Clinical course of chronic hepatitis B (CHB) presented with normal ALT in Asian American patients

The challenges of integrating an immigrant population with chronic hepatitis B into long-term hepatology care: Lessons learned from a Bronx West African screening program

Objectives

Hepatitis B virus (HBV) is endemic in West Africa. Because of immigration to the United States, screening and transition to long-term care is a significant public health concern. We describe the challenges of integrating individuals identified in a screening program into long-term care and the spectrum of disease severity.

Methods

Between 2019 and 2023, 749 individuals were screened. Beginning 2022, all were offered a free serologic evaluation. Details of the previous diagnosis, HBV care, the serologic evaluation, aspartate aminotransferase to platelet ratio index, and Fibrosis index-4 scores were recorded. The results of transient elastography (TE) were correlated with the serologic evaluation.

Results

A total of 75 (10%) individuals were hepatitis B surface antigen-positive, including 58 (77.3%) previously and 17 (22.7%) newly diagnosed. Despite attempts at linkage to care, only 14 (37.8%) of those diagnosed before the offer continued and/or entered long-term care. A total of 63 of 75 (84%) returned for the evaluation. Among 56 HBV treatment-naïve individuals, 66.1% had a serologic profile consistent with the carrier state. A total of 10 (18.2%) individuals met the criteria for HBV therapy, and 10 (21.7%) had ≥F2 fibrosis on TE. There was no correlation between aspartate aminotransferase to platelet ratio index and Fibrosis index-4 scores and TE. Eight (29.6%) of 27 patients with a profile of the HBV carrier state had ≥F2 fibrosis.

Conclusion

Integration of individuals with HBV from West Africa identified in a screening program into long-term care is challenging. Inclusion of a serologic evaluation in programs for immigrant communities should be considered. Up to 30% of individuals with a serologic profile consistent with the HBV carrier state may have ≥F2 fibrosis.

Serum HBsAg and HBcrAg is associated with inflammation in HBeAg-positive chronic hepatitis B patients

Backgrounds & aims

Liver inflammation is the main risk factor for developing liver fibrosis, cirrhosis, and even hepatocellular carcinoma in chronic hepatitis B (CHB) patients. To replace biopsy, additional non-invasive biomarkers to diagnose and grade liver necroinflammation are urgently required in clinical practice.

Method

Ninety-four CHB patients, including 74 HBeAg-positive and 20 HBeAg-negative patients, were enrolled and started entecavir or adefovir therapy. Serum HBV RNA, HBV DNA, HBsAg, hepatitis B core-related antigen (HBcrAg), ALT and AST levels, as well as intrahepatic HBV DNA and cccDNA were measured at baseline and during treatment. Liver inflammation was assessed at baseline and month 60 by liver biopsy. Inflammation regression was defined as a ≥1-grade decrease according to the Scheuer scoring system.

Results

In HBeAg-positive CHB patients, at baseline, serum HBsAg and HBcrAg levels negatively correlated with inflammation grade, while ALT and AST levels positively correlated with inflammation grade. AST plus HBsAg exhibited excellent diagnostic ability for significant inflammation with an AUROC of 0.896. After 60 months of antiviral treatment, almost all the patients’ liver inflammation ameliorated to G1, and no patients had inflammation progression.

Conclusion

Besides ALT and AST, serum HBsAg and HBcrAg correlated with inflammation grade in HBeAg-positive CHB patients before NAs treatment. Moreover, the combination of HBsAg and AST exhibited excellent diagnostic ability for significant inflammation.

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

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

Serum GP73 combined AST and GGT reflects moderate to severe liver inflammation in chronic hepatitis B

BACKGROUND

Non-invasive method to identify chronic hepatitis B (CHB) patients with at least moderate inflammatory lesion but no increased ALT is an unmet need. We evaluated Golgi protein 73 (GP73) based hepatic inflammation model (HIM) as a serum surrogate for liver necroinflammatory activity, especially in those with ALT less than traditional upper concentration.

METHODS

The diagnostic performances of HIM were evaluated in 2 independent cohorts of liver biopsy proved CHB patients by receiver operating characteristic (ROC) curve analysis.

RESULTS

HIM, a suggested index combined GP73, gamma-glutamyltransferase and AST, could significantly improve the diagnostic accuracy for liver necroinflammation (Area under ROC, AUROC: 0.890). More importantly, HIM still exhibit excellent diagnostic value (AUROC: 0.873) to identify patients with at least moderate liver necroinflammatory activity but with ALT <40 U/l. Serum GP73 was the major source of improvement for diagnostic model's accuracy.

CONCLUSION

HIM is probably a promising non-invasive index to identify CHB patients with moderate to severe liver necroinflammation, especially in those with ALT <40 U/l.

Expression of MMP-9 in different degrees of chronic hepatitis B and its correlation with inflammation

Expression of matrix metalloproteinase-9 (MMP-9) in different degrees of chronic hepatitis B (CHB) and the correlation of MMP-9 with inflammation was investigated. A total of 96 CHB patients (observation group) admitted and treated in Dongying People's Hospital from December 2016 to November 2017 were selected, and they were compared with 60 healthy individuals (control group) selected in the physical examination center during the same time period. Enzyme-linked immunosorbent assay (ELISA) was used to detect the expression of MMP-9, tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6), MMP-9 expression in different inflammation grades and fibrosis stages, and the relationship between MMP-9 and inflammation was analyzed. The levels of MMP-9, TNF-α and IL-6 in serum in the observation group were obviously higher than those in the control group (P<0.05). The rank sum test indicated that there were statistically significant differences in the expression levels of MMP-9 among the inflammation grades G0, G1, G2, G3 and G4 (P<0.05). The expression levels of MMP-9 in fibrosis stages S0, S1, S2, S3 and S4 were detected via the rank sum test, and it suggested that the differences among the 5 stages were statistically significant (P<0.05). Pearsons correlation analysis showed that the MMP-9 expression level was positively correlated with TNF-α and IL-6 (P<0.05). In conclusion, the MMP-9 level is elevated remarkably in patients with varying degrees of CHB, it may play an important role in the pathological progress of liver, and it has a close correlation with inflammation, which can provide a theoretical basis for clinical treatment.

Factors Predicting HBsAg Seroclearance and Alanine Transaminase Elevation in HBeAg-Negative Hepatitis B Virus-Infected Patients with Persistently Normal Liver Function

Background

A certain proportion of hepatitis B virus (HBV)-infected patients with persistently normal alanine transaminase (ALT) levels have significant fibrosis. Using liver stiffness measurements (Fibroscan^®) and laboratory data, including serum ALT, quantitative HBsAg (qHBsAg), and HBV DNA, we attempted to predict the natural histories of these patients.

Methods

Non-cirrhotic HBeAg-negative chronic hepatitis B patients with persistently normal ALT were followed up prospectively with the end points of HBsAg seroclearance and ALT elevation above the upper limit of normal. The factors that were predictive of the end points were identified.

Results

A total of 235 patients with an average age of 48.1 +/- 10.7 years were followed up for 7 years. Eight patients (3.4%) lost HBsAg, and 15 patients (6.4%) experienced ALT elevation. The overall cumulative HBsAg seroclearances were 0.4%, 1.3% and 2.3% at years 1, 3 and 5, respectively. Regarding HBsAg seroclearance, the qHBsAg (< 30 IU/ml) cutoff resulted in a hazard ratio (HR) of 19.6 with a 95% confidence interval (CI) of 2.2–166.7 (P = 0.008). The baseline ALT level (odd ratio (OR) 1.075, 95% CI 1.020–1.132, P = 0.006) and a qHBsAg above 1000 IU/ml (3.7, 1.1–12.4, P = 0.032) were associated with ALT elevation. Limited to men, the baseline liver stiffness (1.6, 1.0–2.5, P = 0.031) and a qHBsAg above 1000 IU/ml (10.4, 2.1–52.4, P = 0.004) were factors that were independently associated with ALT elevation.

Conclusion

A low qHBsAg level predicted HBsAg clearance. Baseline ALT and a qHBsAg above 1000 IU/ml were independent predictive factors for ALT elevation. Among the men, the independent predictive factors for ALT elevation were qHBsAg and liver stiffness.