Natural history of chronic hepatitis B virus infection

In chronic hepatitis B virus (HBV) infection acquired during adulthood, which is the type mostly seen in the Caucasian population, there is biochemical and histologic regression after HBeAg seroconversion, and the risk of death from hepatitis B-related causes is low. In chronic HBV infection acquired during birth or early childhood, which is the type most commonly seen in the Asian population, there is a prolonged phase of immunotolerance. The immune clearance phase is characterized by multiple acute exacerbations preceeded by elevations in serum HBV DNA levels, HBeAg concentration and HBeAg/anti-HBe immune complexes. Of these patients, 2.4% may develop hepatic decompensation during the stage of HBeAg seroconversion. The development of cirrhosis occurs more frequently in patients with episodes of decompensation and with repeated severe acute exacerbations. However progression to cirrhosis can be relatively silent and can occur even in children. After HBeAg seroconversion, precore and core promotor mutations occur frequently in the Asian population. However, there is little correlation between the occurrence of these mutations and alanine aminotransferase elevation in patients who are positive for anti-HBe. Although cirrhosis develops during the process of HBeAg seroconversion, 68% of the complications of cirrhosis and of hepatocellular carcinoma occur after HBeAg seroconversion. These complications may still occur even after HBsAg seroclearance.

The recovery potential of central conduction disorder in hypothyroid rats

In an aim to detect the dysfunction of central nervous system among rats with varied durations of hypothyroidism and to elucidate the recovery potential after thyroxine replacement, a series of BAEP were conducted and compared with age-matched controls. BAEP was performed in five groups of the hypothyroid animals 1, 3, 5, 7, and 9 months after thyroidectomy respectively. Following initial electrophysiological assessment, thyroxine replacement was administered to each group of hypothyroid rats, and BAEP was performed at two month intervals, up to two successive normal studies or six months after the initiation of therapy, whichever came first. Before thyroxine treatment, prolonged I-V interpeak latency was the most consistent abnormal finding in all groups of hypothyroid rats, and longer hypothyroid state correlated well with more severe central conduction disorder. Hearing impairment was also noted among those with long duration of hypothyroidism. After thyroxine replacement, the central conduction dysfunction usually returned to normal if the hypothyroid state was not more than 5 months in duration. However, when hypothyroid state persisted over 7 months or more, there would be an incomplete recovery for central conduction disorder. The present study brings out the concept of 'therapeutic window' in reversing the central nervous dysfunction caused by hypothyroidism in adult rats.

Early detection of hepatocellular carcinoma increases the chance of treatment: Hong Kong experience

The prognosis for patients with hepatocellular carcinoma (HCC) is poor because of the low chance of curative treatment. To increase the chance of intervention and to improve survival, early detection of subclinical HCC (SCHCC) by alpha-fetoprotein (AFP) and/or ultrasonography (USG) screening is implemented in many countries. Three hundred six Chinese patients with HCC diagnosed between January 1995 and December 1997 were recruited. They were categorized into two groups: 142 patients (group 1) had SCHCC diagnosed by screening (AFP and/or USG), and 164 patients (group 2) presented with symptomatic HCC. The tumor size was significantly smaller in group 1 compared with that of group 2 (3.5 cm vs. 8.1 cm; P <.0001). A significantly higher proportion of patients had bilobar involvement, multifocal HCC, diffuse-type HCC, portal vein infiltration, and distant metastasis in group 2 when compared with group 1. Operability and feasibility of treatment by transcatheter intra-arterial chemoembolization (TACE) in group 1 patients (26.8% and 45.1%, respectively) were significantly better than in group 2 patients (7.9% and 32.3%, P <.0001 and P =.03, respectively). The cumulative survival rate was significantly higher in group 1 than in group 2 (P <.0001). For those who had surgical resection and those who had TACE, group 1 patients had a higher cumulative survival rate compared with that of group 2 patients (P =.04 and P =.0003, respectively). Screening for HCC by AFP and/or USG can identify tumors at an early stage, resulting in a higher chance of receiving treatment. Whether it can improve survival requires a further prospective, randomized study.

Hypothyroid myopathy-pathological and ultrastructural study

Seventeen patients with hypothyroid myopathy were studied before and after thyroxine (T4) treatment. The severity of clinical myopathy was assessed with the aid of a modified rating scale. Laboratory findings including thyroid function, serum creatine kinase (CK), and electromyography were assessed at regular time intervals until a final muscle biopsy was performed. The average period of follow-up was 1.8 years. The authors emphasize: 1) in skeletal muscle pathology of hypothyroidism, the fiber atrophy and increased central nuclear counts are evidence of clinical myopathy during thyroxine treatment; 2) in ultrastructural pathology, the abnormal glycogen accumulation accounts largely for clinical severity and its ongoing resolution is parallel to steady amelioration following T4 therapy, while mitochondrial abnormalities are insignificant in clinical correlation and probably become permanent in some cases with prolonged hypothyroidism; and 3) serial needle biopsies of skeletal muscle are impractical for long-term study of hypothyroid myopathy, but they may be reserved for those patients with a sustained myopathic complaints on T4 therapy.

Sinus node dysfunction in a patient with lithium intoxication

Lithium can suppress sinus node function, especially when it is used concomitantly with carbamazepine. We describe a 42-year-old woman who took lithium and carbamazepine for manic-depressive psychosis and seizure disorders, and developed marked sinus node dysfunction. Drug screening showed a toxic serum lithium level of 3.38 mmol/L and a normal serum carbamazepine level of 22.1 mumol/L. An electrophysiologic study showed prolongation of the corrected sinus node recovery time (CSNRT) of up to 9,708 msec. After three sessions of hemodialysis, normal sinus rhythm was resumed. The serum lithium level was 0.1 mmol/L 2 weeks later, and the CSNRT shortened to 309 msec. Because the combination of lithium and carbamazepine in psychiatric patients is not uncommon, recognition of the potential complication of severe bradyarrhythmia is essential in the emergency care of such patients.

Antituberculosis drug-related liver dysfunction in chronic hepatitis B infection

Liver toxicity is a common side effect of antituberculosis (anti-TB) drugs. We studied the differences in liver dysfunction observed during anti-TB treatment between hepatitis B virus carriers (HBV) and noncarriers. Three hundred twenty-four patients on anti-TB drugs were recruited and followed up for 1 year. Forty-three patients with HBV and 276 non-HBV patients were included for analysis. Liver function tests and viral markers were monitored monthly. Liver biopsy was requested whenever the alanine transaminase (ALT) was persistently abnormal. Eighty-six HBV carriers who were not given anti-TB drugs were chosen as a second control and evaluated prospectively. The incidence of liver dysfunction was significantly higher in HBV carriers given anti-TB drugs (34.9%) when compared to noncarriers (9.4%, P <.001) and with HBV carriers not given anti-TB drugs (8.1%, P <.001). For patients given anti-TB drugs, HBV carriers who developed liver dysfunction were younger (P =.011) and had more severe liver injury compared with noncarriers (P =.008). By multiple logistic regression analysis, age (P =.002) and hepatitis B infection (P <.001) were the only 2 significant risk factors for hepatotoxicity related to anti-TB therapy.

Imbalance between cell proliferation and cellular DNA fragmentation in hepatocellular carcinoma

AIM/BACKGROUND

Hepatocellular carcinoma (HCC) is known for its rapid growth. This study was undertaken to determine the expression of proliferative markers, apoptosis (DNA fragmentation) and oncogene products known to regulate apoptosis (p53, bcl-2) in HCC.

METHODS

150 Chinese patients with HCC were studied (M:F 128:22, age 14-88 years). Immunohistochemistry was employed to detect cell proliferative markers (PCNA, Ki67), and oncogene products known to regulate apoptosis (p53, bcl-2). DNA fragmentation was determined by terminal dUTP nick end labeling (TUNEL).

RESULTS

98% and 95% of HCC had PCNA (median 2+) and Ki67 (median 2+) detected respectively. TUNEL labeling was detected in only a small number of tumor cells (no labeling in 11%, median 1/1000 cell labeled, range: 0-70/1000 cells). There was no correlation between TUNEL labeling and the clinical parameters (sex, age, cirrhosis, and survival) and the expression of cell proliferative markers. p53 was detected in 53% of the patients (median 1+, range: 0-4+) and bcl-2 was detected in a small proportion of tumor cells in only 13% of the HCCs (range: 0-1 +). The expression of p53 and Bcl-2 did not correlate with TUNEL labeling or the natural survival.

CONCLUSIONS

Cell proliferation in HCC is unmatched by apoptosis, accounting for the rapid growth of this tumor. This lack of apoptosis in HCC is unrelated to the expression of p53 or bcl-2 over-expression.

Antiviral therapy for hepatitis B and C in Asians

The clinical features and treatment of chronic hepatitis C in Chinese patients are the same as in Caucasian patients except that 27% of Chinese chronic hepatitis C patients have hepatitis C virus (HCV) genotype 6a. In contrast, Chinese patients with chronic hepatitis B (CHB) differ from Caucasian patients because the Chinese patients are immunologically tolerant to hepatitis B virus (HBV), having acquired hepatitis B infection perinatally or in early childhood. In the treatment of CHB, the short-term aims of loss of hepatitis B virus early antigen (HBeAg) and HBV-DNA need to be reassessed. In 1296 Chinese CHB patients, 67.7% of those who developed complications of cirrhosis or hepatocellular carcinoma, were HBeAg-antibody positive. Longer follow up of patients is, therefore, required to assess the time efficacy of a treatment regimen. After long-term follow up (median 90 months) of 206 Chinese CHB patients treated with interferon alpha (IFN alpha) compared with 203 untreated subjects, IFN alpha conferred no benefit in cumulative HBeAg seroconversion or in HBV-DNA negativity as determined by polymerase chain reaction assays or in decreasing long-term complications of cirrhosis and hepatocellular carcinoma. Lamivudine is a novel nucleoside analogue. In a recent 1 year study in 358 Chinese CHB patients, lamivudine treatment was associated with substantial histological improvement (including a reduction in fibrosis), with HBV-DNA suppression and normalization of alanine aminotransferase levels. However, lamivudine may have to be given on a long-term basis, as withdrawal of lamivudine results in rebound of HBV-DNA to pretreatment levels. The long-term effects of lamivudine are currently being assessed.

Mannose binding lectin gene mutations are associated with progression of liver disease in chronic hepatitis B infection

Mannose-binding lectin (MBL) plays an important role in immune defense. We examined the MBL gene mutations and MBL levels in Chinese hepatitis B and hepatitis C patients with and without symptomatic cirrhosis. We recruited 190 hepatitis B and C patients, and 117 normal Chinese as controls. Serum MBL levels were measured by enzyme-linked immunosorbent assay. MBL gene mutation at codons 52, 54, and 57 was detected by polymerase chain reaction (PCR) assay. In asymptomatic hepatitis B and C patients, there was no increase in codons 52, 54, and 57 mutation, but the MBL levels were significantly lower than those in the controls. Codon 54 mutation rate was increased to 44.4% (P =.007) in symptomatic hepatitis B cirrhosis and 64.3% (P =.0026) in patients with spontaneous bacterial peritonitis (SBP). There was no increase in codon 54 mutation rate in hepatitis B-related hepatocellular carcinoma (HCC). In chronic hepatitis B infection, the odds ratio for an individual with codon 54 mutation to develop cirrhosis was 1.84 (95% CI: 1.21-2. 81) and to develop SBP was 4.58 (95% CI: 1.73-12.16). Chronic hepatitis B and hepatitis C infection lowered the MBL levels, probably by suppressing MBL production. Codon 54 mutation of MBL was associated with progression of disease in chronic hepatitis B infection.

Twelve-year follow-up of a prospective randomized trial of hepatitis B recombinant DNA yeast vaccine versus plasma-derived vaccine without booster doses in children

A total of 318 children were prospectively randomized in group 1 with two 5-microg doses of recombinant vaccine given at 0 and 1 month; in group 2 with three 5-microg doses of recombinant vaccine given at 0, 1, and 6 months; or in group 3 with three doses of plasma-derived vaccine given at 0, 1, and 6 months. Eleven subjects with a hepatitis B surface antigen antibody (anti-HBs) titer of less than 10 mIU/mL at 12 months were given an extra dose of vaccine and were excluded from analysis. No booster doses were given to any other subjects. All children were followed up yearly for the level of anti-HBs titers and for the detection of hepatitis B infection. At the 12th year of follow-up, there were significantly fewer subjects with anti-HBs of 10 mIU/mL or above in group 1 (60.4%) when compared with group 2 (81.4%; P =.0287) and group 3 (79.0%; P =. 0381). The geometric mean titers (GMTs) of subjects of group 1 were significantly lower than those of group 2 and group 3 throughout the 12 years of follow-up. A total of 65 subjects had one or more episodes of anamnestic response. No subject became positive for hepatitis B surface antigen (HBsAg); 2 became positive for hepatitis B core antigen antibody (anti-HBc). In conclusion, the long-term protective immunity was better with three doses of hepatitis B vaccine (either the recombinant or plasma-derived) than with two doses. However, protection from hepatitis B infection could be equally achieved by either two doses or three doses of the vaccine. Booster doses were not necessary, probably because of effective anamnestic response.

Lymphocyte subsets in renal allograft recipients with chronic hepatitis C virus infection

BACKGROUND

The pathogenetic mechanisms of chronic hepatitis C virus (HCV) infection in renal allograft recipients are not well established. This study aimed to examine the relationship between altered immune status and HCV-related liver disease, by determining the changes in peripheral blood lymphocyte and natural killer (NK) cell subsets in these subjects.

METHODS

Peripheral blood lymphocyte, NK cell and activation markers were detected by flow cytometry in renal allograft recipients with (TpC+) or without (TpC-) HCV infection, and compared with age- and sex-matched patients with post-transfusional chronic HCV infection (TfC+) and healthy controls.

RESULTS

CD19+ cells were reduced in renal allograft recipients compared with controls. TpC+ subjects had increased CD3+CD8+ cells compared with controls, and increased CD3+DR+ cells but reduced CD4+ CD38+ and CD3-CD16/56+ cells compared with controls as well as TfC+ patients. TfC+ patients and controls had similar numbers and proportions for the lymphocyte subsets and NK cells. Chronic liver disease in HCV-infected renal allograft recipients was associated with increased CD3+CD16/56+ cells but reduced CD4+CD38+ cells. Reduction of CD3-CD16/56+ cells was noted in TpC+ subjects without liver disease. Yet among post-transfusional (TfC+) subjects this was associated with chronic hepatitis.

CONCLUSIONS

Peripheral blood suppressor/cytotoxic T lymphocytes are increased, whereas activated helper/inducer T lymphocytes and NK cells are reduced, in renal allograft recipients with HCV infection. Increased non-MHC-restricted cytotoxic T cells and reduced NK cells are associated with the presence or absence of liver disease respectively. These data suggest that immune mechanisms are important in the pathogenesis of chronic hepatitis C after renal transplantation.

Triple therapy for Helicobacter pylori eradication is more effective than long-term maintenance antisecretory treatment in the prevention of recurrence of duodenal ulcer: a prospective long-term follow-up study

BACKGROUND

The effectiveness of Helicobacter pylori eradication treatment and long term acid suppression maintenance in the natural course of duodenal ulcer has not been directly compared.

AIM

To compare in a prospective randomized study the effectiveness of H. pylori eradication on the prevention of recurrence of duodenal ulcer with long-term maintenance acid suppression therapy.

METHODS

One hundred and fourteen duodenal ulcer patients were randomized to the treatment over a 12-month period. Fifty-seven of them received triple therapy consisting of 1 g sucralfate q.d.s. for 28 days, 300 mg metronidazole q.d.s. for 14 days and 250 mg clarithromycin q.d.s. for 14 days. Another 57 received 20 mg omeprazole q.d.s. for 12 months. An upper endoscopy was performed before treatment, at 6 weeks, and 2, 6 and 12 months after the first endoscopy. Side-effects were self-recorded and clinical follow-ups were arranged for up to 4.25 years.

RESULTS

The ulcer healing rate was 90.2% (95% confidence interval (95% CI): 79-97%) in the omeprazole group at 6 weeks as compared to 83.3% (95% CI: 70-93%) in the triple therapy group (P = 0.38). There was a higher success rate of pain control in the omeprazole group. Side-effects were more frequently reported and compliance was poorer in the triple therapy group during the first 4 weeks. During follow-up, more relapses were seen in the omeprazole group (9.8%, 95% CI: 3-21%) than the triple therapy group (4.2%, 95% CI: 1-13%) at 1 year (P = 0.44). All relapses were due to the persistence of H. pylori infection. At the 1 year follow-up, none of the patients who were H. pylori negative had an endoscopic relapse compared to 7 out of 56 patients who remained H. pylori positive (12.5%, 95% CI: 5-24%, P = 0.018). After a mean follow-up of 4.07 years, none of those who remained H. pylori negative had an ulcer relapse while the 11 out of 41 who remained H. pylori positive had an ulcer relapse (26.8%, 95% CI 14-43, P = 0. 0005).

CONCLUSIONS

Both regimens were highly effective in healing ulcers. The eradication of H. pylori infection was associated with more side-effects and poor compliance but was more effective than the maintenance therapy in reducing the recurrence of duodenal ulcers. For the prevention of ulcer recurrence, testing of H. pylori status after triple therapy is more important than maintenance therapy.

Applicability of living donor liver transplantation to high-urgency patients

BACKGROUND

Cadaveric liver donors are scarce in Hong Kong, and the application of liver transplantation to high-urgency patients is limited. We evaluated the use of grafts from living donors in this setting.

METHODS

From July 1994 to January 1998, 49 consecutive adult patients who were intensive care unit-bound because of acute or chronic liver failure were put on a high-urgency list for liver transplantation. Family members were not solicited for living donation, and the initiation and decision for living donor liver transplantation (LDLT) was based on the donor's voluntary intent. Assessment of the living donor, including blood tests, computed tomographic volumetry, and angiography, was performed only after informed consent was executed.

RESULTS

In 25 of 49 (51%) patients, no family member volunteered as living donor; 23 died awaiting donor organs, and 2 received a cadaveric graft. Twenty-four (49%) patients had 36 family members who volunteered as living donors. Before evaluation of living donor was completed, two patients received a cadaveric liver transplant. LDLT was not performed in nine patients because of recipient contraindications (n=4), ABO blood group incompatibility (n=3), and withdrawal of donor (n=2). Eight of these nine patients died, and one received a cadaveric liver graft. The remaining 13 (27%) patients received grafts from living donors. Four of 5 (80%) patients who underwent cadaveric liver transplantation and 11 of 13 (85%) who underwent LDLT survived. Thus, emergency transplantation from living donors increased the applicability of liver transplantation from 10% to 37%, and the survival rate after emergency LDLT (85%) was superior to that of the remaining patients (11%).

CONCLUSIONS

When cadaveric organ donation is scarce, emergency liver transplantation from living donors can be applied to high-urgency adult patients.

Nucleic acid-based cross-linking assay for detection and quantification of hepatitis B virus DNA

A nucleic acid photo-cross-linking technology was used to develop a direct assay for the quantification of hepatitis B virus (HBV) DNA levels in serum. Cross-linker-modified DNA probes complementary to the viral genomes of the major HBV subtypes were synthesized and used in an assay that could be completed in less than 6 h. The quantification range of the assay, as determined by testing serial dilutions of Eurohep HBV reference standards and cloned HBV DNA, was 5 x 10(5) to 3 x 10(9) molecules of HBV DNA/ml of serum. Within-run and between-run coefficients of variation (CVs) for the assay were 4. 3 and 4.0%, respectively. The assay was used to determine HBV DNA levels in 302 serum samples, and the results were compared to those obtained after testing the same samples with the Chiron branched-DNA (bDNA) assay for HBV DNA. Of the samples tested, 218 were positive for HBV DNA by both assays and 72 gave results below the cutoff for both assays. Of the remaining 12 samples, 10 were positive for HBV DNA by the cross-linking assay only; the 2 other samples were positive by the bDNA assay only. Twenty-eight samples had to be retested by the bDNA assay (CV, >20% between the results obtained from the testing of each sample in duplicate), whereas only three samples required retesting by the cross-linking assay. The correlation between the HBV DNA levels, as measured by the two tests, was very high (r = 0.902; P = 0.01). We conclude that the cross-linking assay is a sensitive and reproducible method for the detection and quantification of HBV DNA levels in serum.

[A central nerve conduction study in hypothyroidism: before and after thyroxine replacement]

Employing a Nicolet CA 100 machine, 20 patients of primary hypothyroidism were selected for electrophysiological studies, including somato-sensory evoked potential (SSEP), brainstem auditory evoked potential (BAEP), and visual evoked potential (VEP), to assess the central nerve conduction before and after administration of the thyroid hormone. Before thyroxine replacement therapy, the latencies of N9, N13, and N20 in SSEP showed significant delay, while the central conduction time (CCT) merely had a tendency of prolongation. In BAEP, the peak and interpeak latencies delayed significantly. Additionally, the latency and amplitude of VEP also had significant difference between patients and controls. After thyroxine replacement, the SSEP, BAEP, and VEP studies revealed significant improvement, in correlation with clinical amelioration. In conclusion, the central nerve conduction would be affected in primary hypothyroidism and the improvement was usually the case, reflecting the clinical recovery after appropriate treatment. The electrophysiological study provides an objective method for monitoring the function of central nervous system in hypothyroidism before and after thyroxine treatment.

Presence of serum anti-p53 antibodies is associated with pleural effusion and poor prognosis in lung cancer patients

This study was designed prospectively to evaluate the development of anti-p53 antibodies (Abs) in lung cancer patients in relation to their clinical outcome. Sera, derived from 125 lung cancer patients, consisting of 14 small cell lung cancers (SCLC) and 111 non-SCLCs (NSCLC), were surveyed. The p53-null human NSCLC cell line, NCI-H1299, transfected with a human mutant p53 gene was prepared as the source of p53 antigen for immunoblotting analyses to detect the presence of serum anti-p53 Abs. The control group included sera from 10 healthy adults and 14 patients with benign pulmonary diseases. Clinical data including staging and survival were recorded for statistical analyses. The anti-p53 Abs were found in 8% (10 of 125) of the lung cancer patients studied (8.1% of NSCLC versus 7.1% of SCLC patients), whereas none of the control sera had detectable anti-p53 Abs. The presence of anti-p53 Abs was closely associated with malignant pleural effusions (P = 0.001). The p53 Ab-positive patients had a worse prognosis than the p53 Ab-negative patients (P < 0.02; median survival, 20 versus 41 weeks). In both univariate and multivariate analyses, the tumor extension and probably the presence of anti-p53 Abs were significant predictors for cancer death. The development of anti-p53 Abs (n = 9) was also a predictor for poor survival in patients with malignant effusions (n = 51). In conclusion, the presence of serum anti-p53 Abs is closely associated with malignant pleural effusions in lung cancer patients. It may serve as a negative prognostic factor for survival independent of malignant pleural effusions and tumor staging.

Prevalence and subtypes of dementia in southern Taiwan: impact of age, sex, education, and urbanization

To determine the prevalence and subtypes of dementia in southern Taiwan, a two-phase study consisting of a phase I screening survey using the Mini-Mental Status Examination (MMSE) and a phase II diagnostic examination using the CERAD neuropsychological battery and the neurobehavioral examination was conducted. According to the household records, stratified random sampling by the degree of urbanization of the community was used, and 2915 inhabitants aged 65 and over participated in this study. The ICD-10NA criteria for dementia, NINCDS-ADRDA guidelines for Alzheimer's disease (AD), and NINDS-AIREN criteria for vascular dementia (VaD) were employed. Three hundred and ninety-eight persons who had MMSE scores below the cutoff values were recruited into the phase II study, of whom 108 had dementia. The prevalence rate (PR) of dementia was 3.7%, increasing from 1.3% in people 65-69 years old to 16.5% in people 85 years old and older. The age-standardized PR (ASPR) was 4.0%. AD (58 cases, 53.7%, PR=2.0%, ASPR=2.3%) was the most common cause of dementia, followed by VaD (25 cases, 23.1%, PR=0.9%, ASPR=0.9%), and mixed dementia (eight cases, 7.4%). After adjusting for age, sex and education using logistic regression analysis, aging was a significant risk factor for AD, VaD and total dementia. Female sex and illiteracy were significant risk factors for AD only. We concluded that the prevalence of dementia in Taiwan is lower than in the developed countries, which could be due to a relatively young elderly population and a high mortality from dementia in Taiwan. AD is the leading cause of dementia in Taiwan. Considering the high stroke prevalence, the relatively lower prevalence of VaD in Taiwan deserves further investigation.

A one-year trial of lamivudine for chronic hepatitis B. Asia Hepatitis Lamivudine Study Group

BACKGROUND AND METHODS

In preliminary trials, lamivudine, an oral nucleoside analogue, has shown promise for the treatment of chronic hepatitis B. We conducted a one-year, double-blind trial of lamivudine in 358 Chinese patients with chronic hepatitis B. The patients were randomly assigned to receive 25 mg of lamivudine (142 patients), 100 mg of lamivudine (143), or placebo (73) orally once daily. The patients underwent liver biopsies before entering the study and after completing the assigned treatment regimen. The primary end point was a reduction of at least two points in the Knodell necroinflammatory score.

RESULTS

Hepatic necroinflammatory activity improved by two points or more in 56 percent of the patients receiving 100 mg of lamivudine, 49 percent of those receiving 25 mg of lamivudine, and 25 percent of those receiving placebo (P<0.001 and P=0.001, respectively, for the comparisons of lamivudine treatment with placebo). Necroinflammatory activity worsened in 7 percent of the patients receiving 100 mg of lamivudine, 8 percent of those receiving 25 mg, and 26 percent of those receiving placebo. The 100-mg dose of lamivudine was associated with a reduced progression of fibrosis (P=0.01 for the comparison with placebo) and with the highest rate of hepatitis B e antigen (HBeAg) seroconversion (loss of HBeAg, development of antibody to HBeAg, and undetectable HBV DNA) (16 percent), the greatest suppression of HBV DNA (98 percent reduction at week 52 as compared with the base-line value), and the highest rate of sustained normalization of alanine aminotransferase levels (72 percent). Ninety-six percent of the patients completed the study. The incidence of adverse events was similar in all groups, and there were few serious events.

CONCLUSIONS

In a one-year study, lamivudine was associated with substantial histologic improvement in many patients with chronic hepatitis B. A daily dose of 100 mg was more effective than a daily dose of 25 mg.

Treatment of fibrosing cholestatic hepatitis with lamivudine

Fibrosing cholestatic hepatitis is a histological variant of hepatitis B virus infection with a high rate of mortality. We describe a patient who acquired acute hepatitis B virus infection 8 months after renal transplantation. Clinical features of rapidly progressive liver failure, indicated by prolonged prothrombin time (57 seconds) and increased bilirubin (40.4 mg/dL) and ammonia (129 mumol/L) concentrations, were accompanied by an extremely high serum HBV DNA level (2.153 x 10(6) pg/mL). Liver biopsy specimen showed fibrosing cholestatic hepatitis with widespread balloon degeneration of hepatocytes, focal hepatocyte loss, bile stasis, periportal fibrosis, mild lymphocytic infiltration, and strongly positive immunohistochemical staining for hepatitis B surface antigen (HBsAg) and hepatitis B core antigen. Lamivudine therapy suppressed HBV DNA to < 10 pg/mL within 4 weeks, which was followed by gradual recovery of liver function from a state of hepatic precoma. Twenty-four months after the onset of hepatitis, the patient had normal prothrombin time and bilirubin, transaminase, and albumin levels. She remained HBsAg positive and hepatitis B e antigen negative. Renal allograft function was stable, with a creatinine level of 1.52 mg/dL. HBV DNA remained suppressed after 22 months of lamivudine therapy. Our experience shows that fibrosing cholestatic hepatitis and liver failure caused by HBV infection can be successfully treated with lamivudine.