medical Research Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Mei-Ling Cheng
- Metabolomics Core Laboratory, Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan, ROC
- Department of Biomedical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC
- Clinical Metabolomics Core Laboratory, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, ROC
| | - Yen-Hua Huang
- Center for Systems and Synthetic Biology and Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Kung-Hao Liang
- Translational Research Division, Medical Research Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chien-Wei Su
- Department of Medicine, Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, Division of General Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, Division of Holistic and Multidisciplinary Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Internal Medicine, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chi-Yu Lai
- Translational Research Division, Medical Research Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Li Chen
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, ROC
| | - Jaw-Ching Wu
- Translational Research Division, Medical Research Department, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Cancer Progression Research Center, National Yang Ming Chiao Tung University, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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5
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Kim SR, Kim SK. Hepatocellular Carcinoma and Hepatitis: Advanced Diagnosis and Management with a Focus on the Prevention of Hepatitis B-Related Hepatocellular Carcinoma. Diagnostics (Basel) 2023; 13:3212. [PMID: 37892033 PMCID: PMC10605503 DOI: 10.3390/diagnostics13203212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Though the world-wide hepatitis B virus (HBV) vaccination program has been well completed for almost thirty years in many nations, almost HBV-related hepatocellular carcinoma (HCC) occurs in unvaccinated middle-aged and elderly adults. Apparently, treating 80% of qualified subjects could decrease HBV-related mortality by 65% in a short period. Nevertheless, globally, only 2.2% of CHB patients undergo antiviral therapy. The HBV markers related to HCC occurrence and prevention are as follows: the HCC risk is the highest at a baseline of HBV DNA of 6-7 log copies/mL, and it is the lowest at a baseline of an HBV DNA level of >8 log copies/mL and ≤4 log copies/mL (parabolic, and not linear pattern). The titer of an HBV core-related antigen (HBcrAg) reflecting the amount of HBV covalently closed circular DNA (ccc DNA) in the liver is related to HCC occurrence. The seroclearance of HBs antigen (HBsAg) is more crucial than HBV DNA negativity for the prevention of HCC. In terms of the secondary prevention of hepatitis B-related HCC involving antiviral therapies with nucleos(t)ide analogues (NAs), unsolved issues include the definition of the immune-tolerant phase; the optimal time for starting antiviral therapies with NAs; the limits of increased aminotransferase (ALT) levels as criteria for therapy in CHB patients; the normalization of ALT levels with NAs and the relation to the risk of HCC; and the relation between serum HBV levels and the risk of HCC. Moreover, the first-line therapy with NAs including entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF) remains to be clarified. Discussed here, therefore, are the recent findings of HBV markers related to HCC occurrence and prevention, unsolved issues, and the current secondary antiviral therapy for the prevention of HBV-related HCC.
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Affiliation(s)
| | - Soo Ki Kim
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-0801, Japan;
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6
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Li Z, Yang D, Ge Y, Song S, Lv Q, Ye Y. Histologic changes in immune-tolerant patients with chronic hepatitis B: a systematic review and meta-analysis. Sci Rep 2023; 13:469. [PMID: 36627364 PMCID: PMC9831999 DOI: 10.1038/s41598-023-27545-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
The serological diagnostic criteria for the immune-tolerant (IT) phase have not been strictly defined and it is hard to determine an accurate rate for significant histologic changes among IT patients. The aim of this study was to establish a baseline rate of significant histologic changes and to determine the main characteristics of IT patients. We systematically searched PubMed, Embase, and Web of Science. Studies reporting liver biopsy results (inflammation grade or fibrosis stage) for adults with chronic hepatitis B virus (HBV) infection in the IT phase diagnosed by serological criterion were included to pool the rate of significant histologic changes. Studies that enrolled subjects with confirmed chronic HBV infection in the IT phase diagnosed by serological and liver biopsy criteria (dual criteria) were included to pool the mean values of main characteristics among IT patients. Of 319 studies screened, 15 were eventually included in the meta-analysis. The pooled rates of significant liver fibrosis and inflammatory activity for 10 studies were 10% (95% confidence interval [CI] 0.06-0.18) and 16% (95% CI 0.07-0.31), respectively. The pooled mean values of age, alanine aminotransferase level, HBV DNA level, and HBsAg level for another 5 studies with IT patients diagnosed by dual criteria were 30.7 years (95% CI 27.31-34.09), 26.64 IU/mL (95% CI 24.45-28.83), 8.41 log10 cp/mL (95% CI 7.59-9.23), and 4.24 log10 IU/mL (95% CI 3.67-4.82), respectively. Significant histologic changes were not rare events among IT patients. Strictly defined serological diagnostic criteria for the IT phase are warranted.
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Affiliation(s)
- Zhiguo Li
- Department of Gastroenterology, Beijing Fengtai Hospital of Integrated Traditional and Western Medicine, Beijing, 100072, China.
| | - Dongliang Yang
- Department of Math, Cangzhou Medical College, Cangzhou, Hebei China
| | - Yue Ge
- grid.459359.70000 0004 1763 3154Department of Gastroenterology, Beijing Fengtai Hospital of Integrated Traditional and Western Medicine, Beijing, 100072 China
| | - Shu Song
- grid.459359.70000 0004 1763 3154Department of Gastroenterology, Beijing Fengtai Hospital of Integrated Traditional and Western Medicine, Beijing, 100072 China
| | - Qin Lv
- grid.459359.70000 0004 1763 3154Department of Gastroenterology, Beijing Fengtai Hospital of Integrated Traditional and Western Medicine, Beijing, 100072 China
| | - Yong’an Ye
- grid.24695.3c0000 0001 1431 9176Institute of Liver Diseases, Beijing University of Chinese Medicine, Beijing, China
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7
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Zhu M, Wang H, Lou T, Xiong P, Zhang J, Li L, Sun Y, Wu Y. Current treatment of chronic hepatitis B: Clinical aspects and future directions. Front Microbiol 2022; 13:975584. [PMID: 36160238 PMCID: PMC9493448 DOI: 10.3389/fmicb.2022.975584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/26/2022] [Indexed: 11/23/2022] Open
Abstract
Hepatitis B virus (HBV) infection is a public health threat worldwide, and there is no direct treatment yet available. In the event of infection, patients may present liver cirrhosis and cancer, which threaten the patients’ health globally, especially in the Asia-Pacific region and China. In 2019, Chinese hepatopathologists updated the 2015 Guidelines for the Prevention and Treatment of Chronic Hepatitis B as the clinical reference. The other versions formulated by the American Association for the Study of Liver Diseases (2018 AASLD guidelines) (AASLD, 2018), European Association for the Study of the Liver (2017 EASL guidelines) (EASL, 2017), and Asian-Pacific Association for the Study of the Liver (2015 APASL guidelines) (APASL, 2015) also provide clinical guidance. However, there are still some issues that need to be addressed. In the present study, the following aspects will be introduced successively: (1) Who should be treated in the general population according to the guidelines; (2) Treatment of specific populations infected with HBV; (3) Controversial issues in clinical practice; (4) Perspective.
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Affiliation(s)
- Minmin Zhu
- The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Jinhua, China
| | - Hui Wang
- The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Jinhua, China
| | - Tao Lou
- The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Jinhua, China
| | - Pian Xiong
- The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Jinhua, China
| | - Jiebing Zhang
- The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Jinhua, China
| | - Lele Li
- The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Jinhua, China
| | - Yuchao Sun
- The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Jinhua, China
- International Institutes of Medicine, Zhejiang University, Jinhua, China
| | - Yingping Wu
- The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Jinhua, China
- International Institutes of Medicine, Zhejiang University, Jinhua, China
- *Correspondence: Yingping Wu,
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Lin MH, Li HQ, Zhu L, Su HY, Peng LS, Wang CY, He CP, Liang XE, Wang Y. Liver Fibrosis in the Natural Course of Chronic Hepatitis B Viral Infection: A Systematic Review with Meta-Analysis. Dig Dis Sci 2022; 67:2608-2626. [PMID: 34008117 DOI: 10.1007/s10620-021-07009-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/14/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Quantitative data are limited on the natural course of liver fibrosis in patients with chronic HBV infection (CHB). AIMS To estimate the prevalence of fibrosis status including non-fibrosis, significant fibrosis, advanced fibrosis, and cirrhosis throughout the natural course of CHB. METHODS We searched Cochrane library, EMBASE, PubMed, SCOPUS, Web of Science, and ScienceDirect from January 1993 to November 2019 for studies with histologic data on liver fibrosis in CHB natural course. CHB course was defined based on current criteria for identifying infection phases as recommended by international clinical practice guidelines, including the HBeAg-positive immune-tolerant, HBeAg-positive immune-active, HBeAg-negative immune-inactive, HBeAg-negative immune-reactive, and HBsAg-negative phases. Pooled prevalence rate of fibrosis status at each phase was obtained from random-effect meta-analyses. RESULTS Thirty-three studies with 9,377 adult participants (23.8-49.0 age years; 45.5-88.6% males) were eligible and finally included. The estimated prevalence of non-fibrosis, significant fibrosis, advanced fibrosis, and cirrhosis was, for HBeAg-positive immune-tolerant phase: 31.2% (95%CI 15.6-46.7), 16.9% (95%CI 7.8-26.1), 5.4% (95%CI 0.0-11.2), and 0.0% (95%CI 0.0-1.5); HBeAg-positive immune-active phase: 6.9% (95%CI 3.6-10.2), 50.6% (95%CI 39.2-61.9), 32.1% (95%CI 24.2-40.0), and 12.8% (95%CI 8.6-17.0); HBeAg-negative immune-inactive phase: 32.4% (95%CI 0.0-100.0), 24.8% (95%CI 4.5-45.1), 3.0% (95%CI 0.0-8.3), and 0.0% (95%CI 0.0-1.0); and HBeAg-negative immune-reactive phase: 6.3% (95%CI 3.5-9.2), 50.3% (95%CI 38.9-61.7), 30.3% (95%CI 20.9-39.6), and 10.0% (95%CI 6.6-13.5), respectively. There was only one study for HBsAg-negative phase, thus not allowing further meta-analyses. CONCLUSIONS Fibrosis risk persists through CHB natural course. These data can support risk estimation in clinical practice and provide reference for noninvasive investigation.
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Affiliation(s)
- Mei-Hong Lin
- Department of Infectious Disease and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hai-Qiong Li
- Department of Infectious Disease and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Lin Zhu
- Department of Infectious Disease and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hai-Ying Su
- Department of Infectious Disease and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Li-Shan Peng
- Department of Infectious Disease and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Chuang-Yuan Wang
- Department of Infectious Disease and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China.,The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Cai-Ping He
- Biomedical Research Center, Southern Medical University, Guangzhou, China.,School of Pharmaceutical Science, Southern Medical University, Guangzhou, China
| | - Xie-Er Liang
- Department of Infectious Disease and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yan Wang
- Department of Infectious Disease and Hepatology Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China. .,Biomedical Research Center, Southern Medical University, Guangzhou, China.
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Huang J, Liu Y, Liu Y. Antiviral therapy in hepatitis B virus-infected with immune-tolerant: A meta-analysis. GASTROENTEROLOGÍA Y HEPATOLOGÍA 2022; 46:309-318. [PMID: 35700836 DOI: 10.1016/j.gastrohep.2022.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 04/12/2022] [Accepted: 05/23/2022] [Indexed: 11/30/2022]
Abstract
To access the efficacy of antiviral therapy in patients of HBV-infected with immune-tolerant. We conducted a meta-analysis search of the Cochrane Library, PubMed, ClinicalTrials.gov, Web of science, and EMBASE on through August 2021. We combined the data by means of a random-effect DrSimonian-Laird model and calculated risk ratios (RRs) for the outcomes of hepatitis B surface antigen (HBsAg) loss, hepatitis B e antigen (HBeAg) seroconversion, HBV deoxyribonucleic acid (DNA) negative conversion rate, and the risk for hepatocellular carcinoma (HCC) and cirrhosis. An extensive literature search identified 328 relevant publications, and five were included in the study. Antiviral therapy was in favor of HBsAg loss (RR=2.34, 95%CI 0.68-4.00, p=0.91, I2=0.00%), HBV DNA negative conversion (RR=2.08, 95%CI 0.10-4.05, p=0.07, I2=58.24%) and reduce the risk for HCC (HR=0.189, 95%CI 0.052-0.692, p=0.004) and cirrhosis (HR=0.347, 95%CI 0.095-1.270, p=0.036), but not beneficial to HBeAg seroconversion (RR=0.83, 95%CI -0.03 to 1.70, p=0.11, I2=46.99%). Subgroup-analyzed by the research type was similar results of HBsAg loss, HBV DNA negative conversion, and HBeAg seroconversion.Patients in HBV-infected with immune-tolerant responded well to antiviral therapy. The evidence from this meta-analysis supports antiviral therapy for patients with HBV in the immune tolerance stage. Well-designed, multi-center, larger sample sizes, and excellent quality prospective studies are needed to confirm our conclusion.
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Affiliation(s)
- Ji Huang
- Department of Traditional Chinese Medicine, Ganzhou People's Hospital, Ganzhou, China
| | - Yongqi Liu
- School of Medical Imaging, Binzhou Medical University, Yantai, China
| | - Youshun Liu
- Department of Gastroenterology, Ganzhou People's Hospital, Ganzhou, China.
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Zhao XA, Wang J, Wei J, Liu J, Chen G, Wang L, Wang G, Xia J, Wu W, Yin S, Tong X, Yan X, Ding W, Xiang X, Huang R, Wu C. Gamma-glutamyl Transpeptidase to Platelet Ratio Predicts Liver Injury in Hepatitis B e Antigen-negative Chronic Hepatitis B Patients With Normal Alanine Aminotransferase. J Clin Transl Hepatol 2022; 10:247-253. [PMID: 35528978 PMCID: PMC9039718 DOI: 10.14218/jcth.2021.00151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/24/2021] [Accepted: 06/16/2021] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND AND AIMS Chronic hepatitis B virus (HBV) infection is a serious health problem worldwide. Evaluating liver injury in patients with hepatitis B e antigen (HBeAg)-negative chronic hepatitis B (CHB) with detectable HBV DNA and normal alanine aminotransferase (ALT) is crucial to guide their clinical management. We aimed to investigate the stages of liver inflammation and fibrosis as well as the predictive accuracy of gamma-glutamyl transpeptidase-to-platelet ratio (GPR) in these patients. METHODS A total of 184 treatment-naïve HBeAg-negative CHB patients with detectable HBV DNA and normal ALT were enrolled. The Scheuer scoring system was used to classify liver inflammation and fibrosis. RESULTS The distribution of patients with different liver inflammation grades were as follows: G0, 0 (0%); G1, 97 (52.7%); G2, 68 (37.0%); G3, 12 (6.5%); and G4, 7 (3.8%). The distribution of patients with different liver fibrosis stages were as follows: S0, 22 (12.0%); S1, 72 (39.1%); S2, 42 (22.8%); S3, 19 (10.3%); and S4, 29 (15.8%). The areas under the receiver operating characteristic (AUROC) curves of GPR in predicting significant inflammation, severe inflammation, and advanced inflammation were 0.723, 0.895, and 0.952, respectively. The accuracy of GPR was significantly superior to that of ALT in predicting liver inflammation. The AUROCs of GPR in predicting significant fibrosis, severe fibrosis, and cirrhosis were 0.691, 0.780, and 0.803, respectively. The predictive accuracy of GPR was significantly higher than that of aminotransferase-to-platelet ratio index (APRI) and fibrosis index based on four factors (FIB-4) in identifying advanced fibrosis and cirrhosis, and it was superior to FIB-4 but comparable to APRI in identifying significant fibrosis. CONCLUSIONS Nearly half of the HBeAg-negative CHB patients with detectable HBV DNA and normal ALT levels had significant liver inflammation or fibrosis. GPR can serve as an accurate predictor of liver inflammation and fibrosis in these patients.
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Affiliation(s)
- Xiang-An Zhao
- Department of Gastroenterology, Northern Jiangsu People’s Hospital, Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu, China
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Jian Wang
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Jie Wei
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Jiacheng Liu
- Department of Infectious Diseases, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Guangmei Chen
- Department of Infectious Diseases, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Li Wang
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Guiyang Wang
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Juan Xia
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Weihua Wu
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Shengxia Yin
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Xin Tong
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Xiaomin Yan
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Weimao Ding
- Department of Hepatology, Huai’an No. 4 People’s Hospital, Huai’an, Jiangsu, China
| | - Xiaoxing Xiang
- Department of Gastroenterology, Northern Jiangsu People’s Hospital, Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu, China
| | - Rui Huang
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
- Correspondence to: Chao Wu and Rui Huang, Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, Jiangsu 210008, China. ORCID: https://orcid.org/0000-0002-1657-010X (CW), https://orcid.org/0000-0002-3189-7960 (RH). Tel: +86-25-8310-5890 (CW), +86-25-8310-6666-20201 (RH), Fax: +86-25-8330-7115 (CW), +86-25-8330-7115 (RH), E-mail: (CW), (RH)
| | - Chao Wu
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
- Correspondence to: Chao Wu and Rui Huang, Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, Jiangsu 210008, China. ORCID: https://orcid.org/0000-0002-1657-010X (CW), https://orcid.org/0000-0002-3189-7960 (RH). Tel: +86-25-8310-5890 (CW), +86-25-8310-6666-20201 (RH), Fax: +86-25-8330-7115 (CW), +86-25-8330-7115 (RH), E-mail: (CW), (RH)
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Koffas A, Mak LY, Gill US, Kennedy PTF. Early Treatment Consideration in Patients with Hepatitis B 'e' Antigen-Positive Chronic Infection: Is It Time for a Paradigm Shift? Viruses 2022; 14:v14050900. [PMID: 35632642 PMCID: PMC9143099 DOI: 10.3390/v14050900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 02/04/2023] Open
Abstract
Chronic hepatitis B (CHB) is associated with significant morbidity and mortality, due to the adverse sequelae of cirrhosis and hepatocellular carcinoma (HCC). To date, antiviral therapy has been reserved for patients with ostensibly active liver disease, fibrosis or cirrhosis, and/or increased risk of HCC. Historically, patients with hepatitis B 'e' antigen (HBeAg)-positive chronic infection, were not offered antiviral therapy. Nevertheless, there has been compelling evidence emerging in recent years, demonstrating that this disease phase is in fact not characterized by immunological tolerance. HBV integration into the human genome is a frequent event found in these patients. Additionally, it may well be associated with active inflammation and fibrosis, even in the presence of persistently normal liver enzymes. Likewise, it appears that the mechanisms of hepatocarcinogenesis are already present during this early stage of the disease. This was reflected in the European Association for the Study of the Liver (EASL) guidelines, where treating patients above the age of 30 years with HBeAg-positive chronic infection was proposed. Lowering the treatment threshold to broaden treatment eligibility is likely to slow disease progression and reduce the risk of developing HCC. The current review discusses the reasons to consider early antiviral therapy in HBeAg-positive chronic infection.
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Affiliation(s)
- Apostolos Koffas
- Barts Liver Centre, Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK; (A.K.); (L.-Y.M.); (U.S.G.)
| | - Lung-Yi Mak
- Barts Liver Centre, Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK; (A.K.); (L.-Y.M.); (U.S.G.)
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Upkar S. Gill
- Barts Liver Centre, Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK; (A.K.); (L.-Y.M.); (U.S.G.)
| | - Patrick T. F. Kennedy
- Barts Liver Centre, Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK; (A.K.); (L.-Y.M.); (U.S.G.)
- Correspondence:
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12
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Hong YM, Yoon KT. [Definition and Management of the Immune Tolerance Phase in Chronic Hepatitis B]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:156-160. [PMID: 35473773 DOI: 10.4166/kjg.2022.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/09/2022] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
Abstract
In the natural course of chronic hepatitis B, the immune tolerance phase is characterized by HBeAg positivity, very high levels of HBV DNA, and persistent normal alanine aminotransferase. The international guideline recommendation for patients in this phase is observation without antiviral treatment because of the low risk of disease progression and the lack of effective antiviral agents. However, recent retrospective studies have shown that progression to hepatic fibrosis and hepatocellular carcinoma may occur in patients who are in the immune tolerance phase. Despite the conceptual definition and clinical diagnostic criteria for this phase, it is difficult to accurately diagnose the true immune tolerance phase. Therefore, we should pay attention to the clinical evaluation and interpretation of the immune tolerance phase and understand the clinical situations in which antiviral treatments should be considered.
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Affiliation(s)
- Young Mi Hong
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Liver Center, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Liver Center, Pusan National University Yangsan Hospital, Yangsan, Korea
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13
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KASL clinical practice guidelines for management of chronic hepatitis B. Clin Mol Hepatol 2022; 28:276-331. [PMID: 35430783 PMCID: PMC9013624 DOI: 10.3350/cmh.2022.0084] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 01/10/2023] Open
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14
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Yıldız İE, Bahçeci İ, Ilgar T, Beyazal M, Kostakoğlu U, Ertürk A. Is Liver Biopsy Necessary in Patients with Chronic Hepatitis B with Normal Alanine Aminotransferase Level? Egypt J Immunol 2022. [DOI: 10.4274/vhd.galenos.2021.2021-7-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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A long-term study of liver-related events in Caucasian hepatitis B patients with normal ALT values and high viremia. Acta Gastroenterol Belg 2022; 85:56-61. [PMID: 35304994 DOI: 10.51821/85.1.9160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background and study aims There is ongoing debate whether antiviral therapy should be initiated in hepatitis B e antigen (HBeAg)-negative patients with normal alanine aminotransferase (ALT) levels but high HBV DNA levels >2,000 IU/mL. Since the need for antiviral therapy might be different between Asian and Caucasian patients, we studied the long-term disease outcome in Caucasian patients living in Western Europe. Patients and methods One hundred sixteen patients with high HBV DNA levels (>2,000 IU/mL) at diagnosis were included in the high viremia group, while those with HBV DNA <2,000 IU/mL were used as controls (n = 327). All patients were Caucasian, HBeAg negative, had normal ALT levels and had no significant liver disease at diagnosis. Results Median follow-up was 7 + 9.8 years in the high viremia group and this was 10 + 12.5 years in controls. The cumulative probability of a liver-related event over 10 years was 4.8% vs 0.0% in the control group (p=.008). In multivariable analysis, high viremia group was associated with the occurrence of a liver-related event (hazards ratio (HR) 95% confidence interval (CI): 1.20-11.98, p=.023). In this subgroup, older age at diagnosis (HR 95% CI: 1.01-1.16, p=.023) predicted a higher risk of liver-related event. In the high viremia group, liver-related mortality was 0.9% and none of the patients developed hepatocellular carcinoma. Conclusions HBV DNA >2,000 IU/mL influences the long-term disease outcome in Caucasian HBeAg-negative patients living in Western Europe. Nevertheless, the risk of liver-related events is low.
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Kawanaka M, Nishino K, Kawamoto H, Haruma K. Hepatitis B: Who should be treated?-managing patients with chronic hepatitis B during the immune-tolerant and immunoactive phases. World J Gastroenterol 2021; 27:7497-7508. [PMID: 34887645 PMCID: PMC8613739 DOI: 10.3748/wjg.v27.i43.7497] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/31/2021] [Accepted: 10/31/2021] [Indexed: 02/06/2023] Open
Abstract
New hepatitis B virus (HBV) infections are decreasing owing to improved antiviral therapy and increased HBV vaccination worldwide; however, the number of HBV infections remains a major cause of liver carcinogenesis. HBV triggers cytotoxic immunity to eliminate HBV-infected cells. Therefore, the HBV pathophysiology changes in persistently infected individuals depending on host immune responses and HBV DNA proliferation state. To prevent liver cirrhosis and carcinogenesis caused by HBV, it is important to treat HBV infection at an early stage. Active treatment is recommended for the immunoactive hepatitis B surface-antigen-positive and -negative phase, but not during the immune-inactive phase or immune-tolerant phase; instead, follow-up is recommended. However, these patients should be monitored through regular blood tests to accurately diagnose the immune-inactive or -tolerant phases. The treatment regimen should be determined based on the age, sex, family history of liver cancer, and liver fibrosis status of patients. Early treatment is often recommended due to various problems during the immune-tolerant phase. This review compares the four major international practice guidelines, including those from the Japanese Society of Hepatology, and discusses strategies for chronic hepatitis B treatment during the immune-tolerant, immune-inactive, and resolved phases. Finally, recommended hepatitis B antiviral therapy and follow-up protocols are discussed.
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Affiliation(s)
- Miwa Kawanaka
- Department of General Internal Medicine 2, General Medical Center, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Ken Nishino
- Department of General Internal Medicine 2, General Medical Center, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Hirofumi Kawamoto
- Department of General Internal Medicine 2, General Medical Center, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Ken Haruma
- Department of General Internal Medicine 2, General Medical Center, Kawasaki Medical School, Okayama 700-8505, Japan
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Combination of quantitative hepatitis B core antibody (qHBcAb) and aspartate aminotransferase (AST) can accurately diagnose immune tolerance of chronic hepatitis B virus infection based on liver biopsy. Clin Res Hepatol Gastroenterol 2021; 45:101563. [PMID: 33272888 DOI: 10.1016/j.clinre.2020.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Immune tolerance is defined as HBeAg positive, high hepatitis B virus load (HBV), persistent normal alanine aminotransferase (ALT), no or slight inflammation or fibrosis in liver histology. However, it is still unclear the threshold of high hepatitis B virus load and how to predict histology without liver biopsy. The aim of this study was to predict immune tolerance in HBeAg positive, alanine aminotransferase -normal populations with non-invasive indicators. METHODS Two multi-center prospective cohort study recruited 907 treatment-naïve chronic hepatitis B (CHB) patients who had undergone liver biopsy in mainland China from August 2013 to September 2016 and April 2018 to June2019. Quantitative hepatitis B core antibody, AST and HBV DNA were investigated using commercial diagnostic assays and histological grading and staging was assessed by the Ishak scoring system. RESULTS One hundred and thirteen untreated CHB patients with HBeAg-positive, normal alanine aminotransferase (ALT) and high level of HBV DNA (≥5log10 IU/mL) were enrolled in this study. The area under the receiver operating characteristic curves (AUROCs) of qHBcAb, AST, HBV DNA and qHBcAb-AST index were 79.6%, 80.5%, 76.4% and 87.7%. Our novel qHBcAb-AST index, which combined qHBcAb and AST showed better performance with higher sensitivity (88.6% [95% confidence interval (CI) 72.3% - 96.3%]) and negative predictive value (NPV) (93.8% [95% CI 84.2% - 98.0%]). CONCLUSIONS The combination of qHBcAb and AST can more accurately predict the immune tolerance of people with HBeAg-positive, normal alanine aminotransferase (ALT).
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Zhang C, Li JW, Wu Z, Zhao H, Wang GQ. Significant Histologic Changes Are Not Rare in Treatment-naive Hepatitis B Patients with Normal Alanine Aminotransferase Level: A Meta-analysis. J Clin Transl Hepatol 2021; 9:615-625. [PMID: 34722176 PMCID: PMC8516830 DOI: 10.14218/jcth.2020.00136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Chronic hepatitis B is the main cause of liver cancer. However, the most neglected group has been treatment-naive chronic hepatitis B patients with normal alanine aminotransferase (ALT). People have tended to subjectively assume that the liver lesions of these patients are not serious and do not need antiviral treatment. However, the truth is not as optimistic as we thought. We aimed in this study to analyze the proportion of significant inflammation or fibrosis in aforementioned patients. METHODS Medline, Embase, and Cochrane Library were searched up to January 10th 2020, to identify studies of these patients with liver biopsy. The double arcsine method was used with a random-effect model to combine the proportion of significant inflammation or fibrosis. Potential heterogeneity was explored by subgroup analysis and meta-regression. Outcome of interests included the proportion of significant inflammation or fibrosis and cirrhosis. The secondary outcome was to find the risk factors of significant histological changes. RESULTS Nineteen eligible studies, with 2,771 participants, were included. The pooled proportion of significant inflammation or fibrosis was 35% [95% confidence interval (CI): 27 to 43] and 30% (95% CI: 25 to 36), respectively. The pooled proportion of cirrhosis was 3% [95% CI: 1 to 5, (12 studies; 1,755 participants)]. In subgroup analysis, old age [vs. young (<40 years-old), 44% vs. 26%, p=0.012] was significantly associated with higher fibrosis stage as well as cirrhosis [vs. young (<40 years-old), 4.8% vs. 1.8%, p<0.001]. CONCLUSIONS About 1/3 of the treatment-naive chronic hepatitis B patients with normal ALT show significant histological changes, and some even have cirrhosis.
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Affiliation(s)
- Chi Zhang
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Xicheng District, Beijing, China
| | - Jia-Wen Li
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Xicheng District, Beijing, China
| | - Zhao Wu
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Xicheng District, Beijing, China
| | - Hong Zhao
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Xicheng District, Beijing, China
- Peking University International Hospital, Beijing, China
- Correspondence to: Gui-Qiang Wang and Hong Zhao, Department of Infectious Diseases and Center for Liver Diseases, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing 100034, China. Tel: +86-13911405123, Fax: +86-10-66551680, E-mail: , (GQW); Tel: +86-13810765943, Fax: +86-10-66551680, E-mail: (HZ)
| | - Gui-Qiang Wang
- Department of Infectious Disease, Center for Liver Disease, Peking University First Hospital, Xicheng District, Beijing, China
- The Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, China
- Peking University International Hospital, Beijing, China
- Correspondence to: Gui-Qiang Wang and Hong Zhao, Department of Infectious Diseases and Center for Liver Diseases, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing 100034, China. Tel: +86-13911405123, Fax: +86-10-66551680, E-mail: , (GQW); Tel: +86-13810765943, Fax: +86-10-66551680, E-mail: (HZ)
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Zhou J, Wang FD, Wang ML, Tao YC, Wu DB, Sheng YJ, Xiao GB, Chen XB, Chen X, Chen EQ. Antiviral Therapy for Chronic HBV Infection With Persistently Normal Alanine Aminotransferase: Controversy and Consensus. Front Med (Lausanne) 2021; 8:717125. [PMID: 34527683 PMCID: PMC8435583 DOI: 10.3389/fmed.2021.717125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/09/2021] [Indexed: 02/05/2023] Open
Abstract
ALT is one of the most sensitive biochemical indexes to reflect liver injury. It is generally believed that hepatitis B virus (HBV) infected patients with normal ALT levels are in either immune tolerance or low replication stage of the natural history of hepatitis B, and there is no or only mild inflammation in liver tissue, so antiviral therapy is not recommended. However, chronic HBV-infected patients with normal ALT levels are not always in a stable state. A considerable number of patients will develop active hepatitis or occult progress to liver fibrosis, cirrhosis, and hepatocellular carcinoma. Therefore, whether antiviral therapy should be recommended for chronic HBV infection with normal ALT level has been a hot topic in clinical practice. In this paper, the definition of immune tolerance, the relationship between ALT and liver inflammation, and the benefits of antiviral therapy were reviewed, and we hope it will be helpful for clinicians to have a deeper understanding of whether antiviral therapy should be considered for chronic HBV infection with normal ALT.
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Affiliation(s)
- Jing Zhou
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Fa-Da Wang
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Meng-Lan Wang
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Ya-Chao Tao
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Dong-Bo Wu
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Yun-Jian Sheng
- Department of Infection, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Gui-Bao Xiao
- Department of Infectious Diseases, The First People's Hospital of Ziyang City, Ziyang, China
| | - Xue-Bin Chen
- Department of Infectious Diseases, People's Hospital of Deyang City, Deyang, China
| | - Xin Chen
- Department of Infectious Diseases, The Second People's Hospital of Neijiang, Neijiang, China
| | - En-Qiang Chen
- Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
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Choi J, Lim YS. Secondary prevention of hepatitis B virus-related hepatocellular carcinoma with current antiviral therapies. Kaohsiung J Med Sci 2021; 37:262-267. [PMID: 33502828 DOI: 10.1002/kjm2.12364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 01/05/2021] [Indexed: 12/25/2022] Open
Abstract
Over the past decades, marked advancement has been made in the prevention and treatment of hepatitis B virus (HBV) infection. Due to highly effective antiviral therapies for chronic hepatitis B (CHB), long-term clinical outcomes in patients with CHB has also been dramatically improved. However, current antiviral therapies for CHB cannot completely abolish the risk of hepatocellular carcinoma (HCC). In addition, current treatment guidelines for CHB should be interpreted with caution given that HBV-associated hepatocarcinogenesis could be underway in patients who are not eligible for antiviral therapies by current guidelines. Therefore, efforts to reconcile treatment guidelines with recent clinical evidence should be made for reducing further development of HCC. In this article, we review the secondary prevention of HBV-related HCC with current antiviral therapies.
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Affiliation(s)
- Jonggi Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Wang J, Xia J, Yan X, Yang Y, Wei J, Xiong Y, Wu W, Liu Y, Chen Y, Jia B, Chen Z, Zhang Z, Ding W, Huang R, Wu C. The gamma-glutamyl transpeptidase to platelet ratio predicts liver inflammation in chronic hepatitis B with normal or mildly elevated alanine transaminase. Clin Res Hepatol Gastroenterol 2020; 44:913-922. [PMID: 32147439 DOI: 10.1016/j.clinre.2020.01.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/18/2020] [Accepted: 01/21/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The gamma-glutamyl transpeptidase (GGT) to platelet ratio (GPR) was proposed as a novel index for predicting liver inflammation in chronic hepatitis B (CHB) patients. We aimed to investigate GPR for predicting significant liver inflammation in CHB patients with normal (≤1×upper limit of normal, ULN) or mildly elevated (≤2×ULN) alanine transaminase (ALT). METHODS AND METHODS 431 treatment-naïve CHB patients with normal or mildly elevated ALT who underwent liver biopsy were enrolled. Comparision of GPR and other parameters for significant liver inflammation (G≥3). RESULTS For patients with ALT≤2×ULN, the receiver-operating characteristic curves (AUROCs) of GPR in predicting significant liver inflammation were 0.837 (95%CI 0.796 to 0.878), 0.860 (95%CI 0.809 to 0.910) and 0.809 (95%CI 0.739 to 0.878) in the entire patients, HBeAg positive and HBeAg negative CHB patients, respectively. The diagnostic performance of GPR was higher than ALT (P<0.001, P<0.001, respectively), aspartate transaminase (AST) (P=0.001, P=0.003, respectively) and GGT (P=0.002, P=0.002, respectively) in the entire and HBeAg positive patients, but was comparable with AST (P=0.096) and GGT (P=0.273) in the HBeAg negative CHB patients. For patients with ALT≤1×ULN, the diagnostic accuracy of GPR was significantly higher than ALT, AST and GGT in the entire (P<0.001, P=0.008 and P=0.043, respectively) and HBeAg positive CHB patients (P<0.001, P=0.009 and P=0.024, respectively), while was comparable to AST (P=0.209) and GGT(P=0.555) in the HBeAg negative CHB patients. CONCLUSION GPR has a better diagnostic value than conventional parameters to predict significant liver inflammation in CHB patients with normal or mildly elevated ALT levels, especially for HBeAg positive CHB.
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Affiliation(s)
- Jian Wang
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Juan Xia
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Xiaomin Yan
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yue Yang
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Jie Wei
- Department of Infectious Diseases, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yali Xiong
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Weihua Wu
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yong Liu
- Department of Laboratory Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yuxin Chen
- Department of Laboratory Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Bei Jia
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Zhong Chen
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Zhaoping Zhang
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Weimao Ding
- Department of Hepatology, Huai'an No. 4 People's Hospital, Huai'an, Jiangsu, China
| | - Rui Huang
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China.
| | - Chao Wu
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China.
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Prognosis of Untreated Minimally Active Chronic Hepatitis B Patients in Comparison With Virological Responders by Antivirals. Clin Transl Gastroenterol 2020; 10:e00036. [PMID: 31107725 PMCID: PMC6613858 DOI: 10.14309/ctg.0000000000000036] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Serum hepatitis B virus (HBV)-DNA > 2,000 IU/mL is associated with higher risk of disease progression. However, without hepatocellular carcinoma (HCC) or cirrhosis, nucleos(t)ide analogs (NUCs) are recommended only for patients with elevated serum HBV-DNA and alanine aminotransferase ≥2 × upper normal limit.
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Yim HJ, Kim JH, Park JY, Yoon EL, Park H, Kwon JH, Sinn DH, Lee SH, Lee JH, Lee HW. Comparison of clinical practice guidelines for the management of chronic hepatitis B: When to start, when to change, and when to stop. Clin Mol Hepatol 2020; 26:411-429. [PMID: 32854458 PMCID: PMC7641563 DOI: 10.3350/cmh.2020.0049] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/21/2020] [Indexed: 02/06/2023] Open
Abstract
Clinical practice guidelines are important for guiding the management of specific diseases by medical practitioners, trainees, and nurses. In some cases, the guidelines are utilized as a reference for health policymakers in controlling diseases with a large public impact. With this in mind, practice guidelines for the management of chronic hepatitis B (CHB) have been developed in the United States, Europe, and Asian-Pacific regions to suggest the best-fit recommendations for each social and medical circumstance. Recently, the Korean Association for the Study of the Liver published a revised version of its clinical practice guidelines for the management of CHB. The guidelines included updated information based on newly available antiviral agents, the most recent opinion on the initiation and cessation of treatment, and updates for the management of drug resistance, partial virological response, and side effects. Additionally, CHB management in specific situations was comprehensively revised. This review compares the similarities and differences among the various practice guidelines to identify unmet needs and improve future recommendations.
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Affiliation(s)
- Hyung Joon Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eileen L Yoon
- Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea
| | - Hana Park
- Department of Health Medicine, Asan Medical Center, Seoul, Korea
| | - Jung Hyun Kwon
- Department of Internal Medicine, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Dong Hyun Sinn
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sae Hwan Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Chonan, Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Woong Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Lee HW, Chan HLY. Unresolved issues of immune tolerance in chronic hepatitis B. J Gastroenterol 2020; 55:383-389. [PMID: 32016713 PMCID: PMC7080668 DOI: 10.1007/s00535-020-01665-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 01/07/2020] [Indexed: 02/07/2023]
Abstract
During the natural course of chronic hepatitis B virus infection, immune-tolerant phase is characterized by high viral replication, the presence of HBV e antigen (HBeAg), and normal or minimally elevated serum alanine aminotransferase. Immune-tolerant phase is usually regarded as a benign course of the disease. International guidelines recommend observation rather than treatment during immune-tolerant phase. In this article, we review unresolved issues related to the definition of true immune-tolerant phase and the benefit of antiviral treatment. Defining true immune-tolerant phase requires a careful approach and long-term follow-up. In previous studies, many patients were misclassified as being immune-tolerant phase. Noninvasive methods of assessing fibrosis are warranted for patients in the immune-tolerant phase. Yet, there has been controversy over the benefit and harm of antiviral treatment for immune-tolerant phase patients. Thus, further larger scale studies are needed to investigate the prognosis of patients in true immune-tolerant phase and their need for antiviral therapy.
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Affiliation(s)
- Hye Won Lee
- grid.10784.3a0000 0004 1937 0482Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong ,grid.10784.3a0000 0004 1937 0482Insitute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong ,grid.15444.300000 0004 0470 5454Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Henry Lik-Yuen Chan
- grid.10784.3a0000 0004 1937 0482Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong ,grid.10784.3a0000 0004 1937 0482Insitute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
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Attar BM. CON: All Patients With Immune-Tolerated Hepatitis B Virus Do Not Need to Be Treated. Clin Liver Dis (Hoboken) 2020; 15:25-30. [PMID: 32104574 PMCID: PMC7041959 DOI: 10.1002/cld.893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/11/2019] [Indexed: 02/04/2023] Open
Abstract
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-1-reading-attar a video presentation of this article.
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Affiliation(s)
- Bashar M. Attar
- Division of Gastroenterology and HepatologyCook County HealthChicagoIL
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26
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Choi GH, Kim GA, Choi J, Han S, Lim YS. High risk of clinical events in untreated HBeAg-negative chronic hepatitis B patients with high viral load and no significant ALT elevation. Aliment Pharmacol Ther 2019; 50:215-226. [PMID: 31135074 DOI: 10.1111/apt.15311] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 12/30/2018] [Accepted: 04/29/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND It remains unknown whether antiviral treatment for HBeAg-negative chronic hepatitis B (CHB) patients having high viral loads without significant elevation of alanine aminotransferase (ALT) levels would reduce the risks of clinical events. AIM To compare clinical outcomes of high viral load CHB patients untreated for normal or mildly elevated ALT vs those treated for ALT ≥ 2 upper limit of normal (ULN). METHODS This historical cohort study included 5414 HBeAg-negative CHB patients without cirrhosis at a tertiary hospital in Korea from 2000 to 2013. Inactive phase was defined as serum hepatitis B virus [HBV] DNA < 2000 IU/mL and persistently normal ALT (n = 3572). High viral load (HBV DNA ≥ 2000 IU/mL) patients were classified into three phases by ALT levels: Replicative (persistently normal ALT, n = 900); Mildly active (ALT 1-2ULN, n = 396); and Active (ALT ≥ 2ULN, n = 546) phases. All Active phase patients were treated with nucleos(t)ide analogues. RESULTS The mean age of the patients was 47 years without a significant difference among the groups. Compared with the treated Active phase group, the untreated Replicative phase group showed a significantly higher risk of hepatocellular carcinoma (HCC; HR 1.76; 95% CI 1.00 - 3.10, P = 0.05) and death/transplantation (HR 2.14; 5% CI 1.09 - 4.21, P = 0.03) by propensity score-matched analysis. The untreated mildly active phase patients had further increase in risk of HCC and death/transplantation compared with the treated Active phase group by unadjusted, PS-matched, competing risks, and multivariable-adjusted analyses. CONCLUSIONS Untreated high viral load HBeAg-negative CHB patients without significant ALT elevation had higher risks of clinical events than treated Active phase patients with elevated ALT.
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Affiliation(s)
- Gwang Hyeon Choi
- Departments of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gi-Ae Kim
- Departments of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Jonggi Choi
- Department of Gastroenterology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seungbong Han
- Department of Applied Statistics, Gachon University, SeongNam, Republic of Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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KASL clinical practice guidelines for management of chronic hepatitis B. Clin Mol Hepatol 2019; 25:93-159. [PMID: 31185710 PMCID: PMC6589848 DOI: 10.3350/cmh.2019.1002] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023] Open
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Sung PS, Park DJ, Kim JH, Han JW, Lee EB, Lee GW, Nam HC, Jang JW, Bae SH, Choi JY, Shin EC, Park SH, Yoon SK. Ex vivo Detection and Characterization of Hepatitis B Virus-Specific CD8 + T Cells in Patients Considered Immune Tolerant. Front Immunol 2019; 10:1319. [PMID: 31244857 PMCID: PMC6563765 DOI: 10.3389/fimmu.2019.01319] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/23/2019] [Indexed: 12/21/2022] Open
Abstract
In this study, we aimed to detect and characterize ex vivo virus-specific CD8+ T cells in patients with immune-tolerant hepatitis B virus (HBV) infection. We investigated a Korean chronic hepatitis B cohort composed of 15 patients in the immune-tolerant phase, 17 in the immune-active phase, and 13 under antiviral treatment. We performed enzyme-linked immunospot (ELISpot) assays ex vivo and intracellular cytokine staining after in vitro culture. We also performed ex vivo multimer staining assays and examined the expression of programmed death-1 (PD-1) and CD127 in pentamer-positive cells. Ex vivo ELISpot revealed that HBV-specific T cell function was weaker in immune-tolerant patients than in those under antiviral treatment. In vitro culture of peripheral blood mononuclear cells for 10 days revealed that HBV-specific CD8+ T cells produced interferon-γ in some immune-tolerant patients. We detected HBV-specific CD8+ T cells ex vivo (using the HBV core18-27 pentamer) in patients from all three groups. The PD-1+ subset of pentamer+ CD8+ T cells was smaller ex vivo in the immune-tolerant phase than in the immune-active phase or under antiviral treatment. Interestingly, the proportion of PD-1+ CD8+ T cells in HBV-specific CD8+ T cells correlated with patient age when all enrolled patients were analyzed. Overall, HBV-specific CD8+ T cells are present in patients considered as immune-tolerant, although their ex vivo functionality is significantly weaker than that in patients under antiviral treatment (P < 0.05). Despite the high viral load, the proportion of PD-1 expression in HBV-specific CD8+ T cells is lower in the immune-tolerant phase than in other phases. Our results indicate appropriate stimulation may enhance the effector function of HBV-specific CD8+ T cells in patients considered as being in the immune-tolerant phase.
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Affiliation(s)
- Pil Soo Sung
- Department of Internal Medicine, College of Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Department of Biomedicine & Health Sciences, The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Dong Jun Park
- Department of Biomedicine & Health Sciences, The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jung-Hee Kim
- Department of Biomedicine & Health Sciences, The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ji Won Han
- Graduate School of Medical Science and Engineering, KAIST, Daejeon, South Korea
| | - Eun Byul Lee
- Department of Biomedicine & Health Sciences, The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Gil Won Lee
- Department of Biomedicine & Health Sciences, The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hee Chul Nam
- Department of Biomedicine & Health Sciences, The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Jeong Won Jang
- Department of Biomedicine & Health Sciences, The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Department of Biomedicine & Health Sciences, The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jong Young Choi
- Department of Biomedicine & Health Sciences, The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Eui-Cheol Shin
- Graduate School of Medical Science and Engineering, KAIST, Daejeon, South Korea
| | - Su-Hyung Park
- Graduate School of Medical Science and Engineering, KAIST, Daejeon, South Korea
| | - Seung Kew Yoon
- Department of Biomedicine & Health Sciences, The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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Wei M, Xu Z, Pan X, Zhang X, Liu L, Yang B, Chen Y. Serum GP73 - An Additional Biochemical Marker for Liver Inflammation in Chronic HBV Infected Patients with Normal or Slightly Raised ALT. Sci Rep 2019; 9:1170. [PMID: 30718535 PMCID: PMC6362062 DOI: 10.1038/s41598-018-36480-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/21/2018] [Indexed: 12/24/2022] Open
Abstract
This study aimed to assess the feasibility of GP73 as a diagnostic marker for liver inflammation and fibrosis in chronic HBV patients with normal or slightly raised ALT (<2 ULN) and to develop models based on GP73 and other biochemical parameters to improve diagnostic accuracy. Serum GP73 levels were analyzed in 220 chronic HBV patients with normal or slightly raised ALT who underwent liver biopsy. The results showed that the area under the receiver operating characteristic (ROC) curve (AUC) was 0.806 for predicting significant liver inflammation (≥G2), while it was 0.742 for predicting significant fibrosis (≥S2). These results suggest that GP73 has higher diagnostic value for liver inflammation than liver fibrosis. Combining GP73, AST and ALB, as a diagnostic model for predicting significant liver inflammation, resulted in superior diagnostic performance over GP73 alone (AUC value increased from 0.806 to 0.854, z = 2.299, P = 0.021). By applying this diagnostic model, over 80% of chronic HBV patients with normal or slightly raised ALT will be correctly identified and hence avoid delay in diagnosis and treatment. In conclusion, GP73 would be an additional serum marker for predicting liver inflammation and fibrosis in chronic HBV patients with normal or slightly raised ALT.
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Affiliation(s)
- Meijuan Wei
- Clinical Liver Center, The 910th Hospital of the People's Liberation Army, Quanzhou, 362000, China.,Clinical Liver Center, Decheng hospital of Quanzhou/Affiliated of Huaqiao University, Quanzhou, 362000, China
| | - Zhengju Xu
- Clinical Liver Center, The 910th Hospital of the People's Liberation Army, Quanzhou, 362000, China.
| | - Xingnan Pan
- Clinical Liver Center, Decheng hospital of Quanzhou/Affiliated of Huaqiao University, Quanzhou, 362000, China
| | - Xiaoman Zhang
- Clinical Liver Center, The 910th Hospital of the People's Liberation Army, Quanzhou, 362000, China
| | - LiGuan Liu
- Clinical Liver Center, The 910th Hospital of the People's Liberation Army, Quanzhou, 362000, China
| | - Bishuang Yang
- Clinical Liver Center, The 910th Hospital of the People's Liberation Army, Quanzhou, 362000, China
| | - Yuxia Chen
- Clinical Liver Center, Decheng hospital of Quanzhou/Affiliated of Huaqiao University, Quanzhou, 362000, China
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Satsangi S. Immune-tolerant Chronic Hepatitis B Infection-Is the Liver Really Tolerating? J Clin Exp Hepatol 2018; 8:478-479. [PMID: 30564007 PMCID: PMC6286441 DOI: 10.1016/j.jceh.2018.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Sandeep Satsangi
- Address for correspondence: Sandeep Satsangi, Hepatologist, Department of Global Integrated Liver Care, B.G.S Gleneagles Global Hospital, Kengeri, Bengaluru 560060, India. Tel.: +91 7899243962/080 30444129.
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Zhang J, Du X, Zhou Z, Lv F, Yu Y. Spleen thickness can predict significant liver pathology in patients with chronic hepatitis B with persistently normal alanine aminotransferase or minimally raised alanine aminotransferase: a retrospective study. J Int Med Res 2018; 47:122-132. [PMID: 30213226 PMCID: PMC6384475 DOI: 10.1177/0300060518796760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Liver biopsy is the gold standard test for assessment of liver pathology. This study was performed to assess the predictive value of spleen thickness for liver pathology and the role of routine follow-up procedures in significant liver pathology for patients with chronic hepatitis B (CHB) with persistently normal alanine aminotransferase (PNALT) or minimally raised alanine aminotransferase (ALT). METHODS Patients with CHB who underwent percutaneous liver biopsy were retrospectively reviewed. The relationship of liver pathology with age, ALT, hepatitis B e-antigen, and spleen thickness was statistically analyzed, and the predictive accuracy of spleen thickness was evaluated. RESULTS In total, 80.65% of patients had significant necroinflammation and/or fibrosis. Nearly 60% of patients had splenomegaly, of which 89.12% had a histopathological grade of ≥G2 and/or S2. Spleen thickness was predictive of liver pathology, and significant histological findings increased as the hepatitis B virus (HBV) DNA level increased. CONCLUSIONS Spleen thickness is an effective predictor of liver pathology in patients with PNALT or minimally raised ALT. Additionally, the prevalence of significant histological findings tended to increase as the HBV DNA level increased. Patients with CHB and splenomegaly and a high HBV DNA level should be treated early with antivirals to improve liver pathology.
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Affiliation(s)
- Junli Zhang
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaoxing Du
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhihui Zhou
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fangfang Lv
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Kim GA, Lim YS, Han S, Choi J, Shim JH, Kim KM, Lee HC, Lee YS. High risk of hepatocellular carcinoma and death in patients with immune-tolerant-phase chronic hepatitis B. Gut 2018; 67:945-952. [PMID: 29055908 DOI: 10.1136/gutjnl-2017-314904] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 09/05/2017] [Accepted: 09/26/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE High serum HBV DNA levels are associated with high risks of hepatocellular carcinoma (HCC) and cirrhosis in patients with chronic hepatitis B (CHB). Although the immune-tolerant (IT) phase is characterised by high circulating HBV DNA levels, it remains unknown whether antiviral treatment reduces risks of HCC and mortality. DESIGN This historical cohort study included HBeAg-positive patients with CHB with high HBV DNA levels (≥20 000 IU/mL) and no evidence of cirrhosis at a tertiary referral hospital in Korea from 2000 to 2013. The clinical outcomes of 413 untreated IT-phase patients with normal alanine aminotransferase (ALT) levels (females, <19 IU/mL; males, <30 IU/mL) were compared with those of 1497 immune-active (IA)-phase patients (ALT ≥80 IU/mL) treated with nucleos(t)ide analogues. RESULTS The IT group was significantly younger than the IA group (mean age, 38 vs 40 years at baseline, p=0.04). The 10-year estimated cumulative incidences of HCC (12.7% vs 6.1%; p=0.001) and death/transplantation (9.7% vs 3.4%; p<0.001) were significantly higher in the IT group than the IA group. In multivariable analyses, the IT group showed a significantly higher risk of HCC (HR 2.54; 95% CI 1.54 to 4.18) and death/transplantation (HR 3.38; 95% CI 1.85 to 6.16) than the IA group, which was consistently identified through inverse probability treatment weighting, propensity score-matched and competing risks analyses. CONCLUSIONS Untreated IT-phase patients with CHB had higher risks of HCC and death/transplantation than treated IA-phase patients. Unnecessary deaths could be prevented through earlier antiviral intervention in select IT-phase patients.
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Affiliation(s)
- Gi-Ae Kim
- Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seungbong Han
- Department of Applied Statistics, Gachon University, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Jonggi Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ju Hyun Shim
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kang Mo Kim
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Han Chu Lee
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yung Sang Lee
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Xu Z, Shen J, Pan X, Wei M, Liu L, Wei K, Liu L, Yang H, Huang J. Predictive value of serum Golgi protein 73 for prominent hepatic necroinflammation in chronic HBV infection. J Med Virol 2018; 90:1053-1062. [PMID: 29424455 DOI: 10.1002/jmv.25045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 01/25/2018] [Indexed: 12/17/2022]
Abstract
As a noninvasive marker, serum alanine aminotransferase (ALT) has limitations, because a large proportion of patients chronically infected with hepatitis B virus (HBV) suffer from severe hepatic necroinflammation, but have normal or mildly elevated ALT. In the present study, we aimed to investigate the potential value of serum Golgi protein 73 (GP73) in predicting significant hepatic necroinflamation among chronic HBV infected patients. A cohort of 497 chronic HBV infected patients was retrospectively recruited. Liver biopsy was performed in all patients and serum GP73 levels were measured by enzyme-linked immunosorbent assay. Serum GP73 increased in parallel with the increase in hepatic necroinflammatory activity grade (r = 0.682) and the stage of liver fibrosis (r = 0.539). The positive correlation of serum GP73 with the degree of hepatic necroinflammatory activity was statistically significant, while serum GP73 with the stage of liver fibrosis was weaker than that with hepatic necroinflammation. Furthermore, serum GP73 levels were significantly greater in patients with normal or mildly elevated ALT and significant hepatic necroinflammation (≥G2) than in patients with minimal to mild hepatic necroinflammation. The sensitivity and specificity of GP73 for the diagnosis of G2 hepatic necroinflammation was 42.35% and 95.0%, respectively, at a cut-off value of 88.38 ng/mL. When the cut-off value was set at 124.76 ng/mL, the sensitivity and specificity of GP73 for the diagnosis of G3 hepatic necroinflammation was 55.56% and 97.29%, respectively. These findings indicate that GP73 holds promise as an important candidate for diagnosing significant hepatic necroinflammation.
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Affiliation(s)
- Zhengju Xu
- Clinical Liver Center, The 180th Hospital of the People's Liberation Army, Quanzhou, P.R. China
| | - Jiankun Shen
- Clinical Liver Center, The 180th Hospital of the People's Liberation Army, Quanzhou, P.R. China
| | - Xingnan Pan
- Clinical Liver Center, The 180th Hospital of the People's Liberation Army, Quanzhou, P.R. China
| | - Meijuan Wei
- Central Laboratory of Clinical Hepatology, The 180th Hospital of the People's Liberation Army, Quanzhou, P.R. China
| | - Liguan Liu
- Clinical Liver Center, The 180th Hospital of the People's Liberation Army, Quanzhou, P.R. China
| | - Kaipeng Wei
- Central Laboratory of Clinical Hepatology, The 180th Hospital of the People's Liberation Army, Quanzhou, P.R. China
| | - Lifei Liu
- Department of Pathology, The 180th Hospital of the People's Liberation Army, Quanzhou, P.R. China
| | - Huanwen Yang
- Clinical Liver Center, The 180th Hospital of the People's Liberation Army, Quanzhou, P.R. China
| | - Jinfa Huang
- Clinical Liver Center, The 180th Hospital of the People's Liberation Army, Quanzhou, P.R. China
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Chang Y, Choe WH, Sinn DH, Lee JH, Ahn SH, Lee H, Shim JJ, Jun DW, Park SY, Nam JY, Cho EJ, Yu SJ, Lee DH, Lee JM, Kim YJ, Kwon SY, Paik SW, Yoon JH. Nucleos(t)ide Analogue Treatment for Patients With Hepatitis B Virus (HBV) e Antigen-Positive Chronic HBV Genotype C Infection: A Nationwide, Multicenter, Retrospective Study. J Infect Dis 2017; 216:1407-1414. [PMID: 29029102 DOI: 10.1093/infdis/jix506] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 09/19/2017] [Indexed: 12/16/2022] Open
Abstract
Background Antiviral treatment for hepatitis B virus (HBV) e antigen (HBeAg)-positive chronic HBV infection is still controversial. We assessed whether antiviral treatment reduces the risk of liver disease progression in these patients. Methods This study included consecutive patients in 8 large-volume hospitals in Korea who tested positive for HBeAg and had an HBV DNA level of >20000 IU/mL, an alanine aminotransferase (ALT) level of <40 IU/L, and no evidence of cirrhosis. The primary end point was the development of hepatocellular carcinoma (HCC), and the secondary end point was the development of cirrhosis. Results A total of 484 patients were included: 87 were in the antiviral treatment group, and 397 were in the control group. Baseline liver function was significantly more favorable for the control group. After matching for propensity score to overcome those differences, the antiviral treatment group had a significantly reduced risk for HCC (hazard ratio [HR], 0.234; log-rank P = .046) and cirrhosis (HR, 0.235; log-rank P = .015), compared with the control group. After balancing the baseline characteristics by using inverse probability weighting, antiviral therapy significantly decreased the risk of HCC (HR, 0.189; log-rank P = .004) and cirrhosis (HR, 0.347; log-rank P = .036). Conclusion Antiviral therapy for patients with HBeAg-positive chronic HBV infection and have a high HBV load reduces the risk of HCC, even if the ALT level is below the upper limit of normal.
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Affiliation(s)
- Young Chang
- Department of Internal Medicine, Seoul National University College of Medicine.,Liver Research Institute, Seoul National University College of Medicine
| | - Won Hyeok Choe
- Department of Internal Medicine, Konkuk University School of Medicine
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jeong-Hoon Lee
- Department of Internal Medicine, Seoul National University College of Medicine.,Liver Research Institute, Seoul National University College of Medicine
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine
| | - Hyewon Lee
- Department of Internal Medicine, Yonsei University College of Medicine
| | - Jae-Jun Shim
- Department of Internal Medicine, Kyung Hee University School of Medicine
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul
| | - Soo Young Park
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Joon Yeul Nam
- Department of Internal Medicine, Seoul National University College of Medicine.,Liver Research Institute, Seoul National University College of Medicine
| | - Eun Ju Cho
- Department of Internal Medicine, Seoul National University College of Medicine.,Liver Research Institute, Seoul National University College of Medicine
| | - Su Jong Yu
- Department of Internal Medicine, Seoul National University College of Medicine.,Liver Research Institute, Seoul National University College of Medicine
| | - Dong Ho Lee
- Department of Radiology, Seoul National University College of Medicine
| | - Jeong Min Lee
- Department of Radiology, Seoul National University College of Medicine
| | - Yoon Jun Kim
- Department of Internal Medicine, Seoul National University College of Medicine.,Liver Research Institute, Seoul National University College of Medicine
| | - So Young Kwon
- Department of Internal Medicine, Konkuk University School of Medicine
| | - Seung Woon Paik
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jung-Hwan Yoon
- Department of Internal Medicine, Seoul National University College of Medicine.,Liver Research Institute, Seoul National University College of Medicine
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Yan LB, Zhu X, Bai L, Tang XQ, Du LY, Chen EQ, Liang LB, Tang H. Mutations in basal core promoter is associated with significant fibrosis in both HBeAg positive and negative treatment-naïve chronic hepatitis B. Clin Res Hepatol Gastroenterol 2017; 41:296-302. [PMID: 27988305 DOI: 10.1016/j.clinre.2016.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 09/08/2016] [Accepted: 11/02/2016] [Indexed: 02/05/2023]
Abstract
AIM Assessment of liver fibrosis is important for the decision of whether to administrate antiviral treatment in chronic Hepatitis B (CHB) patients. The objective was to investigate the relationship between clinical factors and fibrosis, identify predictors of significant fibrosis in Chinese CHB patients. METHODS Two hundred and seventy-four treatment-naïve CHB patients (208 HBeAg-positive and 66 HBeAg-negative) who performed transient elastography were consecutively included. We assessed ALT, HBsAg, HBeAg, HBV-DNA, HBV genotype and precore (PC)/basal core promoter (BCP) variants and liver stiffness measurement (LSM) values. RESULTS One hundred and nine patients (39.78%) had significant fibrosis (F≥2, include those with liver cirrhosis). On univariate analysis, significant fibrosis was associated with older age (P<0.001), high ALT levels (P=0.003), lower HBsAg levels (P<0.001), lower HBV DNA levels (P<0.001), HBeAg negative (P<0.001), presence of BCP (P<0.001) and combined BCP/PC mutations (P=0.001). Multivariate logistic regression analysis showed that the strongest independently associated predictors of significant fibrosis (F≥2) were the presence of HBV BCP mutations (P<0.001) and older age (P<0.001), followed by presence of lower HBsAg (P<0.001), higher ALT levels (P=0.006), PC mutations (P=0.011). The diagnostic accuracy of the combination (age, ALT, HBsAg, BCP/PC variants) model with an area under the receiver-operating characteristic curve of 0.819 (cut-off value was 0.349, P<0.001, 95% CI 0.731-0.914) in predicting significant fibrosis. CONCLUSIONS We identified four independent risk factors (age, ALT, HBsAg, HBV BCP/PC variants) in predicting significant fibrosis. HBV BCP variants was the strongest predictor of significant fibrosis. The combination of these four variables may facilitate the assessment and management of fibrosis in HBV infected patients.
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Affiliation(s)
- Li-Bo Yan
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, People's Republic of China
| | - Xia Zhu
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, People's Republic of China
| | - Lang Bai
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, People's Republic of China
| | - Xiao-Qiong Tang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, People's Republic of China
| | - Ling-Yao Du
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, People's Republic of China
| | - En-Qiang Chen
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, People's Republic of China
| | - Ling-Bo Liang
- Department of General Medicine, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China
| | - Hong Tang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, People's Republic of China.
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38
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Wang Y, Hou JL. Fibrosis assessment: impact on current management of chronic liver disease and application of quantitative invasive tools. Hepatol Int 2016; 10:448-61. [DOI: 10.1007/s12072-015-9695-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 12/07/2015] [Indexed: 12/15/2022]
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39
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Sarin SK, Kumar M, Lau GK, Abbas Z, Chan HLY, Chen CJ, Chen DS, Chen HL, Chen PJ, Chien RN, Dokmeci AK, Gane E, Hou JL, Jafri W, Jia J, Kim JH, Lai CL, Lee HC, Lim SG, Liu CJ, Locarnini S, Al Mahtab M, Mohamed R, Omata M, Park J, Piratvisuth T, Sharma BC, Sollano J, Wang FS, Wei L, Yuen MF, Zheng SS, Kao JH. Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update. Hepatol Int 2016; 10:1-98. [PMID: 26563120 PMCID: PMC4722087 DOI: 10.1007/s12072-015-9675-4] [Citation(s) in RCA: 1730] [Impact Index Per Article: 216.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023]
Abstract
Worldwide, some 240 million people have chronic hepatitis B virus (HBV), with the highest rates of infection in Africa and Asia. Our understanding of the natural history of HBV infection and the potential for therapy of the resultant disease is continuously improving. New data have become available since the previous APASL guidelines for management of HBV infection were published in 2012. The objective of this manuscript is to update the recommendations for the optimal management of chronic HBV infection. The 2015 guidelines were developed by a panel of Asian experts chosen by the APASL. The clinical practice guidelines are based on evidence from existing publications or, if evidence was unavailable, on the experts' personal experience and opinion after deliberations. Manuscripts and abstracts of important meetings published through January 2015 have been evaluated. This guideline covers the full spectrum of care of patients infected with hepatitis B, including new terminology, natural history, screening, vaccination, counseling, diagnosis, assessment of the stage of liver disease, the indications, timing, choice and duration of single or combination of antiviral drugs, screening for HCC, management in special situations like childhood, pregnancy, coinfections, renal impairment and pre- and post-liver transplant, and policy guidelines. However, areas of uncertainty still exist, and clinicians, patients, and public health authorities must therefore continue to make choices on the basis of the evolving evidence. The final clinical practice guidelines and recommendations are presented here, along with the relevant background information.
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Affiliation(s)
- S K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - M Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - G K Lau
- Division of Gastroenterology and Hepatology, Humanity and Health Medical Centre, Hong Kong SAR, China
- The Institute of Translational Hepatology, Beijing, China
| | - Z Abbas
- Department of Hepatogastroenterlogy, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - H L Y Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - C J Chen
- Genomics Research Center, Academia Sinica, National Taiwan University, Taipei, Taiwan
| | - D S Chen
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - H L Chen
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - P J Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - R N Chien
- Liver Research Unit, Chang Gung Memorial Hospital and University, Chilung, Taiwan
| | - A K Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Ed Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - J L Hou
- Department of Infectious Diseases and Hepatology Unit, Nanfang Hospital, Guangzhou, China
| | - W Jafri
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - J Jia
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | | | - C L Lai
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - H C Lee
- Internal Medicine Asan Medical Center, Seoul, Korea
| | - S G Lim
- Division of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore
| | - C J Liu
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - S Locarnini
- Research and Molecular Development, Victorian Infectious Diseases Reference Laboratory, Melbourne, Australia
| | - M Al Mahtab
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - R Mohamed
- Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - M Omata
- Yamanashi Hospitals (Central and Kita) Organization, 1-1-1 Fujimi, Kofu-shi, Yamanashi, 400-8506, Japan
| | - J Park
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - T Piratvisuth
- NKC Institute of Gastroenterology and Hepatology, Prince of Songkla University, Songkhla, Thailand
| | - B C Sharma
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India
| | - J Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - F S Wang
- Treatment and Research Center for Infectious Diseases, Beijing 302 Hospital, Beijing, China
| | - L Wei
- Peking University Hepatology Institute, Beijing, China
| | - M F Yuen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Hong Kong, Pofulam, Hong Kong
| | - S S Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
| | - J H Kao
- Graduate Institute of Clinical Medicine and Hepatitis Research Center, National Taiwan University College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Martin P, Lau DTY, Nguyen MH, Janssen HLA, Dieterich DT, Peters MG, Jacobson IM. A Treatment Algorithm for the Management of Chronic Hepatitis B Virus Infection in the United States: 2015 Update. Clin Gastroenterol Hepatol 2015; 13:2071-87.e16. [PMID: 26188135 DOI: 10.1016/j.cgh.2015.07.007] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 07/01/2015] [Accepted: 07/09/2015] [Indexed: 02/07/2023]
Abstract
Chronic hepatitis B (CHB) continues to be an important public health problem worldwide, including in the United States. An algorithm for managing CHB was developed by a panel of United States hepatologists in 2004 and subsequently updated in 2006 and 2008. Since 2008, additional data on long-term safety and efficacy of licensed therapies have become available and have better defined therapeutic options for CHB. The evidence indicates that potent antiviral therapy can lead to regression of extensive fibrosis or even cirrhosis, thus potentially altering the natural history of CHB. In addition, appropriate choice of antiviral agent can minimize the risk of resistance. This updated algorithm for managing CHB is based primarily on evidence from the scientific literature. Where data were lacking, the panel relied on clinical experience and consensus expert opinion. The primary aim of antiviral therapy for CHB is durable suppression of serum hepatitis B virus (HBV) DNA to low or undetectable levels. CHB patients who have HBV DNA >2000 IU/mL, elevated alanine aminotransferase level, and any degree of fibrosis should receive antiviral therapy regardless of their hepatitis B e antigen status. CHB patients with HBV DNA >2000 IU/mL and elevated alanine aminotransferase level but no evidence of fibrosis may also be considered for antiviral therapy. Approved antiviral therapies for CHB are interferon alfa-2b, peginterferon alfa-2a, lamivudine, adefovir, entecavir, telbivudine, and tenofovir, although the preferred first-line treatment choices are peginterferon alfa-2a, entecavir, and tenofovir. In determining choice of therapy, considerations include efficacy, safety, rate of resistance, method of administration, duration, and cost.
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Affiliation(s)
- Paul Martin
- Division of Hepatology, University of Miami School of Medicine, Miami, Florida.
| | - Daryl T-Y Lau
- Liver Center, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California
| | - Harry L A Janssen
- Toronto Centre for Liver Diseases, University Health Network, Toronto, Canada
| | | | - Marion G Peters
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California
| | - Ira M Jacobson
- Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York
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Tan Y, Ye Y, Zhou X, Chen L, Wen D. Age as a predictor of significant fibrosis features in HBeAg-negative chronic hepatitis B virus infection with persistently normal alanine aminotransferase. PLoS One 2015; 10:e0123452. [PMID: 25885705 PMCID: PMC4401737 DOI: 10.1371/journal.pone.0123452] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 03/04/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although alanine aminotransferase (ALT) levels reflect the degree of liver damage, not all patients with chronic hepatitis B virus (HBV) infection exhibit persistently elevated ALT levels. In the present study, we aimed to comprehensively evaluate the characteristics of histological abnormalities in a large population of Chinese patients with chronic HBV and persistently normal ALT levels. METHODS In total, 2303 consecutive patients who underwent liver biopsy were screened. Of these patients, 273 were categorized as having persistently normal ALT levels (PNALT), whereas 618 were categorized as having persistently or intermittently elevated ALT levels (PIALT). All these patients had at least three ALT values recorded in the year prior to the baseline liver biopsy. RESULTS Significant necroinflammation was observed in 9.7% (11/113) patients with PNALT, 23.3% (42/180) patients with PIALT (ALT 1-2× upper limit of normal [ULN]), and 27.8% (42/151) patients with PIALT (ALT > 2× ULN), whereas significant fibrosis was observed in 8.8% (10/113) patients with PNALT, 27.8% (42/151) patients with PIALT (ALT 1-2× ULN), and 21.2% (32/151) patients with PIALT (ALT > 2× ULN). Multiple logistic regression analysis indicated that age parameters were associated with significant histological abnormalities in patients with PNALT. The area under the curve showed that age was associated with significant fibrosis characteristics in patients with hepatitis B extracellular antigen (HBeAg)-negative PNALT. CONCLUSION Significant histological abnormalities are not often observed in Chinese patients with PNALT. Interestingly, age appears to be a predictor of significant fibrosis in patients with HBeAg-negative PNALT.
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Affiliation(s)
- Youwen Tan
- Department of Infectious Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Hepatosis, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang, China
- * E-mail:
| | - Yun Ye
- Department of Hepatosis, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang, China
| | - Xinbei Zhou
- Department of Hepatosis, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang, China
| | - Li Chen
- Department of Hepatosis, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang, China
| | - Danfeng Wen
- Department of Hepatosis, The Third Hospital of Zhenjiang Affiliated Jiangsu University, Zhenjiang, China
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Azmi AN, Tan SS, Mohamed R. Practical approach in hepatitis B e antigen-negative individuals to identify treatment candidates. World J Gastroenterol 2014; 20:12045-12055. [PMID: 25232242 PMCID: PMC4161793 DOI: 10.3748/wjg.v20.i34.12045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 01/17/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
The natural history of chronic hepatitis B is characterized by different phases of infection, and patients may evolve from one phase to another or may revert to a previous phase. The hepatitis B e antigen (HBeAg)-negative form is the predominant infection worldwide, which consists of individuals with a range of viral replication and liver disease severity. Although alanine transaminase (ALT) remains the most accessible test available to clinicians for monitoring the liver disease status, further evaluations are required for some patients to assess if treatment is warranted. Guidance from practice guidelines together with thorough investigations and classifications of patients ensure recognition of who needs which level of care. This article aims to assist physicians in the assessment of HBeAg-negative individuals using liver biopsy or non-invasive tools such as hepatitis B s antigen quantification and transient elastography in addition to ALT and hepatitis B virus DNA, to identify who will remain stable, who will reactivate or at risk of disease progression hence will benefit from timely initiation of anti-viral therapy.
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Xie Q, Hu X, Zhang Y, Jiang X, Li X, Li J. Decreasing hepatitis B viral load is associated with a risk of significant liver fibrosis in hepatitis B e antigen positive chronic hepatitis B. J Med Virol 2014; 86:1828-37. [PMID: 25145769 DOI: 10.1002/jmv.24000] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2014] [Indexed: 12/19/2022]
Abstract
Alanine aminotransferase (ALT), hepatitis B virus (HBV) DNA levels and age are used commonly to assess liver histology in chronic hepatitis B. Increasing levels of HBV DNA are associated with the increasing prevalence of significant fibrosis in HBeAg-negative patients. It is unclear whether these data can be applied to HBeAg-positive patients. In present study, liver biopsies were performed and clinical parameters were measured in 234 treatment-naive chronic HBeAg-positive patients. The proportion of significant fibrosis in patients with ALT 1-2 × ULN was similar to in patients with ALT more than 2 × ULN (48.4% vs. 51.8%). Patients over 30 years of age (>30 years) had a higher prevalence of significant fibrosis than patients 30 years of age and younger (61.0% vs. 33.6%). Negative correlation between HBV DNA levels and significant fibrosis was observed in patients >30 years. The optimal level of serum HBV DNA to evaluate low risk of significant fibrosis was ≥6.7 log10 IU/ml. Patients with serum HBV DNA levels ≥8.5 log10 IU/ml all had no significant fibrosis, however, patients with HBV DNA levels <4.7 log10 IU/ml all had significant fibrosis. Logistic regressions showed that age, aspartate aminotransferase, platelet count, and HBV DNA levels were independent predictors of significant fibrosis. In summary, older age, elevated ALT, and lower HBV DNA levels are associated with significant fibrosis. Decreasing levels of HBV DNA are associated with increasing prevalence of significant fibrosis in patients >30 years. The threshold of HBV DNA levels for treatment of HBeAg-positive patients needs to be combined with age.
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Affiliation(s)
- Qinxiu Xie
- Department of Infectious Disease, the First Affiliated Hospital of Anhui Medical University, Hefei, China
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Nguyen LH, Chao D, Lim JK, Ayoub W, Nguyen MH. Histologic changes in liver tissue from patients with chronic hepatitis B and minimal increases in levels of alanine aminotransferase: a meta-analysis and systematic review. Clin Gastroenterol Hepatol 2014; 12:1262-6. [PMID: 24361419 DOI: 10.1016/j.cgh.2013.11.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 11/22/2013] [Accepted: 11/25/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The level of alanine aminotransferase (ALT) is a marker of hepatitis B severity and response to treatment. However, measurements of ALT level may be of limited use during the immune clearance phase of chronic hepatitis B (CHB) and can be affected by age, weight, and concomitant liver disease. We performed a literature review to determine the proportion of CHB patients with ALT levels of 1- to 2-fold the upper limit of normal who also had significant underlying liver fibrosis (stage ≥2). METHODS We performed a Medline search of original articles published before June 2012, and their references; we also searched abstracts from the 2010 and 2011 annual meetings of the American Association for the Study of Liver Diseases and the 2011 and 2012 Digestive Disease Weeks. Studies were included that had 20 or more consecutive treatment-naive CHB patients with 6 months or more of follow-up evaluation, histologic data, and levels of ALT 1- to 2-fold the upper limit of normal. Study heterogeneity was assessed by a Forest plot and Q and I(2) analyses. Sensitivity was measured using 1-study removed analysis. RESULTS Our analysis included 8 articles and 1 abstract, comprising 683 patients. Based on random-effects modeling, 48% of patients had stage 2 or higher fibrosis (95% confidence interval, 36%-61%). In a sensitivity analysis, exclusion of the study that caused the greatest deflection of the pooled estimate produced a revised estimate of 43%. A subgroup of hepatitis B e antigen-positive and hepatitis B e antigen-negative patients (n = 168 and 170, respectively) showed similar rates of fibrosis (41% vs 47%; P = nonsignificant). CONCLUSIONS Despite heterogeneity in the literature, a substantial proportion of patients with slight increases in ALT level have significant fibrosis. Given the possibility of advanced liver disease, the threshold for antiviral treatment must be individualized. Further studies are needed to investigate patients with modest increases in ALT level.
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Affiliation(s)
- Long H Nguyen
- Department of Internal Medicine, Stanford University School of Medicine, Palo Alto, California
| | - David Chao
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph K Lim
- Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
| | - Walid Ayoub
- Cedar Sinai Medical Center, West Hollywood, California
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California.
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Chao DT, Lim JK, Ayoub WS, Nguyen LH, Nguyen MH. Systematic review with meta-analysis: the proportion of chronic hepatitis B patients with normal alanine transaminase ≤ 40 IU/L and significant hepatic fibrosis. Aliment Pharmacol Ther 2014; 39:349-58. [PMID: 24387289 DOI: 10.1111/apt.12590] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 07/10/2013] [Accepted: 12/01/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic hepatitis B (CHB) may lead to cirrhosis, hepatocellular carcinoma and premature death. Elevated alanine transaminase (ALT) levels ≥ the upper limit of normal (ULN) are a major determinant for initiating anti-viral therapy; however, ALT levels alone may not be predictive of hepatic fibrosis. AIM To determine the proportion of CHB patients with ALT ≤ 40 IU/L and liver fibrosis stage ≥ 2. Secondary goals include subgroup analysis by hepatitis B e antigen (HBeAg) status, high hepatitis B virus (HBV) DNA levels, Asian ethnicity, lower ULN of ≤ 30 IU/L (males) and 19 IU/L (females), and advanced age. METHODS Studies identified in EMBASE and MEDLINE (1/1990-6/2012) using the search criteria: "Hepatitis B"[Mesh] OR "Hepatitis B virus"[Mesh] OR "Hepatitis B, Chronic"[Mesh])) AND "Alanine Transaminase"[Mesh]) and abstracts containing the term 'hepatitis' from recent major U.S. gastroenterology and liver society meetings were considered. RESULTS Among nine studies (N = 830 patients), a significant proportion (20.7%; 95% CI: 16.2-26.0%) of CHB patients with ALT levels ≤ 40 IU/L had significant fibrosis irrespective of HBeAg status, high HBV DNA levels, ethnicity or age, although this proportion may be higher in patients older than 30-40 years old. The corresponding proportion was 27.8% even when the newer ULN of 30 IU/L (males) and 19 IU/L (females) was applied. CONCLUSIONS Approximately one fifth of CHB patients with ALT ≤ 40 IU/L may have significant hepatic fibrosis. The approach to such patients should be individualised, as further evaluation and treatment may be appropriate.
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Affiliation(s)
- D T Chao
- Department of Internal Medicine, University of Pittsburgh Medical Center, Shadyside, Pittsburgh, PA, USA
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Parameters associated with significant liver histological changes in patients with chronic hepatitis B. ISRN GASTROENTEROLOGY 2014; 2014:913890. [PMID: 24616815 PMCID: PMC3927580 DOI: 10.1155/2014/913890] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 11/12/2013] [Indexed: 12/17/2022]
Abstract
This study aimed to evaluate factors associated with significant liver histological changes. Liver biopsies from 157 CHB patients were retrospectively analyzed. Only ALB was significantly correlated with advanced liver necroinflammatory (P = 0.001). Age, ALB, GLOB, AST, PLT, and PT were independent predictors of significant fibrosis (P = 0.002, P < 0.001, P = 0.001, P = 0.048, P < 0.001, and P = 0.001, resp.). AST, WBC, and HBV DNA were significantly correlated with advanced fibrosis in normal ALT patients (P < 0.001, P = 0.041, and P = 0.012, resp.) and age, ALB, GLOB, PLT, and PT in patients with abnormal ALT (P = 0.003, P < 0.001, P = 0.004, P < 0.001, and P = 0.002, resp.). Age, AST, GGT, PLT, and PT were significantly associated with advanced fibrosis in HBeAg+ patients (P = 0.01, P = 0.016, P = 0.027, P = 0.016, and P = 0.009, resp.) and ALB, GLOB, WBC, PLT, and PT in HBeAg− patients (P < 0.001, P = 0.004, P = 0.005, P < 0.001, and P = 0.035, resp.). PLT was an excellent predictor for cirrhosis (P < 0.001 and AUROC = 0.805). ALT was not predictive of advanced fibrosis for patients with HBeAg+ or HBeAg− (P = 0.273 and P = 0.599, resp.). PLT was an excellent predictor for cirrhosis in CHB patients. Liver histopathology can be recommended for chronic HBV carriers of older age, with normal ALT, lower PLT, and lower ALB.
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Liao B, Wang Z, Lin S, Xu Y, Yi J, Xu M, Huang Z, Zhou Y, Zhang F, Hou J. Significant fibrosis is not rare in Chinese chronic hepatitis B patients with persistent normal ALT. PLoS One 2013; 8:e78672. [PMID: 24205292 PMCID: PMC3808379 DOI: 10.1371/journal.pone.0078672] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 09/15/2013] [Indexed: 02/06/2023] Open
Abstract
Background Limited studies have been done on chronic hepatitis B (CHB) patients defined according to the latest Asian-Pacific Association for the Study of the Liver guideline with liver histology by a large sample size. Methods We retrospectively evaluated liver histological characteristics on a cohort of consecutive treatment-naive CHB patients with persistent normal alanine aminotransferase (PNALT) or elevated ALT from May 2005 to October 2011. Histological assessment was based on the Metavir scoring system, significant abnormality was defined as necroinflammation grade ≥A2 and/or fibrosis stage ≥F2. Results A total of 675 CHB patients were recruited, including 516 HBeAg-positive and 159 HBeAg-negative patients. In HBeAg-positive patients, significant fibrosis was found 49.4% (42/85) in PNALT, 69.8% (88/126) in ALT 1-2×upper limit normal (ULN) and 81.6% (249/305) in ALT>2×ULN group, respectively. In HBeAg-negative patients, significant fibrosis was found 30.9% (17/55) in PNALT, 73.3% (33/45) in ALT 1-2×ULN and 94.9% (56/59) in ALT>2×ULN group, respectively. HBeAg-positive patients with PNALT over 30 years old had a higher frequency of significant fibrosis than those under 30 years old (87.5% vs. 45.5%, P = 0.058). Multivariate logistic regression analysis indicated increasing age (P = 0.012), higher aspartate aminotransferase (AST) (P < 0.001) and lower HBV DNA (P < 0.001) were associated with significant necroinflammation, while higher AST (P < 0.001), lower albumin (P = 0.027) and HBV DNA (P = 0.004) were associated with significant fibrosis in HBeAg-positive patients with elevated ALT. Higher AST was associated with significant necroinflammation in HBeAg-negative patients with elevated ALT (P = 0.009). Conclusions Significant fibrosis is not rare in Chinese CHB patients with PNALT, especially HBeAg-positive patients over 30 years old.
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Affiliation(s)
- Baolin Liao
- Hepatology Unit and Key Lab for Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Hepatology, Guangzhou No.8 People’s Hospital, Guangzhou Medical University, Guangzhou, China
| | - Zhanhui Wang
- Hepatology Unit and Key Lab for Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Siwei Lin
- Department of Third Internal Medicine, Yuexiu District Traditional Chinese Medicine Hospital, Guangzhou, China
| | - Ying Xu
- Hepatology Unit and Key Lab for Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junqing Yi
- Department of Hepatology, Guangzhou No.8 People’s Hospital, Guangzhou Medical University, Guangzhou, China
| | - Min Xu
- Department of Hepatology, Guangzhou No.8 People’s Hospital, Guangzhou Medical University, Guangzhou, China
| | - Zuxiong Huang
- Hepatology Unit and Key Lab for Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ying Zhou
- Department of Hepatology, Guangzhou No.8 People’s Hospital, Guangzhou Medical University, Guangzhou, China
| | - Fuchun Zhang
- Department of Hepatology, Guangzhou No.8 People’s Hospital, Guangzhou Medical University, Guangzhou, China
- * E-mail: (FZ); (JH)
| | - Jinlin Hou
- Hepatology Unit and Key Lab for Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- * E-mail: (FZ); (JH)
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Heo J, Park JY, Lee HJ, Tak WY, Um SH, Kim DY, Yoon KT, Park SY, Seo YS, Han KH, Cho M, Ahn SH. A 96-week randomized trial of switching to entecavir in chronic hepatitis B patients with a partial virological response to lamivudine. Antivir Ther 2013; 17:1563-70. [PMID: 22872647 DOI: 10.3851/imp2277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Growing numbers of chronic hepatitis B (CHB) patients in the Asia-Pacific region have failed first-line therapy with low genetic barrier drugs. This prospective, 96-week study investigated the antiviral efficacy, safety and tolerability of switching to entecavir versus maintaining lamivudine in CHB patients with a partial virological response to lamivudine. METHODS A total of 72 hepatitis B e antigen (HBeAg)-positive patients, with serum HBV DNA≥60 IU/ml after ≥6 months lamivudine monotherapy were randomized 1:1 to receive either entecavir 1.0 mg/day, or continued lamivudine 100 mg/day. RESULTS Mean duration of prior lamivudine treatment was 15.1 months in the lamivudine-maintained patients and 16.1 months in the entecavir-switch patients, with mean baseline HBV DNA levels of 4.66 and 4.55 log(10) IU/ml, respectively. A greater proportion of entecavir-switch than lamivudine-maintained patients achieved undetectable HBV DNA at all time points (67.6% versus 11.4% at week 96; P<0.001). Entecavir-switch patients achieved a greater mean decrease in HBV DNA level by week 4, maintained through week 96. Entecavir-switch patients with baseline HBV DNA<5 log(10) IU/ml were more likely to achieve a virological response at week 96. A total of 6 (17.6%) entecavir-switch and 2 (5.7%) lamivudine-maintained patients achieved HBeAg loss, and 3 (8.8%) entecavir and 1 (2.9%) lamivudine patients achieved HBeAg seroconversion. Genotypic resistance to the assigned intervention emerged in 82.9% (29/35) of lamivudine-maintained patients, and in 3% (1/34) of entecavir-switch patients after 96 weeks. CONCLUSIONS Switching to entecavir in patients with a partial virological response to lamivudine resulted in increased virological efficacy and lower rates of antiviral resistance than maintaining lamivudine.
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Affiliation(s)
- Jeong Heo
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
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Turyadi, Thedja MD, Ie SI, Harahap AR, El-Khobar KE, Roni M, Muljono DH. HBsAg, HBeAg and HBV DNA level changes and precore/basal core promoter mutations in the natural history of chronic hepatitis B in Indonesian patients. Hepatol Int 2013. [DOI: 10.1007/s12072-013-9438-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Göbel T, Erhardt A, Herwig M, Poremba C, Baldus SE, Sagir A, Heinzel-Pleines U, Häussinger D. High prevalence of significant liver fibrosis and cirrhosis in chronic hepatitis B patients with normal ALT in central Europe. J Med Virol 2012; 83:968-73. [PMID: 21503908 DOI: 10.1002/jmv.22048] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The indication for antiviral treatment of patients with chronic hepatitis B is based on serum HBV DNA levels, transaminases, and histological grade and stage. The relation of liver fibrosis and inflammation to ALT activity in chronic hepatitis B infection was investigated in a nonendemic, European setting. A total of 253 patients with chronic hepatitis B who had undergone liver biopsy at the Clinic of Gastroenterology, Hepatology, and Infectious Diseases, Düsseldorf,Germany over the past 19 years (1990–2009) were evaluated. Thirty-nine patients had persistently normal transaminases, 86 patients had ALT with 1–2 x ULN (upper limit of normal) and 128 patients had ALT >2 x ULN. Liver fibrosis or inflammation was defined as significant for stages or grades ≥ 2 according to the Desmet/Scheuer score. Significant liver fibrosis (F ≥ 2)was found in 36%, cirrhosis in 18%, and significant inflammation (G ≥ 2) in 27% of patients with normal transaminases. There was no difference in the stage of liver fibrosis and the frequency of cirrhosis between patients with normal and elevated transaminases. The most important factor associated with the presence of cirrhosis in multivariate analysis was age ≥ 40 years (P < 0.003). If concomitant factors like elevated GGT or male sex were furthermore present high prevalences of significant liver disease were found. The data indicate that, in a European setting, patients with chronic hepatitis B infection, and normal transaminases frequently have significant liver fibrosis or cirrhosis.Therefore, liver biopsy or liver stiffness measurement (LSM) should be performed in these patients to determine the stage of liver fibrosis.
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Affiliation(s)
- Thomas Göbel
- Clinic of Hepatology, Gastroenterology, and Infectious Diseases, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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