Corticosteroid for severe acute exacerbation of chronic hepatitis B

Corticosteroid improves liver function but does not curb the clinical progression of hepatitis B virus-related acute-on-chronic pre-liver failure

Background: Hepatitis B virus-related acute-on-chronic pre liver failure (HBV pre-ACLF) has the potential for progression to HBV ACLF. Whether corticosteroid is useful for HBV pre-ACLF remains heterogeneous. This study aimed to evaluate the efficacy of short-term (5 days) and low-dose dexamethasone (5mg/d) toward HBV pre-ACLF.Design and methods: One hundred twenty-one patients with HBV pre-ACLF were randomly divided into two groups: medical comprehensive treatment (MCT) group and corticosteroid treatment (CT) group. Laboratory measurements at admission and 7 days post-admission were compared between the two groups, respectively. Hospitalization periods and clinical progression were also monitored and compared between the two groups.Results: Higher than normal levels of ALT, AST, TBIL, DBIL, TBA and GLO were observed at 7 days after admission in patients in the MCT group than in CT group (p < 0.001).Patients in the CT group had shorter inpatient days than the MCT group (p = 0.002).During hospitalization and treatment, the incidence of HBV ACLF was not substantially different between the two groups (14.8% vs. 8.3%, p = 0.271).Conclusions: Corticosteroid is effective at improving the liver function and decreasing hospitalization periods of patients with HBV pre-ACLF but does not prevent HBV pre-ACLF from progressing to HBVACLF.

Virological efficacy of combination therapy with corticosteroid and nucleoside analogue for severe acute exacerbation of chronic hepatitis B

The short-term prognosis of patients with severe acute exacerbation of chronic hepatitis B (CHB) leading to acute liver failure is extremely poor. We have reported the efficacy of corticosteroid in combination with nucleoside analogue in the early stages, but virological efficacy has not been documented. Our aim was to elucidate the virological efficacy of this approach. Thirteen patients defined as severe acute exacerbation of CHB by our uniform criteria were prospectively examined for virological responses to treatment. Nucleoside analogue and sufficient dose of corticosteroids were introduced as soon as possible after the diagnosis of severe disease. Of the 13 patients, 7 (54%) survived, 5 (38%) died and 1 (8%) received liver transplantation. The decline of HBV DNA was significant between the first 2 weeks (P = 0.02) and 4 weeks (P < 0.01). Mean reduction in HBV DNA during the first 2 weeks was 1.7 ± 0.9 log copies per mL in overall patients, 2.1 ± 0.8 in survived patients and 1.2 ± 0.9 in dead/transplanted patients. The decline of HBV DNA was significant between the first 2 weeks (P = 0.03) and 4 weeks (P = 0.02) in survived patients, but not in dead/transplanted patients. Our study shows that corticosteroid treatment in combination with nucleotide analogue has sufficient virological effect against severe acute exacerbation of CHB, and a rapid decline of HBV DNA is conspicuous in survived patients.

Management of hepatitis B virus-related acute liver failure

Hepatitis B virus (HBV) is the most important cause of acute liver failure (ALF) in Eastern countries. HBV-related ALF may occur after acute HBV infection (A-ALF) or during acute exacerbation (flare) of chronic HBV infection (C-ALF). C-ALF may occur spontaneously or as a result of the effect of immunosuppression due to chemotherapeutic or immunosuppressive agents. The definition of HBV-related ALF is uncertain, because different diagnostic criteria are used in C-ALF, which may present as acute-on-chronic liver failure. Although the pathogenesis differs in the two subgroups of ALF, the symptoms and biochemical parameters can be similar. High titers of immunoglobulin M hepatitis B core antibody and lower viral loads are frequent in A-ALF as compared with C-ALF. The prognosis of C-ALF is significantly poor as compared with that of A-ALF. In C-ALF, most immunosuppression-mediated reactivation of hepatitis B results in fatality. Many case series or case-control studies have not demonstrated the survival benefit of nucleos(t)ide treatment. This treatment failure is probably related to delayed initiation of nucleos(t)ide treatment and viral suppression. Treatment with nucleos(t)ide analogs should be started immediately and should be continued regardless of subgroups of HBV-related ALF. Liver transplantation is the only treatment option that improves the prognosis of HBV-related ALF. Patients under consideration for transplantation should be given nucleos(t)ide analogs as prophylaxis to reduce the likelihood of post-transplant HBV recurrence.