A Practical Approach to Management of Chronic Hepatitis B

Serum Ribonucleotide Reductase Subunit M2 in Patients with Chronic Liver Diseases and Hepatocellular Carcinoma

BACKGROUND

Ribonucleotide reductase subunit M2 (RRM2) plays a key role in cell and hepatitis B virus (HBV) replication. Nevertheless, its clinical implications for managing liver diseases have been inadequately studied.

METHODS

A total of 412 participants were enrolled, including 60 healthy control individuals, 55 patients with chronic hepatitis B (CHB), 173 patients with cirrhosis, and 124 patients with hepatocellular carcinoma (HCC). Serum RRM2 was measured via ELISA.

RESULTS

The level of serum RRM2 in patients with CHB, cirrhosis, and HCC was higher than that in healthy controls (P < .05). A large difference in serum RRM2 was found between HBV-related and non-HBV-related patients in the cirrhosis group (P < .001), compared with the difference between HBV-related HCC and non-HBV-related HCC (P = .86). In the HBV-related cirrhosis group, the serum RRM2 level showed significant positive correlations with HBV DNA, hepatitis B surface antigen, hepatitis B e antigen, Child-Pugh scores, and MELD scores and played a strong role in diagnosing HBV-related cirrhosis in CHB, compared with fibrosis-4 score and aspartate aminotransferase-to-platelet ratio index.

CONCLUSIONS

Serum RRM2 is a reliable biomarker for accurate HBV-related cirrhosis diagnosis and evaluation. Also, serum RRM2 could reflect the expression state of HBV replication in patients with HBV-related cirrhosis.

Killer cell immunoglobulin-like receptor alleles influence susceptibility to occult hepatitis B infection in West African population

Occult hepatitis B infection (OBI) is a public health problem in Burkina Faso. OBI represents a risk factor for the development of cirrhosis and hepatocellular carcinoma (HCC). OBI could be due to mutant viruses undetectable by HBsAg assays or a strong suppression of viral replication and gene expression under the pression of the host immune system. To investigate the role of killer cell immunoglobulin-like receptor (KIR) gene polymorphisms in patients with OBI in Burkina Faso compared to healthy and chronic hepatitis B subjects. A total of 286 participants was recruited, including 42 cases of OBI, 110 cases of chronic hepatitis B and 134 HBV negative subjects. SSP-PCR was performed to search for the presence of KIR genes. The HBV viral load was determined by qPCR. The frequencies of the activator gene KIR2DS5 (P=0.045) and the pseudogene KIR2DP1 (P<0.001) in patients with OBI were higher than those in patients with chronic hepatitis B. These genes are associated with susceptibility of occult hepatitis B infection. The frequencies of the inhibitory KIR gene KIR2DL3 (P=0.01) of patients with occult hepatitis B were lower than those in chronic hepatitis B patients. This gene KIR2DL3 is associated with protection against occult hepatitis B infection. Also, the frequencies of the inhibitory KIR genes KIR2DL2 (P<0.001), KIR2DL3 (P<0.001) and activators KIR2DS2 (P<0.001) in chronic hepatitis B patients were higher compared to the frequencies of the KIR genes in healthy subjects. These genes KIR2DL3, KIR2DL5 (A, B), KIR3DL3, KIR3DS1, KIR2DL2 and KIR2DS2 are thought to be genes associated with the susceptibility to OBI. The KIR2DS5 and KIR2DP1 genes could be associated with susceptibility to OBI. As for the KIR gene KIR2DL3 could be associated with protection against occult hepatitis B infection.

Oral oxymatrine for hepatitis B cirrhosis: A systematic review protocol

BACKGROUND

Characterized by diffuse hepatic fibrosis and nodule formation, hepatitis B cirrhosis (HBC), an important result of chronic hepatitis B development, mainly contains compensated and decompensated stage. Compensated cirrhosis can further develop into decompensated stage and hepatocellular carcinoma with serious complications and high mortality. Antiviral therapy using interferon (IFN) or nucleos(t)ide analogs (NUCs) is essential for improving the prognosis of the disease but IFN has large side effects while NUCs often develop drug resistance. Antifibrosis is also an important strategy, but currently there is no effective antifibrosis drug. Pharmacologic studies have demonstrated that oxymatrine (OM) exhibits anti-hepatitis B virus (HBV) and antifibrosis effects. An increasing number of clinical controlled studies also have found that OM combined with conventional therapy could improve the curative effect and reduce adverse events incidence in treating HBC but there is no systematic review of it. Based on the extensive collection of literature, we will use meta-analysis to assess the efficacy and safety of OM for HBC.

METHODS

PubMed, MEDLINE, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang data, Chinese Scientific Journals Database (VIP), and China biomedical literature database will be searched to obtain the eligible studies published up to July 15, 2018. The primary outcome will be liver function indexes, liver fibrosis indexes, and Child-Pugh score. The secondary outcome will be hepatitis B virus DNA quantification, HBV DNA seroconversion rate, hepatitis B e antigen (HBeAg) seroconversion rate, and adverse events incidence. Data analysis will be conducted using RevMan 5.3 and Stata V.9.0 software. Trial sequential analysis (TSA) will be performed to assess the risk of random error and the validity of conclusion using TSA program version 0.9 beta.

RESULTS

This systematic review will provide a high quality synthesis of OM for HBC from various evaluation aspects including liver function indexes, liver fibrosis indexes and Child-Pugh score, HBV DNA quantification, HBV DNA seroconversion rate, HBeAg seroconversion rate and adverse events incidence.

CONCLUSION

The systematic review will provide evidence to assess the efficacy and safety of OM in the treatment of HBC.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42018095275.

Antiviral therapy with nucleotide/nucleoside analogues in chronic hepatitis B: A meta-analysis of prospective randomized trials

Nucleotide/nucleoside analogues (antiviral therapy) are used in the therapy of HBeAg positive and HBeAg negative chronic hepatitis B. We analyzed ten selected randomized controlled with 2557 patients to estimate the effect of antiviral drugs in chronic hepatitis B with compared to placebo. Virological response, biochemical response, histological response, seroconversion of HBeAg, and loss of HBeAg were estimated as primary efficacy measures. The included studies were subjected for heterogeneity and publication bias. The heterogeneity was assessed with χ2 and I(2) statistics. Publication bias was assessed by funnel plot. Greater rates of improvement obtained in antiviral group for virological response [43.96 % vs. 3.15 %, RR = 0.57, 95 % CI = 0.54-0.61, p-value <0.00001], biochemical response [58.37 % vs. 21.87 %, RR = 0.52, 95 % CI = 0.48-0.56, p-value <0.00001], histological response [58.99 % vs. 27.13 %, RR = 0.56, 95 % CI = 0.50-0.63, p-value <0.0001], seroconversion of HBeAg [10.66 % vs. 5.56 %, RR = 0.94, 95 % CI = 0.91-0.97, p-value = 0.0005], and HBeAg loss [14.59 % vs. 9.64 %, RR = 0.92, 95 % CI = 0.88-0.96, p-value = 0.0002]. The safety analysis were carried out for adverse events such as headache [17.22 % vs. 17.34 %, OR = 1.09, 95 % CI = 0.81-1.46, p-value = 0.58], abdominal pain [16.46 % vs. 14.34 %, OR = 1.24, 95 % CI = 0.90-1.72, p-value = 0.19], and pharyngitis [22.22 % vs. 18.23 %, OR = 1.12, 95 % CI = 0.86-1.45, p-value = 0.40]. Excluding adverse events, all primary efficacy measures shown statistical significant result for chronic hepatitis treatment (p-value <0.05). Antiviral therapy provided significant benefit for the treatment of chronic hepatitis B with no measurable adverse effects.

Relationship between variations in peripheral T-lymphocyte subsets and viral replication levels in Chinese chronic HBV carriers with normal liver function tests

AIM: To investigate the correlations between the variations in peripheral T-cell subpopulations and HBV replication levels in Chinese chronic HBV carriers (HBVc) with normal liver function tests.

METHODS: The relative percentage of T-cell subpopulations in peripheral blood was measured by flow cytometry in 216 HBVc and 100 normal controls. HBV markers were detected by ELISA. Serum viral load was measured by real-time RT-PCR. The relationship between HBV replication level and variations in peripheral T-cell subpopulations was analyzed.

RESULTS: HBVc had a decreased number of CD3⁺ and CD4⁺ cells, a decreased CD4⁺/CD8⁺ ratio, and an increased number of CD8⁺ cells compared with normal controls (P < 0.01). The levels of CD3⁺ and CD4⁺ cells and the CD4⁺/CD8⁺ ratio decreased 20.4%, 17.8% and 35.7%, respectively (P < 0.01), and there was a 21.9% increase in the level of CD8+ cells in HBV DNA (+) HBVc as compared with HBV DNA(-) HBVc (P < 0.01). The level of HBeAg(+) HBVc decreased 19.5%, 14.0% and 28.6% in CD3⁺ and CD4⁺ cells and CD4⁺/CD8⁺ ratio, respectively (P < 0.01), and over 19.6% in CD8⁺ cells, compared with HBeAg (-) HBVc (P < 0.01). There were negative correlations between the levels of CD3⁺ and CD4⁺ cells and the CD4⁺/CD8⁺ ratio and viral load (r = -0.67, -0.54, -0.67, P < 0.01), and a positive correlation between the level of CD8+ cells and viral load (r = 0.61, P < 0.01). Compared with the HBV DNA (+) and HBV DNA(-) groups, the number of CD3⁺ and CD4⁺ cells and the CD4⁺/CD8⁺ ratio were significant lower, and the number of CD8+ cells was significant higher in the HBV DNA (+)/HBeAg (+) group. A similar pattern was seen in HBVc with maternal HBV-infection (MH) status compared with non-MH HBVc (P < 0.01). The percentages of MH HBVc that were HBV DNA (+) and HBeAg (+), and the number with a viral load > 1 × 10¹⁰ copies/L, were significantly higher than those of non-MH HBVc fulfilling these criteria (82.2% vs 34.5%), OR = 8.65, 95% CI: [4.45, 17.33]; (75.2% vs 28.7%), OR = 7.44, 95% CI: [3.91, 14.56]; (65.1% vs 10.3%), OR = 15.94, 95% CI: [7.13, 39.66]. Among the HBVc with MH, the number of CD3⁺ and CD4⁺ cells and the CD4⁺/CD8⁺ ratio were obviously lower, while the number of CD8+ cells was significant higher in HBV DNA(+) and HBeAg (+) patients than in HBV DNA(-) and HBeAg (-) patients, respectively (P < 0.05, P < 0.01). A similar pattern was also seen in non-MH HBVc.

CONCLUSION: Our results suggest that disorders of cellular immunity in Chinese HBVc with normal liver function tests could be caused by HBV infection, and are significantly associated with viral replication level, including viral load and HBeAg expression.

Evaluation of alpha-glutathione-S-transferase as a biomarker of lamivudine therapy for chronic hepatitis B

Hepatic damage associated with chronic hepatitis B (CHB) relies on measurement of serum transaminases and asssessment of hepatic histology. We determined if serum hepatic function tests, including alpha-glutathione-S-transferase ((GST), were of value in monitoring or predicting the effect of lamivudine therapy for CHB. Thirty-nine patients received orally 100 mg of lamivudine daily for 48 weeks. Blood samples were obtained at baseline and at 24 and 48 weeks. At the end of the treatment period the patients were then divided into four groups according to the pattern of HBs and HBe antigens. At baseline and at 24 weeks ALT, AST, and (GST had lower values in the complete response compared to the complete failure groups. Using ROC analysis, only ALT at 24 weeks (area under the curve = 0.803) had significant diagnostic ability in detecting responders. These results reaffirm the value of measuring serum ALT as an indicator of treatment response and provide information on the potential use of (GST as an additional prognostic biomarker in this patient group.

Rapid quantitation of lamivudine-resistant mutants in lamivudine treated and untreated patients with chronic hepatitis B virus infection

BACKGROUND

Long-term lamivudine treatment induces emergence of lamivudine-resistant hepatitis B virus (HBV) in a significant number of patients with chronic HBV infection. Rapid and quantitative methods to determine the percentage of lamivudine-resistant mutants in total HBV are important during lamivudine therapy.

METHODS

We established a quantitative real-time PCR method with selective primers and TaqMan probe to detect the percentage of lamivudine-resistant mutants in total HBV without the need of external DNA standards. This percentage was calculated as the PCR efficiency raised to the differences between threshold cycle number (DeltaCt) of mutant and control reactions. Clones of the HBV polymerase gene containing the different YMDD variants were diluted in series and tested. Serum samples from 145 lamivudine-treated and 98 untreated patients with chronic hepatitis B virus infection were analyzed using this method and compared with DNA sequencing.

RESULTS

As little as 0.1% mutant plasmids in 10(6)-10(9) copies/ml of wild-type plasmids were detected. Among the 145 patients treated with lamivudine, 42 of them had mutants with percentages of 5-100%. In six discordant results between real-time PCR and DNA sequencing, real-time PCR detected mutants with percentages of 5-20%, which were concordant with subclone sequencing. Five of 98 lamividine-untreated patients had mutants of 10-20% in wild-type virus populations. Compared to DNA sequencing, real-time PCR was fast and cost-effective.

CONCLUSION

This real-time PCR is a rapid, sensitive and cost-effective method for relative quantitation of YMDD mutants of HBV.

Detection of YMDD mutants using universal template real-time PCR

AIM: To establish a rapid and accurate method for the detection of lamivudine-resistant mutations in hepatitis B virus and monitor of lamivudine resistance during lamivudine treatment in patients with chronic hepatitis B virus infection.

METHODS: We established a real-time PCR method using a universal template and TaqMan probe to detect YMDD mutants. Variants of YVDD and YIDD were tested by individual reactions (reaction V and reaction I) and total hepatitis B viruses were detected in another reaction for control (reaction C). Results were determined by ΔCt < 3.5 (ΔCt = Ct of reaction V or I - Ct of reaction C). Clones of the HBV polymerase gene containing different YMDD mutations were tested. Serum samples from 163 lamivudine-treated patients with chronic hepatitis B virus infection were detected using this method and the results were confirmed by DNA sequencing.

RESULTS: As many as 1 000 copies per milliliter of wide-type plasmid were detected and nonspecific priming was excluded. In the 163 samples from patients treated with lamivudine, lamivudine-resistant mutations were detected in 51 samples.

CONCLUSION: This universal real-time PCR is a rapid and accurate method for quantification of YMDD mutants of HBV virus in lamivudine-treated patients and can be used to monitor lamivudine-resistant mutations before and during lamivudine therapy.