Spectrum of hepatitis B and renal involvement

Hepatitis B virus-targeting sodium taurocholate cotransporting polypeptide mediates HBV infection and damage in human renal podocytes

Hepatitis B virus (HBV) may directly infect human podocytes (HPCs). However, the mechanism of direct infection is unclear. We found that HPCs express sodium taurocholate cotransporting polypeptide (NTCP), a specific receptor for HBV entry into hepatocytes. Thus, we investigated whether NTCP mediates HBV infection and damage in HPCs and further clarified the specific mechanism. We constructed shRNA-NTCP1,2, shRNA-NC, WT-NTCP, and MUT-NTCP and transfected them into HPCs. HPCs were infected with HBV, and HBV infection markers were detected by enzyme-linked immunosorbent assay (ELISA) and real-time quantitative PCR (RT-qPCR). The functional changes in HPCs were detected by Transwell migration and scratch assays, apoptosis was evaluated by flow cytometry (FCM), and podocytoskeletal proteins (nephrin, CD2AP, and synaptopodin) were determined by western blotting (WB). Compared with the control HPCs, HPCs infected with HBV showed increased levels of HBV infection markers and apoptosis along with decreased podocytoskeletal protein expressions, cell vitality, proliferation, and migration. Compared with the HPCs infected with HBV, the HPCs transfected with HBV + shRNA-NTCP, and HBV + MUT-NTCP showed decreased levels of HBV infection markers and apoptosis along with increased podocytoskeletal protein expressions, cell vitality, proliferation, and migration; the opposite effects were observed in the HPCs transfected with HBV + WT-NTCP. Overall, the changes to NTCP affected the susceptibility of HPCs to HBV and modulated HPC damage and repair. NTCP can mediate direct HBV infection and damage human podocytes, and the NTCP 157-165 locus is the main site of HBV entry. The findings provide a new target and theoretical basis for HBV-associated glomerulonephritis.

IMPORTANCE

This study identified for the first time that sodium taurocholate cotransporting polypeptide (NTCP) can mediate HBV direct infection and damage to human podocytes, and the NTCP157-165 locus is the main HBV entry site. The findings provide theoretical support for the pathogenesis of direct infection of HBV with kidney tissue. The findings provide a new target and theoretical basis for the treatment of HBV-related glomerulonephritis (HBV-GN). Blocking NTCP is a new target for the treatment of HBV-GN. We found that tacrolimus, a calcineurin inhibitor that blocks NTCP, can effectively treat HBV-GN. This study also provides a theoretical basis for the effective and safe treatment of immunosuppressant tacrolimus for HBV-GN.

Expanding the donor pool: Kidney transplantation from serum HBV DNA or HBeAg-positive donors to HBsAg-negative recipients

BACKGROUND & AIMS

HBsAg-positive (HBsAg[+]) donors are rarely accepted for kidney transplantation (KT), especially when the donor is also HBV DNA-positive (HBV DNA[+]) or HBeAg-positive (HBeAg[+]) serologically. This study aimed to report kidney transplant outcomes from HBsAg(+) donors to HBsAg(-) recipients.

METHODS

Consecutive cases were retrospectively identified from 1 July 2017 to 31 December 2020. KTs from HBsAg(-)/HBcAb-positive (HBcAb[+]) donors to HBcAb(-) recipients were selected as the control group. The primary outcomes were de novo HBV infection (DNH), graft and patient survival.

RESULTS

We identified 105 HBsAg(-) recipients who received HBsAg(+) kidneys and 516 HBcAb(-) recipients who received HBcAb(+) kidneys. A higher DNH rate was observed after receiving HBsAg(+) kidneys than after receiving HBcAb(+) kidneys after a median follow-up of 23.0 months (4/105[3.8%] vs. 2/516[0.4%], p = .009). All four infected recipients receiving HBsAg(+) kidneys had HBsAg clearance after treatment. Graft and patient survival were comparable between the groups (p = .630, p = .910). The DNH rates were 0/22(0%), 3/70(4.3%) and 1/13(7.7%) after receiving HBsAg(+), HBV DNA(+) and HBeAg(+) kidneys, respectively (p = .455). The DNH rate was lower if the donor had received antiviral treatment (4/42[9.5%] vs. 0/63[0%], p = .023). HBsAb(-) recipients had a higher DNH incidence than HBsAb(+) recipients (3/25[12.0%] vs. 1/80[1.3%], p = .041).

CONCLUSIONS

The use of HBsAg(+) donors contributed to comparable graft and patient survival, but HBV DNA(+) or HBeAg(+) donors and HBsAb(-) recipients maybe associated with a higher risk of HBV infection. These findings help expand the donor pool and emphasize the role of donor antiviral treatment and recipient HBV immunity in establishing optimal prophylactic regimens.

The effect of hepatitis B virus on the risk of pregnancy outcomes: a systematic review and meta-analysis of cohort studies

BACKGROUND

The effect of HBV on neonatal and maternal outcomes can create a basis for more accurate clinical decision-making. So, the aim of this meta-analysis is to detrmine the effect of chronic hepatitis B virus on the risk of pregnancy outcomes by combining cohort studies.

METHODS

International databases in this meta-analysis included the Cumulated Index to Nursing and Allied Health Literature (CINAHL), SPORT Discuss via the EBSCO interface, PubMed (Medline), Scopus, Web of Science, Embase, which were searched up to April 2023. All cohort studies reporting the risk ratio (RR) with a 95% confidence interval (CI) were included in the study. The quality assessment was done based on the Newcastle-Ottawa Scale (NOS).

RESULTS

Finally, thirty-five cohort studies were selected for meta-analysis. Outcomes of interest included pre-eclampsia, gestational diabetes, abortion, preterm birth, infant death, and other related outcomes. Results showed that the pooled RR for incident gestational diabetes in pregnant women with choronic hepatitis B infection was 1.16 (RR: 1.16; 95% CI 1.13-1.18; I-square: 92.89%; P value: 0.00). Similarly, the association between the presence of hepatitis B infection in pregnant women and the occurrence of pre-eclampsia was 1.10 (RR: 1.10; 95% CI 1.04-1.16; I-square: 92.06%; P value: 0.00). The risk of preterm delivery in pregnant women with hepatitis B infection was 1.17 times that of pregnant women without hepatitis B infection (RR: 1.17; 95% CI 1.14-1.20; I-squared: 94.32%; P value: 0.00).

CONCLUSION

This meta-analysis found that hepatitis B infection during pregnancy may be associated with an increased risk of gestational diabetes, preterm delivery, pre-eclampsia, and eclampsia. However, confirmation of this association, as well as the specific biological pathways involved in the association between HBV infection and pregnancy outcomes, requires further investigation.

Autoimmunity and Infection in Glomerular Disease

The ongoing glomerular damage of infections is not limited to the most widely known form of post-streptococcal glomerulonephritis, which is today less common in the Western world; other forms of glomerulonephritis are associated with several bacterial, viral and parasitic pathogens. The mechanisms responsible range from the direct damage of glomerular cells to the formation and deposition of immunocomplexes to molecular mimicry to the secretion of superantigens. Similarly, in the course of glomerular disease, infections are more frequent than in the general population due to the loss of immunoglobulins in urine and the immunosuppressive agents used to treat the autoimmune disease that decrease the activity of the immune system. Recognizing this two-way link, understanding its pathogenetic mechanism, and identifying the most appropriate therapeutic choice are essential for the personalized management of patients. In this continuously developing field, this short review summarizes the current state of the art as support for physicians, who are increasingly involved in managing patients with glomerular disease and infections.

Infection-Related Glomerulonephritis in Children and Adults

Infection-related glomerulonephritis is an immunologically mediated glomerular injury after an infection. Glomerulonephritis may occur with the infection or after a variable latent period. Poststreptococcal glomerulonephritis (PSGN) is the prototype of infection-related glomerulonephritis. The streptococcal antigens, nephritis-associated plasmin-like receptor and streptococcal exotoxin B, have emerged as major players in the pathogenesis of PSGN. Although PSGN is the most common infection-related glomerulonephritis in children, in adults, glomerulonephritis is secondary to bacteria such as staphylococci, viruses such as hepatitis C, and human immunodeficiency virus, and, rarely, parasitic infections. Supportive therapy is the mainstay of treatment in most infection-related glomerulonephritis. Treatment of the underlying infection with specific antibiotics and antiviral medications is indicated in some infections. Parasitic infections, although rare, may be associated with significant morbidity. Poststreptococcal glomerulonephritis is a self-limiting condition with a good prognosis. However, bacterial, viral, and parasitic infections may be associated with significant morbidity and long-term consequences. Epidemiologic studies are required to assess the global burden of infection-related glomerulonephritis. A better understanding of the pathogenesis of infection-related glomerulonephritis may unravel more treatment options and preventive strategies.

Efficacy and safety of entecavir for hepatitis B virus-associated glomerulonephritis with renal insufficiency

BACKGROUND

HBV-GN is one of the most common secondary kidney diseases in China. Entecavir is a first-line antiviral therapy in patients with HBV-GN.

OBJECTIVE

This retrospective study explored whether entecavir is effective and safe for the treatment of HBV-GN with renal insufficiency.

METHODS

We screened patients diagnosed with HBV-GN in The Affiliated Hospital of Qingdao University who had elevated serum creatinine levels. Group 1 (30 patients) was given entecavir as antiviral treatment. Group 2 (28 patients) was treated with ARBs. Changes in renal function and the possible influencing factors were observed, with a mean follow-up duration of 36 months.

RESULTS

At the end of follow-up, the elevation in the serum creatinine level and reduction in the eGFR were greater in group 1 than in group 2. The overall renal survival rate, using eGFR < 15 ml/min as the primary renal end point, was 96.7% in group 1 and 67.9% in group 2. Urine protein excretion was decreased in both groups. Treatment with entecavir and the remission of proteinuria were protective factors against renal function impairment, while a lower baseline eGFR was a risk factor for progression to ESRD.

CONCLUSIONS

Entecavir slows the progression of renal function impairment in HBV-GN and exerts a significant renal protective effect.

Prevalence of Hepatitis B and Hepatitis C Virus Infection in Patients with Advanced Renal Failure: A Tertiary Care Centre Study from North Indian Population

Abstract: Viral hepatitis (Hepatitis B Virus (HBV) & Hepatitis C Virus (HCV)) related liver disease is a leading cause of morbidity and mortality especially in the patients with advanced renal failure who are treated with dialysis, and this is due to high number of blood transfusion sessions and/or cross contamination from the dialysis circuits. Aims & Objectives: This study aimed to determine the prevalence of HBV and HCV infections in patients with advanced renal failure (ARF). Materials & Methods: A cross-sectional study was done in joint collaboration of Department of Nephrology and Department of Gastroenterology, KGMU, Lucknow, from June 2018 to June 2020 among, CRF patients. Clinical data such as age, gender, duration of dialysis; number of transfusions, Serum sample was collected from each patient. Serological markers for HBV and HCV were determined with ELISA by using commercial diagnostic kits. HCV-RNA and HBV-DNA were determined quantitatively by polymerase chain reaction (PCR) assay. Results: A total 934 patients with advanced renal failure attended the nephrology OPD. Out of 934 patients, 65 (6.96%) patients screened positive for HBV/HCV infection. The results of this study also showed that the prevalence of viral hepatitis infection in the haemodialysis (HD) and without HD patients is 8.25% and 6.3% respectively. Conclusion: It has been found that viral infections, particularly HBV and HCV infections are common in advanced renal failure patients who are on HD.

DNA methyltransferase 1 knockdown reverses PTEN and VDR by mediating demethylation of promoter and protects against renal injuries in hepatitis B virus-associated glomerulonephritis

Background

Aberrant DNA methylation patterns, including hypermethylation of key genes that inhibit fibrosis and inflammation, have been described in human kidney diseases. However, the role of DNA methyltransferase 1 (DNMT1) in hepatitis B virus-associated glomerulonephritis (HBV-GN) remains unclear.

Methods

We explored the underlying mechanism by establishing HBV X protein (HBx) overexpressing renal tubular epithelial (HK-2) cells and human podocytes with DNMT1 knockdown. Using RNA-sequencing to determine the downstream targets of DNMT1 and evaluate its levels of promoter methylation. HBV transgenic mice were used to examine the effects of DNMT1 inhibitor on renal in vivo.

Results

DNMT1 was significantly upregulated in the renal tissue of HBV-GN patients, accompanied by injuries of HK-2 cells and podocytes. HBx markedly upregulated DNMT1 and induced epithelial-mesenchymal transition (EMT) and inflammation in HK-2 cells and human podocytes. This increased DNMT1 expression was attenuated after DNMT1 knockdown, accompanied by restored HK-2 cells and podocyte injuries resulting from the activation of PI3K/Akt/mTOR and nuclear factor-kappa B (NF-κB) pathways. Hypermethylation of the phosphatase and tensin homolog (PTEN) promoter and vitamin D receptor (VDR) was induced in HBx-overexpressing HK-2 cells and podocytes, respectively, whereas DNMT1 knockdown effectively corrected these alterations. Furthermore, PTEN and VDR ablation resulted in marked EMT and inflammation induction in HBx-overexpressing HK-2 cells and human podocytes even with DNMT1 knockdown. Downregulation of the PI3K/Akt/mTOR-related pathway attenuated HBx-induced EMT and inflammation in HK-2 cells. Luciferase reporter assay revealed VDR as a direct target of the Snail family transcriptional repressor 1 (SNAI1) in HBx-overexpressing podocytes. DNA methylation inhibitor 5-azacytidine alleviated urinary protein and renal inflammation in HBV transgenic mice via PTEN-PI3K/Akt signaling and VDR signaling axis.

Conclusions

Our study clarifies the potential epigenetic mechanisms underlying HBx-induced renal injuries in HBV-GN and the renoprotective effects of inhibiting DNMT1, which can provide important insights into the development of treatments for HBV-GN.

Effect of pegylated interferon-α2b add-on therapy on renal function in chronic hepatitis B patients: A real-world experience

Background and aim

Controversy remains as to pegylated interferon-α (PEG-IFNα) antiviral therapy to renal function in chronic hepatitis B (CHB) patients. The aim of this study was to evaluate the influence of PEG-IFNα2b (Y shape, 40 kD) add-on treatment for renal function in CHB patients who received entecavir therapy.

Methods

This was a retrospective observational study to investigate factors related to renal function in 114 CHB patients who received PEG-IFNα2b add-on therapy to entecavir for 48 weeks. Changes of blood urea nitrogen (BUN), serum creatinine (sCr), and estimated glomerular filtration rate (eGFR), which was calculated with both Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease (MDRD) formulas, were analyzed by one-way analysis of variance. A linear mixed effects model for repeated measures was used to assess the correlation between baseline information and eGFR changes at 24 and 48 weeks of therapy. The model considered the baseline age, gender, body weight, viral load, hepatitis B surface antigen, BUN, sCr, and treatment strategy as fixed effects and incorporated random effects for individual subjects.

Results

BUN and sCr was decreased, while eGFR was increased at 12 weeks of therapy. Only eGFR maintained at 24 and 48 weeks of therapy. Patients with female gender, age ≥ 40 years, and baseline HBsAg level &lt; 250 IU/mL showed significant improvement of renal function with PEG-IFNα2b add-on therapy. The linear mixed effects model revealed that female gender, baseline sCr, and PEG-IFNα2b add-on were significant positive predictors for eGFR elevation at 24 and 48 weeks of therapy.

Conclusion

In real-world experience, PEG-IFNα2b add-on therapy might be associated with increased eGFR in CHB patients.

Prevalence and risk factors for chronic kidney disease in Indonesia: An analysis of the National Basic Health Survey 2018

Background

The prevalence of chronic kidney disease (CKD) in Indonesia is rising, but the exact extent of the burden of CKD in Indonesia is unknown. To design a screening program for individuals at high-risk, more knowledge is required regarding the prevalence and risk factors of CKD in Indonesia. The latter could have a big impact on the prevention and management of patients with CKD in Indonesia.

Methods

For this purpose, we analysed data from The National Basic Health Survey 2018 (Riset Kesehatan Dasar, Riskesdas 2018), a descriptive cross-sectional study in 34 provinces, 416 districts and 98 cities in Indonesia. We included subjects aged ≥18 years and analysed the prevalence of CKD. Using multiple logistic regression, we investigated the association between CKD and potential risk factors such as demographic factors (age, gender, occupational status, level of education), lifestyle and behaviours (consumption of salty food, consumption of fruit and vegetables, smoking, alcohol consumption, carbonated drink consumption, physical activity), comorbid conditions (hypertension, heart disease, diabetes mellitus, hepatitis, stroke, nutritional status) and others (clean water supply, pregnancy complication, access to health care).

Results

We included 389 093 subjects in this study out of 713 783 subjects that participated in Riskesdas 2018 survey. The prevalence of CKD was 0.5%. The survey included mostly younger adults age 18-59 years (83.1%) with a mean (SD) age of 44.3 (15.1) years. The majority of subjects were female (60.3%), unemployed (58.4%), and the proportion of obese subject was 25.4%. Hypertension was the major comorbid condition (40.8%), while the proportion of diabetes mellitus (DM), heart disease, stroke and hepatitis were quite low (3.3%, 2.6%, 1.7% and 0.5%; respectively). Despite the high proportion of hypertension, only 36.2% of subjects did receive a prescription for anti-hypertensive medication of which only 21.7% used this medication regularly. The multiple logistic regression analysis demonstrated that hepatitis was the strongest risk factor of CKD (odds ratio (OR) = 3.406; 95% confidence interval (CI) = 2.496-4.648), exceeding the risk of CKD in patients with physical inactivity (OR = 1.236; 95% CI = 1.128-1.354), low education status (OR = 1.307; 95% CI = 1.191-1.434), male (OR = 1.527; 95% CI = 1.398-1.668), stroke (OR = 1.916; 95% CI = 1.570-2.338), heart disease (OR = 2.941; 95% CI = 2.356-3.671), and DM (OR = 2.462; 95% CI = 1.979-3.063). We also observed that DM (OR = 4.280; 95% CI = 3.756-4.876) and male subjects (OR = 1.474; 95% CI = 1.352-1.606) were identified as independent risk factors for CKD in hepatitis-positive subjects.

Conclusions

This population-based survey confirmed the increasing burden of CKD in Indonesia and suggested that besides traditional metabolic risk factors, viral hepatitis has proven to be an independent risk factor for CKD in Indonesia. Furthermore, the risk of CKD is greater in male hepatitis patients with DM. The result of this study demonstrates the need for an aggressive screening program for patients with a high risk for the development of CKD. Apart from patients with traditional cardiometabolic risk factors, such a program should include patients with viral hepatitis.

Favorable outcome in PLA2R positive HBV-associated membranous nephropathy

Introduction

Over half of the patients with hepatitis B virus associated membranous nephropathy (HBV-MN) were found to be phospholipase A2 receptor (PLA2R) positive. Whether MN is really secondary to hepatitis B or just coincidence of hepatitis and PLA2R positive idiopathic MN (IMN) remains controversial.

Methods

We retrospectively studied seven PLA2R positive HBV-MN patients with complete data in Huashan Hospital from 2009 to 2016 and compared them with PLA2R positive idiopathic MN patients.

Results

Proteinuria and renal function of these 7 HBV-MN patients were similar to that of IMN patients. However, 5 of them were female and half showed hypocomplementemia, while in IMN group only 32.4% were female and 20% had hypocomplementemia, and the level of hematuria was 94.5/μL in HBV-MN patients and 64.9 /μL in IMN patients, though there was no statistically significant difference. Renal biopsies revealed significantly increased mesangial eletron-deposits in HBV-MN patients. All 7 patients received antiviral therapy, and one patient received immunosuppresants due to severe nephrotic syndrome with acute myocardial infarction and elevated serum creatinine. Compared with IMN group, the prevalence of remission without immunosuppressive therapy of HBV-MN patients was higher (85.7% vs. 43.7%), while the percentage of patients receiving immunosuppresants was lower (14.3% vs. 47.9%) (P=0.048).

Conclusion

Compared with IMN patients, PLA2R positive HBV-MN patients had a more favorable prognosis after antiviral therapy, indicating a secondary form of MN. For these patients, antiviral treatment is recommended and long observation time should be provided before use of immunosuppressive treatment.

Glomerular Disease in Liver Disease

Glomerular diseases are an important cause of kidney disease in patients with liver disease. Although kidney involvement due to tubular or vascular disease is more common, glomerular diseases became more prevalent as hepatitis infections increased and then subsequently decreased with the widespread availability of hepatitis A and B vaccines and the development of effective antiviral treatments for hepatitis B and C. In this review, we discuss the common glomerular pathologies that are seen in patients with liver disease and the current treatment options available to them.

IFI16 induces inflammation in hepatitis B virus-associated glomerulonephritis by regulating the Caspase-1/ IL-1 ß pathway

Aims and background

IFI16 plays an important role in innate immunity against invasive microbial infection by sensing double-stranded DNA viruses due to caspase-1-dependent inflammasome activation and subsequent maturation and secretion of IL-1β. However, the role of IFI16 in regulating the immune response to viruses in Hepatitis B Virus-Associated Glomerulonephritis (HBV-GN), especially in sensing hepatitis B virus (HBV), has not been determined. In this study, we investigated the inflammatory role of IFI16 in HBV-GN.

Methods

A total 75 kidney tissue including 50 HBV-GN and 25 chronic glomerulonephritis (CCN) were collected to determine the expression of IFI16, Caspase-1 and IL-1β using immunohistochemistry (IHC), then the correlation between them was analyzed. In vitro, the primary human glomerular mesangial (HGM) cells and HEK-293 T cell lines were used in this study. The cell lines were both co-transfected with HBVDNA and overexpression or silencing IFI16. Quantitative Real-time PCR and western blotting were used to determine the expression of IFI16, Caspase-1 and IL-1β.

Results

IFI16 expression in HBV-GN biopsies (80.0%) was significantly higher than in CGN (24.0%) and positively correlated with HBVDNA,caspase-1 and IL-1β expression in HBV-GN. Meanwhile, over expression of IFI16 increased caspase-1 and IL-1β expression in HBV-infected HGM and HEK-293 T cell lines, knockdown of IFI16 mRNA by siRNA resulted in downregulation of the caspase-1 and IL-1β expression in both cell lines.

Conclusions

The elevation of IFI16 during HBV infection or replication may contribute to renal damage due to inflammation, thus providing a putative therapeutic target and a new avenue for researching the pathogenesis of HBV-GN.

A risk prediction model for acute kidney injury in patients with pulmonary tuberculosis during anti-tuberculosis treatment

Background

Acute kidney injury (AKI) is not a rare complication during anti-tuberculosis treatment in some patients with pulmonary tuberculosis (PTB). We aimed to develop a risk prediction model for early recognition of patients with PTB at high risk for AKI during anti-TB treatment.

Methods

This retrospective cohort study assessed the clinical baseline, and laboratory test data of 315 inpatients with active PTB who were screened for predictive factors from January 2019 to June 2020. The elements were analyzed by logistic regression analysis. A nomogram was established by the results of the logistic regression analysis. The prediction model discrimination and calibration were evaluated by the concordance index (C-index), ROC curve, and Hosmer-Lemeshow analysis.

Results

A total of 315 patients with PTB were enrolled (67 patients with AKI and 248 patients without AKI). Seven factors, including microalbuminuria, hematuria, cystatin-C (CYS-C), albumin (ALB), creatinine-based estimated glomerular filtration rates (eGFRs), body mass index (BMI), and CA-125 were acquired to develop the predictive model. According to the logistic regression, microalbuminuria (OR = 3.038, 95%CI 1.168–7.904), hematuria (OR = 3.656, 95%CI 1.325–10.083), CYS-C (OR = 4.416, 95%CI 2.296–8.491), and CA-125 (OR = 3.93, 95%CI 1.436–10.756) were risk parameter, while ALB (OR = 0.741, 95%CI 0.650–0.844) was protective parameter. The nomogram demonstrated good prediction in estimating AKI (C-index= 0.967, AUC = 0.967, 95%CI (0.941–0.984), sensitivity = 91.04%, specificity = 93.95%, Hosmer-Lemeshow analysis SD = 0.00054, and quantile of absolute error = 0.049).

Conclusions

Microalbuminuria, hematuria, ALB reduction, elevated CYS-C, and CA-125 are predictive factors for the development of AKI in patients with PTB during anti-TB treatments. The predictive nomogram based on five predictive factors is achieved good risk prediction for AKI during anti-TB treatments.

Renal autoimmunity: The role of bacterial and viral infections, an extensive review

Autoimmunity is a process by which the loss of self-tolerance results in an immune attack against the body own tissues and organs. For autoimmunity to occur, various elements serving as triggers were described by which infections are considered one of the leading factors. In turn, renal involvement in autoimmune diseases, whether by an organ-specific attack, or as part of a systemic disease process, is well known. As bacterial and viral infections are considered to be common triggers for autoimmunity in general, we aimed to study their association with renal autoimmunity in particular. We performed an extensive search of the recent and relevant medical literature regarding renal autoimmunity syndromes such as infection-associated glomerulonephritis and vasculitis, associated with bacterial and viral infections. By utilizing PubMed and Google Scholar search engines, over 200 articles and case reports were reviewed. Among other mechanisms, direct infection of the renal parenchyma, molecular mimicry, induction of B-cells or secretion of superantigens, bacterial and viral pathogens were found to correlate with the development of renal autoimmunity. Nevertheless, this was not true for all pathogens, as some mimic autoimmune diseases and others show a surprisingly protective effect. The exact immunopathogenesis is yet to be determined, however. For conclusion, bacterial and viral infections are linked to renal autoimmunity by both direct damage and as mediators of systemic diseases. Further research particularly on the immunopathogenetic mechanisms of renal autoimmunity associated with infections is required.

CKD in Recipients of Nonkidney Solid Organ Transplants: A Review

Chronic kidney disease (CKD) after solid organ transplant is a common clinical presentation, affecting 10% to 20% of liver, heart and lung transplant recipients and accounting for approximately 5% of the kidney transplant waiting list. The causes of CKD are different for different types of transplants and are not all, or even predominantly, due to calcineurin inhibitor toxicity, with significant heterogeneity particularly in liver transplant recipients. Many solid organ transplant recipients with advanced CKD benefit from kidney transplantation, but have a higher rate of death while waitlisted and higher mortality following transplant than the general kidney failure population. Recent organ allocation policies and proposals have attempted to address the appropriate identification and prioritization of candidates in need of a kidney transplant, either simultaneous with or following non-kidney transplant. Future research should focus on predictive factors for individuals identified at high risk for progression to kidney failure and death, and strategies to preserve kidney function and minimize the CKD burden in this unique patient population.

Treatment of Chronic Hepatitis B Virus with Oral Anti-Viral Therapy

Nucleoside analogues are the drugs most commonly used in the treatment of chronic hepatitis B. They act by inhibiting viral replication and have minimal impact on HBsAg loss. Nucleoside analogues are indicated in patients with chronic hepatitis, cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, and in those with extrahepatic manifestations. Real-world experience has been ongoing for more than 10 years, and the efficacy and safety results obtained are similar to those reported in clinical trials. Prolonged use is needed to maintain suppression of viral replication, prevent the development of liver cirrhosis and decompensated cirrhosis, and to decrease the risk of hepatocellular carcinoma.

Guidelines for Prevention and Treatment of Chronic Hepatitis B

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

Clinicopathological characteristics and prognosis of hepatitis B associated membranous nephropathy and idiopathic membranous nephropathy complicated with hepatitis B virus infection

The main objective of this study is to analyze the clinical and pathological features and prognosis of patients with Hepatitis B associated membranous nephropathy (HBV-MN) and idiopathic membranous nephropathy (IMN) complicated with hepatitis B virus (HBV) infection. This study will provide more basis for diagnosis and prognosis evaluation. A total of 50 patients with HBV-MN were included in this study. 56 IMN patients complicated with HBV infection diagnosed during the same period formed the control group. Parameters including blood routine, urine routine and plasma levels of albumin (ALB), serum creatinine (SCR), blood urea nitrogen (BUN), urea acid (UA), total cholesterol (T-CHO), triglycerides (TG), complement C3 and C4, glutamic pyruvic transaminase (ALT), glutamic pyruvic transaminase (AST), 24-h urinary protein quantification (24 h-TP), renal phospholipase A2 receptor (PLA₂R) and HBV related markers during the hospitalization and outpatient follow-up study period were collected for all the patients. The proportion of male patients was high in both groups. The average age of the HBV-MN group was 37.2 ± 14.187 years old, it was younger compared with the IMN group (P = 0.003). Nephrotic syndrome was the major clinical manifestation among patients. There was no significant difference between the two groups in the levels of anemia, microscopic hematuria, renal dysfunction, liver dysfunction, liver cirrhosis. The level of serum C3 and C4 in the HBV-MN group was lower compared with the IMN group (P = 0.002, P = 0.014). In the HBV-MN group, serum HBV markers were negative in 6 (12%) patients, 4 patients (8%) were positive for PLA₂R in serum, and 5 patients (10%) were positive for PLA₂R in renal tissue. Stronger IgG1 and C1q and weaker IgG4 staining were found in HBV-MN group renal tissues (P = 0.003, P = 0.025, and P = 0.001, respectively). There were no statistical differences compared with serum and renal PLA₂R between HBV-MN and IMN groups (P = 0.098, P = 0.109). During the 1-year follow-up, there was no significant difference in complete remission rate between the two groups (P = 0.7739). Renal biopsy is crucial to diagnose HBV-MN. IgG subtypes in the HBV-MN group were mainly IgG1 deposition, while those in IMN complicated with HBV infection group were mainly IgG4 deposition. When HBV-associated antigen and PLA₂R are present in renal tissue, lower level of serum C3 and C4, high intensity of renal C1q and IgG1 is more supportive of HBV-MN. The positive of PLA₂R in serum and renal tissue in differentiating HBV from IMN complicated with HBV infection remains to be discussed.

Hepatitis B Virus-Related Glomerulonephritis with Positive and Negative Serum HBsAg: Different Clinicopathologic Characteristics of Two Clinical Subtypes

INTRODUCTION

The clinicopathologic characteristics of Hepatitis B virus-associated glomerulonephritis (HBV-GN) patients with different serum HBsAg are not well known. This study aims to investigate the characteristics and treatments between HBV-GN patients with positive and negative serum HBsAg.

METHODS

A retrospective review of patients with renal biopsies in Guangdong Provincial People's Hospital from 2005 to 2018 was performed. Clinicopathological data, treatments and remission of proteinuria were collected and compared between HBsAg+ and HBsAg- group.

RESULTS

A total of 101 HBV-GN were recruited. Serum HBsAg+ and HBsAg- patients accounted for 62.4% and 37.6%, respectively. HBsAg+ group had poor kidney and liver functions. Pathological data showed the percentage of membranous nephropathy in HBsAg- group is significantly higher than that of HBsAg+ group (60.3% HBsAg+ vs 89.5% HBsAg-, P<0.05). Chronic renal tubular/interstitial injury was more prevalent in HBsAg+ group (16.9% HBsAg+ vs 2.6% HBsAg-, P<0.05). The deposition sites of immune complexes were significant different between the two groups. In addition, more HBsAg+ patients were given anti-HBV and less were given corticosteroid or immunosuppressants for treatment than that of HBsAg- patients. Percentages of clinical remission were increasing in both HBsAg+ and HBsAg- patients from 1, 3, 6 months to 1 year (18.75%, 45.2%, 67.8%, 82.4% vs 24.4%, 41.2%, 62.8%, 59.3%). The differences of remission betwen two groups were not significant (P>0.05).

CONCLUSION

The clinicopathological characteristics and treatments of HBV-GN with serum HBsAg+ and HBsAg- were distinct, which indicated that the pathogenesis might be different and specific treatments were needed for HBV-GN patients with different serum HBsAg.

Efficacy of entecavir in treating hepatitis B virus-associated membranous nephropathy

OBJECTIVE

hepatitis B virus-associated membranous nephropathy (HBV-MN) is the most common pathological type of hepatitis B virus-associated glomerulonephritis. This study evaluated the efficacy of entecavir antiviral therapy for HBV-MN patients due to the intolerable side effects of interferon-alpha and high incidence rate of drug-resistance in lamivudine therapy.

METHOD

thirty-two patients with HBV-MN were identified by biopsy and treated with entecavir for 52 weeks. These patients were followed up to evaluate outcomes of entecavir-treatment. Descriptive statistics were used to summarize patient demographics and treatment outcomes.

RESULTS

entecavir treatment reduced 24-h urinary protein excretion. The total probability of partial proteinuria and complete remission at 24 and 52 weeks was 53.1 and 78.1 %, respectively. A decrease of circulating HBV-DNA was observed in all patients with active HBV replication. The significant decrease of 24-h urinary protein began at 12 weeks, as early as the decrease of serum HBV-DNA level. The serum HBV DNA titers at baseline and after 52 weeks of treatment were 4.3 ± 2.8 log10 and 2.3 ± 1.7 log10, respectively. Meanwhile, eGFR increased from 100.3 ± 20.5 ml/min/1.73 m2 at baseline to 107.7 ± 15.9 ml/min/1.73 m2 after 52 weeks of treatment. The serum alanine aminotransferase level (ALT) gradually decreased to normal during entecavir antiviral treatment.

CONCLUSIONS

entecavir treatment in HBV-MN patients was carefully described. Complete remission and HBV replication suppression were induced by entecavir treatment in HBV-MN patients. Patients with high serum creatinine (Scr), ALT and low eGFR levels benefit more from entecavir treatment. Entecavir therapy is well tolerated by patients and no adverse reactions were observed.

Position paper on liver and kidney diseases from the Italian Association for the Study of Liver (AISF), in collaboration with the Italian Society of Nephrology (SIN)

Liver and kidney are strictly connected in a reciprocal manner, in both the physiological and pathological condition. The Italian Association for the Study of Liver, in collaboration with the Italian Society of Nephrology, with this position paper aims to provide an up-to-date overview on the principal relationships between these two important organs. A panel of well-recognized international expert hepatologists and nephrologists identified five relevant topics: 1) The diagnosis of kidney damage in patients with chronic liver disease; 2) Acute kidney injury in liver cirrhosis; 3) Association between chronic liver disease and chronic kidney disease; 4) Kidney damage according to different etiology of liver disease; 5) Polycystic kidney and liver disease. The discussion process started with a review of the literature relating to each of the five major topics and clinical questions and related statements were subsequently formulated. The quality of evidence and strength of recommendations were graded according to the GRADE system. The statements presented here highlight the importance of strong collaboration between hepatologists and nephrologists for the management of critically ill patients, such as those with combined liver and kidney impairment.

A Case of Rapidly Proliferative Glomerulonephritis Secondary to Syphilis That Responded to Treatment With Penicillin

The involvement of kidneys in syphilis has been reported in the literature with the majority of cases presenting with nephrotic-range proteinuria. We report a case of rapidly proliferative glomerulonephritis in a patient with secondary syphilis. A 40-year-old male with a history of human immunodeficiency virus (HIV), chronic hepatitis B virus, and chronic kidney disease stage 2 presented with fatigue, anorexia, weight loss, arthralgia, chills, and rash throughout the body. The patient was non-compliant with HIV medication and had unprotected sexual intercourse. Labs showed blood urea nitrogen of 57 mg/dL (range: 7-23 mg/dL), creatinine 8.2 mg/dL (range: 0.5-1.3 mg/dL), and high titers of rapid plasma reagin. The biopsy showed crescentic glomerulonephritis with c3 deposition in mesangium and basement membrane. The patient responded to treatment with penicillin therapy with gradual improvement in kidney function.

Organ-organ communication: The liver's perspective

Communication between organs participates in most physiological and pathological events. Owing to the importance of precise coordination among the liver and virtually all organs in the body for the maintenance of homeostasis, many hepatic disorders originate from impaired organ-organ communication, resulting in concomitant pathological phenotypes of distant organs. Hepatokines are proteins that are predominantly secreted from the liver, and many hepatokines and several signaling proteins have been linked to diseases of other organs, such as the heart, muscle, bone, and eyes. Although liver-centered interorgan communication has been proposed in both basic and clinical studies, to date, the regulatory mechanisms of hepatokine production, secretion, and reciprocation with signaling factors from other organs are obscure. Whether other hormones and cytokines are involved in such communication also warrants investigation. Herein, we summarize the current knowledge of organ-organ communication phenotypes in a variety of diseases and the possible involvement of hepatokines and/or other important signaling factors. This provides novel insight into the underlying roles and mechanisms of liver-originated signal transduction and, more importantly, the understanding of disease in an integrative view.

Diagnostic performance of glomerular PLA2R and THSD7A antibodies in biopsy confirmed primary membranous nephropathy in South Africans

Background:

Serum and tissue-based tests using phospholipase A2 receptor 1 (PLA2R) and thrombospondin type-1 domain containing 7A (THSD7A) are established immune biomarkers for the diagnosis of primary membranous nephropathy (PMN). This study assessed the diagnostic performance of these biomarkers in the diagnosis of PMN in South Africans.

Methods

This was a cross-sectional analysis from a single centre in Cape Town, South Africa. Relevant biodata was collected from all patients. Histology, including slides for PLA2R and THSD7A were processed and assessed by typical microscopic and immunohistochemical features. Biopsy tissues of patients with membranous lupus nephritis (LN-V) and diabetic nephropathy (DN) were used as controls. The diagnostic accuracy for diagnosis of PMN using positive PLA2R and THSD7A were evaluated.

Results

Of the 88 patients included, 41 had PMN with a mean age of 44.5 ± 17.5 years and 61.0% were female. Histologically, PLA2R and THSD7A were only positive in the PMN group (51.2% and 4.9%, respectively) but negative in both control groups. The sensitivity of PLA2R and THSD7A for identifying PMN was 51.2% and 4.9%, respectively. The sensitivity of both tests together was 53.7% while the specificity and positive predictive values (PPV) for any of the tests (alone or in combination) was 100%. There was no difference in the sensitivity and specificity when using PLA2R alone compared to combining the two tests (p=0.32).

Conclusion

Glomerular staining of PLA2R and THSD7A could have potential diagnostic values in South Africans. This has implications on how immunotherapies can be initiated and used in these settings.

Maternal HBsAg carriers and pregnancy outcomes: a retrospective cohort analysis of 85,190 pregnancies

Background

Nowadays, a positive HBV carrier status is common among pregnant women, especially in endemic areas (such as China), little is known about the impact of maternal HBV infection on the risk of adverse pregnancy outcomes. Pregnant women with HBV infection often develop obstetric complications, such as pregnancy-induced hypertension (PIH) syndrome, postpartum hemorrhage, and gestational diabetes mellitus (GDM), and their infants often exhibit neonatal complications.

Methods

This study undertook a retrospective cohort analysis to explore the association of HBV carrier status with adverse pregnancy outcomes. A cohort of 85,190 women including 9699 HBsAg-positive and 73,076 HBsAg-negative pregnancies was retrospectively analyzed.

Results

It’s found that HBsAg-positive pregnancies may result in higher risk of various maternal outcomes such as ICP (OR 3.4,95%CI 2.80 to 4.13), postpartum hemorrhage (OR 1.16,95%CI 1.00 to 1.34). Interestingly, there was a decreased risk of Preeclampsia (OR 0.91,95%CI 0.87 to 0.96), premature rupture of membrane (OR 0.91,95%CI 0.87 to 0.96) and gestational hypertension (OR 0.828,95%CI 0.701 to 0.978). And in vaginal delivery subgroup analysis, It’s found that the HBsAg-positive group had a higher risk of placental abruption (OR, 1.44; 95% CI, 1.16–1.79).

Conclusions

The present results suggest that compared with HBV positive pregnancies were more likely to be ICP and postpartum hemorrhage. HBV-positive pregnant women underwent vaginal delivery were more likely to have placental abruption and premature birth compared with HBV-negative women. Obstetricians should be aware of ICP, postpartum hemorrhage, placental abruption and premature birth in HBV-positive pregnant women.

Kidney Transplantation From Hepatitis B Surface Antigen (HBsAg)–Positive Living Donors to HBsAg-Negative Recipients: Clinical Outcomes at a High-Volume Center in China

Background

Data on kidney transplantation (KTx) from hepatitis B surface antigen (HBsAg)–positive (HBsAg+) donors to HBsAg-negative (HBsAg−) recipients [D(HBsAg+)/R(HBsAg-)] are limited. We aimed to report the outcomes of D(HBsAg+)/R(HBsAg−) KTx in recipients with or without hepatitis B surface antibody (HBsAb).

Methods

Eighty-three D(HBsAg+)/R(HBsAg−) living KTx cases were retrospectively identified. The 384 cases of KTx from hepatitis B core antibody–positive (HBcAb+) living donors to HBcAb-negative (HBcAb−) recipients [D(HBcAb+)/R(HBcAb−)] were used as the control group. The primary endpoint was posttransplant HBsAg status change from negative to postive (-− →+).

Results

Before KTx, 24 donors (28.9%) in the D(HBsAg+)/R(HBsAg−) group were hepatitis B virus (HBV) DNA positive, and 20 recipients were HBsAb−. All 83 D(HBsAg+)/R(HBsAg−) recipients received HBV prophylaxis, while no D(HBcAb+)/R(HBcAb−) recipients received prophylaxis. After a median follow-up of 36 months (range, 6–106) and 36 months (range, 4–107) for the D(HBsAg+)/R(HBsAg−) and D(HBcAb+)/R(HBcAb−) groups, respectively, 2 of 83 (2.41%) D(HBsAg+)/R(HBsAg−) recipients and 1 of 384 (0.26%) D(HBcAb+)/R(HBcAb−) became HBsAg+, accompanied by HBV DNA-positive (P = .083). The 3 recipients with HBsAg−→+ were exclusively HBsAb−/HBcAb− before KTx. Recipient deaths were more frequent in the D(HBsAg+)/R(HBsAg−) group (6.02% vs 1.04%, P = .011), while liver and graft function, rejection, infection, and graft loss were not significantly different. In univariate analyses, pretransplant HBsAb−/HBcAb− combination in the D(HBsAg+)/R(HBsAg−) recipients carried a significantly higher risk of HBsAg−→+, HBV DNA−→+, and death.

Conclusions

Living D(HBsAg+)/R(HBsAg−) KTx in HBsAb+ recipients provides excellent graft and patient survivals without HBV transmission. HBV transmission risks should be more balanced with respect to benefits of D(HBsAg+)/R(HBsAg−) KTx in HBsAb-/HBcAb− candidates.

Hepatitis B-related glomerulonephritis and optimization of treatment

Introduction: Multiple studies have revealed a strong relationship between the development of nephropathy and hepatitis B virus (HBV) infection. The underlying pathogenesis of hepatitis B-related glomerulonephritis (HBV-GN) involves immune complexes, which can be isolated from kidney tissues. Clearance of HBV antigenemia improves renal impairment and proteinuria in HBV-GN patients.Areas covered: In this review, we present our current understanding of the epidemiology, pathogenesis, pathology, diagnosis, and treatment of HBV-GN. We discuss the advantages and disadvantages of oral nucleoside/nucleotide analogs (NAs), and the main pharmaceutical treatment for hepatis B.Expert opinion: Currently, antiviral agents are the main HBV-GN therapeutic agents. Although no randomized controlled clinical trials have compared the efficacy of interferon (IFN) and NA, we suggest IFN treatment for pediatric patients (IFN-α in patients ≥1 year; pegIFN-α in patients ≥3 years) considering treatment duration and absence of resistance. Novel NAs have brought about promising treatment options involving high efficacy viral suppression and low resistance rates. NAs with a high barrier to resistance (e.g. entecavir) are recommended as first-line therapy of HBV-GN. Immunosuppression monotherapy, such as corticosteroids, is of little benefit and potentially harmful to HBV-GN patients due to the possibility of viral reactivation.

Diagnosis and management of renal dysfunction in patients with cirrhosis

Introduction: Renal dysfunction commonly occurs in patients with cirrhosis and is typically associated with poor prognosis. Several pathophysiologic mechanisms are responsible for renal disease in these patients, prompt identification permits individualized management.Areas covered: Pathophysiology, evaluation and differential diagnosis, management and prognosis of renal disease in patients with cirrhosis. Special focus on management of hepatorenal syndrome and indications for simultaneous liver-kidney transplantation.Literature search methodology: a detailed literature search was performed using PubMed without date restrictions. Published guidelines and position papers were also used and cross-referenced to identify additional studies.Expert opinion: The prognostic significance of renal dysfunction in patients with cirrhosis is highlighted by the inclusion of serum creatinine in the model for end-stage liver disease (MELD). Both acute and chronic renal dysfunction result in increased mortality in patients with cirrhosis, although there are marked differences related to the etiology of renal disease. Early recognition and prompt intervention determined by the most likely etiology are key in the management of these patients. Simultaneous liver-kidney transplantation improves patient survival compared to isolated liver transplantation in patients with cirrhosis and persistent renal impairment; however, selection of candidates must be judicious and individualized due to the ongoing shortage of donor kidneys.

Hepatitis B virus infection as a risk factor for chronic kidney disease

Introduction: Hepatitis B virus is an important cause of liver disease and has numerous extra-hepatic manifestations. HBV leads to important morbidity and mortality in the general population and recent evidence suggests a role of HBV in the incidence and progression of chronic kidney disease. Areas covered: The mechanisms underlying the link between HBV and CKD remain unclear. Nucleos(t)ide analogues for the antiviral treatment of HBV are currently available; these drugs are provided with high efficacy even in patients with CKD. Expert opinion: A recent meta-analysis of clinical studies showed that HBV results in a greater risk of CKD in the general population. According to an updated review (studies were identified from PubMed, EMBASE, and the Cochrane database), we retrieved six clinical studies (n = 1,034,773 unique patients), adjusted RR, 1.41 (95% CI, 1.09; 1.82, P < 0.001). The significant heterogeneity observed precluded more definitive conclusions. Various mechanisms have been cited to explain the greater risk of CKD among HBsAg positive carriers. Novel evidence shows that untreated HBV and therapy with nucleos(t)ide analogues are associated with increased and decreased risk of end-stage renal disease in CKD population, respectively. We recommend that patients with HBV are assessed for kidney function and urinary changes at baseline and over the follow-up.

[Hepatitis B virus infection: Natural history, clinical manifestations and therapeutic approach]

Chronic hepatitis B infection remains a major public-health problem, with approximately 260 million world-wide cases of infection. Recent advances in the understanding of the natural history of chronic hepatitis B infection have led to progress in the care of infected patients. Sustained viral suppression is now possible for a majority of treated patients and is associated with a decrease in the morbidity and mortality attributable to cirrhosis and hepatocellular carcinoma. Complete cure is however not yet possible, due to the long-term persistence of viral DNA in hepatocytes of treated patients. Assessing the risk of viral reactivation in patients receiving immunosuppressive therapy is an increasingly frequent situation in clinical practice and its management is guided by both the patient's serological status and the potency of the immunosuppressive regimen. This review aims to present the clinical and biological presentations of chronic hepatitis B infection, the modalities of antiviral treatment, and how to assess the risk of viral reactivation in patients receiving immunosuppressive therapy.

Association between hepatitis B virus infection and chronic kidney disease: A cross-sectional study from 3 million population aged 20 to 49 years in rural China

Hepatitis B virus (HBV) infection can lead to different types of chronic kidney diseases (CKD) in clinical practice. However, HBV infection has been observed to have no significant association with CKD indicators in some epidemiological surveys. This research aims to estimate CKD prevalence in HBV infection population and clarify the relationship between HBV infection status and CKD.The participants aged 20 to 49 years were selected by multistage random sampling from January 1, 2010 to December 31, 2012 across 31 provinces and regions in rural China. The data was collected by standard questionnaire and physical check-up. Status of HBV infection was diagnosed as immune tolerant phase, hepatitis B envelope antigen -positive chronic HBV infection, inactive HBV carrier, hepatitis B envelope antigen -negative chronic HBV infection and resolved HBV infection based on serological markers, and the level of hepatic function, respectively.In total, 2,969,502 subjects were included in the study. In population aged 20 to 49 years in rural China, prevalence of HBV infection was 12.17%. Prevalence of proteinuria, hematuria, estimated glomerular filtration rate less than 60 mL/min/1.73m and CKD was 0.94%(95% CI = 0.91-0.97%) vs. 0.65%(95% CI = 0.64-0.66%), 1.92%(95% CI = 1.87-1.96%) vs. 1.19% (95% CI = 1.18-1.21%), 1.02%(95% CI = 0.99-1.06%) vs. 0.77% (95% CI = 0.76-0.78%), and 3.85%(95% CI = 3.78-3.91%) vs. 2.60%(95% CI = 2.58-2.62%) in population with HBV infection and without infection, respectively. Prevalence of CKD and indicators was higher in population in every status of HBV infection than in population without infection, respectively (all P < 0·0001). Every HBV infection status was a risk factor for CKD.CKD prevalence was higher in population in every status of HBV infection than without infection. HBV infection was a risk factor for CKD in population aged 20 to 49 years in rural China.

Management of Hepatitis B Virus Infection: 2018 Guidelines from the Canadian Association for the Study of Liver Disease and Association of Medical Microbiology and Infectious Disease Canada

Hepatitis B virus (HBV) infection is an important public health problem in Canada. In keeping with evolving evidence and understanding of HBV pathogenesis, the Canadian Association for the Study of Liver Disease periodically publishes HBV management guidelines. The goals of the 2018 guidelines are to (1) highlight the public health impact of HBV infection in Canada and the need to improve diagnosis and linkage to care, (2) recommend current best-practice guidelines for treatment of HBV, (3) summarize the key HBV laboratory diagnostic tests, and (4) review evidence on HBV management in special patient populations and include more detail on management of HBV in pediatric populations. An overview of novel HBV tests and therapies for HBV in development is provided to highlight the recent advances in HBV clinical research. The aim and scope of these guidelines are to serve as an up-to-date, comprehensive resource for Canadian health care providers in the management of HBV infection.

Infection-Induced Kidney Diseases

Infection induced kidney diseases are of concern for clinicians because timely detection and treatment of infections may cure or limit the extent of injury inflicted by microorganisms causing the infections. Infections can cause kidney injury by either direct invasion, or indirectly by immune mediated mechanisms, which manifest as post-infectious glomerulonephritis, or infection-related glomerulonephritis. Clinical manifestations may be acute or chronic depending on the microorganisms, endemic/epidemic nature and source of infection. All microbials virus, bacteria, mycobacteria, fungus, and protozoa have been implicated in kidney diseases either causing direct kidney injuries or immune-mediated injuries. Infection control practices in large parts of world is limited by poverty, social behavior, high population density, deforestation, inadequate access to safe drinking water, and poor health care facilities. Although, antimicrobials and vaccinations have successfully eradicated and cured many infectious diseases; however injudicious antimicrobial use and emergence of resistant organisms complicated the disease severity like secondary renal amyloidosis with chronic persistent infection. Re-emergence of various infections has been a recent pattern in developed world leading to uncertain diagnostic challenges, and association with kidney diseases.

Renal complications of liver diseases

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are the major causes of chronic liver disease. HBV and HCV affect nearly 7% of the world's population. Extra-hepatic complications and particularly renal failure have different mechanisms and manifestations. The underlying mechanism, although differing for each disease, mainly involves the immune system and antibody deposits in the kidney, which can lead to tissue damage. Areas covered: We do not cover in this review hepatorenal syndrome. We report on the renal complications of viral hepatitis (HBV, HCV, hepatitis E), autoimmune hepatitis, cirrhosis, and Wilson's disease. The most frequent renal disorders are those related to HBV, and HCV due to their high prevalence worldwide. Expert commentary: Thanks to generalization of vaccination against HBV, prevalence of HBV-related liver diseases will decrease, and thereby its associated renal involvement such as polyarteritis nodosa (an exceptional condition), and glomerulonephritis such as membranous nephropathy. Thanks to direct acting antiviral agents HCV infection will be cured within the next decade. However, HCV-related cryoglobulinemia with or without renal involvement might evolve on its own after the patient has eliminated HCV, necessitating then rituximab therapy. Conversely, orofecal-transmitted hepatitis viruses such as hepatitis A and hepatitis E are still very prevalent in developing countries; however, they are rarely associated with renal manifestations.

Outcomes of kidney transplantation in patients with hepatitis B virus infection: A systematic review and meta-analysis

AIM

To assess outcomes of kidney transplantation including patient and allograft outcomes in recipients with hepatitis B virus (HBV) infection, and the trends of patient's outcomes overtime.

METHODS

A literature search was conducted using MEDLINE, EMBASE and Cochrane Database from inception through October 2017. Studies that reported odds ratios (OR) of mortality or renal allograft failure after kidney transplantation in patients with HBV [defined as hepatitis B surface antigen (HBsAg) positive] were included. The comparison group consisted of HBsAg-negative kidney transplant recipients. Effect estimates from the individual study were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42017080657).

RESULTS

Ten observational studies with a total of 87623 kidney transplant patients were enrolled. Compared to HBsAg-negative recipients, HBsAg-positive status was significantly associated with increased risk of mortality after kidney transplantation (pooled OR = 2.48; 95%CI: 1.61-3.83). Meta-regression showed significant negative correlations between mortality risk after kidney transplantation in HBsAg-positive recipients and year of study (slopes = -0.062, P = 0.001). HBsAg-positive status was also associated with increased risk of renal allograft failure with pooled OR of 1.46 (95%CI: 1.08-1.96). There was also a significant negative correlation between year of study and risk of allograft failure (slopes = -0.018, P = 0.002). These associations existed in overall analysis as well as in limited cohort of hepatitis C virus-negative patients. We found no publication bias as assessed by the funnel plots and Egger's regression asymmetry test with P = 0.18 and 0.13 for the risks of mortality and allograft failure after kidney transplantation in HBsAg-positive recipients, respectively.

CONCLUSION

Among kidney transplant patients, there are significant associations between HBsAg-positive status and poor outcomes including mortality and allograft failure. However, there are potential improvements in patient and graft survivals in HBsAg-positive recipients overtime.

Hepatitis B infection and preeclampsia among pregnant Sudanese women

Background

Previous published studies have reported conflicting results of association between hepatitis B virus (HBV) infection and preeclampsia. There was no published data on HBV and preeclampsia in Africa including Sudan. The aim of the present study was to investigate the association between HBsAg seropositivity and preeclampsia.

Methods

A case –controls study (200 women in each arm) was conducted at Saad Abualila Maternity Hospital, Khartoum, Sudan.

The cases were women with preeclampsia and the controls were healthy pregnant women. Socio-demographic characteristics were gathered using questionnaire and HBsAg was investigated using an ELISA.

Results

There was no significant difference between the cases and the controls in their age, parity, residence, education and blood groups. The majority of the cases were mild preeclampsia (159; 79.5%).

In comparison with the controls, a significantly higher number of the cases were HBsAg seropositive [30 (15.0%) vs.12 (6.0%), P = 0.005]. In binary regression women with HBsAg seropositive were at higher risk of preeclampsia than women who were HBsAg seronegative (OR = 2.86, 95%, CI = 1.41–5.79, P = 0.003).

Conclusion

In the current study HBsAg seropositivity is associated with preeclampsia. Preventive measure should be implemented.

Membranous nephropathy in a patient with ankylosing spondylitis: A case report

RATIONALE

Renal complications in ankylosing spondylitis (AS) were rarely observed, and proteinuria associated with AS can be seen often due to amyloidosis in this kind of complications, while membranous nephropathy (MN) is seldom considered. This article reports a case of coexistence of AS and MN, to provide the exact relationship of these 2 entities and recognized some causes of renal involvement in AS.

PATIENT CONCERNS

A 44-year-old female presented with pain of the left leg for 4 years and pedal edema for 2 weeks.

DIAGNOSES

AS was diagnosed according to the patient's clinical manifestation and sacroiliitis observed on computed tomography (CT) scan. Nephrotic syndrome was found and MN was diagnosed according to kidney biopsy in which thickened capillary loops were observed with light microscopy, granular deposits of IgG along the capillary wall were observed using immunofluorescence staining, and subepithelial electron-dense deposits were observed with electron microscopy. No other secondary causes of MN were found on extensive investigations.

INTERVENTION

Given the diagnoses, the patient received nonimmunosuppressive therapy for MN and adalimumab for AS.

OUTCOMES

The patient got pain relief, as well as urinary protein reduction.

LESSONS

This case suggested a secondary MN in association with AS and the relationship between these 2 diseases needed more concern and further illumination.