Long-term outcome of hepatitis B virus-related glomerulonephritis after therapy with interferon alfa

Favorable outcome in PLA2R positive HBV-associated membranous nephropathy

Introduction

Over half of the patients with hepatitis B virus associated membranous nephropathy (HBV-MN) were found to be phospholipase A2 receptor (PLA2R) positive. Whether MN is really secondary to hepatitis B or just coincidence of hepatitis and PLA2R positive idiopathic MN (IMN) remains controversial.

Methods

We retrospectively studied seven PLA2R positive HBV-MN patients with complete data in Huashan Hospital from 2009 to 2016 and compared them with PLA2R positive idiopathic MN patients.

Results

Proteinuria and renal function of these 7 HBV-MN patients were similar to that of IMN patients. However, 5 of them were female and half showed hypocomplementemia, while in IMN group only 32.4% were female and 20% had hypocomplementemia, and the level of hematuria was 94.5/μL in HBV-MN patients and 64.9 /μL in IMN patients, though there was no statistically significant difference. Renal biopsies revealed significantly increased mesangial eletron-deposits in HBV-MN patients. All 7 patients received antiviral therapy, and one patient received immunosuppresants due to severe nephrotic syndrome with acute myocardial infarction and elevated serum creatinine. Compared with IMN group, the prevalence of remission without immunosuppressive therapy of HBV-MN patients was higher (85.7% vs. 43.7%), while the percentage of patients receiving immunosuppresants was lower (14.3% vs. 47.9%) (P=0.048).

Conclusion

Compared with IMN patients, PLA2R positive HBV-MN patients had a more favorable prognosis after antiviral therapy, indicating a secondary form of MN. For these patients, antiviral treatment is recommended and long observation time should be provided before use of immunosuppressive treatment.

Hepatitis B Virus Infection and Extra-Hepatic Manifestations: A Systemic Disease

People living with hepatitis B virus (HBV) chronic infection are exposed to high rates of liver complications including end-stage liver disease and hepatocellular carcinoma. Extrahepatic manifestations of HBV infection have long been underestimated. Several of these extrahepatic syndromes have been well described, including systemic vasculitides, glomerulonephritis, and cutaneous manifestations. Other manifestations have been more recently described such as hematological malignancies and neurological diseases. These extrahepatic manifestations are associated with significant morbidity and mortality. Although not completely understood, underlying mechanisms include HBV-induced local and systemic inflammation. Suppression of HBV replication usually improves extrahepatic manifestations. This review will discuss how HBV induces inflammation and the extrahepatic manifestations of HBV infection to guide clinical management.

Efficacy of entecavir in treating hepatitis B virus-associated membranous nephropathy

OBJECTIVE

hepatitis B virus-associated membranous nephropathy (HBV-MN) is the most common pathological type of hepatitis B virus-associated glomerulonephritis. This study evaluated the efficacy of entecavir antiviral therapy for HBV-MN patients due to the intolerable side effects of interferon-alpha and high incidence rate of drug-resistance in lamivudine therapy.

METHOD

thirty-two patients with HBV-MN were identified by biopsy and treated with entecavir for 52 weeks. These patients were followed up to evaluate outcomes of entecavir-treatment. Descriptive statistics were used to summarize patient demographics and treatment outcomes.

RESULTS

entecavir treatment reduced 24-h urinary protein excretion. The total probability of partial proteinuria and complete remission at 24 and 52 weeks was 53.1 and 78.1 %, respectively. A decrease of circulating HBV-DNA was observed in all patients with active HBV replication. The significant decrease of 24-h urinary protein began at 12 weeks, as early as the decrease of serum HBV-DNA level. The serum HBV DNA titers at baseline and after 52 weeks of treatment were 4.3 ± 2.8 log10 and 2.3 ± 1.7 log10, respectively. Meanwhile, eGFR increased from 100.3 ± 20.5 ml/min/1.73 m2 at baseline to 107.7 ± 15.9 ml/min/1.73 m2 after 52 weeks of treatment. The serum alanine aminotransferase level (ALT) gradually decreased to normal during entecavir antiviral treatment.

CONCLUSIONS

entecavir treatment in HBV-MN patients was carefully described. Complete remission and HBV replication suppression were induced by entecavir treatment in HBV-MN patients. Patients with high serum creatinine (Scr), ALT and low eGFR levels benefit more from entecavir treatment. Entecavir therapy is well tolerated by patients and no adverse reactions were observed.

Autoimmune Kidney Diseases Associated with Chronic Viral Infections

Autoimmune kidney diseases triggered by viruses are an important cause of kidney disease in patients affected by chronic viral infection. Hepatitis B virus (HBV) infection is associated with membranous nephropathy and polyarteritis nodosa. Hepatitis C virus (HCV) infection is a major cause of cryoglobulinemic glomerulonephritis. Patients with human immunodeficiency virus (HIV) may develop HIV-associated nephropathy, a form of collapsing focal segmental glomerulosclerosis, or various forms of immune-complex-mediated kidney diseases. This article summarizes what is known about the pathogenesis, diagnosis, and management of immune-mediated kidney diseases in adults with chronic HBV, HCV, and HIV infections.

Renal Impairment in Chronic Hepatitis B: A Review

The liver plays a key role in the metabolism of proteins. Liver dysfunction affects many organs because it communicates with the spleen and all digestive organs through the portal vein. Additionally, the kidney is an organ that is closely related to the liver and is involved in liver diseases. Glomerulonephritis is an important extrahepatic manifestation of chronic hepatitis B virus (HBV) infection. Nucleos(t)ide analog (NA) therapy effectively suppresses HBV replication by inhibiting HBV polymerase, thus decreasing the levels of serum HBV-DNA and delaying the progression of cirrhosis. Although NA therapy is recommended for all patients with chronic HBV infection, regardless of the level of renal dysfunction, there is limited information on NA use in patients with chronic kidney disease. In addition, in patients with end-stage liver cirrhosis, hepatorenal syndrome can be fatal. Hence, we should take into account the stage of impaired renal function in patients with cirrhosis. The aims of this article are to review the epidemiology, clinical presentation, treatment, and prevention of HBV-associated nephropathy.

Spectrum of hepatitis B and renal involvement

Renal involvement in hepatitis B occurs in various spectrums and its knowledge is important for clinicians in management of patients. The renal diseases most commonly associated with hepatitis B virus (HBV) infection include membranous nephropathy, membranoproliferative glomerulonephritis and Polyarteritis nodosa. The widespread use of hepatitis B vaccination has decreased the incidence of HBV-related renal diseases. The incidence of HBV infection in dialysis patients has significantly decreased over the past few decades because of screening of blood products for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody, implementation of infection control measures and hepatitis B vaccination. The definition of acute kidney injury has been recently modified in cirrhotic population, helping in prognosis and prediction of mortality. The most common etiologies of acute kidney injury in this cirrhotic population, which account for 80% to 90% of all cases, include volume depletion, acute tubular necrosis and hepatorenal syndrome. Treatment with oral nucleoside/tide analogues (NA) brought a new paradigm in the management of HBsAg positive glomerulonephritis, kidney transplant recipients and dialysis patients, resulting in effective viral suppression, reduced hepatic complications and improved patient survival, without compromising renal allograft outcome. NAs are cleared by the kidneys and therefore their dosage has to be adjusted in all patients with impaired renal function. This article reviews the recent knowledge of the pathogenesis and treatment of HBV-related glomerulonephritis and discusses the management of hepatitis B in patients on dialysis, kidney transplant recipients and cirrhotics, which is continuously evolving.

Glomerular Diseases Associated With Hepatitis B and C

Infections with hepatitis B virus (HBV) and hepatitis C virus (HCV) are prevalent worldwide. In this review, we discuss the epidemiology, pathogenesis, clinical manifestations, and treatment of HBV- and HCV-related glomerulonephritis (GN). The most common histopathologic presentation of HBV-GN is HBV-associated membranous nephropathy, which usually manifests clinically with varying grades of proteinuria and microscopic hematuria. The pathogenesis is likely to be immune complex mediated; however, other host and viral factors have been implicated. The treatment of HBV-GN revolves around antiviral therapy. Various histologic types of glomerular diseases are reported in association with HCV infection, the most frequent being Type 1 membranoproliferative glomerulonephritis, usually in the context of Type 2 mixed cryoglobulinemia. The pathogenesis of HCV-GN can be attributed to glomerular deposition of cryoglobulins or noncryoglobulin-immune complexes. Cryoglobulins typically comprised immunoglobulin Mκ with rheumatoid factor activity. Clinically, patients may present with proteinuria, microscopic hematuria, hypertension, and acute nephritic and/or nephrotic syndrome. The treatment of HCV-GN, especially cryoglobulinemic membranoproliferative glomerulonephritis, encompasses various options including contemporary antiviral therapy with or without conventional and novel immunomodulatory agents.

Effect of nucleoside and nucleotide analogues on renal function in patients with chronic hepatitis B virus monoinfection

BACKGROUND & AIMS

There is controversy regarding whether nucleos(t)ide analogues contribute to renal impairment in patients with chronic hepatitis B virus (HBV) infection. We analyzed changes in renal function in patients with chronic HBV infection and whether these were associated with treatment or comorbidities.

METHODS

We performed a longitudinal observational study to investigate factors associated with renal function in 214 patients (median age, 43 y; 69.2% men) with compensated chronic HBV monoinfection treated with 343 lines of nucleos(t)ide analogues (210 monotherapies, 133 combinations) between 1990 and 2012 (median time, 2.4 y) in France. A linear mixed-effect model was used to model variations of estimated glomerular filtration rate (eGFR, computed with the Chronic Kidney Disease Epidemiology Collaboration formula), adjusting for age, sex, geographic origin, initial liver fibrosis, level of HBV DNA, and an eGFR less than 90 mL/min/1.73 m(2).

RESULTS

The eGFR decreased in patients given adefovir dipivoxil as monotherapy or in a combination (P < .0001 and P < .002, respectively), and remained stable in patients given lamivudine, tenofovir disoproxil fumarate, or entecavir. The eGFR decreased in patients with a baseline eGFR of less than 90 mL/min/1.73 m2, regardless of treatment. The eGFR remained stable or increased, regardless of treatment, in patients with a baseline eGFR of 90 mL/min/1.73 m2 or greater and with an initial HBV DNA level of 100,000 IU/mL or greater. Patients born in areas of high endemicity of HBV were more prone to increases in eGFR with treatment.

CONCLUSIONS

In a real-life study, the eGFR remained stable or increased over time in patients with chronic HBV monoinfection with a baseline eGFR of 90 mL/min/1.73 m2 or higher and treated with tenofovir disoproxil fumarate or entecavir. Patients born in an area of high endemicity of HBV who had initial levels of HBV DNA of 100,000 IU/mL or greater were more likely to have increased eGFR with treatment.

Hepatitis B virus-related glomerulonephritis: not a predominant cause of proteinuria in korean patients with chronic hepatitis B

Background/Aims. Hepatitis B virus (HBV) can form immune complexes which may result in various types of glomerulonephritis (GN). However, proteinuria can occur because of other kidney diseases besides HBV-related GN (HBV-GN). The aim of this study is to elucidate the causes of proteinuria and report on the clinical outcomes of HBV-GN. Methods. We reviewed the medical records of patients positive for serum hepatitis B surface antigen who underwent renal biopsies due to proteinuria at a tertiary medical center in Korea. Results. A total of 55 patients were included. HBV-GN was diagnosed in 20 (36.4%) of the patients by confirming the presence of immune complexes (12 of 13 membranoproliferative glomerulonephritis, 7 of 8 membranous glomerulonephritis, and 1 of 13 immunoglobulin A nephropathy). Twenty-one patients had other types of GN. A total of 13 (65%) HBV-GN patients were treated with antiviral agents for a median of 11 months. However, the degrees of proteinuria were not significantly reduced in the antiviral intervention group when compared to the control group. Conclusions. Proteinuria can be caused by various glomerular diseases and HBV-GN accounts for one-third of total GN cases. Well-designed prospective study is needed to assess whether antiviral therapy against HBV infection may improve the prognosis of HBV-GN.

Renal dysfunction in end-stage liver disease and post-liver transplant

Renal dysfunction is a frequent complication in patients with end-stage liver disease awaiting orthotopic liver transplantation and in the post-liver transplant period. Although the stereotypical form of renal dysfunction is the hepatorenal syndrome, other causes of acute kidney injury in this population include prerenal azotemia and acute tubular necrosis. Renal injury in a patient with cirrhosis is associated with a poor prognosis.

Experience of anti-viral therapy in hepatitis B-associated membranous nephropathy, including Lamivudine-resistant strains

BACKGROUND/AIMS

Chronic hepatitis B infection is a common cause of secondary membranous nephropathy (MN) in endemic areas. Lamivudine treatment improves renal outcome in patients with hepatitis B virus-associated MN (HBV-MN), but prolonged use leads to the emergence of lamivudine-resistant variants. We describe our experience treating lamivudine-resistant and other strains of HBV-MN with new antiviral drugs.

METHODS

Of the 89 patients biopsied and diagnosed with MN from 1996 to 2011, 10 positive for hepatitis B surface antigen were recruited for this study. We investigated the clinical courses, therapeutic responses, and prognoses of patients with HBV-MN.

RESULTS

The incidence of HBV-MN among the original 89 patients was 11.2%. Of these patients, four were treated with supportive care and six with antiviral drugs. One of the four patients treated with supportive care had a spontaneous remission. Four of the six patients treated with antiviral drugs were given lamivudine, and the other two were given entecavir. Two of the four patients treated with lamivudine achieved complete remission with seroconversion (i.e., development of anti-hepatitis B e antigen antibodies), whereas the other two had lamivudine-resistant strains, which were detected at 22 and 23 months after lamivudine treatment, respectively. We added adefovir to the treatment regimen for one of these patients, and for the other patient we substituted clevudine for lamivudine. Both of these patients experienced complete remission, as did the two patients initially treated with entecavir, neither of whom showed resistance to the drug.

CONCLUSIONS

New nucleoside analogues, such as entecavir, adefovir, and clevudine, can be effective for treatment of HBV-MN, including lamivudine-resistant strains.

Complete remission of hepatitis B virus-related membranous nephropathy after entecavir monotherapy

We reported a case of Hepatitis B virus-related membranous nephropathy (HBV-MN) with improvement under an ongoing 4.5-year of entecavir monotherapy. A 37 years old man with a 5 years' history of chronic hepatitis B (CHB) who was taken to our department because of proteinuria and microscopic haematuria. A renal biopsy led to a diagnosis of HBV-MN with mesangioproliferative. Interferon-alpha 2b (IFN-α2b) was stopped after 24 weeks due to the increasement of HBV-DNA and sustained HBeAg positive. Therefore, we started using 0.5mg entecavir per day. After 2 months' treatment, HBV-DNA was not detected in the blood, and the ALT and AST decreased to normal degree. After 3 years of entecavir therapy, virological tests revealed HBeAg seroconversion. With no further intervention during the next one and a half years, there was improvement of proteinuria gradually. This suggested that entecavir monotherapy may induce and maintain complete remission of membranous nephropathy associated with hepatitis B.

A case of adefovir-induced membranous nephropathy related to hepatitis B caused by lamivudine-resistant virus after liver transplant due to Byler's disease

We report on how adefovir-induced membranous nephropathy related to hepatitis B was caused by lamivudine-resistant virus after a liver transplant due to Byler's disease. In 1980, a 2-year-old girl was diagnosed with Byler's disease (familial progressive familial intrahepatic cholestasis). In 1994 (at the age of 14 years) she underwent a liver transplant with her father as the donor. In 2003, hematuria and proteinuria appeared and shortly afterwards her renal function rapidly decreased. A renal biopsy showed atypical membranous nephropathy, which suggested the possibility of a secondary renal disease. The patient had suffered from chronic hepatitis type B (HBV). In 2001 she was administered lamivudine which is an antiviral drug; it was around this time that hematuria and proteinuria appeared as well as an increase of the virus titer. We believed the HBV-related membranous nephropathy was the cause of the virus titer and the renal histology. We concluded that the patient's condition had become resistant to lamivudine medication. Therefore, in February 2004 we administered adefovir, a new drug at the time, to treat the HBV. In April 2004, the HB virus titer decreased and the hematuria and proteinuria decreased. The patient's renal function also showed improvement. HBV-associated nephropathy is caused by HBV antigen deposition in the glomeruli. Generally the first choice of treatment is antivirus therapy. There are many reports demonstrating that administration of interferon and lamivudine are effective; however, there are few reports that show adefovir as an effective treatment for HBV-associated nephropathy.

Autoimmune manifestations in viral hepatitis

Infections by the viruses responsible for hepatitis B, C and D are accompanied by a number of immunopathological manifestations. A link between infection and autoimmunity is particularly well documented for the hepatitis C virus. Immunopathological manifestations range from production of autoantibodies to overt autoimmune disease, including thyroiditis and autoimmune hepatitis, and to immune-complex-mediated disorders, including cryoglobulinaemia, glomerulonephritis and vasculitis. Several of these manifestations improve with successful antiviral treatment, directly incriminating the virus in their pathogenesis. Mechanisms considered responsible for hepatitis virus-related immunopathology, including molecular mimicry, impairment of regulatory T cells and activation of B lymphocytes, will be examined in this review.

Hepatitis B and C co-infection are independent predictors of progressive kidney disease in HIV-positive, antiretroviral-treated adults

Chronic kidney disease (CKD) is an important cause of morbidity and mortality in HIV-positive individuals. Hepatitis C (HCV) co-infection has been associated with increased risk of CKD, but prior studies lack information on potential mechanisms. We evaluated the association between HCV or hepatitis B (HBV) co-infection and progressive CKD among 3,441 antiretroviral-treated clinical trial participants. Progressive CKD was defined as the composite of end-stage renal disease, renal death, or significant glomerular filtration rate (eGFR) decline (25% decline to eGFR <60 mL/min/1.73 m(2) or 25% decline with a baseline <60). Generalized Estimating Equations were used to model the odds of progressive CKD. At baseline, 13.8% and 3.3% of participants were co-infected with HCV and HBV, respectively. Median eGFR was 111, and 3.7% developed progressive CKD. After adjustment, the odds of progressive CKD were increased in participants with HCV (OR 1.72, 95% CI 1.07-2.76) or HBV (OR 2.26, 95% CI 1.15-4.44). Participants with undetectable or low HCV-RNA had similar odds of progressive CKD as HCV seronegative participants, while participants with HCV-RNA >800,000 IU/ml had increased odds (OR 3.07; 95% CI 1.60-5.90). Interleukin-6, hyaluronic acid, and the FIB-4 hepatic fibrosis index were higher among participants who developed progressive CKD, but were no longer associated with progressive CKD after adjustment. Future studies should validate the relationship between HCV viremia and CKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00027352; NCT00004978.

Kidneys in chronic liver diseases

Acute kidney injury (AKI), defined as an abrupt increase in the serum creatinine level by at least 0.3 mg/dL, occurs in about 20% of patients hospitalized for decompensating liver cirrhosis. Patients with cirrhosis are susceptible to developing AKI because of the progressive vasodilatory state, reduced effective blood volume and stimulation of vasoconstrictor hormones. The most common causes of AKI in cirrhosis are pre-renal azotemia, hepatorenal syndrome and acute tubular necrosis. Differential diagnosis is based on analysis of circumstances of AKI development, natriuresis, urine osmolality, response to withdrawal of diuretics and volume repletion, and rarely on renal biopsy. Chronic glomerulonephritis and obstructive uropathy are rare causes of azotemia in cirrhotic patients. AKI is one of the last events in the natural history of chronic liver disease, therefore, such patients should have an expedited referral for liver transplantation. Hepatorenal syndrome (HRS) is initiated by progressive portal hypertension, and may be prematurely triggered by bacterial infections, nonbacterial systemic inflammatory reactions, excessive diuresis, gastrointestinal hemorrhage, diarrhea or nephrotoxic agents. Each type of renal disease has a specific treatment approach ranging from repletion of the vascular system to renal replacement therapy. The treatment of choice in type 1 hepatorenal syndrome is a combination of vasoconstrictor with albumin infusion, which is effective in about 50% of patients. The second-line treatment of HRS involves a transjugular intrahepatic portosystemic shunt, renal vasoprotection or systems of artificial liver support.

Hepatitis-related renal disease

Many glomerular diseases can be caused by viral infections based on the diagnostic criteria, including clinical and laboratory data, and molecular analysis of tissue. Operative pathogenetic mechanisms include kidney tropism of the virus, immune complex formation, direct cytopathogenic effect, and multi-organ failure. Chronic infection with hepatitis virus is etiologically linked to well-defined glomerulopathies. In endemic areas, HBV is associated with both membranous nephropathy and mesangiocapillary glomerulonephritis, while HCV is known to cause cryoglobulinemia-mediated glomerulonephritis and other forms of glomerulonephritis. Renal biopsy with appropriate serological and molecular testing helps to define virus-related glomerular lesions and provides a prognostic and therapeutic guide. Antiviral agents remain the mainstay of treatment.

Management of renal dysfunction in patients receiving a liver transplant

Renal dysfunction is a frequent complication in patients with endstage liver disease awaiting orthotopic liver transplantation. Although the stereotypical form of renal dysfunction is the hepatorenal syndrome, common causes of acute kidney injury include prerenal azotemia and acute tubular necrosis in this population. Management involves hemodynamic support, renal replacement therapy, and mitigation of risk factors. Renal dysfunction in a cirrhotic patient usually implies a poor prognosis in the absence of liver transplantation. An important issue is the frequent need for kidney, in addition to liver, transplantation if renal insufficiency has been persistent in a decompensated cirrhotic.

Treatment of hepatitis B virus-associated nephropathy

Epidemiological studies have shown a relationship between hepatitis B virus (HBV) infection and development of proteinuria in some patients (most commonly children), with a predominance for male gender and histological findings of membranous nephropathy on renal biopsy. The presence of immune complexes in the kidney suggests an immune complex basis for the disease, but a direct relation between HBV and membranous nephropathy (or other types of glomerular diseases) remains to be proven. Clearance of HBV antigens, either spontaneous or following antiviral treatments results in improvement in proteinuria. Thus, prompt recognition and specific antiviral treatment are critical in managing patients with HBV and renal involvement. The present review focuses on treatment of HBV with special emphasis given to antiviral therapies, its complications, and dosing in patients with HBV-associated kidney disease.

Antiviral therapy in patients with hepatitis B virus-associated glomerulonephritis

Hepatitis B virus-associated glomerulonephritis (HBV-GN) is a common clinical condition. Up to now, the optimal therapy is undefined although several approaches have been made. This paper reviews the efficacy and safety of antiviral therapy (including interferon and lamivudine) in the treatment of HBV-GN. Interferon-α is efficacious in remission of proteinuria, clearance of HBeAg and delay of renal function deterioration. Remission of proteinuria is often accompanied by clearance of HBV replication markers. Corticosteroid treatment could not improve renal outcome in patients with HBV-GN.

Hepatitis B and Renal Disease

Glomerulonephritis is an important extrahepatic manifestation of chronic hepatitis B virus (HBV) infection. The uncommon occurrence, variability in renal histopathology, and heterogeneity in clinical course present challenges in clinical studies and have resulted in a relative paucity of data and uncertainty with regard to the optimal management of HBV-related glomerular diseases. The advent of nucleos(t)ide analogue medications that effectively suppress HBV replication has markedly altered the clinical outcomes of kidney transplant recipients with HBV infection, but the emergence of drug resistance is an escalating problem. This article reviews the recent knowledge of the pathogenesis and treatment of HBV-related membranous nephropathy, and discusses the management of hepatitis B in kidney transplant recipients, which is continuously evolving.

Treatment of hepatitis B virus-associated glomerulonephritis: A meta-analysis

AIM: To evaluate the efficacy of antiviral or corticosteroid treatment on hepatitis B virus-associated glomerulonephritis (HBV-GN).

METHODS: Six and five trials were used respectively to evaluate the efficacy of either antiviral or corticosteroid treatment on HBV-GN. Pediatric patients were pooled separately to assess their response to the above treatment modalities. The primary and secondary outcomes were remission of proteinuria and clearance of Hepatitis B e-antigen (HBeAg), respectively. A fixed or random effect model was established to collect the data.

RESULTS: The remission rate of proteinuria (RR = 1.69, 95% CI: 1.08-2.65) and the clearance rate of HBeAg (RR = 6.44, 95% CI: 3.11-13.35) were significantly higher in antiviral treatment group than in control group. The proteinuria remission was significantly associated with HBeAg clearance (P = 0.002). However, the difference in proteinuria remission rate was not statistically significant between corticosteroid treatment group and control group (RR = 1.45, 95% CI: 0.68-3.11). Antiviral therapy could significantly promote the HBeAg clearance in pediatric patients, but neither antiviral nor corticosteroid therapy could significantly decrease proteinuria in pediatric patients compared to controls.

CONCLUSION: Antiviral but not corticosteroid treatment can decrease proteinuria and promote HBeAg clearance in HBV-GN patients.

Membranous nephropathy associated with chronic hepatitis B occurring in a short period after acute hepatitis B virus infection

We herein present a case of membranous nephropathy associated with chronic hepatitis B following acute hepatitis B virus (HBV) infection. A 22-year-old man was admitted to our hospital for evaluation of proteinuria, pitting edema on both legs, and increased body weight in December 2002. At the age of 18, he had suffered from acute hepatitis A and syphilis, and was found to be negative for hepatitis B surface antigen (HBsAg). Furthermore, he suffered from acute hepatitis B (AH-B) at the age of 21; he was found to be positive for HBsAg and anti-IgM antibody to core antigen (IgM HBcAb). However, he discontinued outpatient treatment before confirmation of HBsAg clearance or the appearance of antibody to HBsAg (HBsAb). At the present admission, HBsAg, antibody to hepatitis B e antigen (HBeAg), and HBcAb were positive, while IgM HBcAb was negative. His genotype of HBV was type A (HBV/A). Histopathological findings of the renal biopsy specimen confirmed glomerulonephritis and glomerular deposition of HBsAg. Thus, he was diagnosed as having nephrotic syndrome caused by membranous nephropathy (MN) associated with chronic hepatitis B (CH-B) following AH-B. Although interferon-alpha (IFN-alpha) administration was started for the treatment and temporary improvement of proteinuria was observed, remission of MN was not achieved.

Hepatitis B-related autoimmune manifestations

This article focuses on autoimmune manifestations related to the hepatitis B virus (HBV). Although the HBV vaccination has resulted in the decline of the virus, approximately 400 million individuals are infected worldwide. Up to twenty percent of the afflicted may develop extrahepatic manifestations ranging from the severe polyarteritis nodosa to the many, varied, and less severe clinical and biologic forms. Currently, control of the viral infection is mainly based on the use of antiviral drugs (with the current availability of potent agents). Discussion of two hypotheses of the pathophysiology of the virus is followed by descriptions of the general, renal, rheumatologic, neurologic, skin, ophthalmologic, and hematologic manifestations.

Renal failure in patients with cirrhosis

Renal failure in cirrhosis poses unique diagnostic and therapeutic challenges. Laboratory values and predictive equations grossly overestimate renal function in patients with cirrhosis. Development of renal failure connotes a worse prognosis; mortality is especially high with hepatorenal syndrome. Classification of the causes of renal failure in patients with cirrhosis is provided with more extensive discussion of selected causes. Finally, a suggested diagnostic approach to renal failure in cirrhosis is given.

Systemic abnormalities in liver disease

Systemic abnormalities often occur in patients with liver disease. In particular, cardiopulmonary or renal diseases accompanied by advanced liver disease can be serious and may determine the quality of life and prognosis of patients. Therefore, both hepatologists and non-hepatologists should pay attention to such abnormalities in the management of patients with liver diseases.

[Natural history and clinical manifestations of chronic hepatitis B virus]

Hepatitis B virus (HBV) infection is a serious public health problem worldwide. In the last few decades, major advances have been achieved that have contributed to greater understanding of the natural history and clinical manifestations of this infection. The fluctuation between viral replication and the host's immune response has implications in the pathogenesis and progression of the hepatic lesion. In immunocompetent adults, most HBV infections resolve spontaneously in contrast with progression to chronic infection in most infants. Patients with chronic hepatitis due to HBV or chronic hepatitis B can present at four phases: 1) the immune tolerance phase, 2) HBeAg-positive chronic hepatitis B, 3) inactive HBsAg carrier state, and 4) HBeAg-negative chronic hepatitis. HBeAg-positive or -negative chronic hepatitis can progress to cirrhosis, liver failure and hepatocellular carcinoma. Progression to these complications is more frequent in HBeAg-negative forms, associated with mutations that affect the pre-core region and maintain active viral replication. Risk factors are HBV-DNA positive serum levels, an increase in serum transaminase levels and some genotypes. These factors highlight the need to evaluate and monitor all HBV carriers to identify those who could benefit from early antiviral treatment, thus avoiding progression to more advanced forms of liver disease. These measures could improve prevention and treatment of hepatitis B.

Virological features of hepatitis B virus-associated nephropathy in Japan

Hepatitis B virus (HBV)-associated nephropathy is considered as an immune-mediated disorder which is dependent on interactions between viral, host, and environmental factors. But there are few reports that investigated the relationship between the development of HBV-associated nephropathy and HBV genotypes and the mutations. To clarify the relationship between nephropathy and HBV genotype in Japan, six male patients with HBV-associated nephropathy were examined. The complete genome sequences of HBV were determined directly and the specific mutations associated with the development of HBV-associated nephropathy were examined by comparison of the alignments along with consensus sequences [HBV/A1 (Aa), A2 (Ae), B1 (Bj), B2 (Ba), C1 (Cs) and C2 (Ce)] retrieved from international database. The mean age of the six patients was 33.5 years. HBeAg was found in all patients and serum HBV-DNA levels were relatively high. Histological findings of renal tissues indicated five cases of membranous nephropathy and one membranoproliferative glomerulonephritis. HBV genotypes from the six patients were two HBV/A1, two A2 and two C2, suggesting HBV/A was predominant. G1862T mutation was observed in the two HBV/A1 patients, resulting in the pre-core amino acid substitution with a switch from valine (Val) to phenylalanine (Phe). Only one patient had core deletions. It is concluded that HBV/A may be associated with membranous nephropathy, but little relationship between HBV gene mutations and the development of HBV-associated nephropathy was observed.

Viral hepatitis and proteinuria in an area endemic for hepatitis B and C infections: another chain of link?

BACKGROUND AND OBJECTIVES

Virus hepatitis may lead to nephropathy as one of its multiple extrahepatic manifestations. Proteinuria by dipstick, a simple test in practice, is a useful and cardinal sign of underlying renal abnormalities. The aim of this study was to elucidate the impact of hepatitis B virus (HBV) and/or hepatitis C virus (HCV) infections on the occurrence of proteinuria amongst adults.

DESIGN AND SETTING

A prospective, cross-sectional, community-based study was conducted in an HBV/HCV endemic area of southern Taiwan. Eligible subjects aged 40-65 years (n=9934) underwent testing of hepatitis B surface antigen (HBsAg), HCV antibody (anti-HCV) and other related biochemical profiles. Urinalysis with repeated dipstick for proteinuria detection was performed.

RESULTS

Anti-HCV-positive rate amongst proteinuria subjects was significantly higher than nonproteinuria subjects (9.6% vs. 6.2%, P<0.001). By contrast, HBsAg-positive rate did not differ between subjects with and without proteinuria (13.0% vs. 13.8%, P=0.57). Prevalence of proteinuria amongst anti-HCV-positive subjects (10.2%) was significantly higher than that in HBsAg-positive subjects (6.4%, P=0.004) and in HBsAg-negative or anti-HCV-negative subjects (7.0%, P=0.004). The difference persisted even after excluding diabetics. Multivariate logistic regression analyses showed that diabetes was the most important significant factor associated with proteinuria, followed by hypertension, anti-HCV seropositivity, body mass index, age and triglyceride levels.

CONCLUSION

We demonstrated the significant association between proteinuria and HCV, but not HBV, infection in this HBV/HCV-endemic area.

Meta-analysis: anti-viral therapy of hepatitis B virus-associated glomerulonephritis

BACKGROUND

Hepatitis B virus-associated glomerulonephritis is an infrequent complication of chronic hepatitis B virus (HBV) with significant morbidity. A causal association between hepatitis B virus infection and the development of glomerulonephritis remains controversial. Also, the optimal therapy is undefined although several approaches have been made.

AIM

To evaluate the efficacy and safety of anti-viral therapy (interferon or lamivudine) in HBV-associated glomerulonephritis by a systematic review and meta-analysis of clinical trials.

METHODS

The primary outcome was clinical response (as a measure of efficacy); the secondary outcomes were drop-out rate (as a measure of tolerability), and virological response. We used the random effects model of DerSimonian and Laird, with heterogeneity, sensitivity and meta-regression analyses.

RESULTS

We identified six clinical trials (84 unique patients); three had controlled design. The overall estimate for proteinuria remission was 65.2% (95% confidence intervals: 52.7-75.9%), Q-test for heterogeneity = 7.731, P = 0.172, I(2) = 35.327. The overall estimate for hepatitis B e antigen clearance was 62.0% (95% confidence intervals: 50.5-72.2%). The overall estimate for drop-out rate was 12.7% (95% confidence intervals: 6.4-23.6%). Meta-regression analysis showed a significant link between hepatitis B e antigen clearance and logit rate of proteinuria remission after interferon therapy [coefficient -2.585 (S.E. 1.089), P = 0.017].

CONCLUSION

Remission of the nephrotic syndrome is accompanied by clearance of HBV replication, supporting the role of the virus in the pathogenesis of the disease.

Viral nephropathy

Viral infections can cause many glomerular diseases. The diagnostic criteria for virus-related nephropathy include detailed clinical and laboratory data, and tissue molecular analysis. Several mechanisms are involved in the pathogenesis of virus-related nephropathy, including tropism of the virus in the kidney, induction of abnormal immune complexes, direct cytopathogenic effects, and multiorgan failure. Hepatitis B virus is associated with membranous nephropathy and mesangiocapillary glomerulonephritis in endemic areas. Hepatitis C virus causes various forms of glomerulonephritis, including cryoglobulinemia-mediated glomerulonephritis. Infection with HIV is associated with a collapsing focal segmental glomerulosclerosis, a distinctive disease that affects mainly Africans and African Americans. In the course of HIV infection, other types of immune complex glomerulonephritis can occur, most frequently in whites. Recent reports indicate a role for parvovirus B19 in 'idiopathic' collapsing focal segmental glomerulosclerosis. Both hantaviruses, and coronaviruses associated with severe acute respiratory syndrome, can lead to acute renal failure. Renal biopsy followed by appropriate serological and molecular testing is essential for defining virus-related glomerular lesions and guiding prognostic and therapeutic evaluation.

Lamivudine in hepatitis B-associated membranous nephropathy

BACKGROUND

Although lamivudine is effective for treatment of chronic hepatitis B (HBV) infection, its potential therapeutic impact on HBV-related membranous nephropathy (MN) in adults has not been characterized.

METHODS

We treated 10 HBsAg-positive patients with biopsy-proven MN, elevated serum alanine aminotransferase (ALT), and HBV-DNAemia (group 1), and compared their clinical course with 12 patients diagnosed to have HBV infection, elevated serum ALT, and MN in the pre-lamivudine era (group 2).

RESULTS

Baseline demographic and clinical parameters were not different between the 2 groups. In group 1, lamivudine treatment was associated with significant reduction in proteinuria, increase in serum albumin, normalization of ALT levels, and disappearance of circulating HBV-DNA during the first year. Four (40%) and 6 (60%) patients went into complete remission (proteinuria <0.3 g/d) at 6 and 12 months, respectively. In group 2, significant proteinuria persisted during the first year. One (8.3%) and 3 (25%) patients went into remission. Cumulative 3-year renal survival [using end-stage renal disease (ESRD) as primary end point] was 100% in group 1 and 58% in group 2 (P= 0.024, log rank test). Blood pressure control reached the target of below 130/85 mm Hg in both groups. Lamivudine was well tolerated and not associated with any adverse events. Hepatic decompensation or malignancy was not observed during follow-up in both groups.

CONCLUSION

HBV-related MN leads to ESRD in a significant proportion of patients before the advent of antiviral therapy. Lamivudine treatment improves renal outcome in HBV carriers with MN and evidence of liver disease.

Antiviral therapy: role in the management of extrahepatic diseases

This article considers the extrahepatic manifestations associated with HBV and HCV infection, the strength of the evidence for the association, potential pathological mechanisms, and evidence based therapeutic recommendations. As many of these extra hepatic conditions are uncommon, published reports have been largely uncontrolled or anecdotal.

Extrahepatic manifestations of chronic hepatitis B

Several extrahepatic manifestations are associated with chronic HBV infection, many with significant morbidity and mortality. The cause of these extrahepatic manifestations is generally believed to be immune mediated. PAN is a rare, but serious, systemic complication of chronic HBV affecting the small- and medium-sized vessels. PAN is seen more frequently in North American and European patients and rarely in Asian patients. PAN ultimately involves multiple organ systems, some with devastating consequences, though the hepatic manifestations are often more mild. The optimal treatment of HBV-associated PAN is thought to include a combination of antiviral and immunosuppressive therapies. HBV-associated GN occurs mainly in children, predominantly males, in HBV endemic areas of the world, but is only occasionally reported in the United States. In children, GN is usually self-limited with only rare progression to renal failure. In adults, the natural disease course of GN may be more relentless, slowly progressing to renal failure. Immunosuppressive therapy in HBV-related GN is not recommended, but antiviral therapy with alpha-interferon has shown promise. The serum-sickness like "arthritis-dermatitis" prodrome is seen in approximately one third of patients acquiring HBV. The joint and skin manifestations are varied, but the syndrome spontaneously resolves at the onset of clinical hepatitis with few significant sequelae. Occasionally, arthritis following the acute prodromal infection may persist; however, joint destruction is rare. The association between HBV and mixed essential cryoglobulinemia remains controversial; but a triad of purpura, arthralgias, and weakness, which can progress to nephritis, pulmonary disease, and generalized vasculitis, has characterized the syndrome. Finally, skin manifestations of HBV infection typically present as palpable purpura. Though papular acrodermatitis of childhood has been reported to be caused by chronic HBV, this association remains controversial.

Glomerulonephritis and malignancy: a population-based analysis

BACKGROUND

An association between glomerulonephritis and malignant tumors has previously both been found and discarded in clinical series, but to our knowledge never has been tested in a population-based setting.

METHODS

The Danish Kidney Biopsy Registry includes all kidney biopsies performed from 1985. Using a unique personal identification number, each person in the registry to the National Population Registry and the Danish Cancer Registry were linked. Cancer occurrence after the biopsy was compared in patients with morphological, glomerular diseases with that of the general Danish population, taking into account sex, age, calendar period and time since biopsy, and the 95% confidence interval (95% CI) for the observed-to-expected rates was calculated, assuming a Poisson distribution. Cancer occurrence was stratified to <1 year, 1 to 4, and >or=5 years after a biopsy.

RESULTS

A total of 102 de novo cancers were found in 1958 patients. These cancers represent a two- to threefold excess of the expected number at <1 and 1 to 4, but not >or=5 years after a biopsy. Non-Hodgkin's lymphomas were observed six to eight times more than expected. Cancer excess was seen in glomerulonephritides with a known or suspected virus etiology.

CONCLUSIONS

The excess cancer rate could be the result of underlying undiagnosed tumors whose antigens have initiated glomerulonephritis, or the immunosuppressive therapy that initiated or energized tumor cells. Based on the findings in our study, there is some support for an association to persistent viruses causing first the glomerulonephritides and then the malignancies, perhaps through a common pathogenesis. This calls for other studies to be done that are specifically designed to investigate this issue, with more data on patient characteristics and confounders.

Liver and kidney diseases

The spectrum of renal disease in patients with liver disease is expanding. The recognition of renal complications of liver diseases is essential in the management of these patients. As liver transplantation is a treatment option for many patients with chronic liver disease, the presence of renal complications impacts the decision regarding transplantation and influences the course of these patients after transplantation, especially with regard to the use of immunosuppressive therapy. The involvement of the liver and kidney in systemic conditions is common and adds to the morbidity and mortality of patients.

Extrahepatic manifestations of chronic viral hepatitis

Hepatitis B (HBV) and C (HCV) viruses are well-recognized causes for chronic hepatitis, cirrhosis, and even for hepatocellular carcinoma. Apart from liver disease, these viral infections are known to be associated with a spectrum of extrahepatic manifestations. The prevalence of clinically significant extrahepatic manifestations is relatively low, but it can be associated with significant morbidity and even mortality. An awareness and recognition of these manifestations is of paramount importance in facilitating early diagnosis and in offering treatment. However, treatments are not necessarily effective, and patients may continue with disabling extrahepatic manifestations. Hepatitis B virus has been well recognized as causing a variety of manifestations that include skin rash, arthritis, arthralgia, glomerulonephritis, polyarteritis nodosa, and papular acrodermatitis. More recently, infection with hepatitis C virus has elicited considerable interest for its role in a spectrum of extrahepatic manifestations. Among the best-reported are cryoglobulinemia, glomerulonephritis, high titer of autoantibodies, idiopathic thrombocytopenic purpura, lichen planus, Mooren's corneal ulcer, Sjögren's syndrome, porphyria cutanea tarda, and necrotizing cutaneous vasculitis. The precise pathogenesis of these extrahepatic complications has not been determined, although the majority represent the clinical expression of autoimmune phenomena.

Hepatitis B

The hepatitis B virus is a hepatotropic virus that can produce a variety of clinical syndromes in patients ranging in age from infants to elderly adults. Worldwide, it is among the leading causes of fulminant hepatic failure, cirrhosis, and hepatocellular carcinoma. Recent advances have led to effective antiviral treatments using interferon and nucleoside analogues. Highly effective vaccinations also are used widely and ultimately may lead to eradication of this life-threatening virus.

Renal failure associated with hepatitis C virus infection. Improvement in renal function after treatment with interferon-alpha

Hepatitis C virus infection can result in mixed cryoglobulinemia and associated clinical syndromes including membranoproliferative glomerulonephritis. Reports regarding the efficacy of interferon-alpha (IFN-alpha) in the treatment of patients with membranoproliferative glomerulonephritis and chronic hepatitis C infection have been inconclusive regarding improvement of renal function. We describe two patients with chronic hepatitis secondary to hepatitis C virus complicated by mixed cryoglobulinemia and membranoproliferative glomerulonephritis who developed severe renal failure which resolved after treatment with standard doses of IFN-alpha 2b.

Hepatitis B

Hepatitis B remains a major public health problem around the world. The discovery of the hepatitis C virus has diverted interest from hepatitis B to this new virus and the epidemic associated with it, but hepatitis B remains a significant pathogen for millions of people worldwide. The World Health Organization has suggested that universal vaccination of children against hepatitis B should be implemented in an attempt to reduce the enormous morbidity and mortality associated with infection of this virus group. The review seeks to identify all the newer discoveries relating to hepatitis B that have been made in the past decade. Reference is made to the appearance of hepatitis B mutants which are able to infect patients previously infected with the wild strain of the virus. The implications of mutants on vaccination programmes is raised, as are issues relating to treatment of hepatitis B infection.

Therapy of chronic viral hepatitis

Interferon alpha is effective therapy for patients with chronic hepatitis B and hepatitis C. Only 20% to 40% of patients, however, have a sustained benefit from therapy. For the majority of patients with these diseases, alternative forms of therapy are needed. Nucleoside analogues appear to be extremely promising for the treatment of chronic hepatitis B and will undoubtedly play a major role in the management of this disease. For chronic hepatitis C, prolonged therapy with interferon, improved patient selection, and combined therapy with multiple agents such as ribavirin may lead to an improved therapeutic response.