Hepatitis B infection and changes in interferon-alpha and -gamma production in patients with systemic lupus erythematosus in Taiwan

High Risk of Viral Reactivation in Hepatitis B Patients with Systemic Lupus Erythematosus

HBV reactivation (HBVr) can occur in hepatitis B surface antigen (HBsAg)-positive and negative patients. Here, we determined the incidence of HBVr and its related hepatitis in patients with systemic lupus erythematosus (SLE). From 2000 to 2017, 3307 SLE cases were retrospectively reviewed for episodes of hepatitis. The incidence, long-term outcomes and risk factors associated with HBVr, including HBsAg reverse seroconversion (RS) were analyzed. Among them, 607 had available HBsAg status. Fifty-five (9.1%) patients were positive for HBsAg and 63 (11.4%) were HBsAg-negative/antibody to hepatitis B core antigen (anti-HBc)-positive (resolved hepatitis B infection, RHB). None of them received antiviral prophylaxis before immunosuppressive treatment. During a mean 15.4 years of follow-up, 30 (54.5%) HBsAg-positive patients developed HBVr and seven (23.3%) died of liver failure, whereas only two (3.2%) RHB cases experienced HBsAg reverse seroconversion (RS). Multivariate logistic regression analysis showed that age ≥ 40 years at diagnosis of SLE (HR 5.30, p < 0.001), receiving glucocorticoid-containing immunosuppressive therapy (HR 4.78, p = 0.003), and receiving glucocorticoid ≥ 10 mg prednisolone equivalents (HR 3.68, p = 0.003) were independent risk factors for HBVr in HBsAg-positive patients. Peak level of total bilirubin ≥ 5 mg/dL during HBVr was an independent factor of mortality (p = 0.002). In conclusion, the risk of HBVr was associated with glucocorticoid daily dose. Antiviral prophylaxis is mandatory for SLE patients diagnosed at age of ≥40 years who receive ≥ 10 mg daily dose of oral prednisone or equivalent.

Prevention of infective complications in systemic lupus erythematosus: A systematic literature review for the APLAR consensus statements

Systemic lupus erythematosus (SLE) is a more common autoimmune rheumatic disease in the Asia-Pacific region. The prognosis of SLE remains unsatisfactory in some Asian countries because of delayed diagnosis, limited access to medications, increased complications and issues of tolerability and adherence to treatment. The Asia-Pacific League of Associations for Rheumatology SLE special interest group has recently published a set of consensus recommendations on the management of SLE for specialists, family physicians, specialty nurses, and other healthcare professionals in the Asia-Pacific region. This article reports a systematic literature review of the infective complications of SLE in Asia and evidence for prevention of these infections by pre-emptive antimicrobial therapy and vaccination.

Hepatitis B carrier state among SLE patients: case-control study

The association between hepatitis B and autoimmune disorders has been intriguing for decades. Many reports have speculated on the possible linkage between these two conditions, yet never before data driven from a large national database was utilized in order to investigate this issue. The objective of this study was to investigate the association between SLE and hepatitis B carrier state. Patients with SLE were compared with age- and sex-matched controls regarding the proportion of hepatitis B carrier state in a case-control study. Chi-square and t tests were used for univariate analysis, and a logistic regression model was used for multivariate analysis. The study was performed utilizing the medical database of Clalit Health Services. The study included 5018 lupus patients over the age of 20 years and 25,090 age- and sex-frequency-matched controls without SLE. The proportion of hepatitis B carriers was higher in SLE patients as compared to controls (0.9 and 0.56 %, respectively; p < 0.001). A significant association was also observed among patients in lower socioeconomic status. In a multivariate logistic regression analysis, SLE was significantly associated with hepatitis B (OR = 1.828, 95 % CI = 1.291-2.590). Patients with SLE have a greater proportion of hepatitis B carrier state than matched controls.

Prevalence of hepatitis B virus and hepatitis C virus infection in patients with systemic lupus erythematosus: a systematic review and meta-analysis

We attempted to explore the prevalence of HBV and HCV infections in patients with systemic lupus erythematous (SLE) via a systematic review. Articles published before June 2017 and, related to prevalence rates for HBV and HCV infection in SLE patient were identified in PubMed, Embase, CNKI, and Wanfang databases. Based on these searches 22 studies were selected for further analysis. The OR of HBsAg positive rate in SLE patients compared with control population was 0.28, with significant heterogeneity identified among the studies (I2 = 92%, P < 0.00001). Following exclusion of one study, the adjusted OR of HBsAg in patients with SLE was 0.24, and no significant heterogeneity was observed (I2 = 32%, P = 0.15). The adjusted OR of HBcAb positive rate in SLE patients compared with control population was 0.40, with no significant heterogeneity between studies (I2 = 0%, P = 0.56). The risk of having HCV infection by SLE patients was higher compared with the control subjects (OR = 2.91). In conclusion, this meta-analysis suggested that SLE might exert a role of protection against HBV but not for HCV infection. Further epidemiological and experimental studies are necessary to explore the role and mechanisms by which SLE affects HBV/HCV infections.

Pretreatment Screening for Hepatitis B Virus Infection in Patients with Systemic Lupus Erythematosus

Hepatitis B virus (HBV) infection is one of the most common diseases, and approximately two billion people are infected with HBV in the world. Until recently, hepatitis B surface antigen (HBsAg)-negative patients, carrying hepatitis B surface antibody (anti-HBs) and/or hepatitis B core antibody (anti-HBc), have been considered to have achieved the resolution of HBV infection; however, among those patients, the reactivation of HBV has been increasingly reported after chemotherapy, hematopoietic stem cell transplantation, or immunosuppressive therapy. The reactivation of HBV can cause lethal hepatitis called de novo hepatitis B. Therefore, serological examination for HBV infection before starting immunosuppressive therapy is now recommended for all patients with rheumatic diseases. Systemic lupus erythematosus (SLE) is one of the autoimmune diseases characterized by the production of autoantibodies and usually requires immunosuppressive therapy. However, to date, a few reports are available regarding the prevalence and time course of HBV infection in patients with SLE under immunosuppressive therapy. In this review, we update the prevalence and time course of HBV infection in lupus patients using our data and previous papers available, with a special emphasis on occult HBV infection and a decrease of HBV-related antibodies (anti-HBs and anti-HBc) under immunosuppressive therapy. This review also highlights the screening and management of HBV infection currently recommended and the potential role of HBV infection in the pathogenesis of SLE. Throughout the present review, we recommend the pretreatment screening for HBV infection in patients with SLE as well as patients with other rheumatic diseases.

Hepatitis B Virus Infection Rate and Distribution in Chinese Systemic Lupus Erythematosus Patients

Background

The aim of this study was to investigate the hepatitis B virus (HBV) infection rate in systemic lupus erythematosus (SLE) patients in China, and to determine the age and sex distribution.

Material/Methods

A total of 3981 SLE patients diagnosed in The First Affiliated Hospital of Sun Yat-sen University from January 1996 to December 2011 were retrospectively investigated for evaluation of the HBV infection rate. The HBV infection rate and the positive rate of hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb) were standardized to national census data in 2000 and compared with the prevalence found in the 2006 national survey.

Results

The age and sex standardized HBV infection rate in Chinese SLE patients was 3.3%. The age and sex standardized positive rate of HBsAb and HBcAb were 58.1% and 26.1%, respectively. As compared with the prevalence from the 2006 national survey, the HBV infection rate and the positive rate of HBcAb were lower and the positive rate of HBsAb was higher in SLE patients aged 15–49 years old compared to peers in the general population. There was no difference in HBV infection rate between males and females (4.2% vs. 2.8%, p=0.088) in SLE patients.

Conclusions

The HBV infection rate was relatively lower in SLE patients compared with the general population, but there was no difference in pediatric patients or patients aged above 50 years old. Unlike in the general population, the HBV infection rate had no statistical differences between males and females in SLE patients.

Altered mRNA levels of MOV10, A3G, and IFN-α in patients with chronic hepatitis B

To explore the relationship of the MOV10, A3G, and IFN-α mRNA levels with chronic hepatitis B virus (HBV) infection, Blood samples from 96 patients with chronic hepatitis B (CHB) and 21 healthy individuals as control were collected. HBV DNA load and aminotransferase in the serum were tested using real time PCR and velocity methods, respectively. The MOV10, A3G, and IFN-α mRNA levels in the peripheral blood mononuclear cells (PBMC) were examined through qRT-PCR. The MOV10, A3G, and IFN-α mRNA levels in CHB group was significantly lower than those in the control group (P<0.01, P<0.05, P<0.01, respectively). The A3G mRNA level in the high-HBV DNA load group was lower than that in the low-HBV DNA load group (P<0.05). However, no statistical difference was found in the MOV10 and IFN-α mRNA levels between the two HBV DNA load groups. Furthermore, the MOV10 mRNA level showed positive correlation with IFN-α in the control group. These results indicated that the expression of the innate immune factors MOV10, A3G, and IFN-α is affected by chronic HBV infection.

Prevalence and time course of hepatitis B virus infection in patients with systemic lupus erythematosus under immunosuppressive therapy

OBJECTIVE

To clarify the prevalence and time course of hepatitis B virus (HBV) infection in patients with systemic lupus erythematosus under immunosuppressive therapy.

METHODS

We performed serological examination of 248 lupus patients to determine the presence of HBV, including hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and hepatitis B core antibody (anti-HBc). Serum HBV DNA levels were measured in HBsAg-positive patients or resolved HBV carriers (HBsAg-negative, anti-HBs-positive, and/or anti-HBc-positive). If possible, we repeatedly performed examination of markers of HBV infection in resolved carriers.

RESULTS

Two (0.8%) patients were positive for HBsAg. Among 41 (16.5%) patients who were considered as resolved HBV carriers, 1 (2.4%) showed serum HBV DNA, which indicated occult HBV infection. The mean age and positive rate of anti-double stranded DNA antibody were significantly higher in resolved carriers than in anti-HBs- and anti-HBc-negative patients. Repeated examination showed that the anti-HBs and anti-HBc titer decreased below the threshold in 4 resolved carriers.

CONCLUSIONS

The prevalence of resolved HBV carriers in Japanese lupus patients was 16.5%. Among them, occult HBV infection and decrease in anti-HBs and anti-HBc titer were observed. These findings indicated that all lupus patients should undergo serological examination for HBV before treatment. If patients have already been treated, we must carefully monitor their liver function, even when all HBV markers are negative.

Management of hepatitis B reactivation in patients with lupus nephritis

Hepatitis B is endemic in many Asian countries and immunosuppression may precipitate hepatitic flare. There is little data on the treatment of hepatitis B in patients with systemic lupus erythematosus. We monitored serial transaminase and HBV DNA levels in our HBsAg-positive patients with a history of lupus nephritis and instituted anti-viral treatment in patients who showed virological reactivation. This retrospective pilot study reports the data with this pre-emptive management strategy. Amongst 228 patients with lupus nephritis, eight (3.51%) were HBsAg-positive and five had received Lamivudine treatment for hepatitis B. In two patients the virological flares were preceded by lupus flares that necessitated an increase in immunosuppressive treatment. Median HBV DNA level was 1.9 x 10(7) copies/mL (range 1.2 x 10(4)-1.0 x 10(9) copies/mL) at baseline, and it decreased by 2-5 logs after treatment. Four patients had abnormal transaminase levels at baseline, with mean alanine aminotransferase at 125.0 +/- 67.4 U/L, and all achieved normalisation after 3-24 months (median 13 months) of treatment. Discontinuation of Lamivudine treatment was attempted in three patients after 9-15 months. In one patient treatment was recommenced because of virological flare. For the remaining two patients in whom treatment was not interrupted, one showed sustained viral suppression and one developed drug resistance. All antiviral treatments were well-tolerated. These results indicate the importance of serial monitoring of HBV DNA and transaminase levels, and prompt anti-viral therapy, in the management of HBsAg-positive lupus patients. Also, it may be feasible to discontinue treatment in stable patients to avoid the selection of drug-resistant variants.

Investigations and management of gastrointestinal and hepatic manifestations of systemic lupus erythematosus

Gastrointestinal (GI) manifestations of systemic lupus erythematosus (SLE) are protean. Any part of the GI tract and the hepatobiliary system can be involved. Up to two-third of SLE patients develop GI symptoms at some stage of their illnesses. Clinical presentations of GI lupus are non-specific and can be difficult to differentiate from infective, thrombotic, therapy-related and non-SLE etiologies. Clinical acumen and appropriate endoscopic, biopsy and imaging procedures are essential for establishing the correct diagnosis. Acute abdominal pain in SLE patients can herald an intra-abdominal catastrophe and should be evaluated promptly. Surgical intervention should be instituted without delay if conservative management fails or when there is clinical or radiological suspicion of visceral perforation or intra-abdominal collections.

[Systemic lupus erythematosus and risk of hepatitis B vaccination: from level of evidence to prescription]

INTRODUCTION

Case reports focusing on immunological diseases occurring subsequently to vaccination are often described in the literature. Reporting of such cases may influence physicians' perception of risks related to immunization, and thereby immunization practices. The decision to vaccinate a patient with an immunological disease should not rely on such case reports, but on the level of evidence of a causal relationship between vaccination and the occurrence of an adverse event. This article describes the search for available data supporting such causality before taking the decision to introduce vaccination against hepatitis B in a female patient with systemic lupus erythematosus (SLE).

CURRENT KNOWLEDGE AND KEY POINTS

Data extracted from Medline and surveillance system showed that: 1) biologic plausibility of a relationship between the HBs antigen and SLE was unlikely; 2) case reports or case series were seldom and not convincing regarding potential causality; and 3) there were neither controlled observational studies nor controlled clinical trials. The only available clinical study was of poor quality and did not show any adverse event. The level of evidence of a causal relationship between vaccination against hepatitis B and the occurrence of an adverse event in patients with SLE was low, in-between levels 4 and 5 as defined by the Center for evidence-based medicine. The risk-benefit ratio may therefore rely on these results and guide the decision whether or not vaccination should be introduced.

FUTURE PROSPECTS AND PROJECTS

The type of reasoning reported in this paper can be used for other vaccines or other immunological diseases, and have wider applicability in terms of therapeutic risk management when data and evaluation are lacking that could guide decisions.

Gastrointestinal manifestations of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) can involve any part of the gastrointestinal tract. In this review, we list the gastrointestinal manifestations of SLE and analyze current approaches in investigating and treating these common conditions. Abdominal symptoms and signs may be due to SLE or due to medications used in the treatment of SLE. In patients with abdominal pain and active SLE, it is critical to diagnose vasculitis or thrombosis with appropriate scanning and institute early immunosuppressive or surgical treatment.