Epidemiological and clinical features of hepatitis B virus related liver failure in China

Predictive factors for anti-HBs status after 1 booster dose of hepatitis B vaccine

In Taiwan, infants need to receive 3 doses of hepatitis B virus (HBV) vaccine under the public health policy from the government. However, there are many young adults who even though received complete HBV vaccination in their childhood would lose the positive response of anti-hepatitis B surface antibody (HBs) and need the booster dose of HBV vaccine. The aim of our study is to determine the powerful predictive factor for screening the candidates who need only 1 booster dose of HB vaccine then they can regain positive postbooster anti-HBs status (≧10 mIU/mL) or protective postbooster anti-HBs status (≧100 mIU/mL).We recruited 103 university freshmen who were born after July 1986 with complete HBV vaccination in childhood, but displayed negative results for hepatitis B surface antigen and anti-HBs levels at their health examinations upon university entry. They received 1 booster dose of HB vaccine, and their anti-HBs titers were rechecked 4 weeks after the booster administration. Multivariate analysis logistic regression for positive postbooster anti-HBs status (≧10 mIU/mL, model 1) and protective postbooster anti-HBs status (≧100 mIU/mL, model 2) was done with predictive factors of prebooster anti-HBs level, body mass index, serum glutamate pyruvate transaminase level, and sex.Twenty-four students got positive postbooster anti-HBs status (10-100 mIU/mL) and 50 students got protective postbooster anti-HBs status (≧100 mIU/mL). In the model of multivariate analysis logistic regression for positive postbooster anti-HBs status (≧10 mIU/mL), prebooster anti-HBs level was the strongest predictive factor. The odds ratio was 218.645 and the P value was 0.001. Even in the model of multivariate analysis logistic regression for protective postbooster anti-HBs status (≧100 mIU/mL), prebooster anti-HBs level was still the strongest predictive factor, but the odds ratio of a protective booster effect was 2.143, with 95% confidence interval between 1.552 and 2.959, and the P value was less than 0.001.Prebooster anti-HBs level can be the powerful predictive factor for positive postbooster anti-HBs status (≧10 mIU/mL) and protective postbooster anti-HBs status (≧100 mIU/mL). According to the result of this study, if someone received complete HBV vaccination in childhood, but displayed negative results for hepatitis B surface antigen and anti-HBs levels around 2 decades later, 1 booster dose of HBV vaccine could help him or her to regain positive postbooster anti-HBs status (≧10 mIU/mL) under the strong predictive factor of prebooster anti-HBs level higher than 1 mIU/mL. The other 2 HBV vaccines could be saved and the case could also save money and time.

Model for End-Stage Liver Disease (MELD) score does not predict outcomes of hepatitis B-induced acute-on-chronic liver failure in transplant recipients

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a severe clinical entity and liver transplantation is the only definitive therapy to salvage these patients. However, the timing of liver transplant for these patients remains unclear.

METHODS

Seventy-eight patients undergoing liver transplantation because of hepatitis B ACLF were retrospectively analyzed from June 2004 to December 2010. The areas under the receiver operating characteristic curve (AUC) of Model for End-Stage Liver Disease (MELD) score and Child-Turcotte-Pugh (CTP) score for the post-transplantation outcomes were calculated.

RESULTS

The median age was 44 years (range, 25-64 years), serum bilirubin 418.53 μmol/L (range, 112.90-971.40 μmol/L), INR 3.177 (range, 1.470-9.850), and creatinine 70.84 μmol/L (range, 12.39-844.1 μmol/L); the median MELD score was 32 (range, 21-53) and CTP score 12 (8-15). The AUCs of MELD and CTP scores for 3-month mortality were 0.581 (95% confidence interval [CI], 0.421-0.742; sensitivity, 87.5%; specificity, 32.8%) and 0.547 (95% CI, 0.401-0.693; sensitivity, 75%; specificity, 41%), respectively. Meanwhile, there were no significant differences in hospital mortality (P = .252) or morbidity (P = .338) between the patients with MELD score ≥30 and those <30.

CONCLUSIONS

MELD score had no predictive ability for the outcomes of patients with hepatitis B ACLF after orthotopic liver transplantation.

A population-based study examining hepatitis B virus infection and immunization rates in Northwest China

Background and Aim

Current baseline data regarding the prevalence of hepatitis B virus (HBV) infections and the immune status in hyperendemic areas is necessary in evaluating the effectiveness of ongoing HBV prevention and control programs in northwest China. This study aims to determine the prevalence of chronic HBV infections, past exposure rates, and immune response profiles in Wuwei City, northwest China in 2010.

Methods

Cross-sectional household survey representative of the Wuwei City population. 28,579 participants were interviewed in the seroepidemiological survey ≥1 year of age. House to house screening was conducted using a standard questionnaire. All serum samples were screened by enzyme-linked immunoassays for the presence of hepatitis B surface antigen, antibodies against HBV surface antigen, and antibodies to the hepatitis B core antigen.

Results

Among individuals ≥1 year of age, 7.2% (95%CI: 6.3–8.1%) had chronic HBV infections, 43.9% (CI: 40.4–47.4%) had been exposed to HBV, and 23.49% (CI: 21.6–25.3%) had vaccine-induced immunity. Multi-factor weighted logistic regression analysis showed that having household contact with HBV carriers (OR = 2.6, 95%CI: 2.3–3.0) and beauty treatments in public places (OR = 1.2, 95%CI: 1.1–1.3) were the risk factors of HBV infection in whole population. Having household contact with HBV carriers (OR = 3.8, 95% CI: 2.2–6.5) and lack of hepatitis vaccination (OR = 2.0, 95% CI: 1.4–3.3) were the risk factors for HBV infection in children aged 1–14 years.

Conclusions

Hepatitis B infection remains a serious public health problem in northwest China. Having household contact with HBV carriers and beauty treatments in public places represented HBV infection risk factors. Hepatitis B vaccine immunization strategies need further improvement, particularly by targeting the immunization of rural migrant workers.

HBV genotype C strains with spontaneous YMDD mutations may be a risk factor for hepatocellular carcinoma

HBV has a relatively high mutation rate in its genome and most of these mutations are associated with the curative effect of nucleoside analogs. In this study, 1,424 patients with HBV-related liver diseases not treated with antiviral drugs, including 197 asymptomatic HBV carriers, 769 chronic hepatitis B patients, 145 acute-on-chronic liver failure (ACLF) patients, 187 HBV-related liver cirrhosis patients, and 126 HBV-related HCC patients, were selected to investigate the distribution and clinical significance of spontaneous YMDD mutations in liver diseases at different stages. Spontaneous YMDD mutations were detected in all stages of liver diseases and the YIDD variant was the dominant mutation type. The mutation rate was higher in genotype C strains than in genotype B strains. The χ(2) subdivision method showed that the spontaneous YMDD mutation rate in HCC was higher than that in other liver diseases. The difference in spontaneous YMDD mutation rates in patients with liver diseases infected with genotype C strains at different stages was statistically significant. Spontaneous YMDD mutation rates in patients with liver diseases infected with genotype C strains at different stages were then compared one to one using the χ(2) subdivision method. The results showed that the spontaneous YMDD mutation rate in HCC was higher than that in other liver diseases. Taken together, these results indicated that spontaneous YMDD mutations are more likely to occur in patients infected with genotype C strains, and genotype C strains with spontaneous YMDD mutations may be a risk factor for HCC.

The presence of hepatitis B core antibody is associated with more advanced liver disease in alcoholic patients with cirrhosis

BACKGROUND

Liver disease is more severe in patients with chronic hepatitis B virus (HBV) infections and alcohol-induced liver injury. Whether the same is true for alcoholic patients with cirrhosis who have recovered from previous HBV infections remains to be determined.

OBJECTIVES

To document the extent of liver disease in alcoholic patients with cirrhosis who test negative for hepatitis B surface antigen (HBsAg) and test positive for antibody to hepatitis B core antigen (anti-HBc).

METHODS

Two hundred fifty-four alcoholic patients with cirrhosis were divided into anti-HBc-positive (N = 171) and anti-HBc-negative (N = 83) cohorts. Demographic, clinical, and biochemical features were retrospectively analyzed. Prognostic scores and the prevalence of patients at high risk for short-term mortality were calculated. Logistic regression was used to identify factors associated with an increased risk for short-term mortality.

RESULTS

Jaundice was more common in the anti-HBc-positive cohort (32.2% vs. 18.1%, p = 0.02). This cohort also had higher serum bilirubin (70.9 vs. 50.4 μM/L, p = 0.03), prothrombin times (15.6 vs. 14.4 s, p = 0.01), MELD scores (8.5 vs. 4.6, p = 0.01), i-MELD scores (28.6 vs. 24.7, p = 0.03), MDF scores (14.2 vs. 6.8, p = 0.02) and ABIC scores (7.2 vs. 6.6, p = 0.01). In addition, anti-HBC-positive patients were more often at high risk for short-term mortality (40.4% vs. 26.5%, p = 0.03). Multivariate analysis identified anti-HBc-positive status (OR: 1.84; 95% CI: 1.10-3.36) and alcohol intake ≥150 g/day (OR: 2.01; 95% CI: 1.10-3.66) as independent risk factors for high risk of mortality.

CONCLUSION

The anti-HBc-positive state is associated with more advanced liver disease in alcoholic patients with cirrhosis. A prospective study including HBV-DNA testing and liver biopsies should be considered to validate and further elucidate these findings.

Association of a HLA-DP gene polymorphism with progression of HBV infection

AIM: To explore the association of a HLA-DP gene polymorphism (rs6457617) with progression of hepatitis B virus (HBV) infection.

METHODS: A total of 1009 subjects were enrolled in this study, including 234 asymptomatic chronic HBV carriers (ASC), 300 patients with HBV-related liver cirrhosis (LC), 300 patients with HBV-related hepatocellular carcinoma (HCC), and 175 patients with HBV-related acute liver failure (ALF). The differences in alleles and genotype between the control (ASC) group and case groups (LC, HCC and ALF) were identified using the Taqman assay.

RESULTS: The frequencies of TT, CT and CC genotypes at the rs6457617 locus were 20%, 49.6% and 30% in the case HCC group, which were statistically different from those in the control group (TT: 26%; CT: 51.2%; CC: 22.6%) (χ² = 3.94, P = 0.047, OR = 1.49). The frequency of the C allele differed significantly between the HCC group and ASC group (χ² = 4.98, P = 0.025, OR = 1.21). There were no significant differences in allele frequencies and genotype distributions between the LC and ASC groups, and between the ALF and ASC groups.

CONCLUSION: The C allele at the rs6457617 locus is associated with risk of HCC, and the CC genotype confers susceptibility to HCC. The rs6457617 polymorphism might be involved in the development of HCC.

Comparative study of efficacy of different types of artificial liver treatments in management of hepatitis B-associated liver failure

AIM: To investigate the clinical efficacy of plasma exchange (PE), plasma bilirubin adsorption (PBA), and PE combined with PBA in the treatment of hepatitis B-associated liver failure.

METHODS: The clinical data for 150 patients with hepatitis B-associated liver failure were retrospectively analyzed. These patients were randomly divided into a PE group, a PBA group, and a PE + PBA group. The volume of plasma consumed once, the effective rate, liver function, alanine aminotransferase (ALT), total bilirubin (TBIL), albumin (ALB), prothrombin time (PT), prothrombin time activity (PTA), creatinine (Cr) and plasma ammonia were recorded both before and after treatment and compared among the three groups. The incidence of adverse reactions was also observed.

RESULTS: The total effective rate was higher in the combination group than in the PE group and PBA group (65.45% vs 62.5%, 59.58%), but the difference was not statistically significant (both P > 0.05). TBIL was significantly decreased 4 hours after treatment compared to pre-treatment values in the PE, PBA and combination groups (410.3 µmol/L ± 208.6 µmol/L vs 292.5 µmol/L ± 175.4 µmol/L, 432.7 µmol/L ± 242.5 µmol/L vs 298.8 µmol/L ± 201.7 µmol/L, 468.2 µmol/L ± 241.6 µmol/L vs 288.5 µmol/L ± 184.5 µmol/L, all P < 0.05), but the decline showed no significantly statistical difference among the three groups. After treatment, PT was significantly shortened and PTA was increased in the combination group and PE group (both P < 0.05), but the changes showed no significant difference between the two groups (both P > 0.05). In the PBA group, PT was increased and PTA was decreased after treatment, but the differences were not significant (P > 0.05). Blood ammonia and Cr were significantly decreased in the three groups of patients after treatment (all P < 0.05), although there was no significantly statistical difference among the three groups. No serious adverse reactions occurred. The volume of plasma consumed once was significantly less in the combination group than in the PE group (1107.1 mL ± 212.3 mL vs 2911.5 mL ± 352.3 mL, P < 0.05).

CONCLUSION: PE combined with PBA can effectively reduce the amount of plasma consumed and the incidence of adverse reactions, improve survival and therefore represent a safe and effective treatment for hepatitis B-associated liver failure.

Relationship between hepatocellular carcinoma and hepatitis B virus genotype with spontaneous YMDD mutations

AIM: To investigate the relationship between hepatitis B virus (HBV) genotype with spontaneous YMDD mutations and hepatocellular carcinoma (HCC) in HBV-related cirrhosis.

METHODS: We investigated 264 liver cirrhosis patients who were not treated with antiviral drugs, including 81 patients with HCC. YMDD mutations were detected by fluorescent hybridization bioprobe polymerase chain reaction (PCR) and melting curve assay using the Diagnosis Kit for HBV YMDD Mutation. Serum HBV genotypes were detected by real-time PCR using genotype-specific TaqMan probes. Statistical analysis was performed according to data type using the t test, χ² test and unconditional logistic regression analysis.

RESULTS: In the HCC group, genotype C strains, spontaneous YMDD mutations, and genotype C strains with YMDD mutations were detected in 33 (40.74%), 13 (16.05%) and 11 (13.58%) patients, respectively. In the liver cirrhosis (LC) group, HBV genotype C strains, spontaneous YMDD mutations, and genotype C strains with YMDD mutations were detected in 33 (18.03%), 7 (3.83%) and 2 (1.09%) patients, respectively. The differences in genotype C strains, spontaneous YMDD mutations, and genotype C strains with YMDD mutations between the two groups were statistically significant (χ² = 15.441, P = 0.000; χ² = 11.983, P = 0.001; P = 0.000). In the HCC and LC groups, there were seven patients infected by genotype B strains with YMDD mutations and 13 by genotype C strains with YMDD mutations. Further research revealed that HCC occurred in 2 patients infected by genotype B strains with YMDD mutations and 11 infected by genotype C strains with YMDD mutations. The difference was statistically significant (P = 0.000). Unconditional logistic regression analysis revealed that patients infected by genotype C strains with spontaneous YMDD mutations had a 7.775-fold higher risk for the development of HBV-related HCC than patients infected by other type HBV strains (P = 0.013, 95%CI: 1.540-39.264).

CONCLUSION: Genotype C strains with spontaneous YMDD mutations are an independent risk factor for HCC in LC patients and are important for early warning of HCC.

Liver transplantation in acute-on-chronic liver failure patients with high model for end-stage liver disease (MELD) scores: a single center experience of 100 consecutive cases

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a severe clinical condition for which liver transplantation (LT) is the only curative option. However, there are little published data on risk factors and outcomes of LT for ACLF.

METHODS

The objective of this study was to analyze preoperative, intraoperative, postoperative, and overall survival data on 100 consecutive cases with ACLF in order to try to determine for which patients LT are futile.

RESULTS

One hundred consecutive patients with pathology-confirmed ACLF who underwent LT from June 2004 to September 2012 were enrolled. The preoperative data showed that all patients were in a serious condition with a median high model for end-stage liver disease (MELD) score of 32, total bilirubin of 440.20 umol/L, international normalized ratio (INR) of 3.012, and at least one organ dysfunction as assessed by a Sequential Organ Failure Assessment (SOFA) score of ≥9. The patients had either deceased or a living donor LT with an overall mortality of 20%. The 1-, 3-, and 5-year cumulative survival rates were 76.8%, 75.6%, and 74.1%, respectively, and graft 1-, 3-, and 5-y accumulative survival rates were 73.3%, 72.1%, and 70.6%, respectively. However, the area under receiver operating characteristic of SOFA score, MELD score, as well as Child-Pugh score were 0.552, 0.547, and 0.547, respectively.

CONCLUSIONS

Both deceased and living donor LT are effective therapeutic options for patients with ACLF and the short- and long-term survival rates are encouraging. It is important to conduct more prospective and multi-center studies to define preoperatively which patients would benefit from LT.

Changing etiology of liver failure in 3,916 patients from northern China: a 10-year survey

PURPOSE

To investigate the etiological characteristics of patients with liver failure in the past 10 years.

METHODS

Clinical and investigational data in hospitalized patients with liver failure admitted from 2002 to 2011 were retrospectively analyzed. Standard definitions and criteria were used to assess disease etiology.

RESULTS

Of these 3,916 patients, 3,429 (87.6 %) had acute-on-chronic liver failure (ACLF), 114 (2.9 %) acute liver failure (ALF), and 373 (9.5 %) subacute liver failure. Viral infection was the most common cause of liver failure in the 3,295 patients (84.1 %). Hepatitis of unknown etiology was deemed responsible for 371 cases of liver failure (9.5 %). Drug-induced liver injury, alcoholic hepatitis, and autoimmune hepatitis led to 120 cases (3.1 %), 109 cases (2.8 %), and 19 cases (0.5 %), respectively. The most common cause of ACLF was HBV infection (87.3 %), while the main causes of acute and subacute liver failure were hepatitis of unknown etiology (39.4 %), viral infection (36.6 %), and drug-induced liver injury (19.3 %). Our data showed that the incidence of liver failure caused by HBV gradually decreased from 86.5 % in 2002 to 69.2 % in 2011. However, the incidence of hepatitis of unknown etiology, drug-induced liver injury, and alcoholic hepatitis was increased.

CONCLUSIONS

HBV infection is the main cause of liver failure in China. However, the incidence of HBV-related liver failure has gradually decreased in the past 10 years. Hepatitis of unknown etiology has replaced HBV infection as the most common apparent cause of acute liver failure.

Analysis of short-term prognostic factors in patients with hepatitis B virus-related liver failure

AIM: To investigate the risk factors that influence short-term (3 mo) prognosis in patients with hepatitis B virus (HBV)-related liver failure and to establish a prognostic model.

METHODS: A retrospective analysis of 137 patients with HBV-related liver failure treated at the First Affiliated Hospital of Soochow University from June 2005 to September 2008 was performed to observe their 3-month survival. The t-test, chi-square test and logistic regression analysis were used to identify independent risk factors affecting 3-month prognosis in these patients.

RESULTS: Of the 137 patients with HBV-related liver failure, 86 (63.8%) were alive and 51 (36.2%) died. Univariate analyses indicated that age, 1iver cirrhosis, total bilirubin (TBil), albumin (ALB), platelet ,international normalized ratio (INR), MELD, Child-Pugh, complicating hepatic encephalopathy, hepatorenal syndrome, pulmonary fungal infection, variceal bleeding, ascites, and spontaneous bacterial peritonitis were significant risk factors affecting 3-month prognosis in patients with HBV-related liver failure (P = 0.035, 0.001, 0.001, 0.001, 0.001, 0.001, 0.001, 0.001, 0.001, 0.001, 0.001, 0.001, 0.001, 0.001, respectively). Multivariate Logistic regression analyses demonstrated that age, INR, hepatic encephalopathy, and pulmonary fungal infection were independent risk factors affecting 3-month prognosis in these patients.

CONCLUSION: Age, INR, hepatic encephalopathy, and pulmonary fungal infection are independent risk factors affecting short-term prognosis in patients with HBV-related liver failure.