[Recent etiology and clinical features of acute viral hepatitis in a single center of Korea]

Dual Infection of Hepatitis A Virus and Hepatitis E Virus- What Is Known?

Viral hepatitis is an infection of human hepatocytes resulting in liver damage. Dual infection of two hepatotropic viruses affects disease outcomes. The hepatitis A virus (HAV) and hepatitis E virus (HEV) are two enterically transmitted viruses; they are single-stranded RNA viruses and have common modes of transmission. They are transmitted mainly by the fecal-oral route and ingestion of contaminated food, though the HAV has no animal reservoirs. The HAV and HEV cause acute self-limiting disease; however, the HEV, but not HAV, can progress to chronic and extrahepatic infections. The HAV/HEV dual infection was reported among acute hepatitis patients present in developing countries. The impact of the HAV/HEV on the prognosis for acute hepatitis is not completely understood. Studies showed that the HAV/HEV dual infection increased abnormalities in the liver leading to fulminant hepatic failure (FHF) with a higher mortality rate compared to infection with a single virus. On the other hand, other reports showed that the clinical symptoms of the HAV/HEV dual infection were comparable to symptoms associated with the HAV or HEV monoinfection. This review highlights the modes of transmission, the prevalence of the HAV/HEV dual infection in various countries and among several study subjects, the possible outcomes of this dual infection, potential model systems for studying this dual infection, and methods of prevention of this dual infection and its associated complications.

Seropositive rate of the anti-hepatitis A immunoglobulin G antibody in maintenance hemodialysis subjects from two hospitals in Korea

BACKGROUND/AIMS

Hepatitis A virus (HAV) is a self-limiting infectious disease, but 1% of subjects develop fulminant hepatitis. The prevalence of the anti-HAV immunoglobulin G (IgG) antibody in hemodialysis subjects in Korea remains unknown. The purpose of this study was to describe and compare the seropositive rate of anti-HAV antibody among hemodialysis subjects in two hospitals according to age group.

METHODS

A total of 170 hemodialysis subjects were evaluated for the seropositive rate of the anti-HAV IgG antibody and its titer.

RESULTS

Of the 170 maintenance hemodialysis subjects in two hospitals (Kangnam 92 vs. Chuncheon 78), 79 (46.5%) were male. The mean age was 53.2 years old, and 94.1% of the subjects were over 40 years old. The median vintage of hemodialysis was 29.0 months. Anti-HAV antibody was found in 163 subjects (95.9%), with no significant difference between the two areas (Kangnam 97.8% [n = 90] vs. Chuncheon 93.6% [n = 73]). Subjects younger than 40 years old showed a seropositive rate of 50%, while the seropositive rate increased with age for subjects aged 40 or older (p for trend < 0.001). Seropositive subjects from Kangnam showed a higher anti-HAV antibody titer than those from Chuncheon (median: Kangnam 14.2 vs. Chuncheon 11.7). Only age influenced seropositivity. The only factor that influenced the antibody level was the location of hospital (p < 0.001).

CONCLUSION

The seropositive rate of the anti-HAV antibody in hemodialysis subjects was 95%, which is similar to findings in the general population. Active immunization against hepatitis A is strongly recommended for hemodialysis subjects under 40 years of age after anti-HAV testing.

[Hepatitis E Virus: Epidemiology, Diagnosis, and Management]

The HEV is a known cause of water-borne outbreaks of acute non-A non-B hepatitis in developing countries, which affects young people and may result in high mortality in pregnant women. In recent decades, however, HEV genotypes 3 and 4 have been known as a cause of sporadic zoonotic infections in older males from swine HEV worldwide. Most acute HEV infections are self-limited. On the other hand, in immunosuppressed patients, including solid organ transplant recipients, chronic HEV infections may exist and progress to liver cirrhosis or decompensation. Therefore, physicians need to recognize HEV as a major pathogen for acute and chronic hepatitis of unknown causes and investigate this disease.

Clinical features and risk factors for severe complications among patients with acute hepatitis A virus infection in the Jeonbuk Province of Korea

BACKGROUND/AIMS

The frequency of symptomatic acute HAV infections in adulthood are increasing in Korea. This study analyzes the clinical severity in patients with acute HAV infection and investigates risk factors associated with three severe complications: prolonged cholestasis, acute kidney injury, and acute liver failure.

METHODS

We performed a retrospective analysis of 726 patients diagnosed from January 2006 to December 2010 at three tertiary hospitals in Jeonbuk Province, Republic of Korea with acute HAV infection.

RESULTS

In the group of 726 patients, the mean age was 30.3 years, 426 (58.6%) were male, and 34 (4.7%) were HBsAg positive. Severe complications from acute HAV infection occurred as follows: prolonged cholestasis in 33 (4.6%), acute kidney injury in 17 (2.3%), and acute liver failure in 16 (2.2%). Through multivariate analysis, age ≥40 years (OR 2.63, p=0.024) and peak PT (INR) ≥1.5 (OR 5.81, p=0.035) were found to be significant risk factors for prolonged cholestasis. Age ≥40 years (OR 5.24, p=0.002) and female gender (OR 3.11, p=0.036) were significant risk factors for acute kidney injury. Age ≥40 years (OR 6.91, p=0.002), HBsAg positivity (OR 5.02, p=0.049), and peak total bilirubin (OR 1.11, p=0.001) were significant risk factors for acute liver failure.

CONCLUSIONS

Age ≥40 years, female gender, HBsAg positivity, peak PT (INR) ≥1.5, and peak total bilirubin were significant risk factors for severe complications in acute HAV infections.

Changes in the seroprevalence of IgG anti-hepatitis A virus between 2001 and 2013: experience at a single center in Korea

Background/Aims

The incidence of symptomatic hepatitis A reportedly increased among 20- to 40-year-old Korean during the late 2000s. Vaccination against hepatitis A was commenced in the late 1990s and was extended to children aged <10 years. In the present study we analyzed the changes in the seroprevalence of IgG anti-hepatitis A virus (HAV) over the past 13 years.

Methods

Overall, 4903 subjects who visited our hospital between January 2001 and December 2013 were studied. The seroprevalence of IgG anti-HAV was analyzed according to age and sex. In addition, the seroprevalence of IgG anti-HAV was compared among 12 age groups and among the following time periods: early 2000s (2001-2003), mid-to-late 2000s (2006-2008), and early 2010s (2011-2013). The chi-square test for trend was used for statistical analysis.

Results

The seroprevalence of IgG anti-HAV did not differ significantly between the sexes. Furthermore, compared to the seroprevalence of IgG anti-HAV in the early 2000s and mid-to-late 2000s, that in the early 2010s was markedly increased among individuals aged 1-14 years and decreased among those aged 25-44 years (P<0.01). We also found that the seroprevalence of IgG anti-HAV in individuals aged 25-44 years in the early 2010s was lower than that in the early 2000s and mid-to-late 2000s.

Conclusions

The number of symptomatic HAV infection cases in Korea is decreasing, but the seroprevalence of IgG anti-HAV is low in the active population.

Risk factors for acute hepatitis A infection in Korea in 2007 and 2009: a case-control study

This study aimed to identify the risk factors associated with acute hepatitis A virus (HAV) infection in the Korean population. Participants were recruited from five referral hospitals across the country in 2007 and from 11 hospitals in 2009. Patients with positive anti-HAV IgM antibody tests became the case group, while patients treated for non-contagious diseases at the same hospitals were recruited as controls. A total of 222 and 548 case-control pairs were studied in the 2007 and 2009 surveys, respectively. Data from the surveys were analyzed jointly. In a multivariate analysis, sharing the household with HAV-infected family members (OR, 6.32; 95% CI, 1.4-29.6), contact with other HAV-infected individuals (OR, 4.73; 95% CI, 2.4-9.4), overseas travel in 2007 (OR, 19.93; 95% CI, 2.3-174.4), consumption of raw shellfish (OR, 2.51; 95% CI, 1.8-3.5), drinking bottled water (OR, 1.64; 95% CI, 1.3-8.4), and occupation that involve handling food (OR, 3.30; 95% CI, 1.3-8.4) increased the risk of HAV infection. Avoiding contact with HAV-infected individuals and avoiding raw foods eating could help minimize the risk of hepatitis A infection. Immunization must be beneficial to individuals who handle food ingredients occupationally or travel overseas to HAV-endemic areas.

Phenotypic characteristics of natural killer cells in acute hepatitis

Natural killer (NK) cells are the principal effector cell population in innate immune defense against many types of infections. These cells are enriched in the liver, where they comprise approximately 40% to 60% of the intrahepatic lymphocyte pool compared to the peripheral blood compartment. In chronic HBV and HCV infection, NK cells were reported to be partially dysfunctional due to impaired IFN-Γ secretion. Few studies have examined phenotypic features of NK cells in acute hepatitis. We identified NK (CD56+CD3-) cell populations in patients with acute hepatitis by examining the expressions of phenotypic NK cell markers (CD16, NKG2A, and NKG2D). Peripheral blood mononuclear cells were isolated from patients with acute hepatitis A (7) and patients with non-viral acute toxic hepatitis (6) during the symptomatic and convalescent phases. Expressions of NK (CD56+CD3-) cell markers, CD16, NKG2A, and NKG2D, were measured by flow cytometry. Symptomatic acute hepatitis including non-viral hepatitis and HAV infection showed significant increases of NKG2A expression compared to healthy controls. Interestingly, there was a direct correlation between the proportion of NK cell populations and liver function parameters (AST, ALT) in HAV infection. The strong correlation was also observed between the expression of NKG2A+NK cells and ALT, which suggests that most of NK cells in severe phase of disease express high level of NKG2A on their surface. In addition, decreased number of NK cells (CD56+CD3-) in symptomatic phase began to increase in the convalescent phase of acute hepatitis A. However, the expression of NKG2A tended to be reduced, which indicates that NKG2A, the inhibitory receptor on NK cells, can be a severity parameter in acute hepatitis.

Seroepidemiology of hepatitis a in South Korea: a nationwide study by the Eone Reference Laboratory

Background

We evaluated the recent prevalence of serologic markers of hepatitis A virus (HAV) in South Korea.

Methods

The study data were the results of 60 126 anti-HAV (total) tests and 30 786 anti-HAV IgM tests that were performed during April 2009 through March 2010 by the Eone Reference Laboratory at the request of 1935 institutions throughout Korea.

Results

The overall positivity rate was 51.06% on the anti-HAV (total) test and 11.20% on the anti-HAV IgM test. As compared with the other age groups the rate of anti-HAV (total) positivity was significantly lower (P < 0.001), and the rate of anti-HAV IgM positivity was significantly higher (P < 0.001), among Koreans aged 11 to 40 years. The seroprevalence of anti-HAV IgM significantly differed according to region but not by referral date.

Conclusions

This was the largest nationwide study in South Korea by 1 laboratory, and it provides useful recent baseline data on hepatitis A in Asia. The findings suggest that active immunization of younger Koreans should be made a priority.

Eight-year seroprevalence of HBV, HCV and HIV in Diyarbakir training and research hospital

Distribution of HBV, HCV and HIV results of the inpatients or outpatients, who had been treated for various diagnoses in Diyarbakır Training and Research Hospital between 2005 and 2012, among years was investigated. Files of the patients, who had been treated as inpatient or outpatient 992. to any diagnosis between 01/01/2005 and 31/12/2012 in the clinics or policlinics of Diyarbakır 581 due Training and Research Hospital, were retrospectively reviewed using patient file database. Serum samples (235.534 for HBsAg, 196.727 for Anti-HBs antibody, 98.497 for HBeAg, 97.417 for Anti-HBe antibody, 225.483 for HCV and 138.923 for HIV) of these patients, which had been processed in microbiology laboratory, were studied by chemiluminescence technique using Roche E-170 (Modular Analytics System) device. Prevalence rates between 2005 and 2012 were as follows: 15.9%-9% for HBsAg, 32.9%-52.3% for Anti-HBs, 2.5%-1.8% for HBeAg, 30.4%-25.2% for Anti-HBe, 1%-0.7% for Anti-HCV, and 0.1%-1% for Anti-HIV. Increase in Anti-HBs prevalence is the successful outcome of routine immunization in population. This suggests that, governmental policies focused on this subject have resulted in successful outcomes and that people also take care about this. A prevalence rate decreasing to 9% from 15.9% for HBsAg and prevalence rate increasing to 52.3% from 32.9% for Anti-HBs antibody positivity in 8-year period in our region is quite meaningful. Such favorable developments in our region are of great valuable in terms of indicating to what extent could struggle against HBV is controlled by education and awareness.

The different etiology of fulminant hepatic failure (FHF) in Korea and prognostic factors in patients undergoing liver transplantation for FHF

BACKGROUND

The prognosis of fulminant hepatic failure (FHF) depends on the etiology and reversibility. In this study, we identified the etiological difference of FHF in Korea and analyzed the prognostic factors after liver transplantation (LT) for FHF.

METHODS

We retrospectively reviewed 42 patients with FHF who underwent LT from April 1999 to April 2011 at Samsung Medical Center, Seoul, Korea. The patients were categorized into two groups according to the short-term result of LT, and perioperative profiles were compared to identify the short-term poor prognostic factors.

RESULTS

Unlike Western countries, there was no paracetamol-related FHF but herbal/folk medicines were the most frequent causes of FHF (26.2%). HAV-related FHF increased significantly and comprised the main portion of FHF with Herbal/folk medicines after 2005. Encephalopathy grade, onset time, pre-transplantation need of renal replacement, and ventilator treatment were significantly different between groups in univariate analysis. In multivariate analysis, pre-transplantation renal replacement treatment and hepatic encephalopathy grade IV were the independent prognostic factors after LT.

CONCLUSIONS

The etiologies of FHF in Korea were different compared with Western reports. The requirement of renal replacement treatment and hepatic encephalopathy grade IV were identified as independent poor prognostic factors after LT for FHF in this study.

Type and cause of liver disease in Korea: single-center experience, 2005-2010

Background/Aims

The aim of this study was to describe the types and causes of liver disease in patients from a single community hospital in Korea between April 2005 and May 2010.

Methods

A cohort of patients who visited the liver clinic of the hospital during the aforementioned time period were consecutively enrolled (n=6,307). Consistent diagnostic criteria for each liver disease were set by a single, experienced hepatologist, and the diagnosis of all of the enrolled patients was confirmed by retrospective review of their medical records.

Results

Among the 6,307 patients, 528 (8.4%) were classified as acute hepatitis, 3,957 (62.7%) as chronic hepatitis, 767 (12.2%) as liver cirrhosis, 509 (8.1%) as primary liver cancer, and 546 (8.7%) as a benign liver mass or other diseases. The etiologies in the acute hepatitis group in decreasing order of prevalence were hepatitis A (44.3%), toxic hepatitis (32.4%), other hepatitis viruses (13.8%), and cryptogenic hepatitis (9.1%). In the chronic hepatitis group, 51.2% of cases were attributed to viral hepatitis, 33.3% to nonalcoholic fatty liver disease, and 13.0% to alcoholic liver disease (ALD). Of the cirrhoses, 73.4% were attributable to viral causes and 18.1% to alcohol. Of the hepatocellular carcinoma cases, 86.6% were attributed to viral hepatitis and 11.6% to ALD. Among the benign tumors, hemangioma comprised 52.2% and cystic liver disease comprised 33.7%.

Conclusions

Knowledge of the current status of the type and cause of liver disease in Korea may be valuable as a basis for evaluating changing trends in liver disease in that country.

Seroprevalence of anti-hepatitis E virus (HEV) in a Korean population: comparison of two commercial anti-HEV assays

Background

Hepatitis E virus (HEV) has emerged as an important cause of epidemic and sporadic acute viral hepatitis worldwide. This study investigated the seroprevalence of anti-HEV in a Korean population and compared the performance of two commercially available anti-HEV assays.

Methods

A total 147 health-check examinees were randomly sampled as matched to the age- and sex- adjusted standard population based on the Korean National Census of 2007. Serum immunoglobulin G anti-HEV was determined by using the Genelabs assay (Genelabs, Singapore) and the Wantai assay (Wantai, Beijing, China).

Results

The overall anti-HEV seroprevalence was 23.1% (95% CI, 16.1-30.1%) using the Wantai assay and 14.3% (95% CI, 8.3-20.3%) using the Genelabs assay. Only 12 samples (8.1%) were positive for anti-HEV as measured by both assays; agreement between the two assays was poor (kappa value of 0.315). The anti-HEV seroprevalence increased with age from 2% and 3% in the people younger than 20-years-of-age to 34.6% and 42.3% in those over 59-years-of-age by the Genelabs and Wantai assay, respectively.

Conclusions

The HEV seroprevalence in Korean population is about 20% overall, with seroprevalence increasing in this population with increasing age. There was poor concordance in the results of the Genelabs and Wantai assays, which warrants further study concerning a reliable diagnostic test for the diagnosis of hepatitis E.

Pattern of hepatitis a incidence according to area characteristics using national health insurance data

Objectives

Over the past several years, the incidence of hepatitis A infection has been increasing rapidly in the young-adult population in Korea. We examined the effects of area-level socioeconomic status and environmental hygiene on the incidence of hepatitis A.

Methods

This study is based on the registered national population of Korea and the national health insurance data from 2004 to 2008. A total of 73 459 individuals were confirmed to have had hepatitis A. The standardized incidences of hepatitis A in 232 districts adjusted for sex and age of people were calculated for each year, and the rate ratios of the incidence rates were estimated according to area-level socioeconomic status and environmental hygiene using multiple Poisson regression models.

Results

The incidence rates of hepatitis A infection were 15.6 (per 100 000) in 2004, 19.0 (per 100 000) in 2005, 27.2 (per 100 000) in 2006, 25.1 (per 100 000) in 2007, and 61.7 (per 100 000) in 2008. The analysis of the area-level effects showed that residential areas of the less deprived than other regions, areas with higher levels of education, and heavily populated areas were significantly associated with increased risk.

Conclusions

There is a very strong possibility that both area-level socioeconomic status and environmental hygiene play a role in increasing the risk of hepatitis A infection in Korea. Therefore, to reduce hepatitis A infection, we need a nationwide strategy that considers these area-level characteristics.

Coinfection of hepatitis A virus genotype IA and IIIA complicated with autoimmune hemolytic anemia, prolonged cholestasis, and false-positive immunoglobulin M anti-hepatitis E virus: a case report

A 37-year-old male presented with fever and jaundice was diagnosed as hepatitis A complicated with progressive cholestasis and severe autoimmune hemolytic anemia. He was treated with high-dose prednisolone (1.5 mg/kg), and eventually recovered. His initial serum contained genotype IA hepatitis A virus (HAV), which was subsequently replaced by genotype IIIA HAV. Moreover, at the time of development of hemolytic anemia, he became positive for immunoglobulin M (IgM) anti-hepatitis E virus (HEV). We detected HAV antigens in the liver biopsy specimen, while we detected neither HEV antigen in the liver nor HEV RNA in his serum. This is the first report of hepatitis A coinfected with two different genotypes manifesting with autoimmune hemolytic anemia, prolonged cholestasis, and false-positive IgM anti-HEV.

Rapid increase in the national treatment costs for hepatitis A infections in Korea

The number of symptomatic hepatitis A cases has progressively been increasing during the last several years in Korea. Available cost estimates indicate a growing burden to the public. The purpose of this study was to determine the extent of treatment costs for patients with hepatitis A and to analyze the influential factors with nationwide data. We collected data on 72,921 patients with hepatitis A from 5-year National Health Insurance claim archives between 2004 and 2008. Multiple regression analyses were conducted to examine influential factors affecting treatment costs for hepatitis A. Total treatment costs for patients with hepatitis A during the 5-year period were US$47,902,087 and increased significantly each year. In total, 91.4% of treatment costs were used for hospitalization, and the proportion of inpatients increased gradually throughout the study period. The most influential factor on treatment costs was treatment duration. Our results show that the soaring number of patients with hepatitis A followed by the hospitalization-focused treatment practice is a major factor associated with the rapid increase in treatment costs. Appropriate policies should be promptly developed to control treatment costs and economic burden of hepatitis A infections.

Optimal time for repeating the IgM anti-hepatitis A virus antibody test in acute hepatitis A patients with a negative initial test

BACKGROUND/AIMS

The nonspecific clinical presentation of acute hepatitis A (AHA) mandates the detection of anti-hepatitis A virus IgM antibodies (IgM anti-HAV) in the serum for obtaining a definitive diagnosis. However, IgM anti-HAV might not be present during the early phase of the disease. The aim of this study was to determine the optimal time for repeating the IgM anti-HAV test (HAV test) in AHA patients with a negative initial test.

METHODS

In total, 261 patients hospitalized with AHA were enrolled for this retrospective study. AHA was diagnosed when the test for IgM anti-HAV was positive and the serum alanine aminotransferase (ALT) level was ≥400 IU/L. Repeat HAV test was conducted after 1-2 weeks if the initial HAV test was negative but AHA was still clinically suspected.

RESULTS

The results of the initial HAV test were negative in 28 (10.7%) patients. The intervals from symptom onset to the initial-HAV-test day and from the peak-ALT day to the initial-HAV-test day were significantly shorter in the negative-initial-HAV-test group, but on multivariate analysis only the latter was significantly associated with negative results for the initial HAV test (β=-0.978; odds ratio [95% confidence interval]=0.376 [0.189-0.747]; P=0.005). The HAV test was positive in all patients when it was performed at least 2 days after the peak-ALT day.

CONCLUSIONS

The results of HAV tests were significantly associated with the interval from the peak-ALT day to the HAV-test day. The optimal time for repeating the HAV test in clinically suspicious AHA patients with a negative initial HAV test appears to be at least 2 days after the peak-ALT day.

Fatal outbreaks of jaundice in pregnancy and the epidemic history of hepatitis E

Space-time clustering of people who fall acutely ill with jaundice, then slip into coma and death, is an alarming phenomenon, more markedly so when the victims are mostly or exclusively pregnant. Documentation of the peculiar, fatal predisposition of pregnant women during outbreaks of jaundice identifies hepatitis E and enables construction of its epidemic history. Between the last decade of the 18th century and the early decades of the 20th century, hepatitis E-like outbreaks were reported mainly from Western Europe and several of its colonies. During the latter half of the 20th century, reports of these epidemics, including those that became serologically confirmed as hepatitis E, emanated from, first, the eastern and southern Mediterranean littoral and, thereafter, Southern and Central Asia, Eastern Europe, and the rest of Africa. The dispersal has been accompanied by a trend towards more frequent and larger-scale occurrences. Epidemic and endemic hepatitis E still beset people inhabiting Asia and Africa, especially pregnant women and their fetuses and infants. Their relief necessitates not only accelerated access to potable water and sanitation but also vaccination against hepatitis E.

Clinical features of acute viral hepatitis B in Korea: a multi-center study

BACKGROUND/AIMS

The incidence of Hepatitis B has significantly declined since the introduction of an HBV vaccination program. The aim of this study was to investigate recent clinical features of acute viral hepatitis B (AVH-B) in Korea.

METHODS

A total of 2241 patients with acute viral hepatitis were enrolled and their data were collected from nine medical-centers between January 2006 and December 2009.

RESULTS

One hundred nineteen (5.3%) of the 2241 were diagnosed as AVH-B. Among 78 patients with AVH-B whose data were analyzed, 50 were male, and the mean age was 38.6 years. In an initial test, mean AST, ALT and total-bilirubin levels were 1296.2 IU/L, 2109.6 IU/L and 9.3 mg/dl, respectively. Positivity frequencies for HBeAg and anti-HBe were 55.1% and 67.9%, respectively, and the mean HBV DNA level was 5.2 log10 copies/ml. The mean length of hospitalization was 11.6 days. During follow-up, AST, ALT and total bilirubin levels were normalized or near-normalized in all patients without serious complications. Sixty-three of 66 (95.4%) patients showed HBsAg loss and 37 (56.1%) patients showed HBsAg seroconversion. Only 3 patients (4.5%) showed persistent hepatitis B viremia. There was no case of death or liver transplantation. Nine patients (11.3%) had received anti-viral agents and their clinical outcomes were not significantly different from those of patients treated without antiviral agents.

CONCLUSIONS

The prevalence of AVH-B among acute hepatitis patients is relatively low in Korea. AVH-B infection can be cured without complications in almost all patients, regardless of antiviral treatment.

Comparison of the Clinical Features of Hepatitis A between HBsAg-Positive and HBsAg-Negative Patients

BACKGROUND/AIMS

The notion that acute hepatitis A superimposed on chronic hepatitis B infection leads to a worse outcome than acute hepatitis A alone remains controversial. The aim of this study was to determine the influence of the presence of hepatitis B surface antigen (HBsAg) on the severity of acute hepatitis A.

METHODS

We retrospectively analyzed 449 patients hospitalized for acute hepatitis A from January 2000 to February 2010 and compared clinical outcomes based on the presence of HBsAg.

RESULTS

Of the 449 patients, 30 patients were in the HBsAg-positive group and 419 in the HBsAg-negative group. The HBsAg-positive group was older than the HBsAg-negative group (36.1±8.3 vs 31.8±8.5 years, p=0.004); however, other baseline characteristics were similar between the 2 groups. Mean peak values of prothrombin time, serum total bilirubin, and serum creatinine at admission were significantly higher in the HBsAg-positive group. When comparing clinical outcomes between the 2 groups, gastrointestinal bleeding, acute renal failure, and acute liver failure were more frequently observed in the HBsAg-positive group. In particular, the incidence of acute liver failure was approximately 9-fold higher in the HBsAg-positive group than in the HBsAg-negative group (23.3% vs 3.3%; odds ratio [OR], 8.80; p<0.001). Multivariate analysis showed that HBsAg (OR, 7.43; 95% confidence interval [CI], 2.56 to 21.57) and age (OR, 1.07; 95% CI, 1.02 to 1.13) were independent risk factors for the occurrence of acute liver failure.

CONCLUSIONS

In patients with chronic hepatitis B infection, acute hepatitis A is associated with more severe clinical outcomes, including acute liver failure, compared with patients with acute hepatitis A alone.

Coexistence of IgM antihepatitis A virus and IgM antihepatitis E virus in acute viral hepatitis: a prospective, multicentre study in Korea

This study investigated the clinical, serological and molecular characteristics of coexistence of both immunoglobulin M (IgM) antihepatitis A virus (HAV) and IgM antihepatitis E virus (HEV) in acute viral hepatitis using a prospective, multicentre design. Among a total of 771 symptomatic cases with acute viral hepatitis enrolled in a Korean city from September 2006 to August 2008, coexistence of IgM anti-HAV and IgM anti-HEV was found in 43 patients (A+E group; 6%), while the existence of IgM anti-HAV alone was found in 595 patients (A group; 77%) and that of IgM anti-HEV alone in 14 patients (E group; 2%). Clinical data analysis and measurement of IgM and IgG anti-HEV were performed using two different commercial kits, and HAV RNA and HEV RNA were detected in available serum or stool samples. The clinical features of the A+E group were similar to those of the A group. HAV RNA detection rates in the A+E and A group were similar, while HEV RNA was detected only in the stool samples of the E group, not in the A+E group. Comparative testing of anti-HEV using two different ELISA kits showed markedly discordant results for IgM anti-HEV positivity and consistently low positivity for IgG anti-HEV in the A+E group. Coexistence of IgM anti-HEV measured by the Genelabs ELISA kit in the setting of hepatitis A appears to yield false-positive results in nonendemic areas of HEV infection. Diagnosis of hepatitis E using IgM anti-HEV should be made with caution.

[Clinical features and predictive factors of acute hepatitis A complicated with acute kidney injury]

BACKGROUND/AIMS

we assessed the clinical features and prognosis of acute viral hepatitis A (AHA) complicated with acute kidney injury (AKI) and elucidated predictive factors for AKI in patients with AHA.

METHODS

we reviewed medical record of 391 patients with AHA admitted at our institution since 2000.

RESULTS

AKI was present in 45 patients (11.5%). The proportion of the AKI group increased since 2008 (5.4% before 2008 vs. 15.9% since 2008, p=0.001). The AKI group was older than the non-AKI group (35.7+/-8.7 years vs. 31.3+/-7.8 years, p=0.002). Other baseline clinical characteristics were similar between two groups. Initial hemoglobin, platelet, and serum albumin were significantly low and prothrombin time, serum bilirubin, creatinine, AST, and ALT were significantly high in the AKI group. Hepatic encephalopathy, ascites, gastrointestinal bleeding, and sepsis were more frequently observed in the AKI group. While six patients (13%) in the AKI group received liver transplantation (LT) but three patients died within one month, one patient in the non-AKI group receiving LT is alive. Multivariate analysis showed that older age (OR 1.07, 95% CI 1.02-1.12), initial thrombocytopenia <150,000/mm2 (OR 2.85, 95% CI 1.24-6.57), prothrombin time (PT) prolongation (OR 5.34, 95% CI 2.55-11.19), and hypoalbuminemia (OR 8.24, 95% CI 2.53-26.86) were independently associated with the occurrence of AKI.

CONCLUSIONS

AHA with AKI is an increasing problem showing significant morbidity and mortality in Korea. AKI is highly associated with older age, initial thrombocytopenia, PT prolongation, or low serum albumin, and has bad prognostic effect.

Factors for predicting positive results for anti-HAV IgM retesting among initially seronegative patients

BACKGROUND AND AIMS

The standard diagnostic tool for acute hepatitis A is detection of anti-hepatitis A virus (HAV) immunoglobulin M (IgM). However, a negative result for anti-HAV IgM can be obtained in the early phase of infection. Among clinically suspicious seronegative patients, diagnosis of hepatitis A is sometimes recorded on retesting.

PATIENTS AND METHODS

This study included patients who had attended the Kyung Hee University East-West Neo Medical Center from November 2006 to October 2008. We evaluated 27 patients (15 men, 12 women) who had undergone repeated anti-HAV IgM testing.

RESULTS

Thirteen patients were diagnosed with hepatitis A after retesting, and 14 with non-hepatitis A (non-HA). High initial cutoff index (COI) for anti-HAV IgM (≥0.5), low serum total bilirubin (<1.4 mg/dl), and low platelet count (<165 × 10(3)/μl) were related to a positive result for anti-HAV IgM retesting, although this association was not statistically significant on multivariate analysis. In the HA group, 7 of 13 patients had an initial COI for anti-HAV IgM of >0.5 compared with none of 14 patients in the non-HA group.

CONCLUSIONS

Initial COI for anti-HAV IgM, serum total bilirubin, and platelet count were helpful for predicting positive results for retesting among initially seronegative patients.

[An epidemiological analysis of hepatitis A virus serologic markers during the recent four years in Korea]

BACKGROUND

To establish effective preventive measures for hepatitis A virus (HAV) infection, a nationwide epidemiologic study on seroprevalence of anti-HAV and the disease prevalence is needed. The aim of this study was to analyze the recent sero-epidemiological changes of hepatitis A markers in Korea.

METHODS

The results of 11,068 anti-HAV total and 32,360 anti-HAV IgM tests by electro-chemiluminescence immunoassay (ECLIA) that had been requested in recent four years (2005-2008) to a reference medical laboratory from 1,699 institutions nationwide were retrospectively analyzed according to the distribution of year, sex, and age groups.

RESULTS

The overall positive rate of anti-HAV total was 62.8%. The overall positive rate of anti-HAV IgM was 11.0%, showing a significantly increasing trend by year: 7.7%, 10.9%, 8.9%, and 14.3% in 2005, 2006, 2007, and 2008, respectively (P<0.0001). The positive rate of anti-HAV IgM was higher in male than in female subjects (11.8% vs 10.0%, P<0.0001), and 81.8% (2,916/3,566) of the anti-HAV IgM positive results were observed in the age groups of 21-40 yr. The annual positive rates of anti-HAV total and anti-HAV IgM showed significantly decreasing and increasing trends, respectively, in the age groups of > or = 21 yr.

CONCLUSION

In accordance with a decreasing sero-positivity of anti-HAV total, the prevalence of acute hepatitis A virus infection has been considerably increased during the recent four years in the age groups of > or = 21 yr. The results of this study could be used effectively as a basic data for establishing effective preventive measures for hepatitis A including vaccination in these susceptible age groups.

Current status of liver diseases in Korea: hepatitis B

Hepatitis B virus (HBV) infection is the one of the most common causes of the liver diseases in Korea. Since the discovery of Australia antigen (hepatitis associated antigen, or HBsAg later), hepatitis associated antigen was tested widely. HBsAg was detected in 6.6-8.6% in 1980's. Later, it decreased to 5.7% in 1990's. Remarkably, seropositivity of the children deceased to 0.2% after the nationwide vaccination program. Although hepatitis B vaccines are highly effective, the failure rate of perinatal prophylaxis in babies born to HBsAg positive mother was reported to be 4.25%. Treatment of chronic hepatitis B was initiated after the introduction of interferon alpha. Lamivudine opened a new era of oral antiviral agent, and it has been widely used in Korea since 1999. Adefovir was proven to have a good efficacy for lamivudine-resistant chronic hepatitis B. Newer potent antiviral agents such as entecavir, clevudine, and telbivudine are available currently. Further studies are warranted for understanding factors influencing natural history, improving treatment outcomes, and overcoming vaccine non-response.

Analysis of complete genome sequences of swine hepatitis E virus and possible risk factors for transmission of HEV to humans in Korea

The hepatitis E virus (HEV) is an emerging zoonotic agent, for which pigs are the most important reservoir. Complete genome sequences of two swine HEV strains, designated swKOR-1 and swKOR-2, were determined via RT-PCR and RACE-PCR. The strains contained genomes composed of 7,222- and 7,221-bp excluding the poly(A) tails, respectively. The swKOR-1 and swKOR-2 strains were classified into subtype 3a of genotype 3 via phylogenetic analysis. These strains formed a distinctive cluster in the phylogenetic tree with human and swine HEVs isolated in the USA and human HEVs isolated in Japan. Anti-HEV antibodies were identified via ELISA in 8 of 99 (8.1%) cats, whereas, among 115 cattle and 213 dogs, no HEV-specific antibodies were detected. The conserved RNA-dependent RNA polymerase (RdRp) gene of HEV could be detected via RT-PCR in 8.7% of raw oysters collected from coastal regions in Korea. The HEV RNAs detected in oysters were identified as belonging to subtype 3a. The HEV RNAs in oysters most closely resembled that of the swKOR-2 strain. They also showed a close genetic relationship with the swKOR-1 strain and the swine and human HEVs isolated in the USA. This is the first report describing the detection in oysters of HEV that may have originated from genotype 3 swine HEV in Korea. Pigs and cats infected with HEV, as well as oysters contaminated with HEV, are potential risk factors for HEV transmission to humans.

[Changes in liver stiffness after acute or chronic liver injury due to viral hepatitis--does fibrosis exist after recovery from acute viral hepatitis?]

BACKGROUND/AIMS

Liver stiffness (LS) measurement by transient elastography can estimate the degrees of liver fibrosis in patients with chronic liver disease. However, longitudinal data of LS after recovery of acute viral hepatitis are still lacking. In the present study, we aimed to evaluate among LS of patients at various stages of viral hepatitis and normal control.

METHODS

Patients who had admitted at Korea University Ansan Hospital between January 2006 and January 2007 due to acute viral hepatitis and recovered were recruited (group A, n=22). We compared the liver biochemistry and LS of group A with those of healthy control group (group B, n=23), current acute viral hepatitis group (group C, n=49), and chronic viral hepatitis group (group D, n=66).

RESULTS

Mean ALT, total bilirubin, and LS level of group A were not different from group B (p=0.318, p=0.116, p=0.125, respectively). However, group A had lower ALT, total bilirubin, and LS values compared to group C (all p<0.001), and lower ALT and LS values compared to group D (p=0.007, p<0.001). The mean total bilirubin was not significantly different from group D (p=0.117).

CONCLUSIONS

Our data suggest that liver fibrosis is a long-term sequela of chronic hepatitis, and not developed in patients who recovered from acute viral hepatitis.

[A case of rhabdomyolysis during hospitalization for acute hepatitis A]

A 29-year-old man was admitted to hospital with fever, myalgia, and sore throat. Initial laboratory findings were compatible with acute hepatitis; he was positive for the serologic marker for acute hepatitis A. On the 3rd day of admission, in spite of normalization of body temperature and a reduction in serum liver enzyme levels, serum levels of creatinine phosphokinase had increased up to 16,949 U/L. The patient recovered with supportive therapy and was discharged on the 12th day. We report a case of acute hepatitis A complicated by rhabdomyolysis during hospitalization.

[Clinical outcomes and predictive factors of spontaneous survival in patients with fulminant hepatitis A]

BACKGROUNDS/AIMS

The occurrence of acute hepatitis A is increasing and its progression to fulminant hepatic failure (FHF) is frequent. We investigated the frequency and clinical outcomes of fulminant hepatitis A and also analyzed the predictive factors of spontaneous survival.

METHODS

A total of 568 patients presented with acute hepatitis A from January 2003 to June 2008, of which the 35 (6.2%) patients with FHF were divided into two groups: spontaneous survival and transplant/death. These two groups were compared according to various clinical features including the MELD score and King's College Hospital (KCH) criteria.

RESULTS

The rate of FHF development increased over time among patients with acute hepatitis A: 0% in 2003, 3.4% in 2004, 3.2% in 2005, 6.0% in 2006, 7.7% in 2007, and 13.0% in 2008. Twenty patients (57.1%) showed spontaneous survival, 13 (37.1%) received liver transplantation, and 5 (14.3%) died during hospitalization. The two groups of spontaneous survival (N=20) and transplant/death (N=15) showed significant differences in prothrombin time at admission and at its worst value, albumin at its worst value, and hepatic encephalopathy grade at admission and at its worst value. The MELD score was lower in the spontaneous-survival group than in the transplant/death group (27.0+/-7.8 vs. 37.0+/-7.1, mean+/-SD; P=0.001). However, KCH criteria did not differ significantly between the two groups. On multivariate analysis, HEP grade was the only significant predictive factor, being negatively correlated with spontaneous survival (OR=0.068, P=0.025).

CONCLUSIONS

FHF due to hepatitis A has increased in recent years, and in our cohort the HEP grade was closely associated with spontaneous survival.