A simple algorithm for non-invasive diagnosis of significant liver histological changes in patients with CHB and normal or mildly elevated alanine transaminase levels

Significant liver histological changes (SLHC) were defined as moderate to severe liver inflammation (A2 or higher) and/or fibrosis (F2 or higher) using the METAVIR scoring system. This study aimed to develop an algorithm for the non-invasive detection of SLHC in patients with chronic hepatitis B (CHB) and normal or mildly elevated alanine transaminase (ALT) levels.Using liver histology as gold standard, we developed a simple algorithm for the diagnosis of SLHC in a training set (504 patients), and then validated the diagnostic accuracy in a validation set (166 patients).A new algorithm (AAG) attributed to age, ALT, and gamma-glutamyl transpeptidase (GGT) was developed. In the training set, the area under ROC curve (AUROC) of AAG was significantly higher than that of ALT, aspartate transaminase (AST), GPR, and APRI for the diagnosis of SLHC (0.74, 0.68, 0.65, 0.56, and 0.53, respectively; all P < .05). In the validation set, the AUROC of AAG was also higher than that of ALT, AST, GPR, and APRI (0.73, 0.65, 0.62, 0.62, and 0.61, respectively; all P < .05). Using AAG ≥ 2, the sensitivity and negative predictive value was 84% to 98% and 75% to 94%, respectively, for the diagnosis of SLHC. Using AAG ≥ 6, the specificity and positive predictive value was 93% to 97% and 67% to 79%, respectively, for the diagnosis of SLHC.The AAG algorithm represents a novel noninvasive method for the diagnosis of SLHC in CHB patients with normal or mildly elevated ALT levels.

A dual role for SAMHD1 in regulating HBV cccDNA and RT-dependent particle genesis

Chronic hepatitis B is one of the world's unconquered diseases with more than 240 million infected subjects at risk of developing liver disease and hepatocellular carcinoma. Hepatitis B virus reverse transcribes pre-genomic RNA to relaxed circular DNA (rcDNA) that comprises the infectious particle. To establish infection of a naïve target cell, the newly imported rcDNA is repaired by host enzymes to generate covalently closed circular DNA (cccDNA), which forms the transcriptional template for viral replication. SAMHD1 is a component of the innate immune system that regulates deoxyribonucleoside triphosphate levels required for host and viral DNA synthesis. Here, we show a positive role for SAMHD1 in regulating cccDNA formation, where KO of SAMHD1 significantly reduces cccDNA levels that was reversed by expressing wild-type but not a mutated SAMHD1 lacking the nuclear localization signal. The limited pool of cccDNA in infected Samhd1 KO cells is transcriptionally active, and we observed a 10-fold increase in newly synthesized rcDNA-containing particles, demonstrating a dual role for SAMHD1 to both facilitate cccDNA genesis and to restrict reverse transcriptase-dependent particle genesis.

Clinical and histopathological features of chronic hepatitis B virus infected patients with high HBV-DNA viral load and normal alanine aminotransferase level: A multicentre-based study in China

Background

The aim of this study is to reveal the clinical and histopathological features of HBsAg-positive and HBeAg-positive chronic hepatitis B infected patients with high level of HBV DNA, from 17 hospitals and medical centres in China, with alanine aminotransferase levels within the lower region of normal range versus those with levels within the upper region of normal range and to investigate the clinical risk factors for the requirement of treatment through the examination of liver biopsy.

Methods

Liver biopsy was performed on high level of HBV DNA of 455 patients with HBsAg-positive and HBeAg-positive chronic hepatitis B infection and persistently normal alanine aminotransferase level. Liver necroinflammation and fibrosis were graded per the Knodell histological activity index and Ishak’s fibrosis score, respectively. Univariate analysis of the clinical parameters versus necroinflammation and fibrosis was carried out.

Results

Of the subjects in this multicentre-based study, 5.49% and 10.11% had significant necroinflammation with Knodell histological activity index ≥ 9 and hepatic fibrosis stages with Ishak scores ≥ 3, respectively. The subjects were stratified into three age groups (30–39, 40–49 and ≥ 50 years), and our data clearly suggested that age, particularly in the age group over 50, was an independent predictor of liver necroinflammation and fibrosis. Lower HBV-DNA viral levels were found in patients with Knodell histological activity index ≥ 9 or advanced fibrosis (Ishak scores ≥ 3).

Conclusion

Our results showed that histological changes in liver tissues were observed in a significant proportion of patients with persistently normal alanine aminotransferase level. According to the data evaluation results, liver biopsy is advisable for HBeAg-positive chronic hepatitis B infected patients aged older than 40 and high HBV-DNA viral load in China.

[Difference of Liver Enzymes in Different Metabolism States of Chronic Hepatitis B]

OBJECTIVE

To analyze the difference of liver enzymes in different metabolism state groups of chronic hepatitis B (CHB).

METHODS

We use prospective cross-sectional study to analyze the difference of liver enzymes in different metabolism state groups in 110 cases of CHB, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and glutamyl transferase (GGT).

RESULTS

Regardless of the presence or absence of fatty liver, the levels of ALP and GGT were increased along with the deterioration of glucose metabolism (P<0.05).The levels of ALP and GGT in the presence of fatty liver group were higher than those in the absence of fatty liver group (P<0.05). The levels of AST, ALP and GGT showed the trend of increasing along with the increase of HOMA-IR and the decrease of HOMA-β. There was no difference of liver enzymes among the groups with or without other metabolism disorder (P>0.05).

CONCLUSION

In CHB, abnormal glucose metabolism and fatty liver can lead to the increase of ALP and GGT. The increase of HOMA-IR and the decrease of HOMA-β may lead to the increase of AST, ALP and GGT. Other metabolism disorder did not show any effect on the level of liver enzymes.

The independent predictors of significant liver histological changes in chronic hepatitis B virus infection patients with persistently high-normal or low-normal alanine transaminase levels

OBJECTIVE

To determine the independent predictors of significant liver histological changes (SLHC) defined as inflammatory grade ≥A2 and/or fibrosis stage ≥F2 using the METAVIR scoring system in chronic hepatitis B virus (HBV) infection patients with persistently normal ALT (PNALT) levels.

METHODS

We enrolled 392 chronic HBV infection patients with PNALT defined as normal ALT (≤40 IU/L) measured on at least three occasions at intervals of more than 2 months apart over a period of 12 or more months. Univariate and multiple analyses were performed to identify the independent predictors of SLHC in high-normal ALT (HNALT) (20<ALT≤40 IU/L) and low-normal ALT (LNALT) (ALT≤20 IU/L) groups, respectively.

RESULTS

Of 392 PNALT patients, 291 (74.2%) had HNALT and 101 (25.8%) had LNALT. The prevalence of SLHC in HNALT group is higher than that in LNALT group (36.4% vs. 19.8%, p=0.002). Of 291 HNALT patients, 106 (36.4%) had SLHC, and multivariate analysis showed that age (OR=1.059, 95%CI, 1.027-1.093, p<0.001), ALT (OR=1.018, 95%CI, 1.052-1.167, p<0.001), and gamma-glutamyl transpeptidase (GGT) (OR=1.012, 95%CI, 1.002-1.022, p=0.016) were independent predictors of SLHC. Of 101 LNALT patients, 20 (19.8%) had SLHC, and multivariate analysis showed that age (OR=1.121, 95%CI, 1.044-1.204, p=0.002) was the only independent predictor of SLHC.

CONCLUSION

Age, ALT, and GGT were independent predictors of SLHC in HNALT patients, and age was the only independent predictor of SLHC in LNALT patients. These predictors might be used to screen SLHC, select candidates for liver biopsies, and guide proper antiviral therapy.

Vitamin D serum level is associated with Child-Pugh score and metabolic enzyme imbalances, but not viral load in chronic hepatitis B patients

Vitamin D deficiency is common in patients with chronic liver diseases. However, vitamin D status in persons with chronic hepatitis B virus (HBV) infection is not consistently reported. Specifically, the impact of liver dysfunction on vitamin D status has not been well addressed.We recruited a group of patients (n = 345) with chronic hepatitis B (n = 115), hepatitis B related cirrhosis (n = 115), and age- and gender-matched healthy controls (n = 115). Serum 25-hydroxyvitamin D3 [25(OH)D3], its related metabolic enzymes, intact parathyroid hormone were measured. Calcium, magnesium, and phosphorus were obtained from medical record.Serum 25(OH)D3 levels in chronic hepatitis B patients (7.83 ± 3.47 ng/mL) were significantly lower than that in healthy controls (9.76 ± 4.36 ng/mL, P < 0.001), but significantly higher than that in hepatitis B-related cirrhotic patients (5.21 ± 3.67 ng/mL, P < 0.001). Furthermore, 25(OH)D3 decreased stepwise with higher Child-Pugh classification. However, there were no significant differences in 25(OH)D3 levels between (1) hepatitis B e antigen (HBeAg +) and HBeAg(-) persons, or (2) among persons with different HBV viral load, or (3) between treatment naïve and patients on antiviral therapy. Multiple logistic regression analyses confirmed that higher Child-Pugh score was independently associated with 25(OH)D3 deficiency (<10 ng/mL) with an odds ratio of 1.20 (confidence interval 1.03-1.39, P = 0.016). Levels of cytochrome P450 (CYP) 27A1 were significantly decreased, whereas levels of CYP24A1 were significantly elevated in cirrhotic patients.These results suggest that decreasing vitamin D levels are likely to be a result, rather than a cause, of liver dysfunction and irrespective of HBV viral load. Reduction in 25(OH)D3 levels is possibly due to downregulation of the synthetic hydroxylase CYP27A1 and concurrent upregulation of degrading CYP24A1 in patients with liver cirrhosis.

Non-Invasive Evaluation of Hepatic Fibrosis: The Diagnostic Performance of Magnetic Resonance Elastography in Patients with Viral Hepatitis B or C

PURPOSE

To compare the accuracy of magnetic resonance elastography (MRE) with that of aspartate aminotransferase-to-platelet ratio index (APRI) for estimating the stage of hepatic fibrosis in patients with chronic hepatitis B virus (HBV) or chronic hepatitis C virus (HCV) infection.

MATERIALS AND METHODS

We retrospectively enrolled 160 patients with chronic hepatitis and 25 healthy living liver donors. Fibrosis stage (METAVIR, F0 to F4) was determined histopathologically for all patients. APRI was recorded at the time of histopathologic examination and liver stiffness values were measured on MRE quantitative stiffness maps. The cutoff values, sensitivity, and specificity of MRE and APRI for each fibrosis stage were determined using receiver operating characteristic (ROC) analysis.

RESULTS

MRE had a significantly greater area under the ROC curve than APRI score for discriminating among METAVIR stages F2-F4. Using a cutoff value of 2.80 kPa, MRE had a sensitivity of 94.4% and a specificity of 97.8% for detecting significant fibrosis (≥F2). There were no significant differences in fibrosis stage between patients with HBV and those with HCV infection. For ≥F2, the cutoffs were 2.47 kPa (100% sensitivity), 2.80 kP (maximum sum of sensitivity and specificity), and 3.70 kPa (100% specificity).

CONCLUSIONS

MRE is a more accurate modality than APRI for detecting significant fibrosis in patients with chronic HBV or HCV infection. Antiviral treatment should be considered in patients with liver stiffness values ≥ 2.8 kPa.

Demethylation of tumor necrosis factor-α converting enzyme promoter associated with high hepatitis B e antigen level in chronic hepatitis B

AIM: To evaluate tumor necrosis factor-α converting enzyme (TACE) methylation status in patients with chronic hepatitis B (CHB).

METHODS: Eighty patients with hepatitis B e antigen (HBeAg)-positive CHB, 80 with HBeAg-negative CHB, and 40 healthy controls (HCs) were randomly enrolled in this study. Genomic DNA was extracted from peripheral blood mononuclear cells and methylation status of TACE promoter was determined by methylation-specific polymerase chain reaction. The clinical and laboratory parameters were collected.

RESULTS: One hundred and thirty of 160 patients with CHB (81.25%) and 38 of 40 HCs (95%) displayed TACE promoter methylation. The difference was significant (χ² = 4.501, P < 0.05). TACE promoter methylation frequency in HBeAg-positive CHB (58/80, 72.5%) was significantly lower than that in HBeAg-negative CHB (72/80, 90%; χ² = 8.041, P < 0.01) and HCs (χ² = 8.438, P < 0.01). However, no significant difference was observed in the methylation frequency between HBeAg-negative CHB and HCs (χ² = 0.873, P > 0.05). In the HBeAg-positive group, TACE methylation frequency was significantly negatively correlated with HBeAg (r = -0.602, P < 0.01), alanine aminotransferase (r = -0.461, P < 0.01) and aspartate aminotransferase (r = -0.329, P < 0.01).

CONCLUSION: Patients with HBeAg-positive CHB have aberrant demethylation of the TACE promoter, which may potentially serve as a biomarker for HBeAg seroconversion.

ALT CHANGES AND ADVERSE EVENTS OF TELBIVUDINE IN HEPATITIS-B PATIENTS-AN EXPERIENCE OF 11 PATIENTS

Hepatitis-B virus (HBV) infection is a major global health problem. Of the two billion people who have been infected, more than 350 million have chronic hepatitis. It is estimated that 235,000-328,000 people die annually due to liver cirrhosis and hepatocellular carcinoma, we assessed the short term outcomes of treatment with telbivudine in 11 adults aged 14-41 years with HBeAg-positive or HBeAg-negative chronic hepatitis-B (CHB). Treatment of chronic hepatitis-B patients with telbivudine shows 43.1% reduction in serum ALT with no significant adverse effects.

Inducible nitric oxide synthase expression (iNOS) in chronic viral hepatitis and its correlation with liver fibrosis

BACKGROUND

Nitric oxide (NO) production by the action of the inducible nitric oxide synthase (iNOS or NOS2) is increased in tissues that are stimulated by cytokine and endotoxins. The role of NO in the pathogenesis of chronic viral hepatitis is not fully understood but it seems that its overproduction is responsible for the pathological changes under inflammatory conditions.

AIM

In this paper, we analyzed the correlation between immunohistochemical expression of iNOS and liver fibrosis in chronic viral hepatitis.

MATERIALS AND METHODS

Liver biopsies from patients diagnosed with chronic viral hepatitis B and C were embedded in paraffin and further used for histological staining and immunohistochemical reactions to detect the expression of iNOS and TGF-β1. The degree of liver fibrosis was established using special staining (trichromic Masson and Gömöri's silver impregnation).

RESULTS

In samples with low degree of fibrosis, we observed a discrete positivity for iNOS in periportal hepatocytes and the immunohistochemical reaction for TGF-β1 were limited to the endothelial cells of liver sinusoids and pro-inflammatory cells from the portal tracts. Positive reaction for TGF-β1 increased with the degree of liver fibrosis, while the expression of iNOS was enhanced in hepatocytes, as well as in bile ducts and endothelial cells.

CONCLUSIONS

Infection with hepatitis B and C viruses induces iNOS expression in hepatocytes, suggesting that NO overproduction might have an important role in progression of chronic viral hepatitis to cirrhosis.

PNPLA3 I148M polymorphism and progressive liver disease

The 148 Isoleucine to Methionine protein variant (I148M) of patatin-like phospholipase domain-containing 3 (PNPLA3), a protein is expressed in the liver and is involved in lipid metabolism, has recently been identified as a major determinant of liver fat content. Several studies confirmed that the I148M variant predisposes towards the full spectrum of liver damage associated with fatty liver: from simple steatosis to steatohepatitis and progressive fibrosis. Furthermore, the I148M variant represents a major determinant of progression of alcohol related steatohepatitis to cirrhosis, and to influence fibrogenesis and related clinical outcomes in chronic hepatitis C virus hepatitis, and possibly chronic hepatitis B virus hepatitis, hereditary hemochromatosis and primary sclerosing cholangitis. All in all, studies suggest that the I148M polymorphism may represent a general modifier of fibrogenesis in liver diseases. Remarkably, the effect of the I148M variant on fibrosis was independent of that on hepatic steatosis and inflammation, suggesting that it may affect both the quantity and quality of hepatic lipids and the biology of non-parenchymal liver cells besides hepatocytes, directly promoting fibrogenesis. Therefore, PNPLA3 is a key player in liver disease progression. Assessment of the I148M polymorphism will possibly inform clinical practice in the future, whereas the determination of the effect of the 148M variant will reveal mechanisms involved in hepatic fibrogenesis.

Significant fibrosis is not rare in Chinese chronic hepatitis B patients with persistent normal ALT

Background

Limited studies have been done on chronic hepatitis B (CHB) patients defined according to the latest Asian-Pacific Association for the Study of the Liver guideline with liver histology by a large sample size.

Methods

We retrospectively evaluated liver histological characteristics on a cohort of consecutive treatment-naive CHB patients with persistent normal alanine aminotransferase (PNALT) or elevated ALT from May 2005 to October 2011. Histological assessment was based on the Metavir scoring system, significant abnormality was defined as necroinflammation grade ≥A2 and/or fibrosis stage ≥F2.

Results

A total of 675 CHB patients were recruited, including 516 HBeAg-positive and 159 HBeAg-negative patients. In HBeAg-positive patients, significant fibrosis was found 49.4% (42/85) in PNALT, 69.8% (88/126) in ALT 1-2×upper limit normal (ULN) and 81.6% (249/305) in ALT>2×ULN group, respectively. In HBeAg-negative patients, significant fibrosis was found 30.9% (17/55) in PNALT, 73.3% (33/45) in ALT 1-2×ULN and 94.9% (56/59) in ALT>2×ULN group, respectively. HBeAg-positive patients with PNALT over 30 years old had a higher frequency of significant fibrosis than those under 30 years old (87.5% vs. 45.5%, P = 0.058). Multivariate logistic regression analysis indicated increasing age (P = 0.012), higher aspartate aminotransferase (AST) (P < 0.001) and lower HBV DNA (P < 0.001) were associated with significant necroinflammation, while higher AST (P < 0.001), lower albumin (P = 0.027) and HBV DNA (P = 0.004) were associated with significant fibrosis in HBeAg-positive patients with elevated ALT. Higher AST was associated with significant necroinflammation in HBeAg-negative patients with elevated ALT (P = 0.009).

Conclusions

Significant fibrosis is not rare in Chinese CHB patients with PNALT, especially HBeAg-positive patients over 30 years old.

Serum lactonase and arylesterase activities in alcoholic hepatitis and hepatitis B

BACKGROUND

PON1 is an HDL-associated enzyme having antioxidant activity. PON1 is synthesized in the liver, and there is decreased synthesis of PON1 with increased lipid peroxidation. The study was carried with the aim of establishing whether chronic liver disease (CLD) produced any significant changes in serum arylesterase (AE) and lactonase activities of PON. The second objective was to determine whether there was any correlation between serum AE and lactonase activities and the various routine liver function tests. The usefulness of adding serum lactonase and AE activity to standard liver function tests was analyzed by multiple logistic regression analysis. Finally, the diagnostic efficacy or analytical performance of AE and lactonase in assessing patients with CLD was determined using 'receiver operating characteristic' (ROC) plot.

METHODS

The study group consisted of 120 subjects; 60 were patients with liver disease out of which 40 were having chronic alcoholic liver disease and 20, acute viral hepatitis B, and 60 were healthy controls. Serum PON1 lactonase activity was measured manually using dihydrocoumarin, and AE activity was measured using phenylacetate as substrate. Liver function tests (bilirubin, albumin, AST, ALT, alkaline phosphatise) were done by standard technique.

RESULT

The serum lactonase and AE activities were decreased significantly in patients with chronic alcoholic liver disease (p < 0.001, p < 0.001) and acute viral hepatitis B (p < 0.001, p < 0.001). Both measurements showed higher efficiency in testing liver dysfunction in multivariate regression analysis. Model 1 consisted of bilirubin, albumin, AST, ALT, and alkaline phosphatase, R2 = 0.912. Model 2 consisted of model 1+arylesterase having higher R2 = 0.0.954, and model 3 consisted of model 1+lactonase having R2 = 0.962. ROC plots demonstrated a high diagnostic accuracy for serum PON1 lactonase (area under ROC curve = 0.982) and serum PON1 arylesterase (area under ROC curve = 0.986).

CONCLUSION

Low PON1 lactonase and AE activity were found in acute viral hepatitis B and in chronic alcoholic hepatitis.

[Interleukin-32 expression in serum of patients with HBV-related liver failure and its significance]

OBJECTIVE

To investigate the expression level of IL-32 in serum and its correlation with serum biochemical indices of liver function test and HBV DNA load in patients with HBV-related liver failure.

METHODS

Fifty-five patients with HBV-related liver failure (severe hepatitis group) and twenty normal cases (control group) were enrolled in the study. Total RNA in PBMCs was extracted by using TRIzol. IL-32 mRNA level was assayed by using Real-time PCR. IL-32 protein level in serum was detected by ELSIA method. The correlation between IL-32 and ALT, AST, TBIL, HBV DNA load was analyzed using pearson's correlation analysis, respectively.

RESULTS

Serum IL-32 expression level in severe hepatitis group was higher than that of control group. Moreover, the difference between them was statistically significant (P < 0.05). Serum IL-32 level was positively correlated with serum ALT, AST, TBIL, respectively (P < 0.05), but was not correlated with HBV DNA load (P > 0.05).

CONCLUSION

Serum IL-32 expression level was increased in patients with HBV-related liver failure and was associated with the severity of inflammation. We, therefore, believe that IL-32 might be involved in the pathogenesis of HBV-related liver failure.

[The therapeutic effects of pegasys in chronic hepatitis B patients with low-level ALT]

OBJECTIVE

To observe the therapeutic effects of Pegasys (pegylated interferon alpha-2a) in chronic hepatitis B (CHB) patients with low-level alanine transaminase (ALT) < 2 x upper limit of normal (ULN).

METHODS

One hundred and seven CHB patients were randomized enrolled including 52 with ALT < 2 x ULN and liver tissues inflammation activity > or = G2 as observational group and 55 with ALT > 2 x ULN as control group. All the enrolled patients received pegasys treatment for 48 weeks and the responses between two groups were compared. Measurement data were analyzed using t test and numeration data were analyzed using chi square test.

RESULTS

The reductions of HBV DNA in observational group at different time points were all less than control group (all P < 0.05). At the end of treatment, the HBV DNA negative rate, HBeAg seroconversion rate and HBsAg loss rate in the observational group were 51.9%, 48.8% and 1.9% , respectively, which were all lower than control group (67.3% , 66.7% and 7. 3% , respectivley) ( all P <0. 05). The ALT normalization rates of two groups were 75% and 76.4% (P > 0. 05).

CONCLUSION

Pegasys is efficient for CHB patients with ALT < 2 x ULN and liver tissues inflammation activity > or = G2, while it is still inferior to those with ALT > 2 x ULN.

[The activity of enzymes in lymphocytes of children and adults with chronic viral hepatitis B and C]

It is established that in patients with chronic viral hepatitis B and C the intensity of reaction is increased in lymphocytes of children as compared with adults. The study also established the limitation of turning out of substrates for macromolecular synthesis and the decrease of activity of reactions of tricarbonic acid cycle at the expense of decreasing of substrates flow from amino-acid metabolism included. Under chronic hepatitis C, in lymphocytes the levels of activity of enzymes involved in functioning of main metabolic paths and glutathione system of antioxidant defense of are decreased in children as compared with adults.

Quantitative HBV DNA and AST are strong predictors for survival after HCC detection in chronic HBV patients

Hepatitis B virus infection (HBV) is an important co-factor in the development of hepatocellular carcinoma (HCC). We studied whether quantitative HBV DNA at time of HCC detection influences survival of HCC patients. All diagnosed HCC cases between 2000 and 2008 at our university-based reference centre were analysed to determine the influence of hepatitis B viral load on overall survival. Clinical and virological findings were evaluated in univariate and multivariate analyses, survival rates were assessed for HCC patients with a high viral load (HBV DNA ≥10(5) copies/ml) and low viral load (HBV DNA <10(5) copies/ml). HCC was diagnosed in 597 patients, including 98 patients with HBV. The group of 37 patients (38%) who had a high viral load contained more HBeAg-positive patients, had lower serum albumin levels and higher serum aspartate aminotransferase (AST ) and alanine aminotransferase (ALT ) levels. The one- and five-year survival rates of HCC patients with a high viral load were 58% and 11% and for HCC patients with a low viral load 70% and 35%, respectively. In multivariate analysis a higher AST level and higher viral load were significantly associated with shorter overall survival (HR=2.30; p=0.018, HR=1.22; p=0.015, respectively). HBeAg positivity, low albumin level or high AST or ALT levels in HCC patients are associated with a higher HBV DNA . HBV DNA level at detection is associated with overall survival of HCC patients. These findings support the concept that after HCC detection adequate suppression of HBV DNA by nucleoside analogue therapy may improve survival.

Liver stiffness measurement and biochemical markers in Senegalese chronic hepatitis B patients with normal ALT and high viral load

BACKGROUND AND AIMS

Despite the high prevalence of chronic hepatitis B (CHB) in Africa, few studies have been performed among African patients. We sought to evaluate liver stiffness measurement by FibroScan® (LSM) and two biochemical scores (FibroTest®, Fibrometer®) to diagnose liver fibrosis in Senegalese CHB patients with HBV plasma DNA load ≥3.2 log(10) IU/mL and normal alanine aminotransferase (ALT) values.

METHODS

LSM and liver fibrosis biochemical markers were performed on 225 consecutive HBV infected Senegalese patients with high viral load. Patients with an LSM range between 7 and 13 kPa underwent liver biopsy (LB). Two experienced liver pathologists performed histological grading using Metavir and Ishak scoring.

RESULTS

225 patients were evaluated (84% male) and LB was performed in 69 patients, showing F2 and F3 fibrosis in 17% and 10% respectively. In these patients with a 7-13 kPa range of LSM, accuracy for diagnosis of significant fibrosis according to LB was unsatisfactory for all non-invasive markers with AUROCs below 0.70. For patients with LSM values below 7 kPa, FibroTest® (FT), and Fibrometer® (FM) using the cut-offs recommended by the test promoters suggested a fibrosis in 18% of cases for FT (8% severe fibrosis) and 8% for FM. For patients with LSM values greater than 13 kPa, FT, FM suggested a possible fibrosis in 73% and 70%, respectively.

CONCLUSION

In highly replicative HBV-infected African patients with normal ALT and LSM value below 13 kPa, FibroScan®, FibroTest® or Fibrometer® were unsuitable to predict the histological liver status of fibrosis.

[Liver histological changes in chronic hepatitis B patients with elevated ALT less than 2 x ULN]

OBJECTIVE

To investigate the relevant factors of liver histological changes in chronic hepatitis B (CHB) patients with mildly elevated ALT and to explore the clinical values of these factors on anti-viral treatment.

METHODS

A total of 152 CHB patients with mildly elevated ALT (less than 2 x ULN) who underwent liver biopsy were included in the study. Correlations between routine laboratory markers, liver histological inflammation grade and fibrosis stage were statistically assessed by Spearman correlation analysis, one-way ANOVA, area under the curve (AUC) of the receiver operating characteristic curves (ROC) and Logistic regression statistical analysis.

RESULTS

All patients in the study showed various hepatic histological damages. Among the 152 patients 50 (32.9%) were found with inflammation grade 1 (G1), 42 (27.6%) with G2, 46 (30.3%) with G3 and 14 (9.2%) with G4. 16 patients (10.5%) were found with fibrosis stage 2 (S2), 25 (16.5%) with S3 and 41 (27.0%) with S4. Routine laboratory markers Alb, BPC and WBC were significantly correlated with hepatic histological inflammation grade and fibrosis stage. Marked liver fibrosis and moderate to severe liver damage were significantly higher in patients aged more than 40 years as compared to those less than 40 years of age (P = 0.002, P = 0.010). The regression equation P = 1/[1+e-(9.36250-1625Alb-0.0234BPC)] was established with sensitivity and specificity of 83.3% and 65.0%, respectively.

CONCLUSION

67.8% of CHB patients with mildly elevated ALT have significant injury to the liver tissue. CHB patients aged more than 40 years have a significant increase of marked liver fibrosis and moderate to severe liver damage. The regression equation is valuable to predict whether CHB patients need antiviral therapy or not.

Hepatitis B virus reverse transcriptase sequence variant database for sequence analysis and mutation discovery

Drug resistance resulting from reverse transcriptase (RT) mutations is one of the main obstacles to successful hepatitis B virus (HBV) therapy. Indeed, HBV treatment guidelines recommend HBV genotypic resistance testing for patients receiving nucleos(t)ide RT inhibitors (N(t)RTIs) who develop virological failure. N(t)RTI-resistance mutations at 10 RT positions have been well characterized in phenotypic studies, however, data are lacking on the relative frequency of these mutations in N(t)RTI-treated and untreated individuals. There are also few published data on the extent of amino acid variation at most of the 344 positions of HBV RT and the extent to which this variation is influenced by N(t)RTI treatment. We retrieved 23,871 HBV RT sequences from GenBank and reviewed the published reports of these sequences to ascertain the number of individuals from whom the sequences were obtained, the N(t)RTI treatments of these individuals, and the year and region of virus sampling. We then used these data to populate a relational database we named HBVrtDB. As of July 2010, HBVrtDB contained 6811 sequences from 3869 individuals reported in 281 references. Among these 3869 individuals, 73% were N(t)RTI-naïve and 27% received one or more N(t)RTIs. Among the 10 well-characterized N(t)RTI-resistance mutations, L80I/V, V173L, L180M, A181T, T184S, S202G and M204I/V were significantly associated with treatment with lamivudine, an l-nucleoside analog, and A181S/T/V and N236T were significantly associated with treatment with adefovir, an acyclic nucleoside phosphonate. A similar analysis of ten additional less well-characterized resistance mutations demonstrated a significant association with N(t)RTI treatment for four of the mutations: L82M, S85A, A200V, and Q215S. We also created an interactive program, HBVseq, to enable users to identify mutations in submitted sequences and retrieve the prevalence of these mutations in HBVrtDB according to genotype and N(t)RTI treatment. HBVrtDB and HBVseq are available at http://hivdb.stanford.edu/HBV/releaseNotes/.

Non-response to previous interferon therapy and cirrhosis are risk factors for predicting breakthrough during lamivudine therapy in patients with chronic hepatitis B

AIMS

Lamivudine is a potent oral anti-viral medicine for the treatment of hepatitis B virus (HBV) infection. However, one of the major problems is the breakthrough (BT) followed by flare-up of hepatitis. We examined the influences of clinical background, progression of liver fibrosis, presence or absence of HBeAg and previous interferon (IFN) therapy on the occurrence of breakthrough.

SUBJECTS AND METHODS

This study comprised 51 patients with HBV related chronic hepatitis (CH) or cirrhosis (LC) who were treated with lamivudine for the mean period of 33.8 ± 13.1 months (range 3-63 months). Thirty-six patients were CH, 25 were HBeAg- positive, and 25 had a previous history of IFN therapy. Patients were divided into two groups according to the occurrence of BT, either BT(+) or BT(-). Age, gender, alanine aminotransferase (ALT) and HBV titer before treatment, normalization of ALT (≤ 40 IU/L) and flare-up of hepatitis (ALT > 80 IU/L) rates, degree of hepatic fibrosis (CH/LC), presence or absence of HBeAg (HBeAg(+)/(-), and previous IFN therapy (IFN(+)/(-) were analyzed using Cox's proportional hazards analysis.

RESULTS

Twenty-five patients showed BT. Background data were not different between the patients with and without BT. Flare-up of hepatitis occurred more frequently in BT. Rates of BT were markedly higher in LC (P = 0.025) and IFN(+) (P = 0.036), but HBeAg was not associated with BT. In multivariate analysis, progression of liver fibrosis (P = 0.006) and previous IFN therapy were independent risk factors for BT (P = 0.023).

CONCLUSIONS

BT significantly occurred in patients with LC and the history of previous IFN therapy. Multivariate analysis showed that progression of hepatic fibrosis and previous interferon therapy are independent risk factors for BT.

Liver histology and HBV DNA levels in chronically HBV infected patients with persistently normal alanine aminotransferase

BACKGROUND

Data on histological activity and HBV DNA levels in patients with chronic HBV infection and persistently normal alanine aminotransferase levels are sparse. We aimed to investigate the histological activity and HBV DNA levels in these patients.

METHODS

There were 132 patients with HBeAg negative chronic HBV infection and persistently normal alanine aminotransferase levels that were included prospectively. Data were dichotomized according to the median levels. Associations of histology with HBV DNA and other variables were assessed.

RESULTS

A total of 80 patients were male. The median age was 36 years. The median baseline HBV DNA was 2.9Log10 IU/mL. There were 50 cases (38%) with a total score > or = 5, 53 cases (40.2%) had grade > or = 4 and 40 cases (30.3%) had stage > or = 2. A baseline HBV DNA <2000 IU/mL was seen in 24 cases (48%) of those with total score > or = 5, 28 cases (53%) of those with grade > or = 4 and 9 cases (22.5%) with stage > or = 2. Multivariate analysis of baseline HBV DNA above the median level significantly predicted the total score, grade and stage with an adjusted odds ratio of 5.43, 3.47, and 4.23, respectively when compared to below median values. A second liver biopsy was performed in 61 patients. The median time interval between the two biopsies was 40 months. Total scores of 23 cases (38%) progressed by > or = 2 scores and the HBV DNA of 18 cases (22.5%) increased by > or = 1 Log10 IU when compared to baseline values.

CONCLUSION

HBeAg negative chronic HBV infection with persistently normal alanine aminotransferase is not a silent disease. Active liver disease may be seen in such patients with viral loads less than 2000 IU/mL.

Evaluation of serum matrix metalloproteinase (MMP)-9 to MMP-2 ratio as a biomarker in hepatocellular carcinoma

BACKGROUND/AIMS

Serum matrix metalloproteinase (MMP)-9/ MMP-2 ratios are highly associated with alpha-fetoprotein levels in patients with chronic hepatitis B. In this study, we evaluate the clinical usefulness of this ratio as a biomarker in hepatitis B virus-related hepatocellular carcinoma (HCC).

METHODOLOGY

Serum samples from 181 chronic hepatitis B patients (52 healthy carriers, 47 chronic hepatitis patients, 50 cirrhosis patients, and 32 HCC patients) were collected. MMP-9/ MMP-2 ratio was determined by zymography. The results were analyzed using the Receiver-Operating Characteristic (ROC) curve.

RESULTS

Serum MMP-9/ MMP-2 ratios in HCC patients were significantly higher than those in healthy carriers, chronic hepatitis patients, and cirrhosis patients (p = 0.004, 0.034, and < 0.001, respectively). The sensitivity and specificity at the optimal cutoff (0.97) were 69.7% and 73.4%, respectively. Significantly higher MMP-9/ MMP-2 ratios were found in advanced, inoperable HCC patients, compared to those in early stage HCC patients (p = 0.005). No significant difference was found for alpha-fetoprotein levels between these two groups (p = 0.312).

CONCLUSIONS

The serum MMP-9/ MMP-2 ratio can be used as an accessory diagnostic marker in hepatitis B virus-related HCC. This ratio is useful in distinguishing between patients with early stage HCC and those with advanced HCC.

Antioxidant defense in patients with chronic viral hepatitis B and C type

BACKGROUND

The aim of the present study was to determine erythrocyte glutathione, superoxide dismutase, catalase, glutathione peroxidase, and serum total antioxidant response levels in a large chronic viral hepatitis group who had no antiviral treatment, and also the relationship of these parameters with viral load, fibrosis score, and necro-inflammation of the liver.

METHODS

200 patients who were diagnosed with chronic viral hepatitis and 107 healthy subjects were included in this study. Antioxidant parameters were measured spectrophotometrically. The viral load was assayed using a polymerase chain reaction technique. Histopathologic findings in the liver were scored as necro-inflammatory activity and fibrosis according to Ishak-Knodell score.

RESULTS

Erythrocyte superoxide dismutase, catalase, glutathione peroxidase activities, glutathione, and serum total antioxidant response levels were significantly lower in patients than in controls (p < 0,001). Additionally, no significant correlation was found between these markers and viral load, necro-inflammation, and fibrosis of the liver in patients with chronic viral hepatitis.

CONCLUSIONS

Our data suggest the insufficiency of an antioxidant barrier in patients with chronic viral hepatitis, but the decrease in antioxidant systems was not correlated with viral load, necro-inflammatory activity, and fibrosis score in the liver.

[Relations between ALT level and count of HBV special CTL and non-specific CTL in patients with chronic hepatitis B]

OBJECTIVE

To explore relations between ALT level and hepatitis B virus (HBV) specific CTL and non-specific CTL in patients with chronic hepatitis B (CHB).

METHODS

148 cases of CHB were divided into three groups according to ALT level. 35 cases in group A, ALT > or =2 x upper limit of normal value (ULN)--5 x ULN (100-250 IU/L); 53 cases in group B, ALT > 5 x ULN-- < or =10 x ULN (251-500 IU/L); 60 cases in group C, ALT > 10 x ULN ( > 500 IU/L). Flow cytometry is used to determine non-specific CTV. HBV specific CTL was tested on 74 cases of CHB (17 in group A, 27 in group B and 30 in group C) with positive (HLA)-A2. Compare HBV specific CTL, non-specific CTL, HBV DNA levels and positive rate of HBeAg.

RESULTS

HBV specific CTL: Group A (0.42 +/- 0.10)% is higher than group B (0.25 +/- 0.08)%, t = 6.37, P < 0.01, group B is higher than group C (0.17 +/- 0.004)%, t = 5.14, P < 0.01; Non-specific CTL: Group A (15.01 +/- 3.01)% is lower than group B (18.1 +/- 5.02)%, t = 2.81, P < 0.01, group B is lower than group C (21.5 +/- 6.11)%, t = 3.07, P < 0.01; HBV DNA level: Group A [(4.97 +/- 0.86) log10 copies/ml] is lower than group B [(5.92 +/- 0.92) log10 copies/ml], t = 4.87, P < 0.01. Group B is lower than group C [(6.37 +/- 0.71) log10 copies/ml], t = 2.92, P < 0.01; Positive HBeAg: Group A (15 cases, 42.86%) is lower than group B (32 cases, 60.38%), chi2 = 2.59, P > 0.05. Group B is lower than group C (41 cases, 68.33%), chi2 = 0.78, P > 0.05. Group A is lower than group C, chi2 = 5.929, P < 0.05.

CONCLUSION

The higher the non-specific CTL of patients with CHB is, the higher the ALT level would be, whereas the lower the HBV specific CTL is, the stronger the HBV replication would be.

Predictive factors and virological response to interferon treatment in children with chronic hepatitis B

Further knowledge about factors predicting response to interferon treatment for chronic hepatitis B in children is required, in particular as the benefits of therapy are uncertain. In the present study, baseline characteristics were related to virological and histological responses in 27 children given interferon-alpha for 24 weeks after steroid priming. HBe seroconversion was seen in 8 of 27 HBeAg positive patients and was accompanied by a sustained virological response (SR), with a median 4.1 log HBV DNA reduction. Pretreatment viraemia level was the only baseline parameter associated with SR. After 12 weeks of IFN (mid-treatment), viraemia was significantly reduced in all patients, with a median of 3.0 (range 0.6-5.2) log decline in SR compared with 0.6 (range -0.5-3.6) log decline in non-sustained responders (NSR). HBV DNA levels below 1 million copies/ml at week 12 predicted sustained response with a positive predictive value of 75% and a negative predictive value of 89%. During the latter half of the IFN treatment HBV DNA tended to increase by a mean of 0.4-0.5 log for all patient groups. Flares during IFN treatment were rare or mild as measured by ALT. Pretreatment anti-HBc IgM was associated with liver damage but not with response. Histological inflammation scores were improved in SR. Thus, pretreatment HBV DNA levels were associated with IFN response, and the virological response at week 12 predicts SR and may be useful in the decision to continue or modify therapy.

Long-term outcome of hepatitis B e antigen-negative hepatitis B surface antigen carriers in relation to changes of alanine aminotransferase levels over time

The baseline alanine aminotransferase (ALT) level was reported to have prognostic value in chronic hepatitis B virus (HBV) infection, during which ALT may change over time. Instead of baseline ALT, this study aimed to study the prognostic value of the height of ALT during the course of chronic HBV infection. A total of 4376 asymptomatic hepatitis B e antigen (HBeAg) negative, surface antigen (HBsAg) carriers with baseline ALT less than 2 times the upper limit of normal (ULN) were monitored with ALT measurement and ultrasonography every 3 to 12 month for over 3 years. Maximal ALT levels during follow-up were correlated with long-term outcomes using morbidity and mortality data from hospital records, cancer registration, and national mortality database. Baseline ALT level was normal in 3673 subjects and increased to abnormal level in 1720 (46.8%) during a mean follow-up period of 13.4 +/- 5.2 (3.0-28.7) years. The incidence of liver cirrhosis, hepatocellular carcinoma (HCC), and mortality increased with increasing maximal ALT level during follow-up, especially in those with maximal ALT of at least 2 times ULN, as compared with those who maintained normal ALT. Cox regression analysis indicated that age at entry, sex, and maximal ALT level during follow-up were significant independent factors associated with the development of cirrhosis, HCC, and mortality whereas cirrhosis was also an independent factor for HCC development and mortality.

CONCLUSION

Persistently normal ALT was associated with excellent long-term prognosis, whereas increasing ALT levels of at least 2 times ULN during follow-up was associated with increasing morbidity and mortality. ALT of at least 2 times ULN is therefore an appropriate threshold for anti-HBV therapy, whereas those with ALT 1 to 2 times ULN require liver biopsy for decision.

Peginterferon alfa-2b as monotherapy or in combination with lamivudine in patients with HBeAg-negative chronic hepatitis B: a randomised study

BACKGROUND

The efficacy of pegylated interferon alfa-2b alone or in combination with lamivudine for the treatment of patients with hepatitis B e antigen (HBeAg) negative (-) chronic hepatitis B (CHB) is understudied.

MATERIAL/METHODS

One hundred twenty-six patients with HBeAg(-)chronic hepatitis B received pegylated interferon alfa-2b > or =1.5 micro g/kg/wk for 48 weeks. Ninety of those subjects were randomly selected to receive concomitant treatment with lamivudine 100 mg/d. The coprimary end points were the subjects' virologic (hepatitis B virus deoxyribonucleic acid [HBV DNA] <60 IU/mL) and biochemical (normalization of alanine aminotransferase levels) responses 24 weeks after treatment cessation.

RESULTS

The scores for necroinflammatory activity and fibrosis in patients randomly assigned to receive monotherapy were statistically significantly lower than those in patients receiving combination therapy. HBV DNA levels were statistically significantly higher and alanine aminotransferase levels were statistically significantly lower in patients receiving monotherapy than in those receiving combination therapy. Virologic responses in the monotherapy and combination therapy groups were similar at weeks 48 and 72 (59.1 vs 42.9%). The biochemical response at week 72 was also similar in the treatment groups. The results of multiple regression analysis showed that the virologic response at week 72 was independently correlated with the pegylated interferon alfa-2b dose and that the biochemical response was independently correlated with necroinflammatory activity, the pegylated interferon alfa-2b dose, and lamivudine therapy.

CONCLUSIONS

These data support the use of pegylated interferon alfa-2b in patients with HBeAg(-) chronic hepatitis B; however, the concomitant use of lamivudine produced no additional clinical benefit.

[Investigation of the relationship between serum nitric oxide levels, HBV-DNA and ALT levels in chronic hepatitis B patients]

It has been reported that increased nitric oxide (NO) production by the hepatocytes during chronic inflammatory processes, plays an important role in the pathogenesis of chronic hepatitis B. The aim of this study was to investigate the relationship between serum levels of NOx (nitrite + nitrate) with the viral load and alanine aminotransferase (ALT) levels in chronic hepatitis B (CHB) patients. A total of 93 CHB patients (67 male, 26 female; mean age: 47.3 +/- 10.9 years) and 53 healthy control subjects (17 male, 36 female; mean age: 58.6 +/- 2.1 years) followed-up during 2006-2007 period were included to the study. Hepatitis B virus (HBV) serologic markers, viral load and ALT levels were studied by chemiluminescence method (Ortho-Clinical Diagnostics, USA), by real-time polimerase chain reaction (PCR) (ABI PRISM 7700, Applied Biosystem, CA), and by Aeroset System (Abbott Laboratories, USA), respectively. NOx levels were determined by a method which was based on the reduction of nitrate to nitrite by cadmium. Mean levels of ALT and HBV-DNA of the patients were found as 98.7 +/- 138.4 IU/I and 1.6 x 10(9) +/- 4.0 x 10(9) copies/ml, respectively. In the evaluation of mean levels of NOx in patient and control groups, the difference was found statistically significant (30.6 +/- 21.7 micromol/l and 23.7 +/- 5.2 micromol/l, respectively; p< 0.05). In view of the relationship between the parameters, a positive correlation was detected between viral load and ALT levels (r= 0.768; p< 0.001), besides the significant correlations between NOx and viral load, and NOx and ALT (r= 0.346, p= 0.001 and r= 0.314, p= 0.002, respectively). As a result, although the NOx levels in chronic hepatitis patients were found higher than those in the control group, and significant correlations were detected between NO, viral load and ALT, the exact role of NO in the disease pathogenesis and outcome needs to be studied further at cellular level.

Quantitative analysis of fluorouracil-related genes in chronic viral hepatitis using microdissection

BACKGROUND/AIMS

Dihydropyrimidine dehydrogenase is the initial and rate-limiting enzyme in the catabolism of 5-fluorouracil. The aim of this study was to determine the levels of messenger RNA for 5-fluorouracil-related metabolic enzymes in cirrhotic liver and to assess the correlation between these mRNA levels and clinicopathological features.

METHODOLOGY

The study material consisted of 33 liver samples. The levels of mRNA for the 5- fluorouracil-related metabolic enzymes were quantified by real-time reverse transcription polymerase chain reaction combined with laser-captured microdissection.

RESULTS

The Dihydropyrimidine dehydrogenase mRNA level in patients with grade B liver damage was significantly lower than that in patients with grade A liver damage (p=0.009). The Dihydropyrimidine dehydrogenase and orotate phosphoribosyl transferase mRNA level in al samples was higher than that in a2 and a3 samples (p= 0.01 and 0.013, respectively). Statistically significant correlations were found between the hyaluronic acid and the thymidylate phosphorylase mRNA level (p= 0.0001), and the T-BIL and the dihydropyrimidine dehydrogenase mRNA level (p=0.01).

CONCLUSIONS

The level of Dihydropyrimidine dehydrogenase mRNA may be affected by the clinicopathological status of patients with cirrhosis.

[Increased expression of inducible nitric oxide synthase in chronic hepatitis B patients is correlated with histopathological grading and staging]

OBJECTIVE

To investigate the intrahepatic expression of inducible nitric oxide synthase (iNOS) in patients with chronic hepatitis B (CHB) and its relation to liver histopathology.

METHODS

The intensity and distribution of the immunohistochemical staining of intrahepatic iNOS were studied in the liver biopsy specimens obtained from 74 patients with CHB and statistical analyses were performed between intrahepatic iNOS and ALT, HbeAg, HBV DNA grading of liver inflammation and staging of fibrosis. Seven histologically normal liver sections were used as a control group.

RESULTS

Compared with the control group, the intrahepatic iNOS immunoexpression was significantly higher in patients with CHB (P < 0.05), iNOS immunoreactivity was observed mainly in hepatocytes showing a predominant cytoplasmic staining, with the positive liver cells distributed diffusely throughout the hepatic lobule. Immunopositive staining could also be detected in Kupffer cells, sinusoidal lining cells and vascular endothelial cells. Compared with patients with normal ALT, the hepatocellular iNOS immunoexpression was significantly higher in patients with elevated ALT (P < 0.05) and the iNOS immunoexpression was significantly correlated with the serum level of ALT (r=0.601, P=0.000). Statistical analysis also showed that the intrahepatic iNOS immunoexpression was positively correlated with the grading of liver inflammation and the staging of liver fibrosis (r=0.660, P=0.000; r=0.507, P=0.000). No significant correlation between iNOS and HBeAg and HBV DNA was detected. CONCLUSION The intrahepatic expression of iNOS is elevated in chronic hepatitis B patients and correlated well with the severity of the disease, which indicated that inducible nitric oxide synthase may have a critical role in the pathogenesis of chronic viral hepatitis B.

Retrospective evaluation of serum markers APRI and AST/ALT for assessing liver fibrosis and cirrhosis in chronic hepatitis B and C patients with hepatocellular carcinoma

OBJECTIVE

Aspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase (AST/ALT) ratio, platelet count, AST, albumin, bilirubin and alkaline phosphatase were retrospectively evaluated for the prediction of advanced liver fibrosis and cirrhosis in patients with resectable hepatocellular carcinoma in this study.

PATIENTS

In total, the 97 selected patients consisted of 9 (9.3%) patients with non-B, non-C chronic hepatitis, 48 (49.5%) patients with chronic hepatitis B (CHB) and 40 (41.2%) patients with chronic hepatitis C (CHC).

RESULTS

The APRI, but not AST/ALT or other serum markers, showed a significant correlation with advanced liver fibrosis and cirrhosis (p<0.05). The area under receiver operating characteristic curves (AUROC) for predicting advanced fibrosis was 0.69 in CHB patients and 0.87 in CHC patients, whereas AUROC for predicting cirrhosis was 0.75 in CHB patients and 0.84 in CHC patients. In addition, the sensitivity and specificity of APRI were greater than 80% for predicting advanced fibrosis and cirrhosis in the CHC patients.

CONCLUSION

APRI is a simple and non-invasive biochemical marker of liver fibrosis and cirrhosis, particularly in CHC patients. APRI potentially could be used to decrease the number of liver biopsies.

Adefovir dipivoxil alone or in combination with lamivudine for three months in patients with lamivudine resistant compensated chronic hepatitis B

We studied clinical and laboratory effects of 3 months of lamivudine with adefovir combination and adefovir dipivoxil (AD) alone in the treatment of patients with lamivudine-resistant hepatitis B virus (HBV) infection. Eligible patients were hepatitis B surface antigen-positive men and women with compensated liver disease who were given lamivudine at least more than 6 months and had HBV polymerase gene mutation. Patients were assigned to receive adefovir 10 mg/day (Group 1) or adefovir 10 mg once daily and lamivudine 100 mg once daily combination during first 3 months, and then stopped lamivudine and continued adefovir (Group 2). Median age was 48 years (34 males and 20 females, and 35 were HBeAg-negative). Baseline median ALT, AST, and HBV DNA levels were 66 IU/l, 49 IU/l, and 6.7 log(10) copy/ml, respectively. Median adefovir therapy time and ALT normalization time were 9 and 3.5 months, respectively. There was no significant difference between groups according to the baseline HBV DNA, ALT, HBe Ag status, age, gender, and lamivudine resistance time. Virological and biochemical responses were similar in both groups during therapy. Two patients (8%) had ALT flare more than five times upper limit of normal without any clinical decompensation in Group 1. Mild ALT elevation according to baseline levels were found in 8 (27.6%) and 4 (17.4%) patients, respectively, in Group 2 and Group 1, and no statistically significance between two groups. In conclusion, this study showed that it is not necessary to continue lamivudine therapy while switching to AD therapy. Adefovir alone is effective in the treatment of patients with lamivudine resistant HBV infection and compensated liver disease, without significant clinical and laboratory flares. However, it is not easy to say that switching to AD with cessation of lamivudine is safe, because the study population is not enough for precise conclusion and resistance may be a considerable problem against AD in patients using long-term treatment.

[Clinical significance of serum glutamyl transpeptidase in chronic hepatitis B]

OBJECTIVE

To evaluate the relationship between changes and clinical significance of serum glutamyl transpeptidase (GGT) and the degree of liver lesions in chronic hepatitis B (CHB).

METHODS

Examinations of serum ALT, AST, GGT levels and liver biopsy were carried out and classification and staging of liver fibrosis and inflammation were performed for 70 patients with CHB. The relationship between ALT, AST, GGT and CHB was analyzed.

RESULTS

(1) ALT, AST and GGT increased with the degree of inflammation and fibrosis, but their levels declined with the degree of G4 and S4. The correlation coefficients of ALT and GGT, AST and GGT were (0.322 and 0.328, P less than 0.05). With liver-protective treatment, in the cases with mild CHB, ALT was normalized quickly but GGT remained at a lower level. While ALT declined, GGT was still at a relatively high level for moderate and severe CHB cases, among them the level of GGT fluctuated.

CONCLUSION

Serum GGT reflects the degree of liver inflammation more accurately than ALT and AST do and GGT activity can provide important evidence for clinical assessment of chronic hepatitis B.

Efficacy of vitamin E in children with immunotolerant-phase chronic hepatitis B infection

BACKGROUND

The purpose of the present paper was to investigate the efficacy of vitamin E in children with immunotolerant-phase chronic hepatitis B virus (CHB) infection.

METHODS

Fifty-eight immunotolerant children were prospectively and randomly recruited into two groups. Group 1 (study group) included 30 patients who received vitamin E at a dose of 100 mg/day throughout 3 months; group 2 (control group) contained 28 patients who did not receive any medication. Comparison of serological, virologic, and biochemical response ratios were done at the end of the therapy and after 6 months of vitamin E discontinuation.

RESULTS

Mean alanine transaminase (ALT) values in group 1 at the beginning of the therapy, 3 months after the therapy initiation and 6 months after discontinuation were 30.4 +/- 7.3 IU/L, 31.3 +/- 7.8 IU/L and 32.1 +/- 8.5 IU/L, respectively. The mean hepatitis B virus (HBV)-DNA load of group 1 at onset, and at the third and ninth months of the treatment were 3106 +/- 718 pg/mL, 3530 +/- 137 pg/mL and 3364 +/- 1246 pg/mL, respectively. These changes in both ALT and HBV-DNA values did not reach significant levels (P > 0.05). In group 2, mean ALT values at the beginning of therapy, and at the third and ninth months were 28.0 +/- 1.8 IU/L, 34.6 +/- 8.1 IU/L, and 34.1 +/- 7.0 IU/L, respectively (P > 0.05), and mean viral load of HBV-DNA was 4227 +/- 1435 pg/mL, 3368 +/- 2673 pg/mL, and 3018 +/- 2814 pg/mL, respectively (P > 0.05). There was no statistically significant difference between group 1 and group 2 at the third and ninth months in the mean ALT values and viral load of HBV-DNA (P > 0.05). Hepatitis B s antigen and hepatitis B e antigen clearance or hepatitis B s antibody and hepatitis B e antibody seroconversion were not observed in either group.

CONCLUSION

As a first study investigating the effect of vitamin E in children with immunotolerant CHB infection, no beneficial effect could be demonstrated. Different immunomodulator protocols should be considered for future investigations.

Modulation of MAPK pathways and cell cycle by replicating hepatitis B virus: factors contributing to hepatocarcinogenesis

BACKGROUND/AIMS

Chronic infection with the hepatitis B virus (HBV) is strongly associated with the development of hepatocellular carcinoma but the mechanism by which this occurs is unknown. Numerous studies have focused on the HBV X protein showing that it activates signal transduction pathways while few have investigated these changes in HBV-replicating hepatocytes.

METHODS

We utilized the recombinant adenovirus system to deliver a replication competent HBV genome into Huh7 and primary marmoset hepatocytes (PMH) to examine the effects of active viral replication on the regulation of Ras-ERK signal transduction and related pathways.

RESULTS

Huh7 cells and PMHs replicating HBV demonstrated significant upregulation in phosphorylated ERK, Akt, c-myc together with increased p53, cyclin B1 and p21(cip1) expression and cell cycle progression to G2 phase in the absence of increased cell proliferation. Phosphorylation of the key cell survival kinase, Akt, was significantly increased, resulting in increased serine phosphorylation of the downstream target, GSK3-beta.

CONCLUSIONS

These results demonstrated simultaneous activation of the MAP Kinase and Akt pathways in HBV-replicating hepatocytes that resulted in dysregulation in the control of cell cycle progression and which help explain the early pathogenic mechanisms that underlie malignant transformation associated with chronic hepatitis B infection.

The good and evil of flare: flares in hepatitis B virus chronic hepatitis

Treatment of HBeAg-positive chronic hepatitis B with pegylated interferon achieves HBeAg seroconversion in about 30% of patients and retreatment of nonresponders is followed by a low rate of sustained response. Alanine aminotransferase flares occurring after the introduction of interferon are considered a positive predictor of response. Here we described a young patient with active chronic hepatitis B who underwent four different treatment courses developing lamivudine resistance and showing three elevated flares of different origin and with diverse outcome. We discuss the meaning of each flare and their role in treatment response or virus reactivation.

Clinical significance and evolution of core promoter and precore mutations in HBeAg-positive patients with HBV genotype B and C: a longitudinal study

BACKGROUND/AIMS

The aims of this longitudinal study were to investigate whether the clinical outcome and evolution of core promoter and precore mutations were different during hepatitis B e antigen (HBeAg) seroconversion between hepatitis B virus (HBV) genotypes B and C in HBeAg-positive patients with chronic hepatitis B.

PATIENTS AND METHODS

The core promoter and precore sequences were determined from serial sera of 156 HBeAg-positive patients with chronic HBV infection.

RESULTS

In HBV genotype C, the T1762/A1764 mutant was detected earlier than the A1896 mutant, and the frequency was significantly higher than in HBV genotype Ba over the entire follow-up period. In HBV genotype Ba, A1896 was found earlier than the T1762/A1764 mutant, and the frequency was significantly higher than in genotype C only before HBeAg seroconversion, and the A1896 mutant played an important role in HBeAg seroconversion in HBV genotype Ba. In addition, the T1846 variant was an independent factor associated with HBeAg seroconversion. Furthermore, HBV genotype C was associated with the development of G or C1753 and T1766/A1768 mutations, and the reactivation of hepatitis after HBeAg seroconversion. Based on Cox's regression analysis, the significant risk factors of liver cirrhosis were older age at entry [hazard ratio (HR)=1.085, 95% confidence interval (CI)=1.036-1.136, P=0.001], alanine transaminase (ALT) >80 U/l (HR=3.48, 95% CI=1.37-8.86, P=0.009), and the T1762/A1764 mutant (HR=5.54, 95% CI=2.18-14.08, P<0.001).

CONCLUSIONS

Our study showed that different HBV genotypes were associated with various mutations in the core promoter and precore regions during HBeAg seroconversion. T1762/A1764 mutation could be useful in predicting clinical outcomes in HBeAg-positive patients with HBV infection.

[Long-term use of lamivudine for treating chronic hepatitis B in the State of Mato Grosso]

To assess the results from lamivudine treatment (100 mg or 150 mg) for chronic hepatitis B, 34 patients were followed at a clinic in Cuiabá, Mato Grosso, Central Brazil. Among them, 21 (62%) had liver cirrhosis and 24 (70%) were HBeAg-positive. The viral genotype was determined for 18 patients, among whom genotype A was the most prevalent (12). The median follow-up was 27 months (range from 7 to 64 months). Among the total, 23 (67%) presented a biochemical response after 2 to 24 months of treatment. Among the 24 HBeAg-positive subjects, 13 (54%) became HBeAg-negative during the follow-up. Among the anti-HBe-positive patients, 70% obtained normalization of aminotransferase levels. Fourteen (41%) did not present any initial biochemical or serological response or presented breakthrough. The L180M and M204V mutations were found in six of the non-responders. Four patients died after at least 21 months of lamivudine and three patients with liver cirrhosis developed liver cancer after 24 months. From the third year onwards, complications such as digestive system hemorrhage or liver cancer started to emerge. The present findings suggest that an early response to lamivudine treatment may be associated with better control over chronic hepatitis B.

What is the reason of elevated alanine aminotransferase level in HBeAg negative patients with low viremia: NAFLD or chronic hepatitis?

BACKGROUND AND STUDY AIMS

Increased alanine aminotransferase (ALT) levels with negative hepatitis B virus (HBV) DNA by hybridization is a common problem in Turkey where is a mild endemic region. We aimed to evaluate the causes of elevated ALT levels in patients who are negative for hepatitis B e antigen (HBeAg) and HBV DNA (by hybridization) for at least 6 months.

PATIENTS-METHODS

Forty-nine patients were enrolled in this study. Histological changes [histological activity index (HAI), and the extent of fibrosis] were assessed according to the Knodell scoring system and steatosis were graded by Brunt's classification for NAFLD in all patients.

RESULTS

A mean age of the patients was 34.9 +/- 12.1 years (16-70). 43 (87.8%) of them were male. Mean ALT level was 95 +/- 39.7 IU/L (50- 258). Hyperglycemia (>100 mg/dL) and hyperlipidemia were found in 12 and 24 patients, respectively. Hepatic steatosis (7 patients grade 1; 5 patients grade 2; and 7 patients grade 3), ground-glass hepatocyte, chronic hepatitis, and Wilson disease were found in liver biopsy in 38.8%, 32.6%, 26.6%, 2%, respectively. Mean HAI was 6.5 +/- 3.6 (4-12) in chronic hepatitis. Seven patients (53.9%) were in stage 1 and 2 while 6 patients (46.1%) were in stage 3 and 4.

CONCLUSIONS

Nonalcoholic fatty liver disease is the most common cause of elevated ALT levels in HBeAg negative/HBV DNA negative patients. Chronic hepatitis B was found in 26.6% of these patients.

The natural history and treatment of chronic hepatitis B: a critical evaluation of standard treatment criteria and end points

The definite indications for the treatment of chronic hepatitis B are serum hepatitis B virus (HBV) DNA levels greater than 10(5) copies/mL and alanine aminotransferase (ALT) levels more than 2 times the upper limit of normal. If cirrhosis is present, an HBV DNA level greater than 10(5) copies/mL is the sole criterion for treatment. Treatment end points include hepatitis B e antigen (HBeAg) seroconversion for HBeAg-positive patients, reduction of HBV DNA levels to less than 10(5) copies/mL, and normalization of ALT values. These guidelines may apply to patients who acquire the hepatitis B infection during adolescence or adulthood but are less suitable for most hepatitis B carriers, who are infected in early life. Cirrhosis complications, including hepatocellular carcinoma, often occur in this latter group despite HBeAg seroconversion, HBV DNA levels less than 10(4) copies/mL, or ALT levels between 0.5 and 2 times the upper limit of normal. Therefore, HBeAg seroconversion may not be an adequate end point for these patients; the ideal treatment end points are permanent suppression of HBV DNA to levels undetectable by polymerase chain reaction and reduction of ALT levels to less than 0.5 times the upper limit of normal.

[The follow-up of serum aminotransferase levels and investigation of hepatitis B virus load in inactive HBsAg carriers]

The aim of this study was to follow-up the serum alanine aminotransferase (ALT) levels in inactive HBsAg carriers during one year period and investigate the association between hepatitis B virus (HBV) DNA levels detected at the end of the year. At May 2005, 61 patients with HBeAg negative/anti-HBe positive chronic HBV infection, followed in our viral hepatitis clinic were included to the study. The patients' ultrasonographic examination of the liver were normal, they had no history of taking alcohol or routine medication, were anti-HCV seronegative and had normal ALT levels during the last 6 months and at the beginning of the study. Serum ALT levels of patients were followed in the 3rd, 6th and 12th months of the study, and blood HBV-DNA levels were analysed quantitatively in 12th month. During the one year period 89% (54/61) of the patients yielded continously normal ALT levels, while 11% (7/61) showed at least one ALT value above the normal levels (ALT > 1.2x). Total HBV-DNA positivity rate was found as 59% (36/61). In inactive HBsAg carrier group,--namely HBeAg negative and serum ALT levels constantly normal--57.4% (31/54) of patients were HBV-DNA positive and 23 (42.6%) were negative. Amongst the HBV-DNA positive patients the viral load were detected as 10(4)-10(5) copies/ml in six (19.4%), and <10(4) copies/ml in 25 (80.6%) patients. In patients who had at least one ALT value above normal limits, 71.4% (5/7) of them were found HBV-DNA positive; two with HBV-DNA values of >10(5) copies/ml and three with values between 10(4)-10(5) copies/ml. In conclusion, although ALT levels may be normal, it should always be taken into consideration that more than half of inactive HBsAg carriers exhibited low level viral replication, thus HBV-DNA and liver enzyme levels should be monitored routinely in order not to miss the acute manifestations.

Liver biopsy performance and histological findings among patients with chronic viral hepatitis: a Danish database study

We investigated the variance of liver biopsy frequency and histological findings among patients with chronic viral hepatitis attending 10 medical centres in Denmark. Patients who tested positive for HBsAg or HCV- RNA were retrieved from a national clinical database (DANHEP) and demographic data, laboratory analyses and liver biopsy results were collected. A total of 1586 patients were identified of whom 69.7% had hepatitis C, 28.9% hepatitis B, and 1.5% were coinfected. In total, 771 (48.6%) had a biopsy performed (range 33.3-78.7%). According to the Metavir classification, 29.3% had septal fibrosis (> or =F2) and 13.9% had cirrhosis (F4). The frequency of cirrhosis varied from 8.3 to 18.6% among centres, and was independently associated with age, male gender, elevated alanine-aminotransferase (ALT) and non-Danish origin. Among 141 patients with hepatitis C and known duration of infection, cirrhosis had developed in 23% after 20 y of infection. Age above 40 y was a better predictor of cirrhosis than elevated ALT. National database comparison may identify factors of importance for improved management of patients with chronic viral hepatitis.

Inducible nitric oxide synthase and histopathological correlation in chronic viral hepatitis

BACKGROUND

Chronic liver disorders represent a serious health problem. Nitric oxide (NO) synthesized by inducible nitric oxide synthase (iNOS) can function as an antimicrobial agent able to kill or reduce replication of microorganisms, and plays an important role in immune regulation. This study was undertaken to evaluate the expression of iNOS in chronic viral hepatitis and its relation to histopathology.

METHODS

This study included 56 patients with chronic viral hepatitis (38 hepatitis B, 18 hepatitis C). There were 35 men and 21 women with a mean age of 38.6+/-21.731 years. A modified form of the histology activity index (HAI) designed by Ishak and colleagues was used to assess grading and staging of chronic viral hepatitis. The needle biopsy specimens were fixed in 10% formalin and routinely processed. Routine hematoxylin-eosin, periodic acid-Schiff, and reticulin staining, and iNOS immunoperoxidase technique were performed on paraffin-embedded tissues.

RESULTS

We demonstrated that all liver samples had a marked iNOS expression, with a diffuse distribution pattern. iNOS consistently labeled mononuclear cells infiltrating portal tracts in all samples. Statistical evaluation of data showed that the iNOS expression correlated with the HAI and fibrosis. Furthermore a correlation between iNOS and severity of disease was detected (r=0.772, p=0.000).

CONCLUSIONS

Further investigations are required to determine whether iNOS-related treatment protocols could be useful in reducing disease severity.

Viremia profiles in children with chronic hepatitis B virus infection and spontaneous e antigen seroconversion

BACKGROUND & AIMS

This study investigated the viremia profiles in children with chronic hepatitis B virus (HBV) infection and spontaneous hepatitis B e antigen (HBeAg) seroconversion.

METHODS

Fifty-eight children with chronic HBV infection met the following criteria: normal alanine aminotransferase (ALT) level at enrollment, followed up for more than 10 years, no antiviral treatment, and having undergone spontaneous HBeAg seroconversion during follow-up evaluation. They were grouped according to the post-HBeAg seroconversion HBV-DNA levels: (1) low viremia: transient or never 10(4) copies/mL or greater (n=35) (2) fluctuating high viremia: 10(4) copies/mL or greater at least twice at intervals more than 1 year apart (n=23). Abdominal sonography, ALT, and HBV-DNA levels were assessed annually. Another 14 nonseroconverted children served as controls. The precore mutant (nt1896) and genotypes were examined.

RESULTS

The initial HBV-DNA level of the 58 seroconverters was 10(8.4+/-1.0) copies/mL and decreased to 10(2.9+/-2.0) copies/mL at the end of follow-up period. Their mean ages at enrollment, at peak HBV-DNA, at peak ALT, at HBeAg seroconversion, and at final follow-up were 7.0 +/- 3.7, 13.4 +/- 5.8, 16.3 +/- 6.0, 17.2 +/- 5.8, and 23.7 +/- 4.1 years, respectively. The precore mutant appeared more often in the fluctuating-high-viremia group than in the low-viremia group (60.9% vs 22.9%, P=.004). HBV genotypes had no effect on the viremia profiles. After HBeAg seroconversion, none had persistent abnormal ALT levels.

CONCLUSIONS

Generally, these young seroconverters had decreased viral loads, normal ALT levels, and uneventful courses after HBeAg seroconversion. A longer follow-up period is necessary to elucidate the significance of HBeAg seroconversion occurring in childhood and young adulthood.

Liver enzyme flares and occult hepatitis B in persons with chronic hepatitis C infection

BACKGROUND

Occult hepatitis B (HBV) has been reported in numerous clinical settings, but it remains unclear whether occult HBV contributes to liver damage. Given that typical chronic HBV infections often have periodic flairs in viral replication and liver damage, we hypothesized that occult HBV may also have flares in viral replication that are associated with increased liver enzymes.

STUDY DESIGN

We screened hepatitis B surface antigen negative injection drug users with untreated chronic hepatitis C viral (HCV) infection for unexplained ALT/AST flares. To further enrich for individuals with possible occult HBV flares, we studied those individuals whose flares were associated with IgM antibodies to hepatitis B core antigen. Serum samples were assayed for HBV DNA and serologies were performed in serum collected 6 months before, at the time, and 6 months after the flare. HCV RNA levels were also determined. Controls consisted of individuals who also had ALT/AST flares but who were negative for IgM antibodies to hepatitis B core antigen.

RESULTS

Seven study cases and eight control cases were identified. HBV DNA was detectable during the enzyme flares in 7/7 study cases versus 3/8 controls, p=0.026. HBV DNA levels during the flare were low, averaging 1943 +/- 2341 copies/ml, but were higher in study cases versus controls, p=0.002. No change in HCV levels was associated with the flares.

CONCLUSIONS

In this population at high risk for occult HBV, AST/ALT flares can be associated with detection of HBV DNA. These findings may link occult hepatitis B to liver injury.

Is the increased risk of liver enzyme elevation in patients co-infected with HIV and hepatitis virus greater in those taking antiretroviral therapy?

OBJECTIVES

To investigate if the risk of liver enzyme elevation (LEE) in HIV/hepatitis B or C (HBV, HCV) co-infection is altered by HAART (two or more drugs).

METHODS

Analysis comprised HIV-positive patients in the ICoNA study without acute hepatitis who had >or= 1 positive HCV antibody test and > 1 positive HBV surface antigen test. LEE was defined as > 5x baseline alanine aminotransferase (ALT) or > 3.5x baseline if the baseline was > 40 IU/l. Analysis used Poisson regression with generalized estimating equation correction to examine HBV or HCV co-infection, use of HAART, baseline ALT and demographics as LEE predictors.

RESULTS

Of the 5272 patients, 47.6% were co-infected with HCV/HBV; 29.9% were female and 39% were intravenous drug users. There were 275 episodes of LEE during 18 259 person-years follow up. Taking HAART did not significantly increase risk of LEE [adjusted relative risk (RR), 1.19; 95% confidence interval (CI), 0.81-1.75; P = 0.37]. Co-infection increased the risk of LEE (adjusted RR, 5.07; 95% CI, 3.47-7.48; P < 0.001), with no significant differences if taking HAART (adjusted RR, 4.99; 95% CI, 3.38-7.37) or not (adjusted RR, 6.02; 95% CI, 2.02-17.98) (P = 0.74 for interaction). Females were at lower risk of LEE than males (adjusted RR, 0.59; 95% CI, 0.42-0.83; P = 0.02).

CONCLUSIONS

HIV and HBV/HCV co-infection per se is associated with increased risk of LEE that is not modified by HAART. The recommendation for caution in HAART use in co-infected patients, simply based on a high rate of LEE in people on therapy, may be questionable.

[The condition of pulmonary protective functions in patients with pneumonia accompanied by chronic viral hepatitis B]

Two groups of patients with pneumonia were observed: the main group consisted of patients with pneumonia accompanied by chronic viral hepatitis B (CVHB), and the control group contained patients without CVHB. Main group patients displayed higher activity of lysosomal and redox enzymes, as well as imbalance in the proteinase-inhibitory system and bronchial lavage phospholipid spectrum. Concomitant CVHB impaired the protective function of the lungs and thus delayed the resolution of pneumonia.