The good and evil of flare: flares in hepatitis B virus chronic hepatitis

Fibronectin predicts the outcome of acute-on-chronic hepatitis B liver failure

BACKGROUND

Acute-on-chronic hepatitis B liver failure (ACHBLF) is a serious condition with varied etiologies and manifestations, and is associated with a high mortality rate. Fibronectin is involved in a number of biological processes, including cellular adhesion, motility, differentiation, apoptosis, hemostasis, wound healing and ischemic injury. Serum fibronectin concentrations may provide prognostic information in ACHBLF; however, as a prognostic marker of mortality in patients with ACHBLF, it needs further validation.

METHODS

The aim of this study was to examine whether admission levels of fibronectin in ACHBLF patients are correlated with outcomes. In this prospective study, 78 ACHBLF patients were compared to 70 matched healthy controls. Fibronectin levels were determined using a commercial enzyme-linked immunosorbent assay kit to determine the prognostic value of fibronectin levels on admission.

RESULTS

The median (range) fibronectin level at admission for ACHBLF patients was significantly reduced compared with that of healthy controls (142 [62-275] mg/l vs 265 [190-346] mg/l, respectively; p<0.001). Fibronectin levels were significantly higher in surviving patients than in those who died (155 [70-275] mg/l vs 119 [62-235] mg/l; p=0.020). Receiver operating characteristic curve analysis showed that a cut-off level of 135 mg/l was the best prognostic indicator, yielding positive and negative predictive values of 60% (18/30) and 71% (30/42), respectively.

CONCLUSIONS

Our results suggested that decreased serum fibronectin levels in patients with ACHBLF were correlated to hepatic injury and inflammation. However, because of the lack of specificity, the use of fibronectin as an independent prognostic indicator is limited.

Acute exacerbation of chronic hepatitis B: the dilemma of differentiation from acute viral hepatitis B

Exacerbations of chronic hepatitis B are common in endemic countries. Acute exacerbation of chronic hepatitis B virus (CHB-AE) causing derangement of liver functions may be seen in a flare of HBV in immune clearance phase or as a reactivation of HBV in patients with inactive or resolved HBV infection. While reactivation of HBV is usually seen in HBsAg positive patients, it is being increasingly recognized in patients with apparently resolved HBV infection who do not have HBsAg in serum but have IgG antibody to core antigen (anti-HBc) in the serum, especially so in patients on chemotherapy, immunosuppressive therapy or undergoing hematopoietic stem cell transplantation. In an icteric patient who is HBsAg positive, it may be difficult to differentiate CHB-AE from acute viral hepatitis B (AVH-B). Both may have similar clinical presentation and even IgM anti-HBc, the traditional diagnostic marker of AVH-B, may also appear at the time of exacerbation of CHB. The differentiation between CHB-AE and AVH-B is important not only for prognostication but also because management strategies are different. Most cases of AVH-B will resolve on their own, HBsAg clearance is achieved spontaneously in 90-95% of adults and treatment is rarely indicated except in the few with severe/fulminant disease. In contrast, in CHB-AE, the onset of jaundice may lead to decompensation of liver disease and treatment is warranted. The mechanisms of acute exacerbation and the differentiating features between AVH-B and CHB-AE are reviewed.

Two patterns of alanine aminotransferase increase to predict long-term viral response in chronic hepatitis B patients: virus- or host-induced?

BACKGROUND

Serum alanine aminotransferase (ALT) increase is a well-known phenomenon during interferon treatment for chronic hepatitis B. However, little is known about these increases during nucleoside/nucleotide treatment and the effects on long-term clinical outcomes.

METHODS

A total of 170 treatment-naive hepatitis B e antigen (HBeAg)-positive chronic hepatitis B patients were treated with a nucleoside/nucleotide analogue for at least 2 years and followed up for 1 more year post-treatment. Clinical characteristics were detected and analysed at baseline and at every 3-month interval.

RESULTS

Two patterns of ALT increase, virus- and host-induced, were detected. Virus-induced increases were characterized by a rapid increase in serum ALT and HBV DNA typically after 2 years of treatment, and were more common than host-induced ALT increases (15.9% versus 6.5%; P<0.05) with a median ALT increase of 5.7-fold the upper limit of normal (ULN). Host-induced ALT increases were characterized by moderately increased ALT (median 2.5-fold ULN) with a slow decrease in HBV DNA that occurred mainly in the first year of treatment (63.6%). Most importantly, host-induced increases were associated with favourable long-term treatment outcomes in HBV DNA undetectable rate (82% versus 0%), HBeAg seroconversion (82% versus 7%) and histological improvement. Moreover, interferon-γ-expressing T-helper cells were increased in patients with host-induced ALT increases.

CONCLUSIONS

Two patterns of ALT increases may occur during nucleoside/nucleotide analogue treatment. Host induced ALT increases, accompanied by decreased HBV DNA, lead to better long-term clinical outcomes.