Interferon therapy in HBeAg positive chronic hepatitis reduces progression to cirrhosis and hepatocellular carcinoma

Natural course following the onset of cirrhosis in patients with chronic hepatitis B: a long-term follow-up study

PURPOSE

To elucidate the long-term natural course following the onset of cirrhosis in patients with chronic hepatitis B.

METHODS

Ninety-three patients with chronic hepatitis B who had developed cirrhosis during regular follow-up were included in this long-term follow-up study. At the time of cirrhosis detection, 30% of the patients were seropositive for hepatitis B e antigen (HBeAg) and 73% had a HBV-DNA level >10(4) copies/ml. Follow-up studies included liver biochemistry, viral markers, alpha-fetoprotein and ultrasonography every 3-6 months.

RESULTS

During a mean follow-up period of 102 +/- 60 (12-246; median 97) months, 32 patients (34.4%) experienced 55 episodes of hepatitis flare (7.0%/year), 15 (53.6%) of 28 HBeAg-positive patients seroconverted to anti-HBe (6.3%/yr) and 12 (12.9%) lost HBsAg (1.5%/year). Overall disease progression was observed in 25 (26.9%, 3.2%/year) patients: 12 (12.9%, 1.5%/year) hepatic decompensation, 21 (22.6%, 2.7%/year) hepatocellular carcinoma and 11 (11.8%, 1.4%/year) died. Multivariate analysis showed that age at onset of cirrhosis (P = 0.015) and persistent HBeAg seropositivity (P = 0.019) were the independent factors for overall disease progression.

CONCLUSIONS

These results suggest that patients with older age at onset of cirrhosis and persistent HBeAg seropositivity following the onset of cirrhosis were independent factors for the disease progression in the first 10-year after the development of cirrhosis in patients with chronic hepatitis B.

Peginterferon alpha-based therapy for chronic hepatitis B focusing on HBsAg clearance or seroconversion: a meta-analysis of controlled clinical trials

BACKGROUND

Interferon alpha (IFNα) therapy has been widely used in the treatment of chronic hepatitis B (CHB) for decades. Nucleos(t)ide analogues are also increasingly used to treat CHB recently. More and more studies are being carried out concerning the clearance or seroconversion of HBsAg, which is recognized as an ideal goal of CHB therapy. This study conducted a meta-analysis to estimate the effect of pegylated interferon alpha (peginterferon α, PEG-IFNα)-based therapy on HBsAg clearance or seroconversion in CHB.

METHODS

All available controlled clinical trials, published from 2004 to 2010, with the following antiviral therapies for CHB patients: PEG-IFNα combined with lamivudine (LAM), PEG-IFNα only, conventional IFNα and LAM, with a course ≥24 weeks, were meta-analysed for HBsAg clearance and seroconversion.

RESULTS

Fourteen trials (involving a total of 2,682 patients) were identified, including seven high-quality and seven low-quality studies. The analysis results of the different antiviral therapies on HBsAg clearance or seroconversion were as follows: 1. No significant difference in HBsAg clearance or seroconversion was observed between the combination therapy group and PEG-IFNα monotherapy group [odds ratio (OR) = 1.16, 95% confidence intervals (CI) (0.73-1.85), P = 0.54 and OR = 1.07, 95% CI (0.58-1.97), P = 0.82, respectively]; 2. HBsAg clearance and seroconversion rates in patients with combination therapy were markedly higher than in those with LAM monotherapy [OR = 9.41, 95% CI (1.18-74.94), P = 0.03, and OR = 12.37, 95% CI (1.60-95.44), P = 0.02, respectively]; 3. There was significant difference in HBsAg clearance between the PEG-IFNα group and IFNα monotherapy group [OR = 4.95, 95% CI (1.23-20.00), P = 0.02], but not in seroconversion [OR = 2.44, 95% CI (0.35-17.08), P = 0.37]; 4. PEG-IFNα was superior to LAM in HBsAg seroconversion [OR = 14.59, 95% CI (1.91-111.49), P = 0.01].

CONCLUSIONS

PEG-IFNα facilitated HBsAg clearance or seroconversion in CHB patients. PEG-IFNα-based therapy was more effective than LAM monotherapy in achieving HBsAg clearance or seroconversion for both HBeAg-positive and HBeAg-negative CHB patients. There was no significant difference in HBsAg clearance or seroconversion between PEG-IFNα/LAM combination therapy and PEG-IFNα monotherapy. PEG-IFNα was obviously superior to conventional IFNα in HBsAg clearance, but not in HBsAg seroconversion. Although PEG-IFNα produced significantly higher rates of HBsAg clearance and seroconversion, the absolute change in the proportion of HBsAg clearance and seroconversion was low (about 3-6%). Therefore, additional interventions are needed to improve the rate of positive outcomes.

Peginterferon alpha-based therapy for chronic hepatitis B focusing on HBsAg clearance or seroconversion: a meta-analysis of controlled clinical trials

Background

Interferon alpha (IFNα) therapy has been widely used in the treatment of chronic hepatitis B (CHB) for decades. Nucleos(t)ide analogues are also increasingly used to treat CHB recently. More and more studies are being carried out concerning the clearance or seroconversion of HBsAg, which is recognized as an ideal goal of CHB therapy. This study conducted a meta-analysis to estimate the effect of pegylated interferon alpha (peginterferon α, PEG-IFNα)-based therapy on HBsAg clearance or seroconversion in CHB.

Methods

All available controlled clinical trials, published from 2004 to 2010, with the following antiviral therapies for CHB patients: PEG-IFNα combined with lamivudine (LAM), PEG-IFNα only, conventional IFNα and LAM, with a course ≥24 weeks, were meta-analysed for HBsAg clearance and seroconversion.

Results

Fourteen trials (involving a total of 2,682 patients) were identified, including seven high-quality and seven low-quality studies. The analysis results of the different antiviral therapies on HBsAg clearance or seroconversion were as follows: 1. No significant difference in HBsAg clearance or seroconversion was observed between the combination therapy group and PEG-IFNα monotherapy group [odds ratio (OR) = 1.16, 95% confidence intervals (CI) (0.73-1.85), P = 0.54 and OR = 1.07, 95% CI (0.58-1.97), P = 0.82, respectively]; 2. HBsAg clearance and seroconversion rates in patients with combination therapy were markedly higher than in those with LAM monotherapy [OR = 9.41, 95% CI (1.18-74.94), P = 0.03, and OR = 12.37, 95% CI (1.60-95.44), P = 0.02, respectively]; 3. There was significant difference in HBsAg clearance between the PEG-IFNα group and IFNα monotherapy group [OR = 4.95, 95% CI (1.23-20.00), P = 0.02], but not in seroconversion [OR = 2.44, 95% CI (0.35-17.08), P = 0.37]; 4. PEG-IFNα was superior to LAM in HBsAg seroconversion [OR = 14.59, 95% CI (1.91-111.49), P = 0.01].

Conclusions

PEG-IFNα facilitated HBsAg clearance or seroconversion in CHB patients. PEG-IFNα-based therapy was more effective than LAM monotherapy in achieving HBsAg clearance or seroconversion for both HBeAg-positive and HBeAg-negative CHB patients. There was no significant difference in HBsAg clearance or seroconversion between PEG-IFNα/LAM combination therapy and PEG-IFNα monotherapy. PEG-IFNα was obviously superior to conventional IFNα in HBsAg clearance, but not in HBsAg seroconversion. Although PEG-IFNα produced significantly higher rates of HBsAg clearance and seroconversion, the absolute change in the proportion of HBsAg clearance and seroconversion was low (about 3-6%). Therefore, additional interventions are needed to improve the rate of positive outcomes.

Long-term effect of interferon treatment on the progression of chronic hepatitis B: Bayesian meta-analysis and meta-regression

AIM

  The long-term effects of interferon treatment on the progression of chronic hepatitis B (CHB) have been studied extensively, but its true clinical benefits and the predictors of its efficacy remain unclear.

METHODS

  A systematic published work search was undertaken. Eligible studies included those with interferon treatment and control groups, and with liver cirrhosis (LC), hepatocellular carcinoma (HCC) or death as main outcomes. Bayesian meta-analysis and meta-regression were performed to assess associations between interferon treatment and disease progression, and the impacts of potential covariates.

RESULTS

  Eleven articles met the inclusion criteria. LC, HCC and death were end-points in four, nine and six studies, respectively. In all studies, interferon was associated with significant preventive effects on HCC according to the DerSimonian-Laird method (relative risk [RR] = 0.470, 95% confidence interval [CI] = 0.260-0.850) and Bayesian method adjusting underlying risk (RR = 0.249, 95% Bayesian credible intervals [BCI] = 0.049-0.961), but not according to Bayesian meta-analysis (RR = 0.274, 95% BCI = 0.059-1.031); and it showed similar effects in death but not in LC. However, most of the high-quality studies never revealed protective benefits in these end-points. Bayesian meta-regression identified Asian ethnicity in death, higher hepatitis B e-antigen (HBeAg) seroconversion rate or positivity rate, and length of follow up (≤5 years) in HCC as potentially protective against disease progression. Subgroup analysis confirmed similar effects from these factors in HCC and death.

CONCLUSION

  Additional evidence is needed to support the role of interferon in delaying CHB progression.

The prevention of infection-associated cancers

Collectively, chronic viral and bacterial infections and trematode infestations have been estimated to be associated with approximately one of five human cancers worldwide. The fraction attributable to each one of the chronic infections caused by hepatitis B and C viruses (HBV and HCV), human papillomaviruses (HPV) and Helicobacter pylori, is ∼5%. These infections are the most important causes of major types of cancer, including hepatocellular carcinoma, cervical cancer and stomach cancer, respectively. Taking into account the mechanisms of infection-related carcinogenesis, integrated approaches are addressed to the control of the associated infection as well as to avoidance of cancer occurrence and progression. Large-scale interventions have been implemented, such as the anti-HBV and anti-HPV routine vaccination programs. The latter has been designed with the specific goal of preventing HPV-associated cancers, which is an outstanding breakthrough in cancer prevention. Intriguingly, not only prevention but even therapy of an infectious disease and eradication of a pathogen become a crucial tool for the primary prevention of these cancers. An important role is also played by secondary prevention (e.g. Pap test and DNA testing for HPV-associated cervical cancers) and by tertiary prevention (e.g. antiangiogenesis in Kaposi's sarcoma). The present article reviews the microbial and parasitic diseases that have been associated so far with human cancers, draws an overview of their burden in cancer epidemiology, deals with applicable prevention strategies and provides examples of co-ordinated approaches to the control of cancers associated with HBV, HCV, HPV, human immunodeficiency virus and H.pylori infections.

Does interferon therapy prevent hepatocellular carcinoma in patients with chronic viral hepatitis?

Chronic hepatitis C and B are well-recognized and potentially preventable risk factors for hepatocellular carcinoma (HCC) development. Clinical and epidemiological studies suggest that therapy with interferon-α may reduce the overall risk of HCC development in patients with chronic hepatitis C, who achieve sustained virological response, but even in those who fail to eradicate the infection. In chronic hepatitis B, interferon therapy reduces the risk of HCC development in HBeAg-positive and cirrhotic patients who achieve persistent suppression of viral replication, while in HBeAg-negative patients the beneficial effect of interferon-α is not definitively confirmed. The preventive role of interferon-α after potentially curative treatment for HCC in both chronic hepatitis B and C is uncertain due to methodological flaws of the existing studies and prospective randomized controlled trials with pegylated interferon-α are needed to clarify this issue.

Antiviral therapy in patients with hepatitis B virus-related cirrhosis

Antiviral therapy can lead to biochemical remission, histological improvement, and even complete reversibility of liver cirrhosis in patients with hepatitis B virus-related cirrhosis, thereby significantly reducing the incidence of hepatic decompensation, hepatocellular carcinoma and liver disease-related death. Interferon alpha is not contraindicated in compensated cirrhosis and can be used in finite treatment for 6 or 12 months. Long-term treatment with nucleoside/nucleotide analogues is recommended for both compensated and decompensated cirrhosis. Biochemical and virological changes should be carefully monitored during antiviral treatment to promptly find viral breakthrough and prevent hepatitis B recurrence and liver failure. In addition, hepatocellular carcinoma is required to be screened in all cirrhotic patients.

Use of RNA interference to modulate liver adenoma development in a murine model transgenic for hepatitis B virus

Chronic hepatitis B virus (HBV) infection is closely related to the development of severe liver complications, including hepatocellular carcinoma. In previous studies, we reported that in vivo long-term HBV suppression in transgenic mice can be achieved without apparent toxicity by short hairpin RNA sequentially delivered using adeno-associated viral (AAV) vectors of different serotypes. Our goal herein was to address the clinical utility of this delivery system and, in particular, to determine whether RNA interference (RNAi) and its ability to induce long-term HBV suppression will modulate the development of HBV-associated liver pathology. As a model system, we used a unique HBV transgenic mouse model, containing a 1.3 times over length of the HBV genome, on the ICR mouse background. These transgenic mice produce high serum HBV titers comparable with human chronic HBV patients, and, importantly, manifest characteristic HBV-associated pathology, including progressive hepatocellular injury and the development of hepatocellular adenoma. Using this system, we injected animals with AAV vectors expressing either HBV-specific or a control luciferase-specific short hairpin RNA and followed animals for a total of 18 months. We report herein that AAV-mediated RNAi therapy profoundly inhibits HBV replication and gene expression, with a significant reduction in hepatic regeneration, liver enzymes and, importantly, the appearance of liver adenomas. Indeed, the therapeutic effect of RNAi correlated with the reduction in HBV titers. Our data demonstrate that appropriately designed RNAi therapy has the potential to prevent formation of HBV-associated hepatocellular adenoma.

Efficacy and safety of prolonged 3-year telbivudine treatment in patients with chronic hepatitis B

BACKGROUND

In the GLOBE trial, telbivudine demonstrated superior efficacy to lamivudine at 2 years in patients with chronic hepatitis B (CHB).

AIMS

To investigate the long-term efficacy and safety of telbivudine in the telbivudine-treated cohort from the GLOBE trial.

METHODS

Virological and biochemical responses were assessed in 213 HBeAg-positive and 186 HBeAg-negative CHB patients who continued telbivudine treatment for 3 years.

RESULTS

Undetectable hepatitis B virus DNA and HBeAg seroconversions were achieved by 77 and 37% of HBeAg-positive patients respectively. Cumulative HBeAg seroconversion rate was 46%. HBeAg seroconversion was sustained at 52 weeks off therapy in 84% of the patients enrolled in the off-treatment follow-up arm of the study. Undetectable viraemia and normal alanine aminotransferase (ALT) levels at 3 years were achieved by 85 and 83% of HBeAg-negative patients respectively. Genotypic resistance rates for the study population who continued therapy during the third year were 11.3 in HBeAg-positive and 6.5% in HBeAg-negative patients. Patients with undetectable viraemia at treatment week 24 had optimal outcomes at 3 years. In the HBeAg-positive population, cumulative HBeAg seroconversion occurred in 58%. Resistance rates for HBeAg-positive and HBeAg-negative patients were 3.6 and 6.2% respectively. The telbivudine safety profile during prolonged therapy was similar to that in the GLOBE trial.

CONCLUSIONS

Three years of telbivudine treatment yielded high rates of viral suppression and ALT normalization with a favourable safety profile. High rates of HBeAg seroconversion were achieved with prolonged telbivudine therapy and were sustained in the majority of patients over 52 weeks off therapy.

The role of oncogenic viruses in the pathogenesis of hepatocellular carcinoma

HBV and HCV have major roles in hepatocarcinogenesis. More than 500 million people are infected with hepatitis viruses and, therefore, HCC is highly prevalent, especially in those countries endemic for HBV and HCV. Viral and host factors contribute to the development of HCC. The main viral factors include the circulating load of HBV DNA or HCV RNA and specific genotypes. Various mechanisms are involved in the host-viral interactions that lead to HCC development, among which are genetic instability, self-sufficiency in growth signals, insensitivity to antigrowth signals, evasion of apoptosis, limitless replicative potential, sustained angiogenesis, and tissue invasiveness. Prevention of HBV by vaccination, as well as antiviral therapy against HBV and for HCV seem able to inhibit the development of HCC.

[HBsAg seroclearance: prognostic value for the response to treatment and the long-term outcome]

Chronic hepatitis B is a major cause of liver disease worldwide, ranking as the first cause of cirrhosis and hepatocellular carcinoma. Hepatitis B surface antigen (HBsAg) is usually used as a qualitative marker for the diagnosis of hepatitis B virus (HBV) infection. HBsAg clearance is the closest to cure outcome as one can expect to achieve in hepatitis B. Support for this comes from natural history studies demonstrating increased length of survival, lower rates of hepatic decompensation, reduction in the frequency of hepatocellular carcinoma, and regression of liver fibrosis in patients who clear HBsAg. HBsAg seroclearance may occur spontaneously at a yearly incidence of 1-2%, preceded usually by a long period of inactive disease. Interferon treatment enhanced HBsAg seroclearance by approximately three-fold in western studies and sixfold in Asian studies compared with non-treated patients. Pegylated interferon induced a 10-15% yearly rate of HBsAg seroclearance in patients who developed sustained virological response in clinical trials. By contrast, treatment with nucleos (t) ides analogues did not significantly affect the rate of HBsAg seroclearance, especially in patients with hepatitis B e antigen (HBeAg) - negative disease. Recently, serum HBsAg has been shown to be a surrogate marker of covalently closed circular DNA (cccDNA) concentration in the liver. Quantification of serum HBsAg has also been recently shown to be a promising tool for monitoring virologic response in HBeAg-negative patients treated with pegylated interferon.

The natural history of chronic HBV infection and geographical differences

Although chronic HBV infection is a global health issue, there are geographical differences in the mode of transmission, prevalence and HBV genotype distribution. Chronic HBV infection is a dynamic state of interactions between HBV, hepatocytes and immune cells of the host. Accordingly, the natural history of chronic HBV infection typically starts with an immune tolerant phase, followed by an immune clearance phase and finally an inactive phase. The duration of the immune tolerant phase is usually long in chronic HBV infection acquired perinatally or in early childhood, otherwise the duration is very short. During the inactive phase, spontaneous hepatitis B surface antigen (HBsAg) seroclearance might occur at an annual rate of 1-2%; however, HBV reactivation with hepatitis activity could occur over time in one-quarter to one-third of HBsAg-seropositive patients. This occurs more frequently in males and in patients infected with genotypes D, C and B. The effort of active HBV replication-triggered immune clearance is the driving force of liver injury and subsequent disease progression in patients with hepatitis B e antigen (HBeAg)-positive or HBeAg-negative hepatitis. Clinical studies have shown that chronic HBV infection in western countries is associated with a higher incidence of cirrhosis, but lower incidence of hepatocellular carcinoma, than in Asian countries. The geographical differences in age at the time of infection and predominant HBV genotype could account for the variance in the natural history of chronic HBV infection; however, some of these differences might actually result from comparisons between cohorts with different age, gender distribution or fibrosis stage.

Does antiviral therapy for hepatitis B and C prevent hepatocellular carcinoma?

Approximately 75% to 80% of hepatocellular carcinomas (HCC) worldwide are attributed to chronic hepatitis B virus (HBV) and chronic hepatitis C virus (HCV) infection. Thus, effective prevention of HBV and HCV infection and progression from acute HBV and HCV infection to chronic hepatitis, cirrhosis and HCC might prevent as many as 450,000 deaths from HCC each year. The most effective approach to preventing HCC is to prevent HBV and HCV infection through vaccination. Indeed HBV vaccine is the first vaccine demonstrated to prevent cancers. However, a vaccine for HCV is not available and for persons who are chronically infected with HBV or HCV, antiviral therapy is the only option for preventing HCC. Direct evidence supporting a benefit of antiviral therapy on the prevention of HCC has been shown in a few randomized controlled trials. There is abundant evidence that antiviral therapy, in patients with long-term virological response, can improve liver histology, providing indirect support that antiviral therapy may prevent HCC by slowing progression of liver disease and possibly even reversing liver damage. Nevertheless, the risk of HCC remains in patients with chronic HBV or chronic HCV infection if treatment is initiated after cirrhosis is established. These data indicate that treatment might be of greater benefit if instituted earlier in the course of chronic hepatitis B or C. Safer, more effective, and more affordable antiviral therapies are needed for both hepatitis B and hepatitis C so more patients can benefit from treatment and more HCCs can be prevented.

Safety evaluation of telbivudine

IMPORTANCE OF THE FIELD

Successful treatment of chronic hepatitis B (CHB) often requires long-term oral nucleoside/nucleotide agents which can be associated with viral resistance, patient non-compliance and adverse effects. Telbivudine is one of the more potent options available, with a 6.5- to 6.6-log copies/ml hepatitis B DNA reduction at 12 weeks in an early viral kinetic study, a potency comparable to entecavir. It is also one of the few drugs in the treatment of CHB under FDA pregnancy Category B.

AREAS COVERED IN THIS REVIEW

The efficacy and safety profile of telbivudine in compensated and decompensated CHB patients compared to other agents are discussed. Viral resistance, characteristic adverse effects including elevation in creatine kinase and peripheral neuropathy in telbivudine treatment are reviewed. Infrequent but significant adverse effects of other nucleoside/nucleotide analogs are highlighted.

WHAT THE READER WILL GAIN

Readers are provided the latest update on the clinical profile of long-term use of telbivudine.

TAKE HOME MESSAGE

Long-term telbivudine treatment offers effective viral suppression to CHB patients with certain baseline characteristics and on-treatment virologic response. Creatine kinase elevation is not a good predictor of muscle-related adverse effects with nucleoside/nucleotide analogs. But significant myopathy and neuropathy have been reported in a small number of patients receiving telbivudine.

Impact of hepatitis B therapy on the long-term outcome of liver disease

Chronic hepatitis B virus (HBV) infection is a dynamic series of interactions between HBV, hepatocytes and the patient's immune system. HBV replication is the key motor of disease progression, including the development of cirrhosis and hepatocellular carcinoma (HCC). HBV elimination or suppression can reduce the risk of or slow the progression of liver disease. Studies have shown that a finite course of conventional interferon-α (IFN) therapy provides long-term benefit for achieving a cumulative response as well as reducing the progression of fibrosis and the development of cirrhosis and/or HCC. Long-term therapy with nucleos(t)ide analogues (NUCs) may also improve fibrosis or reverse advanced fibrosis as well as reduce disease progression and the development of HCC. The problems associated with drug resistance can be overcome by the timely use of rescue NUCs without cross-resistance. The outcome with pegylated IFN (PEG-IFN) and newer NUCs may be even better because of more effective treatment and/or a low risk of resistance. However, the treatment outcomes still need to be improved, and more effective, safe and affordable anti-HBV agents/strategies are needed.

Treatment of chronic hepatitis B: Evolution over two decades

There has been a recent paradigm shift in the indications and endpoints of treatment for chronic hepatitis B (CHB). Hepatitis B e antigen (HBeAg)-negative disease is being increasingly recognized. Antiviral treatment for both HBeAg-positive and HBeAg-negative patients should aim at long-term suppression of HBV DNA, with the ultimate ideal endpoint of hepatitis B surface antigen (HBsAg) seroconversion. Conventional interferon alpha (IFN-α), the only agent licensed in 1991, has been superseded by pegylated IFN-α. HBeAg seroconversion using pegylated IFN-α is 33%, with only 25% of HBeAg-positive patients achieving undetectable HBV DNA by polymerase chain reaction (PCR) assay. Five nucleoside/nucleotide analogues have been licensed since 1998. Lamivudine, an L-nucleoside, is limited by the development of resistance in 76% of patients after 5 years of therapy. Telbivudine, another L-nucleoside, is more potent than lamivudine but resistance still develops in 25% of HBeAg-positive and 11% HBeAg-negative patients after 2 years. Adefovir, an acyclic phosphonate, is relatively weak, but is effective against lamivudine- and telbivudine- resistant mutations, for which it should be used in combination (add-on therapy) rather than substituted. Resistance to adefovir develops slowly, rising to 29% for HBeAg-negative patients by year 5, but more rapidly when used alone for lamivudine-resistant HBV. Currently the two first line nucleoside/nucleotides are entecavir and tenofovir. Entecavir, a cyclopentane (D-nucleoside), is very potent, with 94% of patients having undetectable HBV DNA after 5 years. Resistance develops in only 1.2% of treatment-naïve patients. Tenofovir, another acyclic nucleotide, is more potent with less renal toxicity compared to adefovir. It is effective against lamivudine-resistant mutations when used alone. No resistance to tenofovir has been described after its use for 3 years or longer, often for patients with human immunodeficiency virus/HBV co-infection. With these current, potent antiviral agents associated with very low rates of resistance, long-term HBV DNA suppression and possibly even reversal of cirrhosis can now be achieved in a proportion of patients. In addition, long-term treatment with these antiviral agents is associated with a reduced risk of development of hepatocellular carcinoma.

Natural history of chronic HBV infection: special emphasis on the prognostic implications of the inactive carrier state versus chronic hepatitis

The evaluation of the natural history of chronic hepatitis B virus (HBV) infection requires the precise definition of the various clinical conditions that can be encountered (i.e. inactive carrier state or subject with liver disease activity). This can be achieved by repeat monitoring of ALT, serum HBV-DNA levels (over a period of at least 1 year, according to international guidelines) and/or evaluation of HBsAg titre. Liver biopsy may offer additional information although it is not mandatory. Overall, the natural history of the true inactive carrier is benign: reactivation of hepatitis, especially in Western countries, is rare and is usually due to co-factors (like alcohol or drugs); spontaneous HBsAg loss is frequent (around 1% per year) and HCC development rare. On the other hand, in patients with chronic hepatitis B or cirrhosis, the risk of reactivation, of HCC development and of liver-related mortality is much higher, especially in Eastern countries, and should therefore lead to antiviral therapy.

Meta-analysis: reduction in hepatic events following interferon-alfa therapy of chronic hepatitis B

BACKGROUND

The long-term benefit of interferon-alfa (IFN-α) treatment in preventing various hepatic complications is not certain.

AIM

To study the effects of IFN-α on reducing the risk of developing overall hepatic events (hepatocellular carcinoma, cirrhotic complications and liver-related mortality) in chronic hepatitis B patients.

METHODS

Randomized controlled trials, case-control studies and cohort studies were retrieved from electronic databases and conference abstracts. Relative risks (RRs) of different hepatic complications among patients treated by IFN-α vs. no treatment or placebo were studied.

RESULTS

Eleven studies were identified totalling 975 patients treated by IFN-α vs. 1147 untreated controls for analysis. Patients were treated by IFN-α for 1-24 months with a post-treatment follow-up of 1-13 years. Treatment by IFN-α reduced the risk of overall hepatic events (RR 0.55, 95% confident interval or CI 0.43-0.70, P < 0.001) and cirrhotic complications (RR 0.46, 95% CI 0.32-0.67, P < 0.001) by 45% and 54% respectively. Patients who responded to IFN-α had more profound reduction in overall hepatic events (RR 0.20, 95% CI 0.05-0.87, P = 0.03) and cirrhotic complications (RR 0.19, 95% CI 0.09-0.38, P < 0.001) vs. the untreated controls.

CONCLUSION

Interferon-alfa treatment reduces the risk of hepatic events particularly among responders to treatment.

Endpoints of hepatitis B treatment

The goal of hepatitis B treatment is to prevent the development of cirrhosis, liver failure, and hepatocellular carcinoma. Ideally, clinical studies should demonstrate that hepatitis B therapies can prevent liver-related complications; however, these clinical endpoints evolve over years or decades. Therefore, clinical trials have relied on intermediate endpoints to evaluate the efficacy of treatment and to determine when treatment can be stopped. Intermediate endpoints that have been used include biochemical, histological, virological, and serological endpoints. This review will discuss the validity of these intermediate endpoints as surrogates of clinical endpoints, and the rates at which these intermediate endpoints can be achieved with currently available therapies.

Hepatitis B e antigen seroconversion: a critical event in chronic hepatitis B virus infection

BACKGROUND

Replication of hepatitis B virus (HBV) is the primary driver of disease progression and clinical outcomes in patients with chronic hepatitis B (CHB), but other factors, such as hepatitis B e antigen (HBeAg) status, also influence disease course. The importance of HBeAg seroconversion is underscored by current CHB treatment guidelines that recommend limiting the duration of antiviral therapy in HBeAg-positive patients who achieve seroconversion.

AIMS

A 2-day meeting of leading hepatologists with extensive experience managing patients with CHB in the Asia-Pacific region was held with the overall goals of reviewing and evaluating (1) available data on the relationship between HBeAg seroconversion and clinical outcomes for patients with HBeAg-positive CHB, and (2) the ways in which seroconversion should influence patient management.

CONCLUSIONS

It was agreed that HBeAg seroconversion is an important serologic end point for patients with CHB and that achieving this goal should be an important consideration in treatment selection. Patients with HBeAg-positive CHB should consider pegylated interferon if they are aged < 40 years (especially women), have lower HBV DNA levels, can afford this treatment, and have a lifestyle that would support adherence to injection therapy. Alternatively, nucleos(t)ide analogs are recommended in patients with alanine aminotransferase levels ≥ 2 × the upper limit of normal, HBV DNA levels < 9 log(10) IU/ml, and compensated CHB. Entecavir, telbivudine, and tenofovir may be used as first-line therapy; they can be administered as a finite therapeutic course in HBeAg-positive patients who seroconvert. Telbivudine and tenofovir should be considered in women of child-bearing potential.

Incidence of hepatocellular carcinoma in chronic hepatitis B patients receiving nucleos(t)ide therapy: a systematic review

BACKGROUND & AIMS

Chronic hepatitis B patients are at increased risk for hepatocellular carcinoma (HCC). The effect of medium-term nucleos(t)ide analogue therapy on HCC incidence is unclear; therefore, we systematically reviewed all the data on HCC incidence from studies in chronic hepatitis B patients treated with nucleos(t)ide analogues.

METHODS

We performed a literature search to identify studies with chronic hepatitis B patients treated with nucleos(t)ide analogues for> or = 24 months.

RESULTS

Twenty-one studies including 3881 treated and 534 untreated patients met our inclusion criteria. HCC was diagnosed in 2.8% and 6.4% of treated and untreated patients, respectively, during a 46 (32-108) month period (p=0.003), in 10.8% and 0.5% of nucleos(t)ide naive patients with and without cirrhosis (p<0.001) and in 17.6% and 0% of lamivudine resistance patients with and without cirrhosis (p<0.001). HCC developed less frequently in nucleos(t)ide naive patients compared to those without virological remission (2.3% vs 7.5%, p<0.001), but there was no difference between lamivudine resistance patients with or without virological response to rescue therapy (5.9% vs 8.8%, p=0.466).

CONCLUSIONS

Chronic hepatitis B patients receiving medium-term nucleos(t)ide analogue therapy had a significantly lower incidence of HCC compared to untreated patients but treatment does not completely eliminate the risk of HCC. Among the treated patients, cirrhosis, HBeAg negative at baseline and failure to remain in virological remission were associated with an increased risk of HCC.

Optimal treatment increased survival of hepatocellular carcinoma patients detected with community-based screening

BACKGROUND AND AIM

The early detection of hepatocellular carcinoma (HCC) and opportunity to select appropriate treatment are important benefits of HCC screening. Our aim in the present study was to investigate the survival rate, prognostic factors and treatment effects in HCC patients of community-based screening.

METHODS

Community-based ultrasound (US) screening for HCC in adults with platelet counts (< 150 x 10(3)/mm(3)) and/or alpha fetoprotein (AFP) > 20 ng/mL was conducted in 2002 and 2004. As per the Barcelona Clinic Liver Cancer (BCLC) stage, 90 cases of intermediate or earlier stage HCC were detected and 88 cases had sufficient information for analysis (49 men and 39 women, aged 65.8 +/- 9.6 years). The tumor diameter was mostly less than 5 cm (76.1%). The follow up was continued until June 2008.

RESULTS

The 4-year overall survival rate was 46.8%. Old age (> or = 70 years) (P = 0.046), later stage of HCC (intermediate vs earlier) (P = 0.012), low platelet count (< 100 x 10(3)/mm(3)) (P = 0.013) and refusal of modern treatment (P = 0.026) were independent poor prognostic factors. Curative treatment increased survival in patients of all ages. Both curative treatment and transcatheter arterial embolization (TAE) increased survival in cases of intermediate HCC. However, treatment benefits were not found for patients with (very) early stage HCC.

CONCLUSIONS

Early detection and prompt treatment of HCC leads to increased survival. For elderly patients this benefit was seen only for early stage cases receiving curative treatment. Differences between treatment types for patients with (very) early stage HCC might emerge with a longer follow-up period.

Management of end-stage liver disease in chronic hepatitis B

The consequences of chronic hepatitis B virus infection include hepatocellular carcinoma and liver cirrhosis. Effective antiviral therapy in patients with hepatitis B with advanced liver disease with viral suppression and sustained HBeAg seroconversion (where applicable) may abort hepatic decompensation, diminish hepatocellular risk, and reduce the risk of viral recurrence after transplantation. Overt hepatic decompensation is an indication for referral to a transplant center.

Hepatitis B surface antigen seroclearance during chronic HBV infection

Hepatitis B surface antigen (HBsAg) seroclearance in chronic HBV infection occurs at an annual incidence of 1-2%. The long-term outcome after HBsAg seroclearance is excellent if there is no pre-existing cirrhosis or viral superinfection. For this reason, HBsAg seroclearance has attracted recent interest in both long-term studies of the natural history of HBV infection and in patients receiving antiviral therapy. Here, we review a diverse range of studies investigating spontaneous HBsAg seroclearance in varied groups of patients and consider the many predictive factors - of both viral and host origin - for seroclearance. Studies to assess the effects of antiviral therapy, and in particular interferon treatment, are also discussed together with virological, biochemical and histological profiles following HBsAg seroclearance and the long-term outcomes.

[Hepatitis B virus (HBV) infection and hepatocarcinogenesis]

Hepatitis B virus is one of the most important etiologic factors of hepatocellular carcinoma. The present review discusses the molecular mechanisms of virus-induced carcinogenesis, indirect and direct effects of the infection. The cell damage-evoked regeneration and proliferation, as well as the viral proteins that induce chromosomal, genetic and epigenetic changes, play a key role in the multistep process leading to malignant cell transformation. Integration of HBV DNA in to the host DNA, activation of oncogenes and inactivation of tumor suppressor genes are of basic significance. The hepatitis B virus related complications such as cirrhosis and hepatocellular carcinoma can be prevented by vaccination or eradication of the virus with antiviral therapy.

Does chemotherapy prevent HBV-related hepatocellular carcinoma? Cons

The retrospective scrutiny of studies that were originally designed to assess the antiviral activity of interferon (IFN) and nucleos(t)ide analogues (NUC) suggested reduced incidence of hepatocellular carcinoma (HCC) in responders. The interpretation of these studies, however, is questioned by the heterogeneity of patient referral, adoption of surrogate end-points, lack of control arms and, overall, by the lack of power to capture enough hard end-points of the natural history of hepatitis B, including HCC. Another point of criticism is that above all, IFN studies could have been affected by study enrolment skewed towards patients with less advanced liver disease, who had a better predicted compliance to therapy but a lower risk of developing HCC in the short-term. In my opinion, these constraints coupled with the lack of patient stratification by HCC predictors, make the evaluation of the prophylactic activity of IFN and NUC even more difficult. Overall, while single studies provide some evidence for a reduced HCC incidence in virological responders, particularly in those with moderate liver fibrosis, we still lack confirmation that anti-HBV therapy prevents HCC in patients with an established cirrhosis, too. Finally, tertiary prevention with anti-HBV treatments is controversial, due to the existence of a few, methodologically flawed studies.

Does chemotherapy prevent HBV-related hepatocellular carcinoma? Pros

Studies have shown that hepatitis B virus (HBV) replication is the key driver of disease progression, including development of cirrhosis and hepatocellular carcinoma (HCC), in patients with chronic HBV infection. Among the currently available anti-HBV drugs, the most extensive and longest experience has been gained with conventional interferon alpha (IFN) and lamivudine. Both controlled studies and meta-analyses have shown that a finite course of IFN therapy has long-term benefit in achieving cumulative response and corresponding reduction of cirrhosis and/or HCC. Maintained virological response to lamivudine therapy has similar long-term benefits in reducing disease progression. Although emergence of lamivudine drug resistance may negate therapeutic effect, rescue drugs are now available to overcome the adverse effect of drug resistance. Pegylated IFN and newer nucleos(t)ide analogs may have even better long-term outcomes because of better therapeutic efficacy and/or much lower risk of drug resistances. However, the treatment outcomes are still far from satisfactory. The development of safe and affordable anti-HBV agents/strategies is needed to further improve outcomes.

Prevalence of hepatitis B virus genotypes and their relationship to clinical laboratory outcomes in Tibetan and Han Chinese

This study was designed to investigate the prevalence of hepatitis B virus (HBV) genotypes in Tibetan and Han nationalities in Sichuan Province, China, and their clinical significance. Sera from 376 patients (286 Han nationals, 90 Tibetan nationals) were genotyped by polymerase chain reaction. Of the 286 Han nationals, 127 were HBV asymptomatic carriers, 90 were symptomatic patients and 69 had hepatocellular carcinoma. The distribution of HBV genotypes was related to geography as well as ethnicity. The HBV genotype frequencies were: B, 57.9%; C, 16.0%; and BC, 26.1%. Association studies between genotypes and clinical laboratory outcomes showed HBV genotype C to be more virulent. There was a higher prevalence of mixed genotype BC in Tibetan nationals compared with Han nationals. There was no synergistic effect in terms of virulence in patients coinfected with genotypes B and C.

On-treatment monitoring of chronic hepatitis B virus infection: an Asian-Pacific perspective

Chronic infection with hepatitis B virus (HBV) is a major global health problem and an important cause of morbidity and mortality from sequelae of liver cirrhosis and hepatocellular carcinoma. In the past decades, better understanding of the natural history and immunopathogenesis of chronic HBV infection and of the development of many powerful antiviral agents has allowed us to improve therapeutic efficacy. Among these agents, nucleos(t)ide analogs are important and potent viral suppressors. However, when administered alone, they are not able to permanently eradicate HBV, and long-term maintenance therapy is required for therapeutic efficacy. Additionally, prolonged treatment is frequently associated with the emergence of drug-resistant HBV mutants. Before an 'ideal' drug(s), or drug combination, with optimal antiviral efficacy and negligible rates of drug resistance becomes available, the on-treatment monitoring approach using serum HBV DNA level as a predictor for therapeutic efficacy and drug resistance is useful. However, most countries in the Asia-Pacific region have low income economies, insufficient medical care systems, and low awareness of the disease among the general population and government officers. The easy approach of the road-map concept using an affordable drug to treat chronic HBV infection is more important in this region. There is already evidence that the long-term outcomes of chronic HBV infection can be improved under well-managed antiviral therapy. Profound and long-lasting suppression of HBV replication, either maintained on-therapy or sustained after stopping therapy, has been identified as the key determinant for achieving the goals of therapy, for reducing liver damage, and for preventing development of cirrhosis and/ or hepatocellular carcinoma.

[4. Austrian consensus-statement for diagnosis and therapy of hepatitis B 2009]

Hepatitis B is the most common chronic viral infection of the liver. Chronic hepatitis B is estimated to affect at least 350 million people worldwide and is the leading cause of death from liver disease. There have been dramatic developments both in the diagnostic field and in drug treatment of chronic hepatitis B. Today, chronic hepatitis B is a well manageable disease in the vast majority of cases and the main challenge remains the detection of affected patients at an early enough disease stage to prevent end-stage liver disease and its complications. The rapid pace of drug development mandated an update of the Austrian guidelines on the treatment of hepatitis B, which after 1994 and 1998 were now dating back to 2005 in their third version. All chapters from the 3. consensus statement from 2005 were renewed except for the chapter on liver biopsy, which is still valid in its 2005-version. In particular, virologic parameters take now center stage for treatment decisions, HBV-genotyping is now being considered for the choice of treatment, and the oral first line treatment for chronic hepatitis B has been changed. Overall this consensus statement accounts for the major advances in the management of hepatitis B and significantly changes clinical management of patients with hepatitis B in Austria.

Current treatments for patients with HBeAg-positive chronic hepatitis B virus infection: a comparison focusing on HBeAg seroconversion

HBeAg seroconversion, in association with undetectable levels of hepatitis B virus DNA as determined by polymerase chain reaction, is an important goal in the treatment of patients with HBeAg-positive chronic hepatitis B (CHB). Achievement of sustained HBeAg seroconversion at an early age (<40 years) is associated with a reduced incidence of hepatic complications, increased rates of HBsAg loss and seroconversion and improved survival rates, whether the seroconversion is spontaneous or treatment induced. Patients with HBeAg-positive CHB who achieve sustained HBeAg seroconversion and complete 6-12 months of consolidation therapy are eligible for stopping therapy. In randomized clinical studies involving patients with HBeAg-positive CHB, treatment with pegylated interferon (PegIFN)-alpha is associated with higher and more durable HBeAg seroconversion rates than are lamivudine and adefovir. More recently, newer generation oral nucleos(t)ide analogs (NAs) have become available. These include entecavir, telbivudine and tenofovir, and they demonstrate superior antiviral potency and efficacy. This review examines the importance of HBeAg seroconversion as an end point for therapy in the treatment of patients with HBeAg-positive CHB, and examines the rates and durability of HBeAg seroconversion with PegIFN and oral NA therapy. The mechanisms for enhanced HBeAg seroconversion rates with new-generation NAs are also discussed.

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

INTRODUCTION

The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.

METHODS

The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.

RESULTS

Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

INTRODUCTION

The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.

METHODS

The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.

RESULTS

Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Antitumor activity of type I and type III interferons in BNL hepatoma model

Hepatocellular carcinoma (HCC) occurs most commonly secondary to cirrhosis due to chronic hepatitis C or B virus (HCV/HBV) infections. Type I interferon (IFN-alpha) treatment of chronic HCV/HBV infections reduces the incidence of HCC in cirrhotic patients. However, IFN-alpha toxicity limits its tolerability and efficacy highlighting a need for better therapeutic treatments. A recently discovered type III IFN (IFN-lambda) has been shown to possess antiviral properties against HCV and HBV in vitro. In phase I clinical trials, IFN-lambda treatment did not cause significant adverse reactions. Using a gene therapy approach, we compared the antitumor properties of IFN-alpha and IFN-lambda in a transplantable hepatoma model of HCC. BALB/c mice were inoculated with syngeneic BNL hepatoma cells, or BNL cells expressing IFN-lambda (BNL.IFN-lambda cells) or IFN-alpha (BNL.IFN-alpha cells). Despite the lack of antiproliferative activity of IFNs on BNL cells, both BNL.IFN-lambda and BNL.IFN-alpha cells displayed retarded growth kinetics in vivo. Depletion of NK cells from splenocytes inhibited splenocyte-mediated cytotoxicity, demonstrating that NK cells play a role in IFN-induced antitumor responses. However, isolated NK cells did not respond directly to IFN-lambda. There was also a marked NK cell infiltration in IFN-lambda producing tumors. In addition, IFN-lambda and, to a lesser extent, IFN-alpha enhanced immunocytotoxicity of splenocytes primed with irradiated BNL cells. Splenocyte cytotoxicity against BNL cells was dependent on IL-12 and IFN-gamma, and mediated by dendritic cells. In contrast to NK cells, isolated from spleen CD11c+ and mPDCA+ dendritic cells responded directly to IFN-lambda. The antitumor activities of IFN-lambda against hepatoma, in combination with HCV and HBV antiviral activities warrant further investigation into the clinical use of IFN-lambda to prevent HCC in HCV/HBV-infected cirrhotic patients, as well as to treat liver cancer.

Age-specific prognosis following spontaneous hepatitis B e antigen seroconversion in chronic hepatitis B

Hepatitis B e antigen (HBeAg) seroconversion in chronic hepatitis B virus infection confers a favorable prognosis, but untoward outcomes may develop in some patients. The impact of the age of HBeAg seroconversion on prognosis is not clearly known. HBeAg-positive patients with biopsy-proven chronic hepatitis B were followed up long-term. Follow-up studies included liver biochemistry, alpha-fetoprotein, and ultrasonography every 3 to 6 months or more frequently if clinically indicated. Of the patients who underwent spontaneous HBeAg seroconversion, the incidences of HBeAg-negative hepatitis, cirrhosis, hepatocellular carcinoma (HCC), and hepatitis B surface antigen seroclearance were compared between patient groups with different ages at the time of HBeAg seroconversion using Kaplan-Meier survival analysis and Poisson regression model. Spontaneous HBeAg seroconversion was documented in 508 patients. Of the 483 patients who had no evidence of cirrhosis or HCC at the time of HBeAg seroconversion, HBeAg seroconversion occurred before age 30 in 218 patients (group A), between age 31 and 40 in 199 patients (group B), and after age 40 in 66 patients (group C). The 15-year cumulative incidences of HBeAg-negative hepatitis, cirrhosis, and HCC increased with increasing age of HBeAg seroconversion, the lowest being in group A (31.2%, 3.7%, and 2.1%, respectively) and highest being in group C (66.7% [P < 0.0001], 42.9% [P <0.0001], and 7.7% [P = 0.29], respectively). The hazard ratio of HBeAg-negative hepatitis, cirrhosis, and HCC was 2.95, 17.6, and 5.22, respectively, in group C compared with group A.

CONCLUSION

Patients with HBeAg seroconversion before age 30 have excellent prognosis, whereas patients with delayed HBeAg seroconversion after age 40 have significantly higher incidences of HBeAg-negative hepatitis, cirrhosis, and HCC.

Predictors of treatment response in chronic hepatitis B

The ultimate goal of treatment for chronic hepatitis B is to reduce liver-related complications and mortality. Sustained hepatitis B e antigen (HBeAg) seroconversion and hepatitis B surface antigen (HBsAg) clearance 6-12 months after stopping treatment are the short-term surrogate outcomes for interferon or peginterferon therapy. As most patients require long-term nucleos(t)ide analogue treatment, which also has the risk of drug resistance in the case of incomplete viral suppression, maintained hepatitis B virus (HBV) DNA suppression to an undetectable level is the appropriate surrogate outcome. Because no antiviral treatment is perfect, it is desirable for treatment response to be predicted and the treatment regimen modified accordingly. At baseline, high ALT and low HBV DNA levels can predict response to both (peg)interferon and nucleos(t)ide analogues. Genotype A HBV responds best to peginterferon but HBV genotype has no predictive value for nucleos(t)ide analogue treatment. HBV DNA is a good on-treatment predictor of response for nucleos(t)ide analogues but not for (peg)interferon. The data supporting the use of quantitative HBsAg and HBeAg to predict response to peginterferon is stronger than that for nucleos(t)ide analogues. In conclusion, predictors of response are useful to provide the most appropriate antiviral therapy to the most suitable patients, in order to achieve the best response and improve the clinical outcome of chronic hepatitis B patients.

Factors that predict response of patients with hepatitis B e antigen-positive chronic hepatitis B to peginterferon-alfa

BACKGROUND & AIMS

Therapy with pegylated interferon (PEG-IFN)-alfa results in sustained response in a minority of patients with chronic hepatitis B virus (HBV) infection and has considerable side effects. We analyzed data from the 2 largest global trials of hepatitis B e antigen (HBeAg)-positive patients with chronic hepatitis B to determine which are most likely to respond to PEG-IFN-alfa therapy.

METHODS

The study included 542 patients treated with PEG-IFN-alfa-2a (180 microg/wk, 48 wk) and 266 patients treated with PEG-IFN-alfa-2b (100 microg/wk, 52 wk). Eighty-seven patients were excluded, leaving 721 patients for analysis. A sustained response was defined as HBeAg loss and HBV-DNA level less than 2.0 x 10(3) IU/mL 6 months after treatment. Logistic regression analysis was used to identify predictors of sustained response and a multivariable model was constructed.

RESULTS

HBV genotype, high levels of alanine aminotransferase (ALT; >or=2 x upper limit of normal), low levels of HBV DNA (<2.0 x 10(8) IU/mL), female sex, older age, and absence of previous IFN therapy predicted a sustained response. Genotype A patients with high ALT and/or low HBV-DNA levels had a high predicted probability (>30%) of a sustained response. The strongest predictors of response were a high level of ALT in genotype B patients and a low level of HBV DNA in genotype C patients. Genotype D patients had a low chance of sustained response, irrespective of ALT or HBV-DNA levels.

CONCLUSIONS

The best candidates for a sustained response to PEG-IFN-alfa are genotype A patients with high levels of ALT or low levels of HBV DNA, and genotypes B and C patients who have both high levels of ALT and low HBV DNA. Genotype D patients have a low chance of sustained response.

[Long-term clevudine therapy in nucleos(t)ide-naïve and lamivudine-experienced patients with hepatitis B virus-related chronic liver diseases]

BACKGROUNDS/AIMS

Clevudine is an effective antiviral nucleoside analogue, but there are few data regarding its long-term effects, resistance, and safety. The aim of this study was to evaluate the long-term clinical efficacy of clevudine over a 1-year treatment period in nucleos(t)ide-naive and lamivudine-experienced chronic hepatitis B patients.

METHODS

Nucleos(t)ide-naive (group A, n=196) and lamivudine-experienced (serum hepatitis B virus, HBV DNA >2,000 copies/mL without resistant mutants at the start of clevudine therapy, group B, n=75) patients were included in this study. Basic clinical characteristics including age, sex, the presence of cirrhosis, laboratory data, and hepatitis B surface antigen (HBeAg) positivity were similar between the two groups. Pretreatment serum levels of HBV DNA were 7.4 and 6.6 log(10) copies/mL (P<0.001). The mean treatment duration was 8 months for both groups (range for group A: 3-21 months; range for group B: 3-20 months). Genotypic analysis for resistant mutations in the reverse transcriptase of HBV was performed after viral breakthrough.

RESULTS

After 1 year of therapy, 75.0% and 51.9% of groups A and B, respectively, had HBV DNA levels of <2,000 copies/mL (P=0.032), and HBeAg seroconversion rates were 16.9% and 16.7%, respectively. The rates of viral breakthrough at 1 year were 10.0% (8/80) and 44.4% (12/27), respectively (P<0.001). Proven sites of mutation of HBV DNA polymerase in naive patients were, for example, L80I, L180M, A181V/T, M204I and V207I. Ten patients complained of prominent fatigue and revealed elevated serum levels of aspartate aminotransferase (AST) and creatine phosphokinase (CPK). Two of these patients presented with severe myopathy from which they recovered completely after quitting clevudine.

CONCLUSIONS

Clevudine is one of the recommended first-line medicines for the treatment of chronic hepatitis B, but it is not free from resistance, particularly in patients with a history of previous lamivudine treatment, but also in naive patients. Clevudine should be avoided in previously lamivudine-exposed patients. In addition, reelevation of serum AST and CPK levels is not a rare occurrence, and close observation and follow-up tests are essential.

Current challenges in viral hepatitis, antimicrobial resistance and the influenza pandemic

The 3rd Ditan International Conference on Infectious Diseases was held from 29 July to 2 August 2009 at the Beijing International Conference Center, Beijing, China. Over 1000 participants from 27 countries attended the 4-day conference, titled 'World Dialogue on Infectious Diseases'. A broad range of topics were covered this year, including TB, methicillin-resistant Staphylococcus aureus, HIV, influenza and gastrointestinal infections. In addition, there was a particularly strong focus on two contrasting topics of viral hepatitis and antibiotic resistance, which is the focus of this meeting report.

Surrogate end points and long-term outcome in patients with chronic hepatitis B

BACKGROUND & AIMS

It is unclear whether surrogate end points reported in clinical trials correlate with long-term outcome of patients with chronic hepatitis B.

METHODS

Patients with chronic hepatitis B who participated in any of 4 randomized controlled trials were followed prospectively for liver-related events (hepatocellular carcinoma, ascites, spontaneous bacterial peritonitis, variceal bleeding, liver transplantation, and death). Biochemical (normal ALT levels), virologic (levels of hepatitis B virus DNA below 10,000 copies/mL), and histologic (reduction of necroinflammation grading by 2 points or more with no increase in fibrosis staging) responses were evaluated at the end of each trial.

RESULTS

One hundred ninety-five patients with adequate pretreatment and post-treatment liver biopsies (15 mm long and 6 portal tracts) were followed for 86 months (interquartile range, 77-98). Liver-related events occurred in 12 patients (6%). The risk of liver-related events was lower in patients with biochemical (hazard ratio, 0.21; 95% confidence interval, 0.068-0.68) and histologic (hazard ratio, 0.095; 95% confidence interval, 0.012-0.74) responses. Only 1 patient with a histologic response and 1 patient with an ALT level below Prati's cutoffs (30 IU/L in men and 19 IU/L in women) developed liver-related events. Fifteen of 25 patients (60%) with cirrhosis at baseline had regression of cirrhosis, and none of these patients died or developed liver-related events. In contrast, 3 of these patients still developed liver-related events, despite an initial virologic response, and 2 had virologic breakthrough.

CONCLUSIONS

Biochemical and histologic responses, particularly regression of cirrhosis, in patients with chronic hepatitis B are associated with decreased liver-related complications.