An open pilot study exploring the efficacy of fluvastatin, pegylated interferon and ribavirin in patients with hepatitis C virus genotype 1b in high viral loads

OBJECTIVE

Response to pegylated (PEG) interferon (IFN) and ribavirin is achieved only in 40-50% of patients infected with hepatitis C virus (HCV) of genotype 1 in high viral loads, which needs to be improved.

METHODS

In an open-label pilot study, fluvastatin (HMG-CoA reductase inhibitor), 20 mg daily, was given along with PEG-IFN/ribavirin to 21 patients with chronic hepatitis C. They were followed for HCV RNA in serum.

RESULTS

During treatment for 48 weeks, HCV RNA was lost from serum in 93% of the patients. In the 15 patients who received 48-week therapy, a sustained virological response (SVR) with loss of HCV RNA 24 weeks after completion was achieved in 10 (67%), including 7 of the 9 (78%) male and 3 of the 6 (50%) female patients. In the remaining 6 patients who received 72-week therapy, SVR was gained in 4 (67%), including 1 of the 2 male and 3 of the 4 female patients aged 56, 58 and 62 years, respectively.

CONCLUSION

Fluvastatin could be used safely to increase the response to PEG-IFN and ribavirin, especially in aged women who respond poorly to combined PEG-IFN/ribavirin.

Efficacy of platinum analogue for advanced hepatocellular carcinoma unresponsive to transcatheter arterial chemoembolization with epirubicin

AIM

Hepatocellular carcinoma (HCC) often shows resistance to transcatheter arterial chemoembolization (TACE). Such patients often have a poor prognosis and are unresponsive to other forms of therapy. The aim of this retrospective study was to determine the response to TACE using platinum analogues in patients deemed resistant to TACE using epirubicin.

METHODS

We studied 152 consecutive patients with advanced HCC resistant to TACE using epirubicin. All cases were treated with platinum analogue using transcatheter arterial chemotherapy with or without embolization.

RESULTS

Computed tomography at 3 months after therapy showed complete response (CR) in 6 patients (4.0%), partial response (PR) in 28 (18%), stable disease (SD) in 35 (23%), and progressive disease (PD) in 83 (55%). The cumulative survival rates for PR/CR patients who received platinum analogue-transcatheter arterial chemotherapy with or without embolization (81.8% at first year, 53.9% at second year, and 33.1% at third year) were significantly higher than those of SD/PD patients (36.6%, 17.5% and 7.4%, respectively) (P < 0.001). The 50% survival period was extended almost 1.4 year in PR/CR patients who received platinum analogue-transcatheter arterial chemotherapy with or without embolization.

CONCLUSION

Our retrospective study is the first to report the efficacy of platinum analogues for advanced HCC unresponsive to TACE using epirubicin.

High serum des-gamma-carboxy prothrombin level predicts poor prognosis after radiofrequency ablation of hepatocellular carcinoma

BACKGROUND

Currently, surgical resection is considered the first-line treatment for early stage hepatocellular carcinoma (HCC). Radiofrequency ablation (RFA) has been an alternative choice for unresectable HCC. However, RFA is expected to have similar therapeutic efficacy for early stage HCC with fewer invasions.

METHODS

The authors retrospectively analyzed 199 patients who underwent surgery and 209 patients who underwent RFA for HCC with a maximum diameter of < or = 3 cm and tumors numbering < or = 3. All patients were complicated with Child-Pugh A cirrhosis.

RESULTS

The 3- and 5-year survival rates of the resection (90.3%, 79.0%, respectively) and RFA groups were similar (87.4%, 74.8). The 1- and 3-year tumor recurrence-free survival rates of the resection group (83.1%, 51.0%, respectively) were higher than in the RFA group (82.7%, 41.8%; P = .011). Multivariate analysis identified prothrombin time > or = 80% (hazard ratio [HR], 2.72; 95% confidence interval [CI], 1.56-4.74; P < .001) as an independent prognostic factor for survival in the resection group. Des-gamma-carboxy prothrombin (DCP) <100 arbitrary units (AU)/L (HR, 5.49; CI, 2.23-13.5; P < .001) and platelet count > or = 1.0 x 10(5) (HR, 2.70; CI, 1.24-5.88; P = .012) were significant markers in the RFA group. Among patients with DCP > or = 100 AU/L, treatment procedure (HR, 1.26; CI, 1.04-1.53; P = .020) was a significant prognostic factor for survival.

CONCLUSIONS

High DCP levels reflect the biologic aggressiveness and progression of HCC tumors. In the aforementioned cases, we recommend surgical resection rather than RFA for such patients.

Sustained virological response reduces incidence of onset of type 2 diabetes in chronic hepatitis C

Diabetes is present in patients with chronic hepatitis C virus infection. The aim of this retrospective cohort study was to assess the cumulative development incidence and predictive factors for type 2 diabetes after the termination of interferon therapy in Japanese patients positive for hepatitis C virus (HCV). A total of 2,842 HCV-positive patients treated with interferon (IFN) monotherapy or combination therapy with IFN and ribavirin were enrolled. The mean observation period was 6.4 years. An overnight (12-hour) fasting blood sample or a casual blood sample was taken for routine analyses during follow-up. The primary goal was the onset of type 2 diabetes. Evaluation was performed by using the Kaplan-Meier method and Cox proportional hazard analysis. Of 2,842 HCV patients, 143 patients developed type 2 diabetes. The cumulative development rate of type 2 diabetes was 3.6% at 5 years, 8.0% at 10 years, and 17.0% at 15 years. Multivariate Cox proportional hazard analysis revealed that type 2 diabetes development after the termination of IFN therapy occurred when histological staging was advanced (hazard ratio 3.30; 95% confidence interval [CI] 2.06-5.28; P < 0.001), sustained virological response was not achieved (hazard ratio 2.73; 95% CI 1.77-4.20; P < 0.001), the patient had pre-diabetes (hazard ratio 2.19; 95% CI 1.43-3.37; P < 0.001), and age was >or=50 years (hazard ratio 2.10; 95% CI 1.38-3.18; P < 0.001).

CONCLUSION

Our results indicate sustained virological response causes a two-thirds reduction in the risk of type 2 diabetes development in HCV-positive patients treated with IFN.

Efficacy of entecavir treatment for lamivudine-resistant hepatitis B over 3 years: histological improvement or entecavir resistance?

BACKGROUND AND AIMS

Long-term lamivudine therapy is required for patients with chronic hepatitis B, because hepatitis reappears frequently after it has withdrawn. However, hepatitis B virus (HBV) mutants resistant to lamivudine emerge frequently accompanied by breakthrough hepatitis.

METHODS

Effects of entecavir were evaluated in 19 patients who had developed breakthrough hepatitis during lamivudine therapy for longer than 5 years. This study is a subgroup analysis of a previously reported study. Entecavir, in either 0.5 or 1.0 mg/day doses, was given to 10 and nine patients for 52 weeks, respectively, and then all received 1.0 mg/day entecavir for an additional 68-92 weeks.

RESULTS

There were no differences in biochemical and virological responses in the two groups of patients with respect to the two different initial doses of entecavir. Serum levels of alanine aminotransferase were normalized in 17 (90%) patients, and hepatitis B e antigen (HBeAg) disappeared from the serum in two (14%) of the 14 patients who were HBeAg-positive before. Furthermore, a decrease in histological activity index score greater than 2 points was achieved in nine of the 11 (82%) patients in whom annual liver biopsies were performed during 3 years while they received entecavir. HBV mutants resistant to entecavir emerged in five of the 19 (26%) patients, and hepatitis flare occurred in two of them (40%).

CONCLUSION

Entecavir in the long term would be useful for histological improvement of breakthrough hepatitis induced by lamivudine-resistant HBV mutants in patients with chronic hepatitis B. However, the relatively high rate of entecavir resistance is a concern, and other strategies need to be considered when available.

Virological response and hepatocarcinogenesis in lamivudine-resistant hepatitis B virus genotype C patients treated with lamivudine plus adefovir dipivoxil

AIMS

The long-term efficacy of adefovir dipivoxil in combination with lamivudine to chronic hepatitis B virus (HBV) infection is still unclear.

METHODS

Virological response and hepatocarcinogenesis during lamivudine + adefovir were investigated in 183 lamivudine-resistant Japanese patients with chronic genotype C-dominant HBV infection. As the predictors of virological response, an assessment of clinical parameters and a nucleotide (nt) sequence analysis of the negative regulatory element to core gene (nt 1611-2450) were performed at the start of adefovir.

RESULTS

The cumulative HBV-DNA non-detectable and ALT normalization rates were 93.6 and 97.6% at the end of 3 years, respectively. Multivariate analysis identified total bilirubin, AST, and nt substitutions (nt 1762, 1768, 1846, 1896, 2134, 2288, 2441) as determinants of early non-detectable HBV-DNA. The yearly incidence of hepatocellular carcinoma (HCC) during the first 3 years was 2.7%. At the diagnosis of HCC, ALT normalization, HBV-DNA non-detectable, and HBeAg-seronegative conversion rates were 75.0, 83.3, and 57.1%, respectively. Furthermore, the cumulative HBV-DNA non-detectable and ALT normalization rates were not significantly different according to the development of HCC or not.

CONCLUSIONS

Lamivudine-resistant patients treated with lamivudine + adefovir could achieve the excellent virological response and biochemical response, but the low hepatitis activity was not enough to suppress hepatocarcinogenesis.

A matched case-controlled study of 48 and 72 weeks of peginterferon plus ribavirin combination therapy in patients infected with HCV genotype 1b in Japan: amino acid substitutions in HCV core region as predictor of sustained virological response

Substitution of amino acid (aa) 70 and 91 in the core region of HCV genotype 1b is a useful pretreatment predictor of efficacy of 48-week peginterferon (PEG-IFN) plus ribavirin (RBV) therapy. Here, we determined the efficacy of 72-week PEG-IFN/RBV and the predictive factors to such therapy in a case-control study matched for sex, age, and periods from the start of treatment to initial point of HCV RNA-negative. We compared the treatment efficacy of 72-week regimen in 65 patients with that of 48-week in 130 patients, who were infected with HCV genotype 1b and treated with PEG-IFN/RBV. They consisted mainly of late virological responders (LVR) (HCV RNA-positive at 12 weeks and negative at 24 weeks after start of treatment). Sustained virological response (SVR) was achieved by 61.5% and 32.3% of patients of the 72- and 48-week groups, respectively, while non-virological response was noted in 9.2% and 29.2% of the respective groups. Multivariate analysis identified substitution of aa 70 and 91 (Arg70 and/or Leu91) and duration of treatment (72-week) as independent parameters that significantly influenced SVR. For Arg70 and/or Leu91 of core region, SVR rate was significantly higher in 72- (68.0%) than 48-week group (37.8%). For wild-type of ISDR, SVR rate was significantly higher in 72- (61.2%) than in 48-week group (29.3%). We conclude that 72-week PEG-IFN/RBV improves SVR rate for LVR, especially those with Arg70 and/or Leu91 of core region or wild-type of ISDR. Substitution of aa 70 and 91 is also a useful pretreatment predictor of response to 72-week PEG-IFN/RBV.

Clinicopathological features, background liver disease, and survival analysis of HCV-positive patients with hepatocellular carcinoma: differences between young and elderly patients

BACKGROUND

The aim of this retrospective study was to determine the incidence and characteristics of hepatocellular carcinoma (HCC) in hepatitis C virus (HCV) antibody-positive elderly patients with chronic hepatitis without cirrhosis.

METHODS

The study included 65 patients who developed HCC at >or=75 years of age and who received their first HCC therapy at Toranomon Hospital between 1985 and 2005. Their clinicopathological and laboratory data were analyzed and compared with those of 33 patients who developed HCC at <or=50 years of age during the same period.

RESULTS

The ratio of women patients in the elderly group (M: F = 1.1: 1) was higher than in the younger group (M: F = 5.6: 1). Also, patients in the elderly group had better liver function and prothrombin activity (P = 0.001), and lower total bilirubin (P = 0.002) than the young group. Only 11 of 65 elderly patients were diagnosed with liver cirrhosis by biopsy or peritoneoscopy before or at the time of development of HCC. Based on a discriminate score using gamma-globulin, hyaluronate level, platelet count, and sex, 27 (41.5%) elderly patients were considered to have chronic hepatitis, compared with six of 33 (18.1%) patients in the young group (P = 0.025). There were no differences in tumor number or size or tumor markers between the two groups. Survival rate was higher in the younger patients (P = 0.002), who were more likely to receive radical treatment.

CONCLUSIONS

Our results showed distinct differences in HCV-related HCC between elderly and young patients and suggested that elderly patients (especially women) could develop HCC even when liver histology shows chronic hepatitis and lack of cirrhosis.

Combination therapy of peginterferon and ribavirin for chronic hepatitis C patients with genotype 1b and low-virus load

OBJECTIVE

The aim of this study was to evaluate the efficacy of combination therapy of peginterferon and ribavirin in patients infected with hepatitis C virus (HCV) genotype 1b and low virus load.

METHODS

Inclusion criteria were HCV-genotype 1b, serum HCV RNA level of < 100 KIU/mL at the initiation time of treatment. A total of 60 were enrolled in this retrospective cohort study. The treatment period of combination therapy was 39.8+/-16.1 weeks.

RESULTS

Of the 60 study patients, 47 had sustained virological response (SVR) by the intention to treat analysis. SVR occurred when serum HCV RNA was negative 8 weeks after the initiation of the treatment (p=0.004) and continuance of negative HCV RNA during treatment was > or = 30 week (p=0.016). In rapid virological response, all of seven patients with continuance of negative HCV RNA 20 to 29 weeks during treatment had SVR. In early virological response nine of 10 patients with continuance of negative HCV RNA of 30 to 39 week during treatment had SVR.

CONCLUSION

The duration of combination therapy for chronic hepatitis C should be determined based on the time of attainment of negative HCV RNA in patients with genotype 1b and low-virus load.

The efficacy of interferon-beta monotherapy for elderly patients with type C hepatitis of genotype 2

OBJECTIVE

The aim of this study was to elucidate the efficacy of interferon (IFN)-beta monotherapy for elderly patients of > or = 70 years with type C hepatitis (HCV) of genotype 2.

METHODS

The present study was a retrospective cohort study. Inclusion criteria were type C hepatitis patients with HCV genotype 2a or 2b, > or = 70 years, and IFN-beta monotherapy of within 24 weeks. Thirty-one consecutive patients who satisfied the above criteria were enrolled in the present study. Independent factors that might have influenced the sustained virological response (SVR) were studied using logistic regression analysis.

RESULTS

Background of clinical profiles was as follows: median (range) age = 71 (70-76) years, male/female = 13/18, and median (range) HCV-RNA = 260 (< 5-3,800) KIU/mL. Out of 31, 16 patients (51.6%) had SVR by the intention-to-treat analysis. The SVR was significantly associated with the serum HCV RNA level. Logistic analysis showed that SVR occurred when HCV RNA level was < 100 KIU/mL (p=0.020). Based on the difference of the serum HCV RNA level, the SVR rate was 81.8% (9/11) in patients with a serum HCV RNA level of < 100 KIU/mL and 35.0% (7/20) in patients with a serum HCV RNA level of > or = 100 KIU/mL.

CONCLUSION

IFN-beta monotherapy of < or = 24 week is a possible therapy selection for elderly patients of > or = 70 years with type C hepatitis of genotype 2.

Diabetes mellitus worsens the recurrence rate after potentially curative therapy in patients with hepatocellular carcinoma associated with nonviral hepatitis

BACKGROUND AND AIM

The aim of this retrospective study was to examine the relationship between diabetes mellitus and recurrence of hepatocellular carcinoma after potentially curative therapy for hepatocellular carcinoma with nonviral hepatitis.

METHODS

We studied 40 consecutive hepatocellular carcinoma patients who were diagnosed between 1980 and 2006 with hepatocellular carcinoma associated with non-B, non-C hepatitis, and later underwent surgical resection or radiofrequency ablation.

RESULTS

Twenty-two out of the 40 patients developed hepatocellular carcinoma recurrence within a median of 3.7 years. In the 18 patients with diabetes mellitus, the cumulative rates of hepatocellular carcinoma recurrence were 22.2% at the first year, 55.6% at the second year, 61.1% at the third year, 61.1% at the fourth year, and 80.6% at the fifth year. The cumulative rates of hepatocellular carcinoma recurrence in 22 nondiabetic patients were 24.6% at the first year, 24.6% at the second year, 31.5% at the third year, 31.5% at the fourth year, and 31.5% at the fifth year. The hepatocellular carcinoma recurrence rate was significantly higher in diabetic patients than in nondiabetics (P = 0.026). The multivariate Cox proportional model identified old age and diabetes as the only significant predictors for recurrence. The hazard ratio of hepatocellular carcinoma recurrence in diabetic patients was 4.61 (P = 0.007). There was no significant difference in overall survival rate between diabetic and nondiabetic patients (P = 0.392).

CONCLUSION

Diabetes is a significant predictor of tumor recurrence after potentially curative therapy for hepatocellular carcinoma in patients with nonviral hepatitis.

Change of hepatitis B virus genotypes in acute and chronic infections in Japan

During 35 years from 1971 to 2005, 153 patients with acute and 4,277 with chronic HBV infection visited the Toranomon Hospital in Tokyo, Japan. They were grouped into seven 5-year periods, and HBV genotypes/subgenotypes were determined. Patients with acute HBV infection were younger (P = 0.046), predominantly male (P = 0.004), possessed higher alanine aminotransferase levels (P < 0.001), positive more frequently for HBeAg (P < 0.001), and had lower HBV DNA loads (P = 0.014) than those with chronic infection. Sexual transmission was more frequent in patients with acute than chronic HBV infection (67% vs. 3%, P < 0.001). The number of patients with acute infection increased throughout 1971-2005. Patients with chronic infection increased since 1971, peaked in 1986-1990 and then decreased. The number of patients increased since 1990-2000 again, however, reflecting recent boost of acute HBV infection. The distribution of HBV genotypes was considerably different between patients with acute and chronic infections (A, B, and C: 28.6%, 10.3%, and 59.5% vs. 3.0%, 12.3%, and 84.5%, respectively, P < 0.001). Since 1991, genotype A foreign to Japan started to increase sharply in patients with acute infection, and gradually in those with chronic infection. There was a trend for the foreign subgenotype B2/Ba to increase recently (P < 0.05). Despite immunoprophylaxis of high-risk babies born to carrier mothers with hepatitis B e antigen, implemented nationally since 1986, acute and chronic infections with HBV have been increasing in Japan. Based on genotypes/subgenotypes changing with time, the resurgence of hepatitis B could be attributed to infections, with foreign HBV genotypes/subgenotypes, spreading swiftly by sexual contact.

Hepatitis C virus enhances incidence of idiopathic pulmonary fibrosis

AIM: To investigate the cumulative development incidence and predictive factors for idiopathic pulmonary fibrosis in hepatitis C virus (HCV) positive patients.

METHODS: We studied 6150 HCV infected patients who were between 40-70 years old (HCV-group). Another 2050 patients with hepatitis B virus (HBV) were selected as control (HBV-group). The mean observation period was 8.0 ± 5.9 years in HCV-group and 6.3 ± 5.5 years in HBV-group. The primary goal is the development of idiopathic pulmonary fibrosis (IPF) in both groups. The cumulative appearance rate of IPF and independent factors associated with the incidence rate of IPF were calculated using the Kaplan-Meier method and the Cox proportional hazard model. All of the studies were performed retrospectively by collecting and analyzing data from the patient records in our hospital.

RESULTS: Fifteen patients in HCV-group developed IPF. On the other hand, none of the patients developed IPF in HBV-group. In HCV-group, the cumulative rates of IPF development were 0.3% at 10th year and 0.9% at 20th year. The IPF development rate in HCV-group was higher than that in HBV-group (P = 0.021). The IPF development rate in patients with HCV or HBV was high with statistical significance in the following cases: (1) patients ≥ 55 years (P < 0.001); (2) patients who had smoking index (package per day × year) of ≥ 20 (P = 0.002); (3) patients with liver cirrhosis (P = 0.042).

CONCLUSION: Our results indicate that age, smoking and liver cirrhosis enhance the development of IPF in HCV positive patients.

The efficacy of 24-week interferon monotherapy for type C liver cirrhosis in Japanese patients with genotype 1b and low virus load

OBJECTIVES

The aim of this study was to elucidate the efficacy of interferon (IFN) therapy in liver cirrhosis Japanese patients with genotype 1b and low virus load.

METHODS

The present study was a retrospective cohort study. Inclusion criteria were liver cirrhosis, HCV genotype 1b, HCV RNA of <100 KIU/ml, and natural IFN-alpha monotherapy for 24 weeks. In 23 consecutive patients who satisfied the above criteria the efficacy and side effects of IFN were examined. Independent factors that might have influenced a sustained virologic response (SVR) were studied using logistic regression analysis.

RESULTS

The clinical patient profiles were as follows: median (range) age 52 (37-69) years; male/female 18/5, and median (range) HCV RNA 52 (<5-92) KIU/ml. Eight of the 23 patients (34.8%) had SVR by intention-to-treat analysis. Logistic analysis indicated that an HCV RNA level of <50 KIU/ml was associated with SVR (p = 0.049). The median (range) HCV RNA levels were 28 (<5-68) KIU/ml in patients with SVR and 60 (6-92) KIU/ml in patients without SVR.

CONCLUSIONS

24-week IFN monotherapy is a suitable therapy for type C cirrhotic patients with genotype 1b and an HCV RNA level of <50 KIU/ml.

Potential of laparoscopy in chronic liver disease with hepatitis B and C viruses

AIM

The definitive diagnosis of chronic liver disease is made either by a histological examination of a biopsy specimen or upon visualization of the liver surface at laparoscopy. The aim of this retrospective cohort study is to assess whether histological or laparoscopic findings are associated with hepatocellular carcinoma (HCC) development.

METHODS

A retrospective review of paired laparoscopy and histology reports was performed on 4124 hepatitis virus-positive patients who underwent laparoscopy: 2804 patients had hepatitis C virus (HCV group) and 1320 patients had hepatitis B virus (HBV group). Based on the irregularities of the liver surface, the laparoscopic findings were classified into three groups in progression order: smooth, irregular, or nodular. The histological findings were classified according to the extent of fibrosis into four stages (stages 1-4) in progression order.

RESULTS

The number of patients with HCC development was 565 in the HCV group and 115 in the HBV group. The Coxregression hazard model showed that HCC appearance in the HCV group was independently associated with laparoscopic findings (relative risk based on every progression of one rank [RR], RR = 4.31, P < 0.0001) and histological findings (RR = 2.56, P < 0.0001). In the HBV group, however, HCC appearance in was mainly associated with laparoscopic findings (RR = 2.12, P < 0.0001) compared to histological findings (RR = 1.13, P = 0.403).

CONCLUSION

Our data indicate that laparoscopic findings of the liver are dominant predictors for HCC development compared with histological findings in patients with HBV.

Substitution of amino acid 70 in the hepatitis C virus core region of genotype 1b is an important predictor of elevated alpha-fetoprotein in patients without hepatocellular carcinoma

Previous studies identified amino acid (aa) substitutions of the hepatitis C virus core region of genotype 1b (HCV-1b core region) and elevated serum alpha-fetoprotein (AFP) levels as predictors of poor virologic response to pegylated interferon (PEG-IFN) plus ribavirin (RBV), and also as risk factors for hepatocarcinogenesis. The present study evaluated the impact of aa substitutions of HCV-1b core region on AFP, as a surrogate marker of hepatocarcinogenesis, on AFP levels in 569 Japanese patients with HCV-1b but without HCC, and investigated the predictive factors of elevated AFP (> or =11 microg/L). High AFP levels were detected in 27.4% of the patients. The rate of hepatocarcinogenesis in a group of 109 patients who received IFN monotherapy and followed-up for 15 years, was significantly higher in patients with abnormal than normal AFP. Multivariate analysis of 569 patients identified fibrosis stage (F3,4), aspartate aminotransferase (> or =76 IU/L), substitution of aa 70 (glutamine or histidine), and platelet count (<15.0 x 10(4)/microl) as significant determinants of elevated AFP. In 49 patients with abnormal AFP levels and substitutions at aa 70 who were treated with PEG-IFN + RBV, the rate of normalization of AFP was significantly lower in non-virological responders (28.6%) than in transient (71.4%) and sustained (100%) virological responders. The results indicated that substitution of aa 70 of HCV-1b core region is an important predictor of elevated AFP in non-HCC patients, and that eradication of the mutant virus normalizes AFP. The results highlight the importance of eradication of mutant type virus of aa 70 for reducing the risk of hepatocarcinogenesis.

Efficacy of low-dose intermittent interferon-alpha monotherapy in patients infected with hepatitis C virus genotype 1b who were predicted or failed to respond to pegylated interferon plus ribavirin combination therapy

The efficacy of interferon (IFN) monotherapy for non-responders to pegylated interferon (PEG-IFN) plus ribavirin (RBV) combination therapy is still unclear. To evaluate the impact of IFN monotherapy on biochemical response, 200 consecutive patients infected with HCV genotype 1b, who received low-dose intermittent IFN-alpha monotherapy, were investigated. A median IFN dose per day of 3 million units was administered during a median period of 74 weeks. As a whole, the ALT normalization rates were 50.5, 65.9, 58.4, and 61.7% at 4, 12, 24, and 48 weeks, respectively. In 40 patients, who had abnormal AFP levels at the start of treatment, 52.5% achieved normalization of AFP within 48 weeks. Multivariate analysis identified indocyanine green retention rate at 15 min as the parameter that influenced significantly and independently ALT normalization. ALT normalization rates of patients who were predicted to be poor responders to PEG-IFN plus RBV combination therapy (but not substitutions of amino acid 70 and/or 91 in the HCV core region, female sex, and lower levels of low-density lipoprotein cholesterol) were similar to others. Furthermore, the ALT normalization rates in non-responders to combination therapy were 29.2, 60.9, 60.0, and 40.0% at 4, 12, 24, and 48 weeks, respectively. The results suggest that low-dose intermittent IFN monotherapy is an efficacious therapeutic regimen for patients unsuitable for PEG-IFN plus RBV, including non-responders, because it can lead to ALT normalization and thus a reduced risk of hepatocarcinogenesis.

Prolonged-efficacy of bisphosphonate in postmenopausal women with osteoporosis and chronic liver disease

Osteoporosis is present often in postmenopausal women. The aim of this retrospective cohort study is to assess the cumulative appearance incidence and predictive factors for bone fracture in postmenopausal women with osteoporosis and chronic liver disease. The patients were 80 postmenopausal women with osteoporosis and chronic liver disease due to hepatitis virus B or C. These patients were given cyclic etidronate therapy within 3 months after diagnosis of osteoporosis (etidronate-group). Another 400 postmenopausal women with osteoporosis and chronic liver disease were selected as controls (control group). Patients in control group were matched 1:5 with etidronate-group for age. Patients in control group were not given any drugs after diagnosis of postmenopausal osteoporosis. The mean observation period was 8.1 years. Four patients in the etidronate-group and 46 in control group developed bone fracture. The 10th year cumulative appearance rates of bone fracture were 4.9% in etidronate-group and 13.8% in control group. Cox regression model showed that the appearance rate of bone fracture decreased with statistical significance in the following cases: (1) patients <65 years (P<0.001), (2) patients with serum albumin level of >or=3.5 g/dl (P=0.003), and (3) patients treated with etidronate (P=0.020). The cumulative survival rate after bone fracture was 82.2% at the second year, and 57.6% at the fifth year. The present study suggests that a serum albumin level of >or=3.5 g/dl and cyclic etidronate treatment reduce the appearance of bone fracture.

Low risk of adefovir resistance in lamivudine-resistant chronic hepatitis B patients treated with adefovir plus lamivudine combination therapy: two-year follow-up

BACKGROUND/AIMS

We studied the long-term efficacy (median follow-up of 28 months) of adefovir (ADV) in combination with lamivudine (LAM) in 132 LAM-resistant Japanese patients with chronic genotype C-dominant hepatitis B virus (HBV) infection.

METHODS

The viral response (undetectable HBV-DNA by PCR assay) and the predictor of viral response were evaluated. The emergence of ADV-resistant mutants was investigated during the combination therapy.

RESULTS

The cumulative probability of viral response was 69% at 12 months, and 81% at 24 months. Multivariate analysis identified baseline HBe antigen status (P=0.0001), aspartate aminotransferase level (AST) (P=0.001) and HBV-DNA level (P=0.002) as determinants of viral response to treatment. At the beginning of ADV therapy, substitutions at rtA181 (rtA181T and rtA181S) were identified in 3 patients (2.3%). In the remaining 129 patients, the rtM204 mutants were identified at baseline, and two (1.6%) of the 129 patients developed new ADV-resistant mutants; one was rtA181S and another was rtA181T plus rtN236T mutation.

CONCLUSIONS

Adefovir and lamivudine combination therapy effectively suppressed viral replication and maintained the efficacy well in LAM-resistant patients with chronic HBV infection. Genotypic analysis indicated that the emergence of ADV-resistant mutants is rare, at least over a period of 2 years, in patients with combination therapy.

Inhibitory effect of branched-chain amino acid granules on progression of compensated liver cirrhosis due to hepatitis C virus

BACKGROUND

A phase II randomized controlled trial was conducted in patients with compensated liver cirrhosis to investigate the inhibitory effect of branched-chain amino acid (BCAA) granules for oral use (TK-98) on disease progression.

METHODS

Patients who had compensated liver cirrhosis due to hepatitis C virus with baseline serum albumin levels between 3.6 and 4.5 g/dl were assigned to the TK-98 group, which was treated with BCAA granules (TK-98) for 168 weeks, or to a control group (no treatment).

RESULTS

No symptoms indicating decompensated cirrhosis, including ascites, edema, and hepatic encephalopathy were reported in either the TK-98 or control group during the study observation period. Hepatocellular carcinoma (HCC) was noted in eight of the 39 patients studied, and of these three received TK-98 (15.8%) and five were untreated (25.0%). A time-to-event analysis for the effect of BCAA therapy on development of HCC revealed no statistically significant differences between the two groups. However, an additional analysis of data from a subgroup with a baseline serum albumin level of <4.0 g/dl showed that the incidence of HCC was likely to be lower in BCAA-treated patients.

CONCLUSIONS

BCAA may inhibit hepatic carcinogenesis in patients with compensated cirrhosis with a serum albumin level of <4.0 g/dl.

Efficacy in patients with dose reduction in combination therapy of peginterferon and ribavirin for chronic hepatitis C

OBJECTIVE

The aim of this study was to elucidate efficacy after dose reduction in combination therapy of peginterferon and ribavirin for chronic hepatitis C.

METHODS

Inclusion criteria were hepatitis C virus (HCV) genotype 1b, serum HCV RNA level of >/=100 KIU/ml, dose reduction of peginterferon and/or ribavirin between the first 4 weeks and 20 weeks after the initiation of treatment. 164 patients were enrolled in this retrospective cohort study. Predictive factors for sustained viral response (SVR) after dose reduction were examined.

RESULTS

Out of the 146 patients treated with dose reduction, 57 had SVR. Multivariate analysis showed that SVR occurred when serum HCV RNA at the time of dose reduction was negative (p < 0.001) and total ribavirin dose was >/=100% of the anticipated total dose (p < 0.001). 57% (55/97) of patients with undetectable serum HCV RNA at the time of dose reduction had SVR. In contrast, only 4% (2/49) of patients with detectable serum HCV RNA at the time of dose reduction had SVR.

CONCLUSIONS

On dose reduction of combination therapy for chronic hepatitis C, undetectable serum HCV RNA at the time of dose reduction and attainment of the total ribavirin dose of >/=100% enhance SVR.

New ablation procedure for a radiofrequency liver tissue coagulation system using an expandable needle

OBJECTIVE

The stepwise hook extension technique for an expandable needle, which we reported previously, allowed roll-off in short time with low power. The aim of this study was to investigate experimentally the efficacy of a modified extension procedure.

METHODS

Three pigs underwent 10 radiofrequency ablation (RFA) procedures using the 10-hook electrode of LeVeen needle. The conventional technique was used in five RFA (group 1; the electrode was deployed in four steps to full extension), while the new technique was used in the other five RFA (group 2; the electrode was closed after the same three steps as group 1 and then fully extended).

RESULTS

The shape of the RFA-induced zone was cone-like or irregular in group 1 and oval-like in group 2. The diameter vertical to the shaft was larger in group 2 (37, range 33-42 mm) than in group 1 (23, range 20-29 mm). The median ablation time was longer in group 2 (10 min 13 s) than in group 1 (3 min 56 s). Although the required energy was higher in group 2 than in group 1, that per volume was comparable between the groups (median 0.9 vs. 1.4 kJ/mm(3)).

CONCLUSIONS

Our new procedure requires a longer session but produces larger necrosis of a uniform ellipsoid volume, making it potentially suitable for tumours more than 3 cm in diameter.

Hepatocarcinogenesis following HCV RNA eradication by interferon in chronic hepatitis patients

OBJECTIVE

Interferon (IFN) therapy reduces the incidence of hepatocarcinogenesis in patients with hepatitis C viral (HCV) infection who achieve a sustained virological response (SVR). The aim of the present study was to determine the rate of hepatocarcinogenesis and the risk factor in sustained virological responders.

PATIENTS AND METHOD

The study subjects were 1,193 patients with HCV-related chronic liver disease and IFN- or IFN plus ribavirin-induced SVR. The age, male/female ratio, and liver fibrosis stage [(F0-F3)/LC] were 15-83 years, 808/385, and 1106/41, respectively. Patients were followed-up for 8.3 years (range, 0 to 19.0 years) and the incidence of hepatocellular carcinoma was recorded.

RESULTS

Hepatocellular carcinogenesis was detected in 23 patients during the follow-up. The crude rates of hepatocarcinogenesis at 5, 10, and 15 years were 1.5%, 2.4% and 4.1%, respectively. Multivariate analysis identified cirrhosis, male sex and age older than 50 years as determinants of hepatocarcinogenesis with hazard ratios of 12.9 (p<0.001), 6.45 (p=0.012), and 20.2 (p=0.004), respectively.

CONCLUSION

Long-term follow-up of patients with chronic HCV infection is necessary even in those who show SVR, especially in male elderly patients with cirrhosis.

The efficacy of short-term interferon-beta therapy for chronic hepatitis C patients with low virus load

OBJECTIVE

The aim of this study was to elucidate the efficacy of short-term interferon (IFN) therapy for chronic hepatitis C patients with low virus load.

METHODS

The present study was a retrospective cohort study. Inclusion criteria were biopsy-proven chronic hepatitis, the serum hepatitis C virus (HCV) RNA level of less than 100 KIU/ml, IFN period of 8 weeks or less. One hundred and eleven consecutive patients satisfied above criteria were treated with IFN-beta (dose: 6 MU, daily for 4, 6, or 8 weeks).

RESULTS

Background of clinical profiles were as follows: median (range) age=56 (20-73) years, male/female=64/47, genotype 1b/2a/2b=40/68/3, and median (range) HCV-RNA=34 (4.5-81) KIU/ml. Out of 111, 64 patients (57.7%) had sustained viral response (SVR). Based on the difference of HCV genotype, the SVR rate was 47.5% (19/40) in genotype 1 and 63.3% (45/71) in genotype 2. In genotype 1, the SVR rate in patients treated with the 8-week-regimen was significantly higher than that in patients treated with the 4- or 6-week regimen. In contrast, in genotype 2, the SVR in patients treated with the 8-week regimen was not significantly different from that in patients treated with the 6-week regimen. None of the patients had severe IFN-related side effects.

CONCLUSIONS

The 6 or 8-week regiment of IFN-beta therapy is one selection of therapy for chronic hepatitis C patients who have tended to have a SVR and who show IFN-related adverse events.

The efficacy of short-term interferon-beta therapy for type C cirrhotic patients with genotype 2a and low virus load

OBJECTIVE

The aim of this study was to elucidate the efficacy of short-term interferon (IFN) therapy for type C cirrhotic patients with genotype 2a and low virus load.

METHODS

The present study was retrospective cohort study. Inclusion criteria were liver cirrhosis, hepatitis C virus (HCV) genotype 2a, the serum HCV RNA level of less than 100 KIU/mL, and IFN period of 6 or 8 weeks. Twenty-five consecutive patients who satisfied the above criteria were treated with IFN-beta daily at the dosage of 6 MU for 6 or 8 weeks. Independent factors that might have influenced sustained virologic response (SVR) were studied using multiple logistic regression analysis.

RESULTS

Background of clinical profiles were as follows: median (range) age=64 (53-76) years, male/female=13/12, and median (range) HCV-RNA=31 (8-90) KIU/mL. Out of 25, 14 patients (56.0%) had SVR by the intention-to-treat analysis. The SVR was significantly associated with serum HCV RNA level. Logistic analysis showed that SVR occurred when HCV RNA level was <50 KIU/mL (p=0.047). Based on the difference of the serum HCV RNA level, the SVR rate was 68.4% (13/19) in patients with a serum HCV RNA level of <50 KIU/mL and 16.7% (1/6) in patients with a serum HCV RNA level of > or =50 KIU/mL.

CONCLUSIONS

The 6 or 8-week IFN-beta therapy is a possible selection of therapy for cirrhotic patients with HCV genotype 2a and a serum HCV RNA level of <50 KIU/mL.

Suitable treatment period in patients with virological response during combination therapy of peginterferon and ribavirin for chronic hepatitis C

OBJECTIVE

The aim of this study was to determine the suitable treatment period in patients who achieve virological response during combination therapy of peginterferon and ribavirin for chronic hepatitis C virus infection.

METHODS

Inclusion criteria were HCV-genotype 1b, serum HCV RNA level of > or =100 KIU/ml before treatment, and negativity of serum HCV RNA during treatment. The 366 patients were enrolled in this retrospective cohort study. Patients were classified into four groups according to difference of response: rapid-virological response (RVR) at week 4 after the initiation of treatment (n=37), early-virological response (EVR) at week 5-12 (n=161), late-virological response (LVR) at week 13-24 (n=131), and superlate-virological response (SLVR) at week 25-48 (n=37). A non-relapse in patients with undetectable HCV RNA during therapy was defined as clearance of HCV RNA 6 month after the cessation of therapy.

RESULTS

Of the 366 patients, 241 had non-relapse and the non-relapse rate in each group was 89% (33/37) in RVR, 79% (127/161) in EVR, 54% (71/131) in LVR, and 27% (10/37) in SLVR. In RVR, 26 of 27 patients with continuance of negative HCV RNA of > or =30 weeks during treatment had non-relapse. In EVR, patients with period of negative HCV RNA of > or =40 weeks had non-relapse rate of 90% (71/79). In LVR and SLVR, all nine patients with continuance of negative HCV RNA of > or =60 weeks had non-relapse.

CONCLUSION

A suitable treatment period of combination therapy for chronic hepatitis C should be determined based on the time of attainment of negative HCV RNA.

Natural human interferon beta plus ribavirin combination therapy in Japanese patients infected with hepatitis C virus and a high viral load

OBJECTIVE

The aim of this pilot study was to determine the safety and efficacy of natural human interferon beta (nIFNbeta) plus ribavirin (RBV) in patients with chronic hepatitis C who did not respond to pegylated interferon alpha (PEG-IFN), with special emphasis on the incidence of mental disorders or refusal for fear of adverse effects.

METHODS

We studied 19 patients with HCV genotype 1b, 2a or 2b and a high viral load, including 8 patients with mental disorders. They were treated with nIFNbeta-RBV. Eleven patients with HCV genotype 1b of these patients were treated with nIFNbeta-RBV for 48 weeks (group A), and compared with 22 matched controls treated with PEG-IFN plus RBV for 48 weeks (group B). The other 8 patients with HCV genotype 2 were treated with nIFNbeta-RBV for 24 weeks.

RESULTS

Six of 8 patients with mental disorders and 9 of 11 patients without mental disorders completed nIFNbeta-RBV therapy; 1 patient with mental disorder dropped out due to exacerbation of depression, and 3 patients suspended the therapy due to insufficient response. The sustained virological response (SVR) was 27% (3/11) in group A and 41% (9/22) in group B (p = 0.70). During treatment, platelet count increased in group A but not in group B. SVR was 88% (7/8) in patients of genotype 2 and high viral load treated with nIFNbeta plus RBV.

CONCLUSION

nIFNbeta-RBV therapy offers sufficient safety and efficacy for patients with mental disorders, and thus could represent an excellent second-line therapy for subpopulations that are not suitable for PEG-IFN-RBV.

Viral elimination reduces incidence of malignant lymphoma in patients with hepatitis C

PURPOSE

A high prevalence of malignant lymphoma among patients with hepatitis C virus (HCV) infection has been reported. The aim of this retrospective study was to determine the incidence of malignant lymphoma and the relationship between malignant lymphoma and viral elimination in patients with HCV.

METHOD

We studied 501 consecutive HCV-infected patients who had never received interferon therapy and 2708 consecutive HCV-infected patients who received interferon therapy.

RESULTS

In the non-interferon group, the cumulative rates of malignant lymphoma development were 0.6% at the 5th year, 2.3% at the 10th year, and 2.6% at the 15th year. The cumulative rates of malignant lymphoma development in interferon-treated patients with sustained virologic response were 0% at the 5th year, 0% at the 10th year, and 0% at the 15th year. The cumulative rates of malignant lymphoma development with persistent infection were 0.4% at the 5th year, 1.5% at the 10th year, and 2.6% at the 15th year. The malignant lymphoma development rate was higher in patients with persistent infection than in patients with sustained virologic response (P=.0159). The hazard ratio of lymphomagenesis in 1048 patients with sustained virologic response was significantly lower than in patients with persistent infection (hazard ratio: 0.13; P=.049).

CONCLUSION

Our retrospective study is the first to determine the annual incidence of malignant lymphoma among patients with HCV at 0.23%. Our results indicate that sustained virologic response induced by interferon therapy protects against the development of malignant lymphoma in patients with chronic HCV.

Loss of hepatitis B surface antigen from the serum of patients with chronic hepatitis treated with lamivudine

Although loss of hepatitis B e antigen (HBeAg) from the serum is sought by treatment with lamivudine, clearance of hepatitis B surface antigen (HBsAg) is the eventual goal of any antiviral therapy. In a single hepatology center in the Metropolitan Tokyo, 486 patients with chronic hepatitis B were followed up for longer than 3 years after they started treatment with lamivudine. HBsAg disappeared from the serum in 17 (3.5%). Age >or=50 years and low HBsAg levels (hemagglutination titer <or=2(7)) at the start of lamivudine were significantly more frequent in the patients who did than did not lose HBsAg from the serum. Except for these two factors, there were no differences between the two groups of patients in the prevalence of HBeAg and HBV DNA levels at the baseline, as well as the development of YMDD mutants and breakthrough hepatitis during lamivudine treatment. Using multivariate analysis, age >or=50 years at the start of lamivudine was the only factor predicting the loss of HBsAg (hazard ratio: 2.96 [95% confidence interval: 1.14-7.68], P = 0.028). By the method of Kaplan-Meier performed on the 486 patients, the loss of HBsAg was estimated to occur in 3% and 13% of patients, respectively, who had received lamivudine therapy for 5 and 10 years. These results indicate that loss of HBsAg occurs in a minority (3.5%) of patients with chronic hepatitis B who receive lamivudine therapy and more frequently in those with lower HBsAg titers and older ages at the start of treatment.

Interferon-induced prolonged biochemical response reduces hepatocarcinogenesis in hepatitis C virus infection

The aim of this study was to elucidate indicator of interferon (IFN) therapy for reducing hepatocellular carcinoma (HCC) in chronic hepatitis C patients without eradicating hepatitis C virus (HCV) RNA during IFN therapy. Inclusion criteria were biopsy-proven chronic hepatitis or liver cirrhosis, IFN period for more than 1.5 years and persistently positive HCV-RNA during IFN therapy. Two hundred thirty-six patients satisfied above criteria were treated with IFN for 1.5-5 years (median 1.8 years, mean 2 years). Mean age was 55.1 years and male was 145 (61%). Eighty-one (34%) patients had severe fibrosis of the liver. These patients were prospectively monitored about HCC after the termination of IFN therapy. We regarded biochemical response (BR) as normalization of serum aminotransferase and alpha-fetoprotein for more than 1 year during IFN therapy. Cumulative rate of development of HCC after the termination of IFN therapy was 9.1% at 5th year and 26.5% at 10th year. Cox proportional analysis showed that HCC development after the termination of IFN therapy occurred when histological staging was advanced (P < 0.0001) and BR was not achieved (P = 0.009), age was >60 years (P = 0.026). The relative risk of HCC development in patients with BR was 0.36 compared with patients without BR. The attainment of BR during IFN therapy is effective in reducing hepatocarcinogenesis for patients with chronic HCV infection.

Amino acid substitutions in the hepatitis C virus core region are the important predictor of hepatocarcinogenesis

We showed previously that amino acid (aa) substitutions in hepatitis C virus core region (HCV-CR) are negative predictors of virologic response to pegylated interferon (IFN) plus ribavirin therapy. HCV-CR induces hepatocellular carcinoma in transgenic mice, but the clinical impact is still unclear. To evaluate the impact of aa substitutions in HCV-CR on hepatocarcinogenesis, we performed a follow-up study on 313 noncirrhotic consecutive naïve patients infected with HCV genotype 1b who received IFN monotherapy. The median follow-up was 14.7 years. A sustained virologic response (SVR) after the first IFN was achieved by 65 patients (20.8%) (group A). Of 248 patients (79.2%) of non-SVR after first IFN, 112 (35.8%) did not receive additional IFN (group B), and the remaining 136 (43.5%) received multicourse IFN monotherapy (group C). As a whole, cumulative hepatocarcinogenesis rates in double wild-type (arginine at aa 70/leucine at aa 91) of HCV-CR were significantly lower than those in nondouble wild-type. Multivariate analyses identified 3 parameters (fibrosis stage 3, nondouble wild-type of HCV-CR, and group B) that tended to or significantly influenced hepatocarcinogenesis independently. With regard to hepatocarcinogenesis rates in group C according to HCV-CR and the mean alanine aminotransferase (ALT) during IFN-free period, significantly higher rates were noted in patients of nondouble wild-type with ALT levels of more than 1.5 times the upper limit of normal (25.7%) compared with the others (2.4%).

CONCLUSION

Amino acid substitutions in the HCV-CR are the important predictor of hepatocarcinogenesis. In multicourse IFN therapy to nondouble wild-type, we emphasize the importance of reducing the risk of hepatocarcinogenesis by mean ALT during an IFN-free period below 1.5 times the upper limit of normal.

Predictors of viral kinetics to peginterferon plus ribavirin combination therapy in Japanese patients infected with hepatitis C virus genotype 1b

For chronic hepatitis C virus (HCV) infection, evaluation of response to peginterferon (PEG-IFN) plus ribavirin (RBV) therapy based on viral kinetics is useful as an early predictor of treatment efficacy, but the underlying mechanisms of the different viral kinetics to treatment are still unclear. The response to 48-week PEG-IFN-RBV combination therapy was evaluated in 160 Japanese adult patients infected with HCV genotype 1b and determined the rapid virological response (at 4 weeks), early virological response (at 12 weeks), end-of treatment response, and sustained virological response (6 months after end of treatment). The proportion of patients who showed rapid, early and sustained virological, and end-of treatment responses were 50%, 73%, 47%, and 71%, respectively. Furthermore, 66% of patients who achieved early virological response also showed sustained virological response. Multivariate analysis identified substitutions of amino acid (aa) 70 and 91 in the HCV core region (double-wild-type) as a predictor of early HCV-RNA negativity, rapid, early, and sustained virological responses and end-of treatment response, and lipid metabolic factors (high levels of LDL cholesterol and total cholesterol) as predictors of early and rapid virological responses and end-of treatment response. Male sex and low levels of alpha-fetoprotein were other predictors of sustained virological response. Furthermore, female sex and severity of liver fibrosis were determinants of lack of sustained virological response in spite of early virological response. This study identified predictors of efficacy of PEG-IFN-RBV therapy based on viral kinetics in Japanese patients infected with HCV genotype 1b.

Evaluation of long-term biochemical responses to combination therapy of interferon plus ribavirin in those infected with hepatitis C virus genotype 1b and high baseline viral load

AIM

The aim of this study was to determine the long-term effects in non-responders (NRs) to 48-week interferon (IFN) and ribavirin combination treatment in patients infected with hepatitis C virus (HCV) genotype 1b and high baseline viral loads.

METHODS

We measured serum alanine aminotransferase (ALT) and HCV-RNA levels in 52 consecutive patients infected with HCV genotype 1b and high viral loads who received combination therapy for 48 weeks.

RESULTS

Sustained virologic response (SVR) was noted in 30 patients (57.7%). Virologic response (VR), that is serum HCV-RNA negativity by the end of treatment and positivity during follow-up, was noted in nine patients (17.3%). Thirteen (25.0%) patients were NRs. Significantly lower serum albumin (P = 0.007) and ribavirin doses according to body weight (P = 0.021) and higher gamma glutamyl transpeptidase (GGT,P = 0.038) were noted at baseline in the NR group than in the SVR and VR groups. ALT normalization rates at six months after the completion of treatment were 55.6% (5/9) in VR and 61.5% (8/13) in NRs. Sustained ALT normalization at two years after the completion of treatment was noted in 55.6% (5/9) and 58.3% (7/12), respectively.

CONCLUSION

Our study indicates a high rate of ALT normalization in patients infected with HCV genotype 1b and high baseline viral loads who received combination therapy and that such a rate could be maintained after the completion of therapy, even in NRs. Our results suggest that combination therapy should be continued in NRs who show ALT normalization in order to prevent potential hepatocarcinogenesis.

Efficacy and anticarcinogenic activity of interferon for hepatitis C virus-related compensated cirrhosis in patients with genotype 1b low viral load or genotype 2

BACKGROUND

We assessed the efficacy and anticarcinogenic effects of interferon (IFN) therapy in patients with hepatitis C virus (HCV)-related cirrhosis.

METHODS

The study subjects were 123 Japanese patients with HCV-related cirrhosis with genotype 1b low viral load or genotype 2 who received IFN from 1989 to 2005 (18 patients continue to receive IFN therapy). They included 81 men and 42 women aged 29-74 years (median, 56 years).

RESULTS

Univariate analysis identified four parameters that significantly influenced SVR; viral load (low HCV concentration, P < 0.001), duration of IFN therapy (>/= 52 weeks, P = 0.029), daily dose of IFN (>/= 6 million units, P = 0.018), induction therapy (presence, P = 0.010) and choline esterase (> 1.0 DeltapH, P = 0.037). Multivariate analysis identified viral load (risk ratio = 6.329, P < 0.001) and daily dose of IFN (risk ratio = 2.62, P = 0.042) as two independent parameters thatinfluenced SVR. During the observation period, newly developed hepatocellular carcinoma (HCC) was detected in 22 patients. The rates of development of HCC in patients with SVR were 5.8% at the fifth year and 10.3% at the 10th year, compared with 25.8% at the fifth year and 42.5% at the 10th year in non-SVR patients. Multivariate analysis showed that IFN efficacy (SVR) was the only independent factor of hepatocarcinogenesis (hazard ratio: 0.185, 95% confidence interval: 0.042-0.810, P = 0.025) CONCLUSION: Among patients with HCV-related cirrhosis, the rate of development of HCC is significantly less in patients with SVR.

Prediction of response to pegylated interferon and ribavirin in hepatitis C by polymorphisms in the viral core protein and very early dynamics of viremia

OBJECTIVE

To evaluate power of amino acid polymorphisms in core protein of hepatitis C virus (HCV) for predicting sustained virological response (SVR) to pegylated interferon (Peg-IFN)/ribavirin, when they were combined with virological response.

METHODS

Peg-IFN/ribavirin was given to 118 patients infected with HCV genotype 1b in high viral loads. Amino acid polymorphisms (Arg70 vs. Gln70 and Leu91 vs. Met91) in combination with on-treatment virological responses were correlated with SVR.

RESULTS

End-of-treatment response (ETR) was achieved in 71% and SVR in 47% of the 118 patients. In multivariate analysis, Arg70 and Leu91, and higher ribavirin dose were independently associated with ETR. In patients with Gln70 and/or Met91, SVR was more frequent in those with than without prompt virological response (PVR) for a decrease in viral load >or=1.0 log by 48 h. Specificity in predicting patients without ETR and SVR, in combination with core polymorphisms, was not different between PVR and early virological response at 12 weeks.

CONCLUSION

Core polymorphisms combined with PVR would be useful in promptly identifying the patients who will not respond to Peg-IFN/ribavirin, thereby avoiding unrewarding side effects and high costs.

Prolonged-interferon therapy reduces hepatocarcinogenesis in aged-patients with chronic hepatitis C

The aim of this study was to elucidate the reduction of hepatocarcinogenesis by prolonged interferon (IFN) monotherapy in aged chronic hepatitis C patients. Inclusion criteria were biopsy-proven chronic hepatitis or liver cirrhosis, 60 years and over, elevated serum aminotransferase and positive hepatitis C virus (HCV)-RNA. One hundred and twenty patients satisfied the above criteria were treated with natural IFN-alpha (dose: 3 million unit (MU), two or three times weekly for 0.5-15.5 years, mean 2.47 years) (IFN group). Another 240 patients treated with herbal medicines excluding IFN were selected as control (no-IFN group). The patients not treated with IFN were matched 2:1 with IFN group patients for sex and age. The clinical and biological differences were compared after treatment with the IFN group and the untreated group. Serum alpha-fetoprotein (AFP) level decreased with statistical significance after initiation of treatment with IFN compared to no treatment. The 5- and 10-year cumulative rates of hepatocellular carcinoma (HCC) were 5.9 and 13.7%, and 17.1 and 32.8%, for the IFN and untreated group, respectively. HCC development occurred when histologic staging was advanced, and IFN was not given, the AFP level after treatment was >10 ng/ml. Cox regression analysis indicated that the relative risk of HCC in patients in the IFN group was 0.3 times of that in the untreated patients. The relative risk rate for HCC in severe fibrosis was 3.9 compared with mild or moderate fibrosis. In conclusion, long-term IFN therapy for aged patients with chronic HCV infection is effective in decreasing the serum AFP level and preventing hepatocarcinogenesis.

Diabetes mellitus increases the risk of hepatocarcinogenesis in patients with alcoholic cirrhosis: A preliminary report

AIM

Diabetes mellitus (DM) has been reported to increase the risk of hepatocellular carcinogenesis in chronic liver diseases. This study aims to elucidate whether DM is an independent risk factor for the appearance of hepatocellular carcinoma (HCC) in patients with alcoholic cirrhosis.

METHODS

Forty-seven patients with alcoholic cirrhosis were retrospectively observed for a median of 6.8 years. The patients showed a history of heavy alcohol intake of 500 kg or more until the diagnosis of cirrhosis, and no patients had hepatitis B surface antigen, hepatitis B virus DNA measured by nested polymerase chain reaction, or antihepatitis C virus.

RESULTS

During the observation period, HCC developed in nine patients (19.1%). Cumulative appearance rates of HCC were 10.5%, 23.8% and 33.3% at the end of the fifth, 10th and 15th years, respectively. When they were divided into two groups according to the association of diabetes, carcinogenesis rates in patients with (n = 11) and without (n = 36) DM, cumulative carcinogenesis rates were 32.7% and 3.2% at the end of fifth year, 32.7% and 20.2% at the tenth year, and 66.3% and 20.2% at the 15th year, respectively. Crude carcinogenesis rate in the patient with DM was significantly higher than that of patients without DM (P = 0.0034). Multivariate analysis disclosed a higher age (hazard ratio 28.1, P = 0.007), and association of DM (hazard ratio 21.7, P = 0.006) significantly affected future carcinogenesis rate.

CONCLUSION

DM seemed to be an independent risk factor for hepatocarcinogenesis in the cohort study of patients with alcoholic cirrhosis.

Changes in viral loads of lamivudine-resistant mutants during entecavir therapy

AIM

Entecavir therapy is effective against lamivudine-resistant virus in patients with hepatitis B virus infection. We investigated viral load changes of YMDD mutant virus (rtM204I [YIDD sequence], rtM204V [YVDD]) in serial serum samples during entecavir treatment for lamivudine-resistant virus and determined changes in viral precore and core promoter mutants.

METHODS

Nineteen patients were treated in randomized, double-blind phase II clinical trials of entecavir at 0.5 or 1.0 mg for breakthrough hepatitis due to lamivudine-resistant virus. Viral changes in YMDD mutants (rtM204I, rtM204V), amino acid changes in the polymerase reverse transcriptase region and precore/core promoter mutations at 52 weeks were determined in 18 patients.

RESULTS

Changes in viral loads of rtM204I and rtM204V were similar. No differences in load changes were seen betweenthe 0.5 and 1.0 mg groups. However, load changes for rtM204I alone were greater than those for the rtM204I + rtM204V mixed-type (P = 0.042, at both 40 and 52 weeks). Load changes in rtM204I and rtM204V with G1896A tended to be greater than those without. Moreover, G1896A was replaced by wild-type virus in two patients at 52 weeks.

CONCLUSION

RtM204I only or the existence of precore mutation was more sensitive to entecavir therapy against lamivudine-resistant virus.

Efficacy of lamivudine therapy in elderly patients with chronic hepatitis B infection

BACKGROUND

The aim of this study was to evaluate the efficacy of lamivudine therapy in elderly patients with chronic HBV infection.

METHODS

Patients aged >or=60 years (n = 40) received lamivudine monotherapy between February 1995 and September 2005 at Toranomon Hospital. We compared the efficacy of lamivudine therapy in these patients and in 639 patients aged <60 years, including 80 patients aged <60 years matched for sex, hepatitis B e antigen (HBeAg) status, and hepatitis B virus (HBV) DNA level.

RESULTS

The rates of normalization of alanine aminotransferase (ALT) level in 40 patients aged >or=60 years and 639 patients aged <60 years were 85% versus 76%, and 86% versus 73% at 1 and 3 years, respectively. The respective rates of loss of HBV-DNA were 74% versus 74%, and 76% versus 68% at 1 and 3 years. The respective cumulative emergence rates of the YMDD mutant were 16% and 17% at 1 year, and 46% and 49% at 3 years. In 80 patients <60 years old matched for sex, HBeAg status, and HBV-DNA level, the rates of normalization of the ALT level and loss of HBV-DNA were similar to those in the 639 patients aged <60 years. The emergence rate of YMDD mutants in patients aged >or=60 years were similar to those in matched patients aged <60 years. Multivariate analyses identified low serum bilirubin (<1 mg/dl) as an independent factor associated with the emergence of the YMDD motif mutation in patients aged >or=60 years.

CONCLUSIONS

Our results suggest that treatment with lamivudine is both well tolerated and efficacious in elderly patients with chronic HBV infection.

Factors associated with the virological response of lamivudine-resistant hepatitis B virus during combination therapy with adefovir dipivoxil plus lamivudine

BACKGROUND

The aim of this study was to investigate the factors associated with the response of lamivudine-resistant hepatitis B virus (HBV) during combination therapy with adefovir dipivoxil plus lamivudine.

METHODS

Sixty-three patients with breakthrough hepatitis received a 10-mg once-daily dose of oral adefovir dipivoxil.

RESULTS

The rates of undetectable serum HBV-DNA were 49.2% after 24 weeks, 61.9% after 48 weeks, and 67.2% after 72 weeks. The cumulative hepatitis B e antigen (HBeAg) loss rates in patients with alanine aminotransferase (ALT) levels of more than twice the upper limit of normal (ULN) were significantly higher than in patients with ALT less than twice the ULN (P = 0.0145). Multivariate analysis revealed that baseline ALT level (P = 0.003) and HBeAg status (P = 0.049) were associated with early virological response.

CONCLUSIONS

Baseline ALT level was associated with HBeAg loss and seroconversion, and baseline ALT level and HBeAg status were associated with the virological response of lamivudine-resistant HBV during combination therapy with adefovir dipivoxil plus lamivudine.

A nucleotide sequence variation detection system for the core region of hepatitis C virus-1b

Amino-acid substitution at positions 70 and 91 of the hepatitis C virus (HCV)-1b core region is a factor that contributes to a non-virological response in treatment using interferon/ribavirin combination. In this study, a system was developed for detection of nucleotide sequence variation in the core region that is simpler and less expensive than the current direct sequencing method. A PCR detection method using mutation-specific primers was developed, and amino acids at positions 70 and 91 were identified. The protein type was determined based on band intensity in electrophoresis, and classified into wild (70:R, 91:L), mutant (70:Q/H, 91:M) and competitive types. The detection rate, sensitivity and reproducibility were investigated in 108 patients with HCV-1b who were treated with interferon/ribavirin combination therapy, and correlation with the results of direct sequencing was examined. The detection rate was 94.4%, the sensitivity was 10 KIU/mL, the reproducibility was high, and in detectable cases the consistency with direct sequencing was 97.1%; inconsistency was noted in two competitive-type cases and in one case with an unusual amino-acid substitution. The results suggest that the system described in this paper provides an effective, simple and low-cost approach to detection of nucleotide sequence variation in the core region of HCV-1b.

Randomized controlled trial for the efficacy of hepatic arterial occlusion during radiofrequency ablation for small hepatocellular carcinoma--direct ablative effects and a long-term outcome

OBJECTIVE

To evaluate the efficacy of temporary balloon arterial occlusion during radiofrequency ablation (RFA), randomized controlled trial was performed.

METHODS

Twenty patients with hypervascular hepatocellular carcinoma measuring <or=30 mm were randomly treated with RFA combined with arterial occlusion (group A), or RFA alone (group B). Tumour ablation was performed in both groups using our 'stepwise hook extension technique.'

RESULTS

Median diameters of the longer and shorter axis of RF-induced area measured on computer tomography were 38 mm (range, 31-52) and 36 mm (25-40) in group A, and 34 mm (26-45) and 26 mm (22-32) in group B respectively. Although the longer axis was not statistically significant, the shorter axis of group A was significantly larger than in group B (P=0.003). The median volume of the ablated lesion was 25.3 cm3 (15.6-48.7) in group A and 16.1 cm3 (9.3-23.8) in group B. The lesion volume was significantly larger in group A than in group B (P=0.005). The time and energy requirement of RFA of both groups were not significantly different. In addition, no serious adverse effects were observed in both groups. Intrasubsegmental tumour recurrence was found in 0% in group A and 30% in group B at the end of the third year (P=0.082).

CONCLUSIONS

Hepatic arterial balloon occlusion during RFA is useful for extending the area of ablation in RF-induced lesions, and the procedure tended to decrease tumour recurrence from the same subsegment of ablated tumour.

Predictive factors of early and sustained responses to peginterferon plus ribavirin combination therapy in Japanese patients infected with hepatitis C virus genotype 1b: amino acid substitutions in the core region and low-density lipoprotein cholesterol levels

BACKGROUND/AIMS

We showed previously that amino acid (aa) substitutions in the HCV core region (HCV-CR) are predictors of non-virological response (NVR) to peginterferon (PEG-IFN) plus ribavirin (RBV) therapy. Here, we determined the predictive factors of sustained virological response (SVR) and early virologic response (EVR) to this treatment.

METHODS

We evaluated the response to 48-week PEG-IFN-RBV therapy in 114 Japanese adults infected with HCV genotype 1b and determined the predictors of EVR and SVR.

RESULTS

EVR was achieved by 70% and SVR by 45% of patients. 64% of patients who achieved EVR also showed SVR, while none of non-EVR achieved SVR. Multivariate analysis identified low-density lipoprotein cholesterol (LDL-C) (>or=86 mg/dl), aa substitutions in HCV-CR (double-wild-type; arginine at aa 70/leucine at aa 91), gamma-glutamyl transpeptidase (GGT) (<109 IU/l), RBV dose (>or=11.0mg/kg), and leukocyte count (>or=4500/mm3) as significant determinants of EVR, and aa substitutions in HCV-CR (double-wild-type), LDL-C (>or=86 mg/dl), male gender, ICG R15 (<10%), GGT (<109 IU/l), and RBV dose (>or=11.0 mg/kg) as determinants of SVR. Prediction of response to therapy based on combination of these factors had high sensitivity, specificity, positive, and negative predictive values.

CONCLUSIONS

Our study identified aa substitutions in the core region and serum LDL-C as predictors of response to PEG-IFN-RBV therapy in Japanese patients infected with HCV genotype 1b.

Long-term outcome after interferon therapy in elderly patients with chronic hepatitis C

OBJECTIVE

The purpose of this study was to elucidate the long-term outcome after interferon (IFN) therapy in chronic hepatitis C elderly patients.

METHODS

We studied the incidence of hepatocellular carcinoma (HCC) and survival probability after the initiation of IFN therapy in 500 Japanese chronic hepatitis C patients >60 years. The mean age of initiation of IFN was 63 years and the mean follow-up period was 7.4 years. Cox proportional hazard regression analysis was used to evaluate the long-term outcome after initiation of IFN therapy. Sustained virological response (SVR) was defined as negative HCV-RNA by RT-nested PCR 6 months after the completion of long-term IFN therapy. Non-response (NR) was applied to patients who did not show SVR. Hepatic fibrosis was defined as the fibrosis score (score 0-4) according to Knodell et al.

RESULTS

140 patients (28%) had an SVR and 360 patients (72%) had an NR. 71 of 500 patients developed HCC during follow-up. The cumulative incidence of HCC was 9.6% at the 5th year, 17.4% at the 10th year, and 31.3% at the 15th year. HCC developed with significance when: (1) HCV was not cleared after IFN therapy (p < 0.0001), (2) sex was male (p < 0.0001), and (3) staging of liver fibrosis was >2 (p = 0.008). 53 of the patients died. The cumulative survival probability was 95.7% at the 5th year, 86.4% at the 10th year, and 78% at the 15th year. Patients achieved a long survival with significance when: (1) staging of liver fibrosis was 1 (p < 0.0001), (2) HCV was cleared after IFN therapy (p = 0.034), and (3) sex was female (p = 0.015).

CONCLUSION

Chronic hepatitis C patients with clearance of HCV after IFN therapy had a significantly reduced risk of HCC appearance and achieved prolonged survival even if they are > or =60 years.

Long-term presence of HBV in the sera of chronic hepatitis B patients with HBsAg seroclearance

OBJECTS

The aim of this study was to elucidate the presence of serum hepatitis B virus (HBV) DNA at a prolonged time after seroclearance of hepatitis B surface antigen (HBsAg).

METHODS

Seventy Japanese patients who had been observed for >5 years after HBsAg seroclearance were included in this study. Anti-HBs, anti-HBe and anti-HBc antibodies were measured 0, 5 and 10 years after HBsAg seroclearance. Serum HBV DNA was measured using nested polymerase chain reaction (PCR) at 0, 5 and 10 years after HBsAg seroclearance. The PCR detection of serum HBV DNA using the X gene and core gene primers was done. The HBV DNA was regarded as positive when PCR detection of HBV DNA using either or both the X gene and core gene primers was positive. A multivariate regression analysis was used to assess the factors contributing to the positivity of serum HBV DNA 5 years after HBsAg seroclearance: the factors examined included age, gender, histological findings, HBV genotype, aminotransferase, total protein and interferon administration.

RESULTS

The titers of 200-fold diluted serum anti-HBc were 6.5 +/- 4.0 at 0 year after HBsAg seroclearance, 1.8 +/- 1.4 at 5 years and 0.9 +/- 0.7 at 10 years. The titers of 200-fold diluted serum anti-HBc decreased 5 and 10 years after HBsAg seroclearance with statistical significance. The positive rate of HBV DNA by the nested PCR was 71.4% (50/70) at 0 year after HBsAg seroclearance, 21.4% (15/70) at 5 years and 14.3% (3/21) at 10 years. However, there were no significant factors contributing to the positivity of serum HBV DNA 5 years after HBsAg seroclearance.

CONCLUSION

Our results suggest that serum HBV DNA disappears with an incidence of 10-20% 5 and 10 years after HBsAg seroclearance.

Prolonged hepatitis after acute infection with genotype H hepatitis B virus

We present a case report of a Japanese patient who showed prolonged infection after acute hepatitis B with genotype H. The patient was a 60-year-old man who underwent an annual health care check every year for several years and was never pointed out to have any liver damage, and markers for hepatitis B and C were negative. He was found to be positive for hepatitis B surface antigen (HBsAg) at his health care check in December 2005. After one month, he had an elevated aminotransferase level with hepatitis B e antigen and a high level of serum HBV DNA. He was diagnosed as having acute hepatitis B. On HBV genotype, he had genotype H by the direct sequence method, and he was given a 100 mg of lamivudine daily. However, his acute hepatitis tended to go toward prolonged infection. After two months, he was treated with interferon daily for 28 days. He had negative HBsAg in August 2006. Genotype H, the newest type of hepatitis B, could be the type which shows a poor response to lamivudine. The present paper is the first report, describing the clinical course of acute hepatitis B with genotype H from onset to remission.

Side effects of combination therapy of peginterferon and ribavirin for chronic hepatitis-C

OBJECTIVE

The aim of this study was to elucidate the side effects after combination therapy of peginterferon and ribavirin for Japanese patients with chronic hepatitis C.

METHODS

Inclusion criteria were HCV-genotype 1b and serum HCV RNA level of > 100 KIU/ml. Six hundred and twelve patients were received combination therapy and enrolled in this non-randomized prospective cohort study. Patients were monitored until the discontinuation of combination therapy based on treatment-related side effects. The percentage of each medication actually taken during treatment was calculated.

RESULTS

Sixty-eight patients were stopped the combination therapy due to side effects. The cumulative discontinuation rate due to side effects of therapy was 8.4% at 0.5 year and 14.9% at one year. Discontinuation rate due to side effects was high with statistically significant in the following cases: 1) patients > or = 65 years, 2) patients who had diabetes. Sustained viral response (SVR) was 17.6% (12/68) in the discontinuation group. In the discontinuation group, when the percentage of both peginterferon and ribavirin actually taken during treatment was > or = 60%, SVR was 31% (9/29). On the other hand, when the percentage of each medication actually taken during treatment was < 60%, SVR was 7.7% (3/39). In the discontinuation group, patients with adherence of > 60% to the total of scheduled dose tended to have a high SVR compared to those with < or = 60% adherence to the total of scheduled dose.

CONCLUSION

In combination therapy, patient age and complications of patient are important factors contributing to the safety. In the discontinuation group, patients with adherence of > 60% to the total of scheduled dose tend to have a high SVR.