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Leow YW, Chan WK, Goh GBB, Wong VWS, Fan JG, Kim YS, Kim SU, Nakajima A, Seto WK, Lee IC, Huang YH, Kim YJ, Young JJ, Chow WC. Hepatic steatosis and metabolic risk factors among patients with chronic hepatitis B: The multicentre, prospective CAP-Asia study. J Viral Hepat 2023; 30:319-326. [PMID: 36606597 DOI: 10.1111/jvh.13796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023]
Abstract
We aimed to compare the severity of liver disease, metabolic profile and cardiovascular disease (CVD) risk of chronic hepatitis B (CHB) patients with and without hepatic steatosis and patients with non-alcoholic fatty liver disease (NAFLD). Patients with NAFLD and CHB were prospectively enrolled from 10 Asian centres. Fibroscan was performed for all patients and hepatic steatosis was defined based on controlled attenuation parameter >248 dB/m. CVD risk was assessed using the Framingham risk score. The data for 1080 patients were analysed (67% NAFLD, 33% CHB). A high proportion (59%) of CHB patients had hepatic steatosis. There was a significant stepwise increase in alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transpeptidase, controlled attenuation parameter and liver stiffness measurement, from CHB patients without hepatic steatosis to CHB patients with hepatic steatosis to NAFLD patients (p < 0.001 for all comparisons). There was a significant stepwise increase in the proportion of patients with metabolic syndrome and in CVD risk, with very high or extreme CVD risk seen in 20%, 48% and 61%, across the groups (p < 0.001 between CHB patients with and without hepatic steatosis and p < 0.05 between CHB patients with hepatic steatosis and NAFLD patients). In conclusion, there was a high proportion of CHB patients with hepatic steatosis, which should be diagnosed, as they may have more severe liver disease, so that this and their metabolic risk factors can be assessed and managed accordingly for a better long-term outcome.
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Affiliation(s)
- Yong-Wen Leow
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wah-Kheong Chan
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - George Boon-Bee Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Jian Gao Fan
- Department of Gastroenterology and Hepatology, Shanghai Jiaotong University School of Medicine Xinhua Hospital, Shanghai, China
| | - Young Seok Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SoonChunHyang University, Bucheon Hospital, Bucheon-si, Korea
| | - Seung Up Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Seoul, Korea
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - I-Cheng Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yoon Jun Kim
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | | | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
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2
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Lin KW, Kumar R, Shen F, Chan HLY, Wong GLH, Kumar R, Chow WC, Lin S, Wong VWS, Fan JG, Goh GBB. The utility of non-invasive tests to assess advanced fibrosis in Asian subjects with chronic hepatitis B and concomitant hepatic steatosis. Liver Int 2023; 43:1008-1014. [PMID: 36855842 DOI: 10.1111/liv.15541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 01/11/2023] [Accepted: 02/07/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Chronic hepatitis B (CHB) is endemic to Asia and is a leading cause of liver-related morbidity. The prevalence of concomitant CHB and hepatic steatosis (HS) is increasing in Asia. Non-invasive tests (NITs) including FIB-4, NFS and APRI assess fibrosis in populations with a single aetiology, but not in subjects with concomitant CHB and HS. AIM To explore the accuracy of NITs in predicting advanced fibrosis in patients with concomitant CHB and HS. METHODOLOGY This multicentre study of CHB patients who underwent liver biopsy explored clinical characteristics of these subjects, stratified by presence of HS. Fibrosis scores from NITs were compared against histological fibrosis stage in CHB subjects with and without HS. RESULTS 2262 subjects were enrolled, 74.5% were males, and the mean age was 39.5 years ±11.8 SD. 984 (44.4%) had HS, 824 (36.4%) had advanced fibrosis. In the CHB group, the AUROC for advanced fibrosis were 0.65 (95% CI 0.62-0.69) for FIB-4 and 0.63 (95% CI 0.60-0.66) for APRI. The specificities were 0.94 for FIB-4 greater than 3.25 and 0.81 for APRI greater than 1.5. In the CHBHS group, the AUROC for advanced fibrosis were 0.67 (95% CI 0.63-0.71) for FIB-4, 0.60 (95% CI 0.56-0.64) for APRI and 0.65 (95% CI 0.61-0.69) for NFS. The specificities were 0.95 for FIB-4 greater than 3.25, 0.88 for APRI greater than 1.5 and 0.99 for NFS greater than 0.675. CONCLUSION The performance of NITs to exclude advanced fibrosis did not differ greatly regardless of HS. FIB-4 and NFS have the best negative predictive values of 0.80 and 0.78, respectively, to exclude advanced fibrosis in CHBHS subjects.
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Affiliation(s)
- Kenneth W Lin
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Feng Shen
- Department of Gastroenterology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Henry L-Y Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Department of Internal Medicine, Union Hospital, Hong Kong, Hong Kong
| | - Grace L-H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.,Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Su Lin
- Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Clinical Research Center for Liver and Intestinal Diseases of Fujian Province, Fuzhou, China
| | - Vincent W-S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Jian-Gao Fan
- Department of Gastroenterology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - George B-B Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Academic Medical Centre, Singapore, Singapore
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3
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Ding R, Morvil G, Goh BBG, Krishnamoorthy TL, Chia PY, Tan HK, Ekstrom VSM, Cheah CCM, Tan JYT, Teo PSE, Chang PEJ, Tan CK, Xin X, Chow WC, Kumar R. Perception of disease, well-being and financial burden by patients with chronic hepatitis B: A self-reported assessment. Ann Acad Med Singap 2022; 51:378-380. [PMID: 35786760 DOI: 10.47102/annals-acadmedsg.202216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Ruojun Ding
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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4
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Lee JWJ, Zhu F, Srivastava S, Tsao SKK, Khor C, Ho KY, Fock KM, Lim WC, Ang TL, Chow WC, So JBY, Koh CJ, Chua SJ, Wong ASY, Rao J, Lim LG, Ling KL, Chia CK, Ooi CJ, Rajnakova A, Yap WM, Salto-Tellez M, Ho B, Soong R, Chia KS, Teo YY, Teh M, Yeoh KG. Severity of gastric intestinal metaplasia predicts the risk of gastric cancer: a prospective multicentre cohort study (GCEP). Gut 2022; 71:854-863. [PMID: 33975867 PMCID: PMC8995828 DOI: 10.1136/gutjnl-2021-324057] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/15/2021] [Accepted: 04/30/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the incidence of gastric cancer (GC) attributed to gastric intestinal metaplasia (IM), and validate the Operative Link on Gastric Intestinal Metaplasia (OLGIM) for targeted endoscopic surveillance in regions with low-intermediate incidence of GC. METHODS A prospective, longitudinal and multicentre study was carried out in Singapore. The study participants comprised 2980 patients undergoing screening gastroscopy with standardised gastric mucosal sampling, from January 2004 and December 2010, with scheduled surveillance endoscopies at year 3 and 5. Participants were also matched against the National Registry of Diseases Office for missed diagnoses of early gastric neoplasia (EGN). RESULTS There were 21 participants diagnosed with EGN. IM was a significant risk factor for EGN (adjusted-HR 5.36; 95% CI 1.51 to 19.0; p<0.01). The age-adjusted EGN incidence rates for patients with and without IM were 133.9 and 12.5 per 100 000 person-years. Participants with OLGIM stages III-IV were at greatest risk (adjusted-HR 20.7; 95% CI 5.04 to 85.6; p<0.01). More than half of the EGNs (n=4/7) attributed to baseline OLGIM III-IV developed within 2 years (range: 12.7-44.8 months). Serum trefoil factor 3 distinguishes (Area Under the Receiver Operating Characteristics 0.749) patients with OLGIM III-IV if they are negative for H. pylori. Participants with OLGIM II were also at significant risk of EGN (adjusted-HR 7.34; 95% CI 1.60 to 33.7; p=0.02). A significant smoking history further increases the risk of EGN among patients with OLGIM stages II-IV. CONCLUSIONS We suggest a risk-stratified approach and recommend that high-risk patients (OLGIM III-IV) have endoscopic surveillance in 2 years, intermediate-risk patients (OLGIM II) in 5 years.
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Affiliation(s)
- Jonathan W J Lee
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore,Department of Medicine, National University of Singapore, Singapore,Singapore Gastric Cancer Consortium, Singapore
| | - Feng Zhu
- Department of Medicine, National University of Singapore, Singapore,Singapore Gastric Cancer Consortium, Singapore
| | | | - Stephen KK Tsao
- Department of Gastroenterology & Hepatology, Tan Tock Seng Hospital, Singapore
| | - Christopher Khor
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Khek Yu Ho
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore,Department of Medicine, National University of Singapore, Singapore
| | - Kwong Ming Fock
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
| | - Wee Chian Lim
- Department of Gastroenterology & Hepatology, Tan Tock Seng Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Jimmy Bok Yan So
- Singapore Gastric Cancer Consortium, Singapore,Department of Surgery, National University of Singapore, Singapore
| | - Calvin J Koh
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore,Department of Medicine, National University of Singapore, Singapore,Singapore Gastric Cancer Consortium, Singapore
| | - Shijia Joy Chua
- Department of Medicine, National University of Singapore, Singapore
| | | | - Jaideepraj Rao
- Department of Surgery, Tan Tock Seng Hospital, Singapore
| | | | | | | | | | - Andrea Rajnakova
- Andrea's Digestive, Colon, Liver and Gallbladder Clinic Pte Ltd, Singapore
| | - Wai Ming Yap
- Department of Pathology, Tan Tock Seng Hospital, Singapore
| | - Manuel Salto-Tellez
- Precision Medicine Centre of Excellence, Queen's University Belfast, Belfast, UK,Integrated Pathology Unit, Institute of Cancer Research, London, UK
| | - Bow Ho
- Department of Microbiology, National University of Singapore, Singapore
| | - Richie Soong
- Cancer Science Institute of Singapore, National University of Singapore, Singapore,Department of Pathology, National University of Singapore, Singapore,Pascific Laboratories, Singapore
| | - Kee Seng Chia
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Yik Ying Teo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Ming Teh
- Singapore Gastric Cancer Consortium, Singapore,Department of Pathology, National University of Singapore, Singapore
| | - Khay-Guan Yeoh
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore .,Department of Medicine, National University of Singapore, Singapore.,Singapore Gastric Cancer Consortium, Singapore
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5
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Hafezi M, Lin M, Chia A, Chua A, Ho ZZ, Fam R, Tan D, Aw J, Pavesi A, Krishnamoorthy TL, Chow WC, Chen W, Zhang Q, Wai LE, Koh S, Tan AT, Bertoletti A. Immunosuppressive Drug-Resistant Armored T-Cell Receptor T Cells for Immune Therapy of HCC in Liver Transplant Patients. Hepatology 2021; 74:200-213. [PMID: 33249625 DOI: 10.1002/hep.31662] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS HBV-specific T-cell receptor (HBV-TCR) engineered T cells have the potential for treating HCC relapses after liver transplantation, but their efficacy can be hampered by the concomitant immunosuppressive treatment required to prevent graft rejection. Our aim is to molecularly engineer TCR-T cells that could retain their polyfunctionality in such patients while minimizing the associated risk of organ rejection. APPROACH AND RESULTS We first analyzed how immunosuppressive drugs can interfere with the in vivo function of TCR-T cells in liver transplanted patients with HBV-HCC recurrence receiving HBV-TCR T cells and in vitro in the presence of clinically relevant concentrations of immunosuppressive tacrolimus (TAC) and mycophenolate mofetil (MMF). Immunosuppressive Drug Resistant Armored TCR-T cells of desired specificity (HBV or Epstein-Barr virus) were then engineered by concomitantly electroporating mRNA encoding specific TCRs and mutated variants of calcineurin B (CnB) and inosine-5'-monophosphate dehydrogenase (IMPDH), and their function was assessed through intracellular cytokine staining and cytotoxicity assays in the presence of TAC and MMF. Liver transplanted HBV-HCC patients receiving different immunosuppressant drugs exhibited varying levels of activated (CD39+ Ki67+ ) peripheral blood mononuclear cells after HBV-TCR T-cell infusions that positively correlate with clinical efficacy. In vitro experiments with TAC and MMF showed a potent inhibition of TCR-T cell polyfunctionality. This inhibition can be effectively negated by the transient overexpression of mutated variants of CnB and IMPDH. Importantly, the resistance only lasted for 3-5 days, after which sensitivity was restored. CONCLUSIONS We engineered TCR-T cells of desired specificities that transiently escape the immunosuppressive effects of TAC and MMF. This finding has important clinical applications for the treatment of HBV-HCC relapses and other pathologies occurring in organ transplanted patients.
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Affiliation(s)
- Morteza Hafezi
- Emerging Infectious Diseases Program, Duke-NUS Medical School, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Meiyin Lin
- Emerging Infectious Diseases Program, Duke-NUS Medical School, Singapore, Singapore.,Institute of Molecular and Cell Biology, Agency for Science and Technology, Singapore, Singapore
| | - Adeline Chia
- Emerging Infectious Diseases Program, Duke-NUS Medical School, Singapore, Singapore
| | | | | | - Royce Fam
- Lion TCR Pte Ltd, Singapore, Singapore
| | - Damien Tan
- Institute of Molecular and Cell Biology, Agency for Science and Technology, Singapore, Singapore
| | - Joey Aw
- Institute of Molecular and Cell Biology, Agency for Science and Technology, Singapore, Singapore
| | - Andrea Pavesi
- Institute of Molecular and Cell Biology, Agency for Science and Technology, Singapore, Singapore
| | | | - Wan Cheng Chow
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Wenjie Chen
- Department of Biotherapy, The Third Affiliated Hospital of Sun Yat-Sen University, Guandong, China
| | - Qi Zhang
- Department of Biotherapy, The Third Affiliated Hospital of Sun Yat-Sen University, Guandong, China
| | - Lu-En Wai
- Lion TCR Pte Ltd, Singapore, Singapore.,Singapore Immunology Network, Agency for Science and Technology, Singapore, Singapore
| | - Sarene Koh
- Lion TCR Pte Ltd, Singapore, Singapore.,Singapore Immunology Network, Agency for Science and Technology, Singapore, Singapore
| | - Anthony T Tan
- Emerging Infectious Diseases Program, Duke-NUS Medical School, Singapore, Singapore
| | - Antonio Bertoletti
- Emerging Infectious Diseases Program, Duke-NUS Medical School, Singapore, Singapore.,Singapore Immunology Network, Agency for Science and Technology, Singapore, Singapore
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6
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Kumar R, Chan KP, Ekstrom VSM, Wong JCC, Lim KL, Ng WC, Woo SM, Chan KS, Thangaraju S, Kee TYS, Gan SSW, Foo MWY, Oon LLE, Chow WC. Hepatitis C virus antigen detection is an appropriate test for screening and early diagnosis of hepatitis C virus infection in at-risk populations and immunocompromised hosts. J Med Virol 2021; 93:3738-3743. [PMID: 32797627 DOI: 10.1002/jmv.26433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 12/11/2022]
Abstract
Early diagnosis remains key for effective prevention and treatment. Unfortunately, current screening with anti-hepatitis C virus antibody (anti-HCV Ab) test may have limited utility in the diagnosis of HCV infection and reinfection. This is of special concern to at-risk population, such as immunocompromised hosts and end-stage renal failure patients on hemodialysis. HCV antigen (Ag) could be useful in identifying the ongoing infection in such clinical scenarios. Hence, we aimed to study the utility of HCV Ag testing for the diagnosis of acute and chronic hepatitis C. Of 89 samples studied, 19 were from acute hepatitis C patients who were immunocompromised or were on hemodialysis, 43 were from active chronic hepatitis C patients and 27 were from patients treated for chronic hepatitis C. All samples were tested for HCV Ag using the Abbott ARCHITECT HCV Ag assay. HCV Ag was reactive in 19/19 samples from acute hepatitis C patients and 42/43 samples from active chronic hepatitis C patients. It was nonreactive in all samples from treated patients. The test showed a sensitivity and specificity of 98.4% and 100.0%, respectively. The positive and negative predictive values were 100.0% and 96.4%, respectively. The HCV antigen test has high clinical sensitivity and specificity and is useful for the diagnosis of acute and chronic hepatitis C infection in at-risk and immunocompromised patients. Its short turnaround time and relatively low cost are advantageous for use in patients on hemodialysis and other at-risk patients who require monitoring of HCV infection and reinfection.
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Affiliation(s)
- Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Kwai Peng Chan
- Department of Microbiology, Singapore General Hospital, Singapore
- Academic Clinical Program for Pathology, Duke-NUS Medical School, Singapore
| | | | - Judith Chui Ching Wong
- Department of Microbiology, Singapore General Hospital, Singapore
- National Environmental Agency, Environmental Health Institute, Singapore
| | - Kun Lee Lim
- Department of Molecular Pathology, Singapore General Hospital, Singapore
| | - Wee Ching Ng
- Department of Microbiology, Singapore General Hospital, Singapore
| | - Shi Min Woo
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Kian Sing Chan
- Department of Molecular Pathology, Singapore General Hospital, Singapore
| | | | | | | | | | | | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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7
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Chang PE, Tan CK, Cheah CC, Li W, Chow WC, Wong YJ. Validation of the Expanded Baveno-VI Criteria for Screening Gastroscopy in Asian Patients with Compensated Advanced Chronic Liver Disease. Dig Dis Sci 2021; 66:1343-1348. [PMID: 32440746 DOI: 10.1007/s10620-020-06334-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/08/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND The expanded Baveno-VI criteria may further reduce the need for screening gastroscopy compared to Baveno-VI criteria. AIM We sought to validate the performance of these criteria in a cohort of compensated advanced chronic liver disease (cACLD) patients with predominantly hepatitis B infection. METHODS Consecutive cACLD patients from 2006 to 2012 with paired liver stiffness measurements and screening gastroscopy within 1 year were included. The expanded Baveno-VI criteria were applied to evaluate the sensitivity (SS), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) for the presence of high-risk varices (HRV). RESULTS Among 165 cACLD patients included, 17 (10.3%) had HRV. The commonest etiology of cACLD was chronic hepatitis B (36.4%) followed by NAFLD (20.0%). Application of expanded Baveno-VI criteria avoided more screening gastroscopy (43.6%) as compared to the original Baveno-VI criteria (18.8%) without missing more HRV (1 with both criteria). The overall SS, SP, PPV and NPV of the expanded Baveno-VI criteria in predicting HRV were 94.1%, 48.0%, 17.2% and 98.6%, respectively. CONCLUSION Application of the expanded Baveno-VI criteria can safely avoid screening gastroscopy in 43.6% of cACLD patients with an excellent ability to exclude HRV.
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Affiliation(s)
- Pik-Eu Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Chee-Kiat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Chang-Chuen Cheah
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Yu-Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore.
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8
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Tan CJ, Kumar R, Koomanan N, Loo WS, Farid M, Tao M, Somasundaram N, Poon E, Chan JY, Yang VS, Chang E, Lim ST, Chow WC, Chan A, Tang T. Clinical and economic evaluation of a surveillance protocol to manage hepatitis B virus (HBV) reactivation among lymphoma patients with resolved HBV infection receiving rituximab. Pharmacotherapy 2021; 41:332-341. [PMID: 33547823 DOI: 10.1002/phar.2508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/09/2021] [Accepted: 01/15/2021] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE To evaluate a surveillance protocol in managing the risk of hepatitis B virus (HBV) reactivation among lymphoma patients with resolved HBV infection receiving rituximab. DESIGN Prospective, single-arm study. SETTING National Cancer Centre, Singapore. PATIENTS Lymphoma patients with resolved HBV infection and scheduled to receive rituximab-based treatment. INTERVENTION Close monitoring of HBV DNA levels, ie. every 4-6 weeks during rituximab treatment, every 6-8 weeks in the first year post-treatment, and every 3-4 months in the second year post-treatment. MEASUREMENTS The efficacy of the surveillance protocol was examined by evaluating the rates of reactivation-related events. Feasibility was evaluated based on patient adherence. An economic analysis using a cost-minimization approach was conducted to compare the costs between the surveillance protocol and universal prophylaxis with entecavir 0.5 mg daily up to 1 year after cessation of rituximab. MAIN RESULTS A total of 66 patients provided analyzable data with a follow-up period of 966.6 months. No hepatitis flare or reactivation-related events were detected. The median adherence rate to the surveillance protocol was 90.5%. Cost savings of US$946.40 per patient over the entire surveillance period were achieved if the surveillance protocol was adopted and was most affected by changes in prophylaxis duration and the cost of antiviral prophylaxis. CONCLUSIONS The surveillance protocol is an effective, feasible and cost-saving strategy to manage HBV reactivation among lymphoma patients with resolved HBV infection receiving rituximab.
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Affiliation(s)
- Chia Jie Tan
- Department of Pharmacy, National University of Singapore, Singapore City, Singapore.,Department of Pharmacy, National Cancer Centre Singapore, Singapore City, Singapore
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore City, Singapore
| | - Narendran Koomanan
- Department of Pharmacy, National University of Singapore, Singapore City, Singapore
| | - Wei Sheng Loo
- Department of Pharmacy, National Cancer Centre Singapore, Singapore City, Singapore
| | - Mohamad Farid
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Miriam Tao
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Nagavalli Somasundaram
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Eileen Poon
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Jason Yongsheng Chan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Valerie Shiwen Yang
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore.,Institute of Molecular and Cell Biology, A*STAR, Singapore City, Singapore
| | - Esther Chang
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Soon Thye Lim
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore City, Singapore
| | - Alexandre Chan
- Department of Pharmacy, National Cancer Centre Singapore, Singapore City, Singapore.,Department of Clinical Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University of California, Irvine, California, USA
| | - Tiffany Tang
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
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9
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Woong NL, Ekstrom VSM, Xin X, Lim C, Boon ESK, Teo SWJ, Ng PCS, Ang TPS, Lim SH, Lam AYR, Fan EMP, Ang SY, Chow WC. Empower to connect and connect to empower: experience in using a humanistic approach to improve patients' access to, and experience of, care in isolation wards during the COVID-19 outbreak in Singapore. BMJ Open Qual 2021; 10:bmjoq-2020-000996. [PMID: 33408099 PMCID: PMC7789203 DOI: 10.1136/bmjoq-2020-000996] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 12/01/2020] [Accepted: 12/10/2020] [Indexed: 12/25/2022] Open
Abstract
Patients admitted to the isolation ward during the COVID-19 outbreak face multiple psychosocial stressors including the disruptive experience of being in quarantine, anxiety over contracting a newly emerging infectious disease and limited access to their healthcare team. This quality improvement project aims to leverage on technology to improve patients’ access to, and experience of, care while in isolation. Patients admitted to two isolation wards in Singapore General Hospital (SGH) between 28 February and 19 March 2020 were each provided an iPad loaded with the MyCare application (app), curated materials and mobile games. During this period, 83 of them accessed the device and the app. MyCare app is an app developed by the nursing team in SGH as part of an existing interprofessional collaboration to help patients navigate their care during their inpatient stay. In response to COVID-19, MyCare app was supplemented with materials to address affected patients’ informational and psychosocial needs. These materials included an information sheet on COVID-19, interviews with previous severe acute respiratory syndrome survivors, psychosocial support materials, and uplifting literature, illustrated storybooks and artwork. This paper describes the process of planning for, and executing, the intervention and reports the initial results of its effect. Initial feedback indicated a positive response to the intervention. 9 out of 10 respondents (90%) rated their hospital experience with a maximum of five stars and all 10 respondents (100%) rated the psychosocial support materials with five stars. Doctors managing the patients also observed a reduction in the number of commonly asked questions following the deployment of the iPad. This quality improvement project is ongoing with plans for further research to determine how to better support the psychosocial needs of patients in isolation during a novel disease outbreak. This report is written based on the Standards for Quality Improvement Reporting Excellence guidelines.
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Affiliation(s)
- Natalie Liling Woong
- Internal Medicine, Singapore General Hospital, Singapore .,Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Victoria Sze Min Ekstrom
- Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore.,Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Xiaohui Xin
- Health Services Research Unit, Singapore General Hospital, Singapore
| | - Crystal Lim
- Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore.,Medical Social Services, Singapore General Hospital, Singapore
| | | | - Shaun Wei Jie Teo
- Integrated Health Information Systems, SingHealth Chief Informatics Officer Office, SingHealth, Singapore
| | - Patrick Chee Sang Ng
- Integrated Health Information Systems, SingHealth Chief Informatics Officer Office, SingHealth, Singapore
| | | | - Shu Hui Lim
- Nursing, Singapore General Hospital, Singapore
| | - Amanda Yun Rui Lam
- Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore.,Endocrinology, Singapore General Hospital, Singapore
| | | | | | - Wan Cheng Chow
- Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore.,Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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10
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Lum JHM, Cheah MCC, Leow WQ, Wan WK, Lim TKH, Chow WC, Chang JPE, Goh GBB. Clinical profile of non-alcoholic fatty liver disease in nonobese patients. J Gastroenterol Hepatol 2021; 36:257-261. [PMID: 32557741 DOI: 10.1111/jgh.15154] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/19/2020] [Accepted: 06/14/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIM Non-alcoholic fatty liver disease (NAFLD) is associated with metabolic syndrome. Worryingly, it has been increasingly reported among nonobese patients. This study aims to analyse patient characteristics of biopsy-proven NAFLD in an Asian cohort and explore differences stratified by body mass index (BMI). METHODS Clinical, laboratory, and histological data were collected from 263 adults with biopsy-proven NAFLD. Patients with and without obesity (BMI cut-off 25) were compared. The ability to predict advanced liver fibrosis with three non-invasive scores, the NAFLD Fibrosis score (NFS), Fibrosis-4 (FIB4), and the aspartate aminotransferase to platelet ratio index (APRI), was compared. RESULTS Obese subjects had a lower mean age (49.5 ± 12.5 vs 54.0 ± 12.9 years, P = 0.017), a higher prevalence of diabetes (52.4% vs 36.8%, P = 0.037), and a higher waist circumference (113.9 ± 16.0 cm vs 87.0 ± 18.4 cm, P = 0.022). The prevalence of dyslipidaemia (68.0% vs 61.4%, P = 0.353) and hypertension (61.7% vs 49.1%, P = 0.190) was comparable between the two groups. The distribution of non-alcoholic steatohepatitis (NASH) (63.1% versus 61.4%, P = 0.710) and advanced fibrosis (31.6% versus 26.3%, P = 0.447) were also similar in both groups. All three non-invasive scores (NFS, FIB4, and APRI) performed poorly in predicting advanced fibrosis in nonobese patients with NAFLD. The FIB4 was the most accurate non-invasive score in predicting advanced fibrosis in the obese group. CONCLUSIONS Obese and nonobese patients are equally at risk of NASH and advanced fibrosis. While the FIB4 is the most accurate non-invasive score in predicting advanced fibrosis among obese individuals, further research is warranted to develop a nonobese specific score to correctly identify nonobese NAFLD patients with advanced fibrosis.
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Affiliation(s)
| | | | - Wei Qiang Leow
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Wei Keat Wan
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Tony Kiat Hon Lim
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Medicine Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Jason Pik Eu Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Medicine Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - George Boon Bee Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Medicine Academic Clinical Program, Duke-NUS Medical School, Singapore
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11
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Lum JHM, Cheah MCC, Leow WQ, Wan WK, Lim TKH, Chow WC, Chang JPE, Goh GBB. Clinical profile of non-alcoholic fatty liver disease in nonobese patients. J Gastroenterol Hepatol 2021. [PMID: 32557741 DOI: 10.19538/j.ek2021040605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIM Non-alcoholic fatty liver disease (NAFLD) is associated with metabolic syndrome. Worryingly, it has been increasingly reported among nonobese patients. This study aims to analyse patient characteristics of biopsy-proven NAFLD in an Asian cohort and explore differences stratified by body mass index (BMI). METHODS Clinical, laboratory, and histological data were collected from 263 adults with biopsy-proven NAFLD. Patients with and without obesity (BMI cut-off 25) were compared. The ability to predict advanced liver fibrosis with three non-invasive scores, the NAFLD Fibrosis score (NFS), Fibrosis-4 (FIB4), and the aspartate aminotransferase to platelet ratio index (APRI), was compared. RESULTS Obese subjects had a lower mean age (49.5 ± 12.5 vs 54.0 ± 12.9 years, P = 0.017), a higher prevalence of diabetes (52.4% vs 36.8%, P = 0.037), and a higher waist circumference (113.9 ± 16.0 cm vs 87.0 ± 18.4 cm, P = 0.022). The prevalence of dyslipidaemia (68.0% vs 61.4%, P = 0.353) and hypertension (61.7% vs 49.1%, P = 0.190) was comparable between the two groups. The distribution of non-alcoholic steatohepatitis (NASH) (63.1% versus 61.4%, P = 0.710) and advanced fibrosis (31.6% versus 26.3%, P = 0.447) were also similar in both groups. All three non-invasive scores (NFS, FIB4, and APRI) performed poorly in predicting advanced fibrosis in nonobese patients with NAFLD. The FIB4 was the most accurate non-invasive score in predicting advanced fibrosis in the obese group. CONCLUSIONS Obese and nonobese patients are equally at risk of NASH and advanced fibrosis. While the FIB4 is the most accurate non-invasive score in predicting advanced fibrosis among obese individuals, further research is warranted to develop a nonobese specific score to correctly identify nonobese NAFLD patients with advanced fibrosis.
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Affiliation(s)
| | | | - Wei Qiang Leow
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Wei Keat Wan
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Tony Kiat Hon Lim
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Medicine Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Jason Pik Eu Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Medicine Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - George Boon Bee Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Medicine Academic Clinical Program, Duke-NUS Medical School, Singapore
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12
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Zhang X, Goh GBB, Chan WK, Wong GLH, Fan JG, Seto WK, Huang YH, Lin HC, Lee IC, Lee HW, Kim SU, Chow WC, Wong VWS. Unhealthy lifestyle habits and physical inactivity among Asian patients with non-alcoholic fatty liver disease. Liver Int 2020; 40:2719-2731. [PMID: 32799384 DOI: 10.1111/liv.14638] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Lifestyle modification is the cornerstone for the management of non-alcoholic fatty liver disease (NAFLD). We aim to understand lifestyle habits of NAFLD patients, compare across Asian regions and identify area of deficiency. METHODS In the multi-centre controlled attenuation parameter (CAP)-Asia study, we collected clinical data and lifestyle habit data of NAFLD patients from Singapore, mainland China, Hong Kong, Taiwan and Malaysia. Physical activity was assessed using the International Physical Activity Questionnaire. RESULTS A total of 555 patients were included in the final analysis (mean age 54.5 ± 11.2 years, 54.1% men and median liver stiffness 6.7 kPa). More patients from mainland China (27.4%) and Taipei (25.0%) were smokers. Modest drinking was more common in Taiwan (25.0%) and Hong Kong (18.2%); only 1.3% had binge drinking. Majority of patients drank coffee (64.0%) and tea (80.2%), with varying amounts and durations in different regions. Soft drinks consumption was most common in Singapore (62.2%) and Malaysia (57.7%). Only 29.7% of patients met the Physical Activity Guidelines Recommendations, with no major differences across regions. Patients with liver stiffness <10 kPa were more likely to report any vigorous activity, and sitting time was an independent factor associated with high CAP. Tea and coffee consumption were independently associated with high CAP and liver stiffness, respectively. CONCLUSIONS Despite some heterogeneity, unhealthy lifestyle and physical inactivity are common across Asian regions. Patients with liver stiffness <10 kPa were more likely to report any vigorous activity. Healthcare providers may use the comparative data to identify areas of deficiency.
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Affiliation(s)
- Xinrong Zhang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.,State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - George B-B Goh
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Wah-Kheong Chan
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Grace L-H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.,State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Jian-Gao Fan
- Department of Gastroenterology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Yi-Hsiang Huang
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Han-Chieh Lin
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - I-Cheng Lee
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Wan Cheng Chow
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Vincent W-S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.,State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
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13
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Chan SL, Liew HZW, Nguyen F, Thumboo J, Chow WC, Sung C. Prescription patterns of outpatients and the potential of multiplexed pharmacogenomic testing. Br J Clin Pharmacol 2020; 87:886-894. [PMID: 32559336 DOI: 10.1111/bcp.14439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/02/2020] [Accepted: 06/09/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Pre-emptive pharmacogenomic (PGx) testing is potentially an efficient approach to improve drug safety and efficacy but the target population to test is unclear. OBJECTIVES We aim to describe the prescription pattern of PGx drugs among adult medical outpatients. METHODS We estimated the 5-year cumulative incidence (CI) for receiving three groups of PGx drugs using competing risks analysis: (i) all PGx drugs, (ii) PGx drugs with guidelines and (iii) PGx drugs with serious clinical effects. Comparisons of CIs were also done by patient characteristics using Gray's test. RESULTS The 5-year CIs of receiving any new PGx drug, PGx drug with guidelines and serious clinical effects were 42.6%, 37.3% and 13.7%, respectively. The 5-year CI of receiving any new PGx drug was higher for patients >40 years old (43.6% vs ≤40 years old 36.0%, P < 2.2 × 10-22 ), Malays and Indians (50.3% and 49.8% vs Chinese 31.1%, P < 2.2 × 10-22 ), those who attended one of the following four specialties at the index visit compared to other specialties (infectious diseases [46.2% vs 42.6%, P = 2.9 × 10-4 ], psychiatry [48.3% vs 42.3%, P = 7.4 × 10-13 ], renal [49.8% vs 40.9%, P < 2.2 × 10-22 ], and rheumatology and immunology [54.8% vs 41.7%, P < 2.2 × 10-22 ]) and those prescribed ≥5 drugs at index visit (51.7% vs 0-4 drugs 41.7%, P < 2.2 × 10-22 ). CONCLUSIONS Medical outpatients have a substantial probability of benefiting from pre-emptive PGx testing and this is higher in certain subgroups of patients.
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Affiliation(s)
- Sze Ling Chan
- Health Services Research Centre, SingHealth, Singapore
| | | | | | - Julian Thumboo
- Department of Rheumatology and Immunology and Health Services Research Unit, Singapore General Hospital, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Cynthia Sung
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
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14
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Lim CT, Goh GBB, Li H, Lim TKH, Leow WQ, Wan WK, Azhar R, Chow WC, Kumar R. Presence of Hepatic Steatosis Does Not Increase the Risk of Hepatocellular Carcinoma in Patients With Chronic Hepatitis B Over Long Follow-Up. Microbiol Insights 2020; 13:1178636120918878. [PMID: 32435130 PMCID: PMC7223198 DOI: 10.1177/1178636120918878] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 03/16/2020] [Indexed: 12/11/2022] Open
Abstract
Background Chronic hepatitis B (CHB) infection and nonalcoholic fatty liver disease (NAFLD) are liver diseases which may lead to hepatocellular carcinoma (HCC) formation. Both disease entities have been attributed independently to increase risk of HCC development. While concomitant hepatic steatosis in patients with CHB are becoming more frequent in view of increasing NAFLD prevalence, there is no conclusive evidence linking presence of hepatic steatosis and increased HCC risk in patients with CHB infection. This study explores the association of hepatic steatosis among CHB-infected individuals in HCC development. Methods This is a retrospective study on a cohort of patients with CHB who underwent liver biopsy between January 2000 and December 2014. They were stratified according to presence and severity of histologically proven hepatic steatosis and subsequently followed up to evaluate the association between hepatic steatosis and HCC development. Results Among 289 patients with a median follow-up of 111.1 months, hepatic steatosis was present in 185 patients (64.0%). In all, 27 patients developed HCC on follow-up and 21 of them had hepatic steatosis. Univariate Cox analysis showed that age (hazard ratio [HR] = 1.08, 95% CI = 1.042-1.12), type 2 diabetes mellitus (T2DM) (HR = 4.00, 95% CI = 1.622-9.863), and Ishak score (HR = 1.221, 95% CI = 1.014-1.472) were associated with HCC development, whereas multivariate Cox analysis demonstrated that age and T2DM (HR = 2.69, 95% CI = 1.072-6.759) were significant risk factors for development of HCC. Conclusions Concurrent hepatic steatosis in patients with CHB infection is not a risk factor for hepatocellular carcinoma formation.
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Affiliation(s)
- Chong Teik Lim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - George Boon Bee Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore
| | - Huihua Li
- Department of Health Services Research Unit, Singapore General Hospital, Singapore.,Centre of Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Tony Kiat-Hon Lim
- Duke-NUS Graduate Medical School, Singapore.,Department of Pathology, Singapore General Hospital, Singapore
| | - Wei Qiang Leow
- Duke-NUS Graduate Medical School, Singapore.,Department of Pathology, Singapore General Hospital, Singapore
| | - Wei Keat Wan
- Duke-NUS Graduate Medical School, Singapore.,Department of Pathology, Singapore General Hospital, Singapore
| | - Rafay Azhar
- Duke-NUS Graduate Medical School, Singapore.,Department of Pathology, Singapore General Hospital, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore
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15
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Khoo S, Wong VWS, Goh GBB, Fan J, Chan WK, Seto WK, Chow WC. Suboptimal treatment of dyslipidemia in patients with nonalcoholic fatty liver disease. J Gastroenterol Hepatol 2020; 35:320-325. [PMID: 31336392 DOI: 10.1111/jgh.14794] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/06/2019] [Accepted: 07/15/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIM Nonalcoholic fatty liver disease (NAFLD) patients often have dyslipidemia, and optimal treatment of dyslipidemia lowers the risk of cardiovascular disease and mortality. Our aim was to study the prescription of statin and low-density lipoprotein cholesterol treatment targets in NAFLD patients. METHODS Consecutive NAFLD patients attending five clinics in Asia were included in this study. The 10-year cardiovascular disease risk was calculated based on the Framingham Heart Study, and patients were categorized as moderate, high, or very high risk for cardiovascular disease on the basis of the American Association of Clinical Endocrinologist 2017 Guidelines. The low-density lipoprotein cholesterol treatment goal for each of the risk groups was 2.6, 2.6, and 1.8 mmol/L, respectively. RESULTS The data for 428 patients were analyzed (mean age 54.4 ± 11.1 years, 52.1% male). Dyslipidemia was seen in 60.5% (259/428), but only 43.2% (185/428) were on a statin. The percentage of patients who were at moderate, high, and very high risk for cardiovascular disease was 36.7% (157/428), 27.3% (117/428), and 36.0% (154/428), respectively. Among patients who were on a statin, 58.9% (109/185) did not achieve the treatment target. Among patients who were not on a statin, 74.1% (180/243) should be receiving statin therapy. The percentage of patients who were not treated to target or who should be on statin was highest among patients at very high risk for cardiovascular disease at 79.6% (78/98) or 94.6% (53/56), respectively. CONCLUSION This study highlights the suboptimal treatment of dyslipidemia and calls for action to improve the treatment of dyslipidemia in NAFLD patients.
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Affiliation(s)
- Stanley Khoo
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Jiangao Fan
- School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wah Kheong Chan
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Wan Cheng Chow
- Department of Medicine, Singapore General Hospital, Singapore
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16
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Li XY, Goh GBB, Shim HH, Fook-Chong SMC, Loh YH, Chow WC. Fructose intake in patients with non-alcoholic fatty liver disease. Proceedings of Singapore Healthcare 2019. [DOI: 10.1177/2010105819840370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Although growing evidence suggests that fructose intake contributes to the development of non-alcoholic fatty liver disease (NAFLD), fructose intake in NAFLD patients has not been documented locally. Objectives: The objectives of this study were to compare fructose intake between NAFLD patients and controls with chronic hepatitis B, and to ascertain whether fructose intake was associated with the presence of NAFLD. Methods: This was a cross-sectional, case–control study. Thirty-four patients diagnosed with NAFLD and 34 controls with chronic hepatitis B participated in this study between 2012 and 2014 in the Singapore General Hospital outpatient setting. Fructose, energy and nutrient intake were assessed by using food frequency questionnaires. Results: NAFLD patients had higher body mass index (28.6±4.0 vs. 22.5±3.9 kg/m2, p<0.001) and waist circumference (100.0±7.9 vs. 80.2±11.7 cm, p<0.001) than controls. Cases reported higher intakes of energy (2378±708 vs. 1796±398 kcal, p<0.001), protein (109±37 vs. 84±25 g, p<0.01), fat (87±33 vs. 62±19 g, p<0.001), total carbohydrate (294±83 vs. 232±63 g, p<0.001) and fructose (42±17 vs. 31±15 g, p<0.05). Logistic regression analysis showed waist circumference (odds ratio: 1.25; 95% confidence interval: 1.11–1.41; p<0.001) and energy intake (odds ratio: 1.002; 95% confidence interval: 1.001–1.004; p<0.05) were significant risk factors for NAFLD. Conclusions: Total calorie, macronutrient and fructose intake in NAFLD patients were significantly higher than in controls. Waist circumference and energy intake were significantly associated with NAFLD. Reducing total calorie intake and adopting healthy eating habits should be emphasized to NAFLD patients to manage their clinical conditions.
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Affiliation(s)
- Xiao Ying Li
- Department of Dietetics, Singapore General Hospital, Singapore
| | - George Boon-Bee Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Hang Hock Shim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | | | - Yet Hua Loh
- Department of Dietetics, Singapore General Hospital, Singapore
| | - Wan Cheng Chow
- Division of Medicine, Singapore General Hospital, Singapore
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17
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Soh BYM, Kumar R, Ekstrom VSM, Lin CYH, Thangaraju SD, Tan HH, Chan KP, Choong LHL, Teo D, Chow WC. Authors' reply. Singapore Med J 2019; 60:323. [PMID: 31243464 PMCID: PMC6595062 DOI: 10.11622/smedj.2019063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Benjy Yi-Min Soh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Victoria Sze-Min Ekstrom
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Clement Yi-Hao Lin
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Sobhana D/O Thangaraju
- Duke-NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Kwai Peng Chan
- Duke-NUS Medical School, Singapore
- Department of Microbiology, Singapore General Hospital, Singapore
| | - Lina Hui Lin Choong
- Duke-NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Diana Teo
- Health Sciences Authority, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
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18
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Tan AT, Yang N, Lee Krishnamoorthy T, Oei V, Chua A, Zhao X, Tan HS, Chia A, Le Bert N, Low D, Tan HK, Kumar R, Irani FG, Ho ZZ, Zhang Q, Guccione E, Wai LE, Koh S, Hwang W, Chow WC, Bertoletti A. Use of Expression Profiles of HBV-DNA Integrated Into Genomes of Hepatocellular Carcinoma Cells to Select T Cells for Immunotherapy. Gastroenterology 2019; 156:1862-1876.e9. [PMID: 30711630 DOI: 10.1053/j.gastro.2019.01.251] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/26/2018] [Accepted: 01/17/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Hepatocellular carcinoma (HCC) is often associated with hepatitis B virus (HBV) infection. Cells of most HBV-related HCCs contain HBV-DNA fragments that do not encode entire HBV antigens. We investigated whether these integrated HBV-DNA fragments encode epitopes that are recognized by T cells and whether their presence in HCCs can be used to select HBV-specific T-cell receptors (TCRs) for immunotherapy. METHODS HCC cells negative for HBV antigens, based on immunohistochemistry, were analyzed for the presence of HBV messenger RNAs (mRNAs) by real-time polymerase chain reaction, sequencing, and Nanostring approaches. We tested the ability of HBV mRNA-positive HCC cells to generate epitopes that are recognized by T cells using HBV-specific T cells and TCR-like antibodies. We then analyzed HBV gene expression profiles of primary HCCs and metastases from 2 patients with HCC recurrence after liver transplantation. Using the HBV-transcript profiles, we selected, from a library of TCRs previously characterized from patients with self-limited HBV infection, the TCR specific for the HBV epitope encoded by the detected HBV mRNA. Autologous T cells were engineered to express the selected TCRs, through electroporation of mRNA into cells, and these TCR T cells were adoptively transferred to the patients in increasing numbers (1 × 104-10 × 106 TCR+ T cells/kg) weekly for 112 days or 1 year. We monitored patients' liver function, serum levels of cytokines, and standard blood parameters. Antitumor efficacy was assessed based on serum levels of alpha fetoprotein and computed tomography of metastases. RESULTS HCC cells that did not express whole HBV antigens contained short HBV mRNAs, which encode epitopes that are recognized by and activate HBV-specific T cells. Autologous T cells engineered to express TCRs specific for epitopes expressed from HBV-DNA in patients' metastases were given to 2 patients without notable adverse events. The cells did not affect liver function over a 1-year period. In 1 patient, 5 of 6 pulmonary metastases decreased in volume during the 1-year period of T-cell administration. CONCLUSIONS HCC cells contain short segments of integrated HBV-DNA that encodes epitopes that are recognized by and activate T cells. HBV transcriptomes of these cells could be used to engineer T cells for personalized immunotherapy. This approach might be used to treat a wider population of patients with HBV-associated HCC.
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Affiliation(s)
| | - Ninghan Yang
- Genome Institute of Singapore, Agency for Science and Technology (A*STAR), Singapore
| | | | - Vincent Oei
- Emerging Infectious Diseases, Duke-NUS Medical School, Singapore
| | | | | | | | - Adeline Chia
- Emerging Infectious Diseases, Duke-NUS Medical School, Singapore
| | - Nina Le Bert
- Emerging Infectious Diseases, Duke-NUS Medical School, Singapore
| | - Diana Low
- Institute of Molecular and Cell Biology, Agency for Science and Technology (A*STAR), Singapore
| | - Hiang Keat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Farah Gillan Irani
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | | | - Qi Zhang
- Department of Biotherapy, The Third Affiliated Hospital of Sun Yat-Sen University, Guandong, China
| | - Ernesto Guccione
- Institute of Molecular and Cell Biology, Agency for Science and Technology (A*STAR), Singapore
| | - Lu-En Wai
- Lion TCR Pte Ltd, Singapore; Singapore Immunology Network, Agency for Science and Technology (A*STAR), Singapore
| | - Sarene Koh
- Lion TCR Pte Ltd, Singapore; Singapore Immunology Network, Agency for Science and Technology (A*STAR), Singapore
| | - William Hwang
- Department of Haematology, Singapore General Hospital, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Antonio Bertoletti
- Emerging Infectious Diseases, Duke-NUS Medical School, Singapore; Singapore Immunology Network, Agency for Science and Technology (A*STAR), Singapore.
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Soh BYM, Kumar R, Ekstrom VSM, Lin CYH, Thangaraju SD, Tan HH, Chan KP, Choong LHL, Teo D, Chow WC. Prevalence of hepatitis C virus infection and the IL28B genotype polymorphism among blood donors and high-risk populations. Singapore Med J 2019; 60:34-39. [PMID: 29926111 PMCID: PMC6351688 DOI: 10.11622/smedj.2018078] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION To study the prevalence of hepatitis C virus (HCV) infection in blood donor (BD), haemodialysis (HD) and intravenous drug user (IVDU) populations in Singapore and assess the IL28B polymorphism if HCV positive. METHODS The BD population were healthy volunteers, the HD population were patients who were on haemodialysis for at least six months of follow-up between January 2009 and December 2014. IVDU population was from inmates at halfway houses who consented. RESULTS Between 2011 and 2014, of 161,658 individuals who underwent screening prior to blood donation, 95 (0.059%) were positive for HCV. Of the 42 sera available, common genotypes (GTs) were GT-3 (47.6%) and GT-1 (31.0%). Of 1,575 HD patients, 2.2% were anti-HCV positive. The HCV GT distribution was HCV GT-1 (32.4%), HCV GT-3 (20.5%) and GT-6 (8.8%). 83 halfway house inmates were screened. Of the 47 IVDUs, 36.2% were anti-HCV positive with predominant GT-3 (%). IL28B polymorphism was noted to be CC predominantly 85.3%. CONCLUSION Prevalence of HCV infection has decreased in both the BD and HD populations. However, it remains high in the IVDU population. GT-1 remains the most common in the HD population; however, GT-3 infection is now more common among the BD population in Singapore. IL28B - CC is the predominant variant among the HCV-infected individuals in Singapore.
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Affiliation(s)
- Benjy Yi-Min Soh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Victoria Sze-Min Ekstrom
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Clement Yi-Hao Lin
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Sobhana D/O Thangaraju
- Duke-NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Kwai Peng Chan
- Duke-NUS Medical School, Singapore
- Department of Microbiology, Singapore General Hospital, Singapore
| | - Lina Hui Lin Choong
- Duke-NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Diana Teo
- Health Sciences Authority, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
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20
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Chang PE, Hartono JL, Ngai YL, Dan YY, Lim KB, Chow WC. Optimal liver stiffness measurement values for the diagnosis of significant fibrosis and cirrhosis in chronic liver disease in Singapore. Singapore Med J 2018; 60:532-537. [PMID: 30556091 DOI: 10.11622/smedj.2018156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Despite the widespread use of transient elastography for non-invasive assessment of liver fibrosis, the optimal cut-off liver stiffness measurement (LSM) values remain unclear. This study aimed to validate the optimal cut-off LSM values for significant fibrosis and cirrhosis in patients with chronic liver disease (CLD). METHODS Prospective multicentre data of CLD patients who underwent paired liver biopsy and LSM was analysed to determine the optimal cut-off LSM values for predicting significant fibrosis (METAVIR F ≥ 2) and cirrhosis (METAVIR F4). A high-quality cohort was selected by excluding those with failed LSM and invalid LSM readings. RESULTS Of the 481 patients recruited, 322 fulfilled the pre-defined quality criteria. CLD aetiology was chronic hepatitis B (CHB) in 49%, non-alcoholic steatohepatitis (NASH) in 16% and chronic hepatitis C (CHC) in 12%. Area under the receiver operating characteristic curve for LSM was 0.775 (95% confidence interval [CI] 0.724-0.826) for significant fibrosis and 0.810 (95% CI 0.738-0.882) for cirrhosis. Optimal cut-off LSM values were 9 kPa for significant fibrosis and 13 kPa for cirrhosis in the general cohort. Optimal cut-off LSM values were 9 kPa for significant fibrosis and 12 kPa for cirrhosis for both CHB and CHC, while the corresponding values for NASH were 11 kPa and 15 kPa. CONCLUSION Optimal cut-off LSM values should be selected based on disease aetiology. In Singapore, the optimal cut-off LSM values for CHB and CHC are 9 kPa for significant fibrosis and 12 kPa for cirrhosis. Optimal cut-off values for NASH require further validation.
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Affiliation(s)
- Pik Eu Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Juanda Leo Hartono
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Yee Lin Ngai
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Yock Young Dan
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Kieron Bl Lim
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
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Kumar R, Testoni B, Fresquet J, Lim TKH, Hao Y, Tan HH, Chow WC, Zoulim F. Development of hepatocellular carcinoma in chronic hepatitis B patients with advanced fibrosis is independent of viral genotype. J Med Virol 2016; 89:845-848. [PMID: 27709629 DOI: 10.1002/jmv.24707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2016] [Indexed: 01/04/2023]
Abstract
Hepatitis B is leading cause of liver related morbidity in Asia with predominant genotypes B and C in East-Asia. Data on Serum, intrahepatic viral-markers, and long-term follow-up of prevalent genotypes (GT) B and C in patients with biopsy proven advanced fibrosis are sparse. To compare serum, intrahepatic viral-markers and development of hepatocellular carcinoma (HCC) in GT-B and C in patients with advanced fibrosis (Ishak ≥ 4). Sixty-three treatment-naïve patients identified with advanced fibrosis on liver-biopsy performed between 1998 and 2000 at Singapore General Hospital. FFPE tissue was available for 59 patients and serum for 42 patients. HBV-DNA was quantified in serum and liver while qHBsAg quantified in serum. Patients were followed-up till December 2015. The median age was 47 ± 16 years, with 77.7% males. About 19 were GT-B, 43 patients were GT-C, and 1 had both GT-B and C. Mean follow-up was 13.5 years. The median serum HBV-DNA was 6.25 ± 2.17 and 6.58 ± 1.85 log IU/ml, serum HBsAg was 3.29 ± 0.80 and 3.45 ± 1.85 log IU/ml, and intrahepatic HBV-DNA was 0.52 ± 3.73 copies/cell and 0.4 ± 1.37 copies/cell in the GT-B and C, respectively (P > 0.1 in all). Complete cirrhosis (Ishak-6) was present in 47.6%, Ishak-5 fibrosis in 33.3%, and Ishak-4 fibrosis in 19% at recruitment. On follow-up HCC developed in 8/43 in GT-C and in 3/19 GT-B (P = 0.86). Advanced age and cirrhosis were significant factors for development of HCC. No difference in serum HBV-DNA, qHBsAg or intrahepatic HBV-DNA was seen in the two genotypes. HCC development seen over long-term follow-up was independent of genotypes in patients with advanced fibrosis. J. Med. Virol. 89:845-848, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Rajneesh Kumar
- Cancer Research Centre of Lyon, INSERM U1052, CNRS 5286, Lyon, France.,Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Barbara Testoni
- Cancer Research Centre of Lyon, INSERM U1052, CNRS 5286, Lyon, France
| | - Judith Fresquet
- Cancer Research Centre of Lyon, INSERM U1052, CNRS 5286, Lyon, France
| | - Tony Kiat Hon Lim
- Department of Pathology, Singapore General Hospital, Singapore, Singapore
| | - Ying Hao
- Division of Medicine, Singapore General Hospital, Singapore, Singapore
| | - Hui Hui Tan
- Cancer Research Centre of Lyon, INSERM U1052, CNRS 5286, Lyon, France
| | - Wan Cheng Chow
- Cancer Research Centre of Lyon, INSERM U1052, CNRS 5286, Lyon, France
| | - Fabien Zoulim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
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Ekstrom V, Kumar R, Zhao Y, Yee ML, Sung C, Toh D, Loh PY, Tan J, Teo EK, Chow WC. Real world experience with pegylated interferon and ribavirin in hepatitis C genotype 1 population with favourable IL28B polymorphism. Gastroenterol Rep (Oxf) 2016; 5:208-212. [PMID: 28852525 PMCID: PMC5554392 DOI: 10.1093/gastro/gow033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 08/22/2016] [Accepted: 09/04/2016] [Indexed: 02/07/2023] Open
Abstract
Background and aim: Conventional hepatitis C treatment using pegylated interferon (PEG-IFN) and ribavirin is associated with significant side effects. IL28B polymorphism can predict response to treatment, with CC genotype having a better response. ITPA gene deficiency protects against clinically significant anaemia induced by treatment. The purpose of this study was to determine IL28B polymorphism and ITPA variation among hepatitis C genotype 1 patients who have undergone therapy with PEG-IFN and ribavirin and their association with sustained viral response (SVR). Methods: All hepatitis C genotype 1 patients who had been treated with PEG-IFN and ribavirin over the past 10 years were identified by available medical records and were contacted by letter of invitation to participate in the study. Blood samples for IL28B and ITPA genotyping were obtained. Medical records were reviewed for verification of treatment response, development of anaemia and if treatment reduction was required during the treatment. Results: A total of 61 patients with hepatitis C genotype 1 were treated with PEG-IFN and ribavirin, of whom 42 agreed to participate in the study. Mean age was 45.6±12.9 years at time of treatment, and 83.3% of patients were males. Thirty-three (78.6%) had IL28B CC genotype, of whom 25 (75.8%) obtained SVR compared with only 3 of 9 (33.3%) non C/C genotype patients who achieved SVR (P=0.041). Eleven (26.1%) patients had ITPA AC genotype, and 30 (71.4%) had CC genotype. There was no statistically significant difference between ITPA AC and CC genotypes in predicting clinically significant anaemia (45.5% vs 63.3%, P=0.302). Even among patients who developed anaemia, 70.8% still managed to achieve SVR. Treatment reduction also had no impact on SVR. Conclusion: Hepatitis C genotype 1 patients should be informed of the response rate for treatment with PEG-IFN and ribavirin in a population with favourable IL28B genotype before consideration of newer therapeutic options.
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Affiliation(s)
- Victoria Ekstrom
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Yi Zhao
- Department of Clinical Translational Research, Singapore General Hospital, Singapore
| | - Mei Ling Yee
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Cynthia Sung
- Health Products Regulation Group, Health Sciences Authority, Singapore.,Emerging Infectious Disease Programme, Duke-NUS Medical School, Singapore
| | - Dorothy Toh
- Health Products Regulation Group, Health Sciences Authority, Singapore
| | - Poh Yen Loh
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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23
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Goh GBB, Kwan C, Lim SY, Venkatanarasimha NK, Abu-Bakar R, Krishnamoorthy TL, Shim HH, Tay KH, Chow WC. Perceptions of non-alcoholic fatty liver disease - an Asian community-based study. Gastroenterol Rep (Oxf) 2015; 4:131-5. [PMID: 26463276 PMCID: PMC4863187 DOI: 10.1093/gastro/gov047] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 08/23/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease and is closely related to metabolic syndrome and its risk factors. Worldwide, epidemiological studies have reported NAFLD prevalence rates of 5% to 30% depending on geographical variations. While epidemiological data suggest a progressively increasing prevalence of metabolic risk factors in Singapore, there are limited data about NAFLD per se in the community. We aim to explore the prevalence and perceptions of NAFLD in Singapore. METHODS Attendees at a gastroenterology public forum were enrolled in a cross-sectional observational study evaluating demographic, anthropometric and clinical information. The diagnosis of NAFLD was based on sonographic criteria. Metabolic syndrome was defined according to International Diabetes Federation guidelines. Perceptions of NAFLD were explored using a self-administered survey questionnaire. RESULTS A total of 227 subjects were recruited, with NAFLD being diagnosed in 40% of the cohort. Relative to those without NAFLD, subjects with NAFLD had higher male preponderance, older age, higher body mass index, waist circumference and more metabolic syndrome (all P < 0.05). Although 71.2% subjects had heard about NAFLD before, only 25.4% of them felt that they were at risk of NAFLD. Comparable responses were observed in subjects with no metabolic risk factors relative to subjects with one or more metabolic risk factors (P > 0.05). Of note, 75.6% of subjects with one or more metabolic risk factors did not think that they were at risk of NAFLD. CONCLUSION Our study suggests a significant local prevalence of NAFLD in the community including non-obese individuals. Considering the tendency to underestimate risk of NAFLD, enhanced public education about NAFLD is warranted to improve understanding.
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Affiliation(s)
- George B B Goh
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore, Duke-NUS Graduate Medical School, Singapore and
| | - Clarence Kwan
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Sze Ying Lim
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | | | - Rafidah Abu-Bakar
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | | | - Hang Hock Shim
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Kiang Hiong Tay
- Duke-NUS Graduate Medical School, Singapore and Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore, Duke-NUS Graduate Medical School, Singapore and
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Chang PE, Wong GW, Li JW, Lui HF, Chow WC, Tan CK. Epidemiology and Clinical Evolution of Liver Cirrhosis in Singapore. Ann Acad Med Singap 2015; 44:218-225. [PMID: 26292950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Liver cirrhosis is a common cause of morbidity and mortality and an important burden on the healthcare system. There is limited literature on liver cirrhosis in Singapore. We aimed to describe the epidemiology and clinical characteristics of cirrhotic patients seen in an ambulatory setting in a tertiary referral centre. MATERIALS AND METHODS This is a retrospective observational cohort study of cirrhotic patients attending the ambulatory clinic of Singapore's largest tertiary hospital over 5 years. Cirrhosis was diagnosed on characteristic radiological features and/or histology. Aetiology of cirrhosis was determined by history, serology, biochemistry and/or histology. Data on decompensation events and death were retrieved from computerised hospital records. RESULTS The study included 564 patients with median follow-up of 85 months. Mean age was 60.9 ± 12.5 years with 63.8% males. Main aetiologies of cirrhosis were chronic hepatitis B (CHB) (63.3%), alcohol (11.2%), cryptogenic (9%) and chronic hepatitis C (CHC) (6.9%). CHB was the predominant aetiology in Chinese and Malays whereas alcohol was the main aetiology in Indians. CHC cirrhosis was more common in Malays than other races. Majority had compensated cirrhosis with 76.8%/18.3%/5%; Child-Pugh A/B/C respectively. Decompensation events occurred in 155 patients (27.5%) and 106 of them (18.8%) died. Diagnosis of cirrhosis via surveillance ultrasound was associated with improved 10-year survival. Age at diagnosis, portal vein thrombosis, Child-Pugh class and decompensation within 1 year of diagnosis were independent predictors of mortality. CONCLUSION CHB is the primary cause of liver cirrhosis in Singapore. The major aetiologies of cirrhosis vary amongst the different ethnic groups. Cirrhotics with advanced age, portal vein thrombosis, poorer liver function and early decompensation have a higher mortality risk.
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Affiliation(s)
- Pik Eu Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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25
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Wong VWS, Lampertico P, de Lédinghen V, Chang PE, Kim SU, Chen Y, Chan HLY, Mangia G, Foucher J, Chow WC, Ahn SH, Hou J. Probability-based interpretation of liver stiffness measurement in untreated chronic hepatitis B patients. Dig Dis Sci 2015; 60:1448-56. [PMID: 25563720 DOI: 10.1007/s10620-014-3488-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 12/07/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Liver stiffness measurement (LSM) by transient elastography is a popular noninvasive test of fibrosis. Traditional LSM cutoffs dichotomize patients and do not clearly indicate the confidence of diagnosis. AIM We derived and validated probability functions of fibrosis and cirrhosis based on LSM and determined the effect of alanine aminotransferase (ALT) on the scores. METHODS Consecutive chronic hepatitis B patients who underwent liver function tests, LSM, and liver biopsies at six European and Asian centers (2/3 in the training cohort and 1/3 in the validation cohort) were recruited. Binary logistic regression was performed to predict the probabilities of different fibrosis stages based on LSM and/or ALT. RESULTS A total of 1,051 patients were included in the final analysis (53 % with ALT ≥ 60 IU/L, 32 % F2, 20 % F3, and 24 % F4). The probability functions (LiFA-HBV score) with and without ALT adjustment closely mirrored the proportion with different fibrosis stages in both the training and validation cohorts. For a range of up to 300 IU/L, ALT maintained a weak linear relationship with LSM for each fibrosis stage (r (2) = 0.018-0.13). Based on relative integrated discrimination improvement, the addition of ALT to the LiFA-HBV score increased the correct reclassification of F3-4 and F4 by 5 and 17 %, respectively. CONCLUSIONS ALT increases LSM in a linear fashion in chronic hepatitis B patients at any fibrosis stage. The LiFA-HBV score accurately predicts the probability of fibrosis. ALT adjustment increases the rate of reclassification modestly and is not essential.
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Affiliation(s)
- Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
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Kumar R, Krishnamoorthy TL, Tan HK, Lui HF, Chow WC. Change in model for end-stage liver disease score at two weeks, as an indicator of mortality or liver transplantation at 60 days in acute-on-chronic liver failure. Gastroenterol Rep (Oxf) 2014; 3:122-7. [PMID: 25391261 PMCID: PMC4423461 DOI: 10.1093/gastro/gou075] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 10/11/2014] [Indexed: 12/14/2022] Open
Abstract
Background: Acute-on-chronic liver failure (ACLF) is characterised by a sudden deterioration of underlying chronic liver disease, resulting in increased rates of mortality and liver transplantation. Early prognostication can benefit optimal allocation of resources. Methods: ACLF was defined as per the disease criteria of the Asian Pacific Association for the Study of the Liver. Inpatient discharge summaries from between January 2001 and April 2013 were reviewed. The primary outcome was mortality or liver transplantation within 60 days from onset of ACLF. Absolute ‘model for end-stage liver disease' (MELD) score and change in MELD at Weeks 1, 2 and 4 were reviewed in order to identify the earliest point for prediction of mortality or liver transplantation. Results: Clinical data were collected on 53 subjects who fulfilled the inclusion and exclusion criteria. At 60 days from presentation, 20 patients (37.7%) died and 4 (7.5%) underwent liver transplantation. Increased MELD of ≥2 after 2 weeks was 75.0% sensitive and 75.9% specific for predicting mortality or liver transplantation. If the MELD score did not increase at 2 weeks, predictive chance of survival was 93.8% over the next 60 days. MELD change at 1 week showed poor sensitivity and specificity. Change at 4 weeks was too late for intervention. Conclusion: Change in MELD score at 2 weeks provides an early opportunity for prognostication in ACLF. A MELD score that does not deteriorate by Week 2 would predict 93.8% chance of survival for the next 60 days. This finding warrants further validation in larger cohort studies.
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Affiliation(s)
- Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | | | - Hiang Keat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Hock Foong Lui
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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27
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Tan AT, Hoang LT, Chin D, Rasmussen E, Lopatin U, Hart S, Bitter H, Chu T, Gruenbaum L, Ravindran P, Zhong H, Gane E, Lim SG, Chow WC, Chen PJ, Petric R, Bertoletti A, Hibberd ML. Reduction of HBV replication prolongs the early immunological response to IFNα therapy. J Hepatol 2014; 60:54-61. [PMID: 23994382 DOI: 10.1016/j.jhep.2013.08.020] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 08/19/2013] [Accepted: 08/20/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS The interaction between HBV replication and immune modulatory effects mediated by IFNα therapy is not well understood. We characterized the impact of HBV DNA replication on the early IFNα-induced immunomodulatory mechanisms. METHODS We interrogated the transcriptional, serum cytokine/chemokine and cellular immune profiles of 28 patients with HBeAg+ chronic HBV infection (CHB) randomly assigned to one of 4 treatment cohorts (untreated n=5, weekly dosing of 360 μg Pegasys [PegIFNα] n=11, daily dose of 300 mg Viread [tenofovir disoproxil fumarate, TDF] n=6, or a combination of both n=6). Samples were characterized at multiple early time points through day 14 of therapy, after which all patients were given standard of care (180 μg Pegasys injected subcutaneously, weekly). RESULTS PegIFNα induced a distinct and rapid up-regulation of IFN signaling pathway that coincided with increase detection of distinct serum cytokines/chemokines (IL-15, IL-6, and CXCL-10) and the up-regulation of the frequency of proliferating NK and activated total CD8+ T cells. IFNα treatment alone did not result in rapid decay of HBV replication and was not able to restore the defective HBV-specific T cell response present in CHB patients. In addition, the IFNα immune-stimulatory effects diminished after the first dose, but this refractory effect was reduced in patients where HBV replication was simultaneously inhibited with TDF. CONCLUSIONS We present here the first comprehensive description of the early effects of IFNα treatment on immune and viral biomarkers in HBeAg+ CHB patients. Our results show that PegIFNα-induced innate immune activation directly benefits from the suppression of HBV replication.
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Affiliation(s)
- Anthony T Tan
- Singapore Institute for Clinical Sciences, A(⁎)STAR, Singapore
| | | | | | | | | | | | | | - Tom Chu
- Hoffmann-La Roche, Switzerland
| | | | | | | | - Ed Gane
- Auckland City Hospital, Auckland, New Zealand
| | | | | | - Pei-Jer Chen
- National Taiwan University Hospital, Taipei, Taiwan
| | | | - Antonio Bertoletti
- Singapore Institute for Clinical Sciences, A(⁎)STAR, Singapore; Program in Emerging Infectious Disease, Duke-NUS Graduate Medical School, Singapore.
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Sablan BP, Kim DJ, Barzaga NG, Chow WC, Cho M, Ahn SH, Hwang SG, Lee JH, Namini H, Heyward WL. Demonstration of safety and enhanced seroprotection against hepatitis B with investigational HBsAg-1018 ISS vaccine compared to a licensed hepatitis B vaccine. Vaccine 2012; 30:2689-96. [PMID: 22342916 DOI: 10.1016/j.vaccine.2012.02.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 12/05/2011] [Accepted: 02/01/2012] [Indexed: 02/01/2023]
Abstract
Adults 40 years of age and older have been shown to be hypo-responsive immunologically to the currently available hepatitis B virus (HBV) vaccines. Three intramuscular doses of a Toll-like receptor 9 agonist, 1018 immunostimulatory sequence (1018 ISS) adjuvant, combined with recombinant hepatitis B surface antigen (HBsAg) demonstrated faster, superior, and more durable seroprotection than three doses of a licensed comparator HBV vaccine (Engerix-B(®)). This investigational vaccine, HBsAg-1018 ISS, was well tolerated with a safety profile similar to the comparator vaccine. These results suggest that HBsAg-1018 may be more effective in this hypo-responsive population.
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Affiliation(s)
- Benjamin P Sablan
- Out-Patient Department, Philippine General Hospital, Manila, Philippines
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29
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Chow WC, Chong R, Guan R, Ho KYL, Leo YS, Loy KL, Lui HF, Ng HS, Siew WF, Teo EK, Yeo T. Ministry of Health clinical practice guidelines: Chronic Hepatitis B Infection. Singapore Med J 2011; 52:307-313. [PMID: 21552794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The Ministry of Health (MOH) publishes clinical practice guidelines on Chronic Hepatitis B Infection to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Chronic Hepatitis B Infection, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=26108). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.
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Koo YX, Tan DSW, Tan IB, Tao M, Chow WC, Lim ST. Hepatitis B virus reactivation and role of antiviral prophylaxis in lymphoma patients with past hepatitis B virus infection who are receiving chemoimmunotherapy. Cancer 2010; 116:115-21. [PMID: 19899164 DOI: 10.1002/cncr.24742] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Individuals who had past hepatitis B virus (HBV) infection appeared to clear their serum hepatitis B surface antigen (HBsAg) while producing antibody to the hepatitis B core antigen (HBcAb), which is detectable in their serum. Currently, it is uncertain whether patients with past HBV infection require routine antiviral prophylaxis during chemotherapy, although some cancer agencies recommend its routine use. The objective of the current study was to determine the prevalence of past HBV infection in patients with lymphoma and its relevance in terms of HBV-related complications. METHODS The authors reviewed 430 patients with lymphoma from May 2006 to May 2008. RESULTS Among the 430 patients, 233 had both the HBsAg and HBcAb tests performed, whereas 197 had only the HBsAg test performed. Among those with both tests performed, 34.3% (80 of 233) were HBcAb positive only. Of these 80 patients, 58 had a concomitant HBV DNA level test, which was positive in 3 (5.2%). Of the 67 patients with past and 26 with chronic HBV infection who received chemotherapy, HBV reactivation occurred in 1.5% and 42.3% of patients, respectively (P<.0001). Prophylactic lamivudine was administered in 7 (10.4%) patients with past HBV infection and in 18 (69.2%) with chronic HBV infection. CONCLUSIONS The low rate of HBV reactivation reported in our study coupled with the high prevalence of past HBV infection in an endemic area suggests that routine usage of antiviral prophylaxis may not be required for all patients with past HBV infection. Close surveillance remains a reasonable and viable option for the majority of patients.
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Affiliation(s)
- Yu Xuan Koo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Poon D, Anderson BO, Chen LT, Tanaka K, Lau WY, Van Cutsem E, Singh H, Chow WC, Ooi LL, Chow P, Khin MW, Koo WH. Management of hepatocellular carcinoma in Asia: consensus statement from the Asian Oncology Summit 2009. Lancet Oncol 2009; 10:1111-8. [PMID: 19880065 DOI: 10.1016/s1470-2045(09)70241-4] [Citation(s) in RCA: 304] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Asia has a disproportionately large share of the world's hepatocellular carcinoma (HCC), mainly because of the endemic status of chronic hepatitis B and C viruses, which leads to liver cirrhosis and an increased risk of HCC. This etiological factor presents important opportunities for prevention, early detection, diagnosis, and treatment of HCC. This consensus statement reviews the available medical evidence for management of HCC in Asia, and gives treatment recommendations that are adapted to resource availability in this diverse region with disparate health-care delivery systems.
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Affiliation(s)
- Donald Poon
- National Cancer Centre, Singapore; Duke-NUS Graduate Medical School, Singapore.
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Tan HH, Lee GH, Thia KTJ, Ng HS, Chow WC, Lui HF. Minimal hepatic encephalopathy runs a fluctuating course: results from a three-year prospective cohort follow-up study. Singapore Med J 2009; 50:255-260. [PMID: 19352567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Minimal hepatic encephalopathy (mHE) has been reported in up to 84 percent of cirrhotics. The natural history of mHE has not been well-described. We designed a three-year prospective cohort study to determine the prevalence and natural history of mHE among cirrhotic patients. METHODS The patient cohort comprising 62 consecutive outpatients with cirrhosis were assessed at baseline and followed-up with a repeat assessment three years later. The assessments include: (1) Neuropsychometric analysis (digit-symbol substitution test, block-design test, number-connection test A); (2) Clinical, biochemical assessment; and (3) Quality of life (QOL) assessment (abbreviated sickness impact profile). RESULTS Baseline characteristics were: age 52.9 +/- 11.0 years; Child's A:B:C was 46:14:2. mHE was detected in 33.9 percent of the cohort. Older age, a higher Child-Pugh score and female gender were independently associated with mHE. mHE was associated with a poorer QOL. Follow-up assessment three years later showed that seven patients had died, while six were lost to follow-up; these patients had significantly higher baseline Child's scores. Of the remaining patients, 36/49 (73 percent) agreed to a repeat evaluation. In this group, none had mHE. QOL remained impaired despite the resolution of mHE. CONCLUSION It has been shown for the first time that mHE can revert to a normal state in a significant proportion of patients with well-compensated cirrhosis.
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Affiliation(s)
- H H Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Outram Road, Singapore 169608.
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Thia TJK, Tan HH, Chuah THC, Chow WC, Lui HF. Imatinib mesylate-related fatal acute hepatic failure in a patient with chronic myeloid leukaemia and chronic hepatitis B infection. Singapore Med J 2008; 49:e86-e89. [PMID: 18362995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Imatinib mesylate (Gleevec) is widely-used in the treatment of chronic myeloid leukaemia (CML) and gastrointestinal stromal tumour. Up to four percent of patients treated with imatinib may develop hepatotoxicity, which usually resolves with discontinuation of the drug. We report a 45-year-old Chinese man with CML and chronic hepatitis B virus infection, on imatinib treatment, presenting with herpetic rash and acute liver failure. This case illustrates the diagnostic challenges in the management of such a patient, as well as the need for greater vigilance in the monitoring of liver function tests for patients treated with imatinib. A short review on imatinib-related hepatotoxicity is also presented.
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Affiliation(s)
- T J K Thia
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Outram Road, Singapore 169608.
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Yew BS, Ong WC, Chow WC, Lui HF. A study into the characteristics and outcome of variceal bleeding in a tertiary hospital in Southeast Asia. Med J Malaysia 2007; 62:201-205. [PMID: 18246907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
This retrospective study evaluated patients admitted to the Department of Gastroenterology, Singapore General Hospital for variceal bleeding in the year 2004. Improvement in outcome of variceal bleeding has been reported in the West. There is no regional data on this condition. This study aims to determine the characteristics and outcome of variceal bleeding in a tertiary hospital in Southeast Asia. Twenty-two patients were eligible. The main aetiologies of liver cirrhosis were chronic hepatitis B (38%) and alcohol (33%). Child's A, B and C were 29%, 48% and 24% respectively. Nineteen patients (86%) had bleeding oesophageal varices (band ligation performed). The remaining three patients (14%) had bleeding gastric varices (N-butyl-2-cyanoacrylate injection performed). Detailed description of certain endoscopic findings was absent in up to 18 patients (82%). All patients received antibiotics and vasoactive drug. In-hospital mortality and rebleeding were 9% and 18% respectively. We conclude that the relatively low in-hospital mortality and rebleeding rates in our series are most probably due to the smaller proportion of patients with severe liver dysfunction and management which adhered to recommendations. Documentation of endoscopic findings needs to be improved to facilitate the continuation of care.
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Affiliation(s)
- B S Yew
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Outram Road, Singapore 169608
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Chow WC, Tai ES, Lian SC, Tan CK, Sng I, Ng HS. Significant non-alcoholic fatty liver disease is found in non-diabetic, pre-obese Chinese in Singapore. Singapore Med J 2007; 48:752-7. [PMID: 17657385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
INTRODUCTION To characterise the anthropometrical and metabolic parameters of a group of non-diabetic and non-obese patients who had histologically-proven nonalcoholic steatohepatitis (NASH). METHODS During September 1997 to November 1999, consent for liver biopsies were sought from a consecutive series of patients, whose body mass index (BMI) were equal to or less than 30 kg per square metres, and who had persistently elevated serum alanine transaminase (more than 2.5 times upper limit of normal for more than six months), with no associated viral hepatitis, alcohol or drug-induced liver disease, hereditary liver disease and diabetes mellitus. Patients who were found to have steatohepatitis histologically were further studied. Their body weight, height, waist and hip circumferences were taken, and fasting serum lipid and glucose measured. Serum insulin was measured in six patients and insulin resistance (IR) was calculated by homeostasis model assessment. Oral glucose tolerance tests were done if fasting glucose levels were greater than 6 mmol/L. All liver biopsies were reviewed by a single histopathologist. Three age- and sex-matched controls were randomly selected for each patient. RESULTS 11 of 12 patients who underwent liver biopsies were found to have NASH. All 11 were Chinese: eight males and three females. 73 percent of them had hepatic fibrosis. Overall, compared to controls, they had significantly higher body weight, BMI, IR and triglyceridaemia. The female patients also had a higher waist-hip ratio than controls. None had diabetes mellitus, and one had impaired glucose tolerance/fasting glycaemia. Nine out of 11 had BMI between 25 and 30 kg per square metres. CONCLUSION Significant histological changes of NASH with hepatic fibrosis were found in Singaporean Chinese non-diabetic patients with BMI of less than 30 kg per square metres.
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Affiliation(s)
- W C Chow
- Department of Gastroenterology, Singapore General Hospital, Outram Road, Singapore 169608.
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Tan HH, Ong WMC, Lai SH, Chow WC. Nimesulide-induced hepatotoxicity and fatal hepatic failure. Singapore Med J 2007; 48:582-5. [PMID: 17538762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase-2 (cox-2) inhibitors are structurally heterogeneous drugs that share similar therapeutic actions and adverse effects. Hepatotoxicity, although a relatively rare adverse effect of this class of drugs, can be severe. This has led to the withdrawal of some NSAIDs from the market. Nimesulide is an NSAID, with cox-2 preference, which has been reported to cause death from hepatic failure. However, most reports have been from European countries. Asian reports include that from Israel and India. We report three patients who presented with acute hepatitis after being prescribed nimesulide, one of whom died from fulminant hepatic failure.
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Affiliation(s)
- H H Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.
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McCaughan GW, Omata M, Amarapurkar D, Bowden S, Chow WC, Chutaputti A, Dore G, Gane E, Guan R, Hamid SS, Hardikar W, Hui CK, Jafri W, Jia JD, Lai MY, Wei L, Leung N, Piratvisuth T, Sarin S, Sollano J, Tateishi R. Asian Pacific Association for the Study of the Liver consensus statements on the diagnosis, management and treatment of hepatitis C virus infection. J Gastroenterol Hepatol 2007; 22:615-33. [PMID: 17444847 DOI: 10.1111/j.1440-1746.2007.04883.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Thia TJK, Lui HF, Ooi LL, Chung YF, Chow PKH, Cheow PC, Tan YM, Chow WC. A study into the risk of exacerbation of chronic hepatitis B after liver resection for hepatocellular carcinoma. J Gastrointest Surg 2007; 11:612-8. [PMID: 17468919 DOI: 10.1007/s11605-007-0121-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Accepted: 01/11/2007] [Indexed: 01/31/2023]
Abstract
Liver resection is commonly performed for solitary hepatocellular carcinoma (HCC) in well-compensated cirrhotic and noncirrhotic patients. Data concerning exacerbation of chronic hepatitis B (ECHB) post-liver resection are scant. To determine the incidence, risk factors, and clinical outcomes of ECHB in patients who underwent hepatic resection for HCC. The methods consisted of a retrospective review of consecutive patients with chronic hepatitis B virus (HBV) infection who had undergone liver resection for HCC from January 2002 to December 2004. Seventy-seven patients underwent 82 liver resections; the mean age was 58.0 +/- 12.1 years; 87% male; 20% hepatitis B e-antigen positive. Incidence of all causes of postoperative hepatitis was 25.6% (n = 21), and ECHB was 8.5% (n = 7). Both groups had their peak alanine aminotransferases, 231.0 IU/L (74-1,400) and 312 IU/L (147-1,400), respectively, observed at day 84 postresection. Three patients died as a result of ECHB within 4 months postsurgery. One- and 2-year survival rates were poorest for the ECHB group at 42.9 and 21.4%, compared with those with postoperative hepatitis due to other causes at 60.3 and 45.2% and those without postoperative hepatitis at 87.7 and 73.5% (p < 0.001). Liver resection for HCC in patients with chronic HBV infection carries a risk for ECHB, and affected patients have poorer clinical outcomes. There is a need for close monitoring of these patients preoperatively and in the early postoperative period.
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Affiliation(s)
- Teck Joo Kelvin Thia
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Outram Road, Singapore 169608, Singapore.
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Thong BYH, Koh ET, Chng HH, Chow WC. Outcomes of Chronic Hepatitis B Infection in Oriental Patients with Rheumatic Diseases. Ann Acad Med Singap 2007. [DOI: 10.47102/annals-acadmedsg.v36n2p100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Introduction: The aim of this study was to ascertain the outcomes of chronic hepatitis B (CHB) infection following immunosuppressive therapy in 38 consecutive oriental patients with systemic rheumatic diseases.
Materials and Methods: This is a retrospective consecutive, non-comparative study.
Results: The majority of patients were female (26, 68.4%), predominantly Chinese (92.1%), with a mean age 54 ± 14 years (range, 16 to 87). The mean duration of rheumatic disease was 9 ± 11 years (range, 0.1 to 48), with rheumatoid arthritis (52.6%) and systemic lupus erythematosus (23.7%) being the most common. The mean duration of CHB infection was 6 ± 5 years (range, 0.1 to 17), with the majority diagnosed during pre-methotrexate screening (50.0%) and asymptomatic transaminitis following initiation of immunosuppressive therapy (23.7%). Upon diagnosis of rheumatic disease, all patients had normal alanine aminotransferase (ALT). Of these, 18.2% were positive for hepatitis B e antigen (HBeAg) and 78.1% were positive for anti-HBe antibody. Twenty (52.6%) developed ALT elevation, which was more than twice the upper limit of normal in 12 patients. ALT normalised spontaneously in 12 patients without hepatic decompensation or change in therapy. Seven (18.4%) patients received lamivudine for 18 ± 22 months (range, 2 to 61). Two patients developed YMDD mutation subsequently treated with adefovir (1) and adefovir/lamivudine (1). There were 3 (7.9%) hepatitis B virus (HBV)-unrelated deaths [infection (2), genitourinary malignancy (1)], and 1 from HBV-reactivation complicated by septicaemia. None have developed hepatocellular carcinoma.
Conclusion: Elevated ALT occurred in 52.6% of patients, with only 18.4% requiring anti-viral therapy for HBV reactivation. HBV-related mortality was low. With the appropriate precautionary measures, prednisolone and immunosuppressants (except methotrexate and leflunomide) may be used safely in patients where clinically indicated.
Key words: Ankylosing spondylitis, Lamivudine, Rheumatoid arthritis, Spondyloarthropathies
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40
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Thong BYH, Koh ET, Chng HH, Chow WC. Outcomes of chronic hepatitis B infection in Oriental patients with rheumatic diseases. Ann Acad Med Singap 2007; 36:100-5. [PMID: 17364075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
INTRODUCTION The aim of this study was to ascertain the outcomes of chronic hepatitis B (CHB) infection following immunosuppressive therapy in 38 consecutive oriental patients with systemic rheumatic diseases. MATERIALS AND METHODS This is a retrospective consecutive, non-comparative study. RESULTS The majority of patients were female (26, 68.4%), predominantly Chinese (92.1%), with a mean age 54 +/- 14 years (range, 16 to 87). The mean duration of rheumatic disease was 9 +/- 11 years (range, 0.1 to 48), with rheumatoid arthritis (52.6%) and systemic lupus erythematosus (23.7%) being the most common. The mean duration of CHB infection was 6 +/- 5 years (range, 0.1 to 17), with the majority diagnosed during pre-methotrexate screening (50.0%) and asymptomatic transaminitis following initiation of immunosuppressive therapy (23.7%). Upon diagnosis of rheumatic disease, all patients had normal alanine aminotransferase (ALT). Of these, 18.2% were positive for hepatitis B e antigen (HBeAg) and 78.1% were positive for anti- HBe antibody. Twenty (52.6%) developed ALT elevation, which was more than twice the upper limit of normal in 12 patients. ALT normalised spontaneously in 12 patients without hepatic decompensation or change in therapy. Seven (18.4%) patients received lamivudine for 18 +/- 22 months (range, 2 to 61). Two patients developed YMDD mutation subsequently treated with adefovir (1) and adefovir/lamivudine (1). There were 3 (7.9%) hepatitis B virus (HBV)-unrelated deaths [infection (2), genitourinary malignancy (1)], and 1 from HBV-reactivation complicated by septicaemia. None have developed hepatocellular carcinoma. CONCLUSION Elevated ALT occurred in 52.6% of patients, with only 18.4% requiring anti-viral therapy for HBV reactivation. HBV-related mortality was low. With the appropriate precautionary measures, prednisolone and immunosuppressants (except methotrexate and leflunomide) may be used safely in patients where clinically indicated.
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Affiliation(s)
- Bernard Y H Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore.
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Lau GKK, Piratvisuth T, Luo KX, Marcellin P, Thongsawat S, Cooksley G, Gane E, Fried MW, Chow WC, Paik SW, Chang WY, Berg T, Flisiak R, McCloud P, Pluck N. Peginterferon Alfa-2a, lamivudine, and the combination for HBeAg-positive chronic hepatitis B. N Engl J Med 2005. [PMID: 15987917 DOI: 10.1016/s0084-3954(08)70087-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Current treatments for chronic hepatitis B are suboptimal. In the search for improved therapies, we compared the efficacy and safety of pegylated interferon alfa plus lamivudine, pegylated interferon alfa without lamivudine, and lamivudine alone for the treatment of hepatitis B e antigen (HBeAg)-positive chronic hepatitis B. METHODS A total of 814 patients with HBeAg-positive chronic hepatitis B received either peginterferon alfa-2a (180 microg once weekly) plus oral placebo, peginterferon alfa-2a plus lamivudine (100 mg daily), or lamivudine alone. The majority of patients in the study were Asian (87 percent). Most patients were infected with hepatitis B virus (HBV) genotype B or C. Patients were treated for 48 weeks and followed for an additional 24 weeks. RESULTS After 24 weeks of follow-up, significantly more patients who received peginterferon alfa-2a monotherapy or peginterferon alfa-2a plus lamivudine than those who received lamivudine monotherapy had HBeAg seroconversion (32 percent vs. 19 percent [P<0.001] and 27 percent vs. 19 percent [P=0.02], respectively) or HBV DNA levels below 100,000 copies per milliliter (32 percent vs. 22 percent [P=0.01] and 34 percent vs. 22 percent [P=0.003], respectively). Sixteen patients receiving peginterferon alfa-2a (alone or in combination) had hepatitis B surface antigen (HBsAg) seroconversion, as compared with 0 in the group receiving lamivudine alone (P=0.001). The most common adverse events were those known to occur with therapies based on interferon alfa. Serious adverse events occurred in 4 percent, 6 percent, and 2 percent of patients receiving peginterferon alfa-2a monotherapy, combination therapy, and lamivudine monotherapy, respectively. Two patients receiving lamivudine monotherapy had irreversible liver failure after the cessation of treatment--one underwent liver transplantation, and the other died. CONCLUSIONS In patients with HBeAg-positive chronic hepatitis B, peginterferon alfa-2a offers superior efficacy over lamivudine, on the basis of HBeAg seroconversion, HBV DNA suppression, and HBsAg seroconversion.
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Affiliation(s)
- George K K Lau
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China.
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Lau GKK, Piratvisuth T, Luo KX, Marcellin P, Thongsawat S, Cooksley G, Gane E, Fried MW, Chow WC, Paik SW, Chang WY, Berg T, Flisiak R, McCloud P, Pluck N. Peginterferon Alfa-2a, lamivudine, and the combination for HBeAg-positive chronic hepatitis B. N Engl J Med 2005; 352:2682-95. [PMID: 15987917 DOI: 10.1056/nejmoa043470] [Citation(s) in RCA: 1098] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current treatments for chronic hepatitis B are suboptimal. In the search for improved therapies, we compared the efficacy and safety of pegylated interferon alfa plus lamivudine, pegylated interferon alfa without lamivudine, and lamivudine alone for the treatment of hepatitis B e antigen (HBeAg)-positive chronic hepatitis B. METHODS A total of 814 patients with HBeAg-positive chronic hepatitis B received either peginterferon alfa-2a (180 microg once weekly) plus oral placebo, peginterferon alfa-2a plus lamivudine (100 mg daily), or lamivudine alone. The majority of patients in the study were Asian (87 percent). Most patients were infected with hepatitis B virus (HBV) genotype B or C. Patients were treated for 48 weeks and followed for an additional 24 weeks. RESULTS After 24 weeks of follow-up, significantly more patients who received peginterferon alfa-2a monotherapy or peginterferon alfa-2a plus lamivudine than those who received lamivudine monotherapy had HBeAg seroconversion (32 percent vs. 19 percent [P<0.001] and 27 percent vs. 19 percent [P=0.02], respectively) or HBV DNA levels below 100,000 copies per milliliter (32 percent vs. 22 percent [P=0.01] and 34 percent vs. 22 percent [P=0.003], respectively). Sixteen patients receiving peginterferon alfa-2a (alone or in combination) had hepatitis B surface antigen (HBsAg) seroconversion, as compared with 0 in the group receiving lamivudine alone (P=0.001). The most common adverse events were those known to occur with therapies based on interferon alfa. Serious adverse events occurred in 4 percent, 6 percent, and 2 percent of patients receiving peginterferon alfa-2a monotherapy, combination therapy, and lamivudine monotherapy, respectively. Two patients receiving lamivudine monotherapy had irreversible liver failure after the cessation of treatment--one underwent liver transplantation, and the other died. CONCLUSIONS In patients with HBeAg-positive chronic hepatitis B, peginterferon alfa-2a offers superior efficacy over lamivudine, on the basis of HBeAg seroconversion, HBV DNA suppression, and HBsAg seroconversion.
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Affiliation(s)
- George K K Lau
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China.
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Liaw YF, Sung JJY, Chow WC, Farrell G, Lee CZ, Yuen H, Tanwandee T, Tao QM, Shue K, Keene ON, Dixon JS, Gray DF, Sabbat J. Lamivudine for patients with chronic hepatitis B and advanced liver disease. N Engl J Med 2004. [PMID: 15470215 DOI: 10.1056/nejmoa0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The effectiveness of antiviral therapy in preventing disease progression in patients with chronic hepatitis B and advanced fibrosis or cirrhosis is unknown. METHODS Patients with chronic hepatitis B who had histologically confirmed cirrhosis or advanced fibrosis were randomly assigned in a 2:1 ratio to receive lamivudine (100 mg per day) or placebo for a maximum of five years. Of 651 patients, 436 were assigned to receive lamivudine and 215 to receive placebo. The primary end point was time to disease progression, defined by hepatic decompensation, hepatocellular carcinoma, spontaneous bacterial peritonitis, bleeding gastroesophageal varices, or death related to liver disease. An independent data and safety monitoring board monitored the progress of the study and performed interim analyses of the data. RESULTS We randomly assigned 651 patients (98 percent Asian and 85 percent male) to receive lamivudine or placebo. The study was terminated after a median duration of treatment of 32.4 months (range, 0 to 42) owing to a significant difference between treatment groups in the number of end points reached. End points were reached by 7.8 percent of the patients receiving lamivudine and 17.7 percent of those receiving placebo (hazard ratio for disease progression, 0.45; P=0.001). The Child-Pugh score increased in 3.4 percent of the patients receiving lamivudine and 8.8 percent of those receiving placebo (hazard ratio, 0.45; P=0.02), whereas hepatocellular carcinoma occurred in 3.9 percent of those in the lamivudine group and 7.4 percent of those in the placebo group (hazard ratio, 0.49; P=0.047). Genotypic resistance YMDD mutations developed in 49 percent of the patients treated with lamivudine, and the Child-Pugh score was more likely to increase in patients with these mutations than in the other patients treated with lamivudine (7 percent vs. <1 percent). Overall, 12 percent of the patients in the lamivudine group and 18 percent of the patients in the placebo group reported serious adverse events. CONCLUSIONS Continuous treatment with lamivudine delays clinical progression in patients with chronic hepatitis B and advanced fibrosis or cirrhosis by significantly reducing the incidence of hepatic decompensation and the risk of hepatocellular carcinoma.
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Affiliation(s)
- Yun-Fan Liaw
- Liver Research Unit, Chang Gung Memorial Hospital and University, Taipei, Taiwan.
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Liaw YF, Sung JJY, Chow WC, Farrell G, Lee CZ, Yuen H, Tanwandee T, Tao QM, Shue K, Keene ON, Dixon JS, Gray DF, Sabbat J. Lamivudine for patients with chronic hepatitis B and advanced liver disease. N Engl J Med 2004; 351:1521-31. [PMID: 15470215 DOI: 10.1056/nejmoa033364] [Citation(s) in RCA: 1648] [Impact Index Per Article: 82.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The effectiveness of antiviral therapy in preventing disease progression in patients with chronic hepatitis B and advanced fibrosis or cirrhosis is unknown. METHODS Patients with chronic hepatitis B who had histologically confirmed cirrhosis or advanced fibrosis were randomly assigned in a 2:1 ratio to receive lamivudine (100 mg per day) or placebo for a maximum of five years. Of 651 patients, 436 were assigned to receive lamivudine and 215 to receive placebo. The primary end point was time to disease progression, defined by hepatic decompensation, hepatocellular carcinoma, spontaneous bacterial peritonitis, bleeding gastroesophageal varices, or death related to liver disease. An independent data and safety monitoring board monitored the progress of the study and performed interim analyses of the data. RESULTS We randomly assigned 651 patients (98 percent Asian and 85 percent male) to receive lamivudine or placebo. The study was terminated after a median duration of treatment of 32.4 months (range, 0 to 42) owing to a significant difference between treatment groups in the number of end points reached. End points were reached by 7.8 percent of the patients receiving lamivudine and 17.7 percent of those receiving placebo (hazard ratio for disease progression, 0.45; P=0.001). The Child-Pugh score increased in 3.4 percent of the patients receiving lamivudine and 8.8 percent of those receiving placebo (hazard ratio, 0.45; P=0.02), whereas hepatocellular carcinoma occurred in 3.9 percent of those in the lamivudine group and 7.4 percent of those in the placebo group (hazard ratio, 0.49; P=0.047). Genotypic resistance YMDD mutations developed in 49 percent of the patients treated with lamivudine, and the Child-Pugh score was more likely to increase in patients with these mutations than in the other patients treated with lamivudine (7 percent vs. <1 percent). Overall, 12 percent of the patients in the lamivudine group and 18 percent of the patients in the placebo group reported serious adverse events. CONCLUSIONS Continuous treatment with lamivudine delays clinical progression in patients with chronic hepatitis B and advanced fibrosis or cirrhosis by significantly reducing the incidence of hepatic decompensation and the risk of hepatocellular carcinoma.
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Affiliation(s)
- Yun-Fan Liaw
- Liver Research Unit, Chang Gung Memorial Hospital and University, Taipei, Taiwan.
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Soong YL, Lee KM, Lui HF, Chow WC, Tao M, Li Er Loong S. Hepatitis B reactivation in a patient receiving radiolabeled rituximab. Ann Hematol 2004; 84:61-2. [PMID: 15449029 DOI: 10.1007/s00277-004-0948-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2004] [Accepted: 08/18/2004] [Indexed: 01/13/2023]
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Chow WC, Lee ASG, Seo YC, Tan CK, Ng HS. Prevalence of hepatitis G virus infection in patients with liver diseases in Singapore. Singapore Med J 2002; 43:067-9. [PMID: 11993892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
The prevalence of hepatitis G virus (HGV) infection in patients with liver diseases in Singapore and its pathogenic role in these patients was studied. One hundred and forty-eight patients who had chronic hepatitis or acute non A-E hepatitis were studied. Presence of HGV RNA was determined by nested polymerase chain reaction of the 5'non-coding region of the virus in all the patients. Hepatitis G IgG antibody to the envelope (E2) antigen was tested with an enzyme immunoassay (Boehringer Mannheim, Singapore) in 76 of them. Most patients (93%) were ethnically Chinese, predominantly males (74%) and chronic hepatitis B (72%) patients. Others had chronic hepatitis C (19%) or cryptogenic cirrhosis (6%). Four patients had acute non A-E hepatitis. HGV RNA and anti-HGenv were present in 3.5% and 8.3% of those with chronic liver disease. HGV infection did not account for any of the acute non A-E hepatitis and most of the cryptogenic cirrhosis.
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Affiliation(s)
- W C Chow
- Department of Gastroenterology, Singapore General Hospital, Singapore.
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Chow WC. Hepatitis C: issues from the Southeast Asian perspectives. Singapore Med J 2001; 42:97-8. [PMID: 11405557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
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Abstract
This paper addresses two difficult issues in the treatment of hepatitis C: patients who fail to achieve a sustained response after the first course of treatment, and those who simultaneously suffer from chronic renal failure. With the recent improvements in firstline treatment, retreatment is mainly applicable to those who have previously received 6-month of interferon monotherapy at 3 MU thrice weekly. For those who had an end-of-treatment response but relapsed, there is a choice between interferon monotherapy at increased dose and/or duration of treatment, or a 6-month course of combination therapy. Retreatment of non-responders is generally unsuccessful, but some patients may respond to interferon-alpha 3 MU and ribavirin 1.0-1.2 g/day. For patients with chronic renal failure and hepatitis C, combination treatment is not possible because ribavirin is contraindicated. Interferon given at a dose of 1.5 MU thrice weekly was reported to be fairly well tolerated by patients who were on dialysis and resulted in end-of-treatment and sustained biochemical and virological response in some cases. Interferon given in the usual doses may be associated with severe adverse effects in patients with renal failure, and can precipitate allograft rejection in patients who have undergone renal transplantation.
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Affiliation(s)
- W C Chow
- Department of Gastroenterology, Singapore General Hospital, Singapore.
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Abstract
Granulocytic sarcoma (GS) is an increasingly common relapse feature of acute myeloid leukemia (AML), late in the disease course or post bone marrow transplantation (BMT). Any solid organ can be affected, and there have been a number of reports of GS in breast tissue in female patients. We present a unique case of GS in a male AML patient, presenting as painless gynecomastia immediately before BMT at advanced disease. Aberrant expression of CD56 was found in the relapsed GS tissue but not in the original AML clone. Twelve months after allogeneic BMT, leukemia relapsed again in the same breast, with normal marrow morphology and full donor chimerism. The lesion failed to respond to donor lymphocyte infusion, chemotherapy and radiotherapy, and disseminated to other subcutaneous tissues.
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Affiliation(s)
- W Y Au
- Department of Medicine, University Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
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Parveen S, Morshed SA, Arima K, Nishioka M, Czaja AJ, Chow WC, Ng HS. Antibodies to Ro/La, Cenp-B, and snRNPs antigens in autoimmune hepatitis of North America versus Asia: patterns of immunofluorescence, ELISA reactivities, and HLA association. Dig Dis Sci 1998; 43:1322-31. [PMID: 9635626 DOI: 10.1023/a:1018880429469] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To assess whether demography is one of the important factors determining antibody response to nuclear antigens [ANA: SSA-Ro (52K and 60K), SSB-La, snRNPs (A, 70K, B'/B), and Cenp-B], we investigated 95 and 47 sera of autoimmune hepatitis (AIH) from North America and Asia, respectively, by immunofluorescent (IF) and recombinant ELISA. Correlations among nuclear IF patterns, ELISA, and disease indices were analyzed. The frequency and titer of individual antibodies differed significantly between the groups. Patients with speckled patterns were younger in both regions and had higher aspartate aminotransferase levels only in North America. HLA-A1, B8, DQ2, and DR4 or DR3 or both in North America, and A2, B61, DQ7, and DR4 in Asia were predominant. In Asia, B61 correlated with anti-70K, and DQ7 correlated with antibodies to 52K, Cenp-B, and B'/B. In North America, A1, B8, DR3 haplotype, and DQ2 correlated with antibodies to A and 70K. Anti-B'/B and DR4 in North America, and A2 in Asia, were associated with concurrent immunologic disorder. Individual ANA clusters correlated with individual HLA in the demography, and different HLA alleles might determine disease expression as well as different ANA being produced in AIH.
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Affiliation(s)
- S Parveen
- Third Department of Internal Medicine, Kagawa Medical School, Japan
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