Diagnosis and Management of Hepatitis Delta Virus Infection

Hepatitis D virus (HDV) depends on hepatitis B virus (HBV) to enter and exit hepatocytes and to replicate. Despite this dependency, HDV can cause severe liver disease. HDV accelerates liver fibrosis, increases the risk of hepatocellular carcinoma, and hastens hepatic decompensation compared to chronic HBV monoinfection. The Chronic Liver Disease Foundation (CLDF) formed an expert panel to publish updated guidelines on the testing, diagnosis, and management of hepatitis delta virus. The panel group performed network data review on the transmission, epidemiology, natural history, and disease sequelae of acute and chronic HDV infection. Based on current available evidence, we provide recommendations for screening, testing, diagnosis, and treatment of hepatitis D infection and review upcoming novel agents that may expand treatment options. The CLDF recommends universal HDV screening for all patients who are Hepatitis B surface antigen-positive. Initial screening should be with an assay to detect antibodies generated against HDV (anti-HDV). Patients who are positive for anti-HDV IgG antibodies should then undergo quantitative HDV RNA testing. We also provide an algorithm that describes CLDF recommendations on the screening, diagnosis, testing, and initial management of Hepatitis D infection.

EASL Clinical Practice Guidelines on hepatitis delta virus

Hepatitis D virus (HDV) is a defective virus that requires the hepatitis B virus to complete its life cycle and cause liver damage in humans. HDV is responsible for rare acute and chronic liver diseases and is considered the most aggressive hepatitis virus. Acute infection can cause acute liver failure, while persistent infection typically causes a severe form of chronic hepatitis which is associated with rapid and frequent progression to cirrhosis and its end-stage complications, hepatic decompensation and hepatocellular carcinoma. Major diagnostic and therapeutic innovations prompted the EASL Governing Board to commission specific Clinical Practice Guidelines on the identification, virologic and clinical characterisation, prognostic assessment, and appropriate clinical and therapeutic management of HDV-infected individuals.

Hepatitis Delta: Prevalence, Natural History, and Treatment Options

Half a century after its discovery, hepatitis delta remains a pertinent global health issue with a major clinical impact in endemic regions and an underestimated prevalence worldwide. Hepatitis delta virus infection follows a challenging clinical course and is responsible for significant liver-related morbidity. Although the only currently available treatment (pegylated interferon) does not provide consistent results, emerging therapeutic options are promising. This article explores the epidemiology, natural history, as well as current and potential therapeutic options for hepatitis delta virus infection.

[Recent advances in managing hepatitis D]

Discovered in 1977, Hepatitis D is the most severe form of chronic hepatitis, with rapid development of cirrhosis, hepatic failure and hepatocellular carcinoma. Despite all this, it is still largely underdiagnosed and there is no standardised management. The current treatment options are scarce and bear frequent side-effects, but the early diagnosis and an optimal follow-up with identification of the patients suitable for treatment improve significantly their survival rate and quality of life. Moreover, new promising treatments are entering phase III trials and offer new perspectives for our patients.

Hepatitis delta: virological and clinical aspects

There are an estimated 400 million chronic carriers of HBV worldwide; between 15 and 20 million have serological evidence of exposure to HDV. Traditionally, regions with high rates of endemicity are central and northern Africa, the Amazon Basin, eastern Europe and the Mediterranean, the Middle East and parts of Asia. There are two types of HDV/HBV infection which are differentiated by the previous status infection by HBV for the individual. Individuals with acute HBV infection contaminated by HDV is an HDV/HBV co-infection, while individuals with chronic HBV infection contaminated by HDV represent an HDV/HBV super-infection. The appropriate treatment for chronic hepatitis delta is still widely discussed since it does not have an effective drug. Alpha interferon is currently the only licensed therapy for the treatment of chronic hepatitis D. The most widely used drug is pegylated interferon but only approximately 25% of patients maintain a sustained viral response after 1 year of treatment. The best marker of therapeutic success would be the clearance of HBsAg, but this data is rare in clinical practice. Therefore, the best way to predict a sustained virologic response is the maintenance of undetectable HDV RNA levels.

[Is there hope for hepatitis delta ?]

Hepatitis D or delta is a chronic liver disease globally reaching 15‑20M people. Its agent, hepatitis D virus (HDV) requires the presence of hepatitis B virus (HBV) to complete its life cycle. It represents one of the most severe forms of viral hepatitis. Current therapy with pegylated interferon alpha leads to viral eradication only in 25 % of cases. New treatments targeting the virus life cycle are sought. For example Myrcludex-B, which inhibits the entry into hepatocytes, lonafarnib which prevents the assemblage of the viral particle and the molecule REP 2139 which, among other unclear mechanisms, impedes the exit of the virus. This allows considering a better management of a condition for which there is currently no satisfactory treatment.

[The return of the hepatitis delta virus]

- There are several regions worldwide with a high prevalence of infection with the hepatitis delta virus (HDV) in hepatitis B virus (HBV) carriers.- Chronic HDV infection is occurring with increasing frequency due to increased immigration.- HDV transmission can take place through the same routes as HBV by simultaneous infection with both viruses (co-infection) or infection of an HBV carrier with HDV (superinfection).- Delta hepatitis is considered as the most severe form of viral hepatitis with a high risk of progression to cirrhosis and hepatocellular carcinoma.- Chronic delta hepatitis is exclusively observed in patients who are HBV carriers.- Pegylated interferon is currently the only registered therapy for patients with delta hepatitis, but leads to a persistent virological response in only a minority of them, and rarely leads to a complete cure.- New antivirals, such as viral entry blockers, prenylation inhibitors and anti-sense oligonucleotides are promising and currently being investigated in phase 2 trials.

[Viral hepatitis delta. Is there the delta infection problem in the Russian Federation?]

Hepatitis delta (HD) is characterized by rapid progression to fibrosis, and development of hepatocellular carcinoma, and a high mortality rate. The article presents data on the epidemiology, diagnosis, treatment of HD. The views of the epidemiological, clinical and virological characteristics of HD-infection among population of the Russian Federation (RF) are limited due to absence of official HD registration and detection of antibodies to the HD virus (anti-HDV) in HBsAg-positive individuals. However, some areas of the country are characterized by a high HDV circulation (Republic Tyva (RT) - 46,5%, Republic Sakha (Yakutia) - 12,5%) according to our studies conducted in 6 regions of Russia. Clinical-epidemiological situation of HDV infection in RT can be considered as a model to create a program of optimize diagnosis, prevention and treatment of HDV-infection in the Russian Federation.

[Hepatitis D: forgotten but not gone]

Hepatitis D virus (HDV) is a subviral agent which depends on the envelope proteins (HBsAg) of hepatitis B virus (HBV). Therefore, hepatitis D is observed only in patients infected with HBV. Chronic hepatitis D is the least frequent albeit most severe form of chronic viral hepatitis. A resurgence of chronic hepatitis D has been observed in Northern and Central Europe, mainly due to immigration of patients from regions with high prevalence. Every HBsAg-positive patient should be screened for concurrent HDV infection. Standard treatment consists of pegylated interferon-alpha for at least one year. Sustained virological response rates are approximately 20%. Liver transplantation should be considered in patients with advanced cirrhosis or limited hepatocellular carcinoma. Preventive measures for hepatitis D are the same as for hepatitis B.

Costs and efficacy of "on demand" low-dose immunoprophylaxis in HBV transplanted patients: experience in the Romanian program of liver transplantation

BACKGROUND

HBV in liver transplant (LT) patients is associated with good outcomes and the challenges are primarily focused around optimizing prophylactic regimens with hepatitis B immune globulin (HBIG) and minimizing related costs.

AIM

To identify recurrence rates in patients transplanted for HBV or HBV+HDV infection in whom a combined "on demand" low-dose HBIG was used, maintaining low anti-HBs titres (not below 50 IU/L).

METHODS

Medical records of 42 patients transplanted for HBV or HBV+HDV induced cirrhosis between April 2000 and September 2007 at Fundeni Clinical Institute were analyzed. Patients received immunoprophylaxis with lamivudine and HBIG (10,000 IU within anhepatic phase and daily within the first postoperative week, followed by 2,500 IU on demand). HBV recurrence rates and survival during follow-up were evaluated using the Kaplan Meier method.

RESULTS

HBV recurrence rate was 4.8% after a median of 1.8 years. Three year patient survival rate was 70%. None of the patients died due to liver failure related to HBV recurrence. Using our "on demand" low-dose administration of HBIG, the total mean cost for HBIG and lamivudine for patient per month of survival was 598.3 Eur. The projected monthly cost for the "ideal" schedule/patient was 2,017 Eur.

CONCLUSION

Individualization of immunoprophylaxis after LT for HBV related disease according to the lowest protective anti-HBs titers in combination with lamivudine is probably the best approach for non-replicative pre-LT patients in terms of costs and efficacy.

Natural Course and Treatment of Hepatitis D Virus Infection

Hepatitis D virus (HDV) is a subviral satellite with hepatitis B virus (HBV) as its natural helper virus. After entry into hepatocytes, it utilizes host cellular enzymes to replicate by a double-rolling-circle mechanism. HDV is most often transmitted by contact with contaminated blood and body fluid, similar to HBV infection. Approximately 5% of the global HBV carriers are coinfected with HDV, leading to a total of 10-15 million HDV carriers worldwide. HDV infection can occur concurrently with HBV infection (coinfection) or in a patient with established HBV infection (superinfection). The pathogenesis of HDV remains controversial. A decline in the prevalence of both acute and chronic hepatitis D (CHD) has been observed worldwide. At present, therapy for chronic HDV infection is by the use of interferon-alpha. Compared to chronic hepatitis B or C, CHD treatment requires a higher dosage and a longer duration of treatment, and post-treatment relapses are common. In order to prevent the progression of CHD and its related morbidity and mortality, more effective treatments are needed.

Treatment of hepatitis D

Delta virus related chronic hepatitis is difficult to treat. The response to alpha-interferon (IFN), which still represents the only therapy for chronic hepatitis D, varies widely and occurs at different times from the beginning of treatment. The rate of response is proportional to the dose of IFN, with 9 million units (MU) three times a week being more effective than 3 MU thrice weekly. Sustained responses are unusual and are accompanied by the clearance of serum hepatitis B virus surface antigen (HBsAg), seroconversion to anti-HBs and improvement of liver histology. Although disease of a short-standing may respond better to therapy, clear predictors of response are still unidentified. Besides IFN, other therapeutic approaches such as immunosuppressive drugs, acyclovir, ribavirin and thymosin, have been unhelpful. Available evidence does not support the use of deoxynucleotide analogues. Famciclovir has no effect on disease activity and hepatitis D virus (HDV)-RNA levels. Twelve- or 24-month lamivudine treatment does not significantly affect biochemical, virological or histological parameters. Pegylated-IFN could represent a reasonable therapeutic option in the long-term treatment required for chronic hepatitis D. Antisense oligonucleotides and prenylation inhibitors hold promise as therapeutic agents of the future. Liver transplantation provides a valid option for end-stage HDV liver disease; the risk of re-infection is lower for HDV than for HBV under long-term administration of hyperimmune serum against HBsAg. Molecularly tailored drugs capable of interfering with crucial viral replicative processes of HDV appear to be the best prospect in the treatment of hepatitis D.

[Hepatitis and pregnancy--a short review]

Viral hepatitis is one of the most serious infections in pregnant women. There are now at least five hepatitis viruses. This educational review describes the various types of hepatitis, clinical manifestations, their impact on mother and fetus, prevention and treatment options, risks of perinatal transmission and differential diagnosis. Several open questions regarding vaccination as well as perinatal transmission have been addressed.

Sexually acquired hepatitis

OBJECTIVES

To assess current knowledge of sexually transmitted viral hepatitis in relation to epidemiology, clinical presentation, management, and diagnosis with particular reference to resource-poor settings.

METHOD

A search of published literature identified through Medline from 1966 to October 2001, the Cochrane Library, and reference lists taken from each article obtained. Textword and MeSH searches for hepatitis A, B, C, D, E, G, delta, GB virus, GBV-C, and TT virus were linked to searches under the textword terms sex$, prevent$, and MeSH subheadings, microbiology, complications, drug therapy, therapy, diagnosis, epidemiology, transmission, and prevention and control.

CONCLUSIONS

In heterosexual relationships, hepatitis B is readily transmitted sexually and hepatitis C and D less so, with no evidence for sexual transmission of hepatitis A. Hepatitis types A-D are all transmissible sexually in male homosexual relationships under certain conditions. In resource-poor countries sexual transmission is generally only a significant route of transmission for hepatitis B.

Hepatitis B transplantation: special conditions

Patients with hepatitis B virus (HBV) infection may be coinfected with other viral diseases, such as hepatitis C virus (HCV) and/or D virus (HDV), or have serious diseases secondary to the hepatitis, such as hepatocellular carcinoma. These coexisting conditions have an impact on the success of treatment and of liver transplantation. Patients with HBV and HDV are at lower risk for HBV recurrence than are patients with HBV alone; likewise, patients with HBV/HCV coinfection appear to have a higher 5-year survival rate posttransplantation. Treatment of coinfection is similar to that used for HBV alone. Hepatitis B immune globulin and interferon have been found to be effective in varying degrees. Recurrence or reinfection of disease after liver transplantation presents many clinical problems that will require new therapeutic approaches. Future studies will help to begin solving these challenges.

Hepatitis delta virus: the molecular basis of laboratory diagnosis

Infection with hepatitis delta virus (HDV), a satellite virus of hepatitis B virus (HBV), is associated with severe and sometimes fulminant hepatitis. The traditional methods for the diagnosis of HDV infection, such as detection of serum anti-HD antibodies, are sufficient for the clinical diagnosis of delta infection. However, such techniques lack the sensitivity and specificity required to more accurately characterize the nature of HDV infection and to assess the efficacy of therapies. Recent improvements in molecular techniques, such as HDV RNA hybridization and RT-PCR, have provided increased diagnostic precision and a more thorough understanding of the natural course of HDV infection. These advances have enhanced the clinician's ability to accurately evaluate the stage of HDV infection, response to therapy, and occurrence of reinfection after orthotopic liver transplant. This review focuses on the recent advances in the understanding of the molecular biology of HDV and in the laboratory diagnosis of HDV infection.

Liver transplantation and HBsAg-positive postnecrotic cirrhosis: adequate immunoprophylaxis and delta virus co-infection as the significant determinants of long-term prognosis

BACKGROUND/AIMS

The place of liver transplantation in hepatitis B viral (HBV)-related diseases remains controversial because of the high rate of reinfection. The aim of this study was to define the determinants of long-term prognosis after transplantation.

METHODS

Fifty-eight patients were transplanted during the period February 1984-September 1996. Six patients died during the early (< 3 months) posttransplant period from causes unrelated to HBV infection. All 52 long-term (> 3 months) survivors were evaluated in relation to the mode of presentation, viral replication at time of transplantation, absence of hepatocellular cancer at time of transplantation and use of adequate immunoprophylaxis (IP). Adequate immunoprophylaxis, defined as maintenance of anti-HBs levels over 100 mUI/ml, was introduced in December 1989. Intention-to-treat IP analysis compared patients transplanted before and after this date. The median follow-up was 74 months (range 4 to 131). Forty-seven patients (90%) had a minimal follow-up of 3 years.

RESULTS

Five-year actuarial survival rates of 58 patients and of 52 long-term survivors were 72 +/- 6% and 80 +/- 6%, respectively. Univariate analysis showed that delta co-infection (n = 25) significantly improved survival (p < 0.001) [96 +/- 4% vs 63 +/- 10% in HBV patients (n = 27) at 5 years] as did absence of hepatocellular cancer (n = 36) (p = 0.020) [89 +/- 5% vs 61 +/- 12% in 16 non-cancer patients]. IP, however, significantly influenced 5-year survival in the HBV-patient group (n = 17) (p = 0.001) [85 +/- 10% vs 30 +/- 14% in 10 patients without IP). Multivariate analysis selected delta co-infection (p = 0.002) and IP (p = 0.01) as the significant determinants of prognosis independently influencing survival. Uni- and multivariate analyses showed that survival without reinfection was significantly influenced by IP (p = 0.002) [73 +/- 8% (n = 31) versus 33 +/- 12% in 15 non-treated patients).

CONCLUSIONS

Delta virus co-infection and immunoprophylaxis are the most important prognostic factors after transplantation for postnecrotic HBsAg-positive cirrhosis. Transplantation can be proposed as a therapeutic tool only if life-long adequate adjuvant therapy can be achieved. Under this condition good results can even be obtained if there is viral replication at the time of transplantation.

Alpha-interferon treatment in HBeAg positive children with chronic hepatitis B and associated hepatitis D

The main problem of children with HBeAg positive hepatitis B and associated hepatitis D is progression to liver cirrhosis with decompensation of liver function and need for liver replacement therapy within 15-20 years after infection. To determine whether interferon-alpha (IFN-alpha) therapy has a positive effect on HBV replication and inflammatory activity, we evaluated clinical and serological data of 8 children treated with IFN-alpha and 6 historic control patients without treatment. 4 of the nontreated patients seroconverted from HBeAg to anti-HBe between 7 to 17 years after initial diagnosis and showed decreased inflammatory activity in the liver. In the treatment group, the rate of seroconversion to anti-HBe (3 early, 2 late seroconverters) corresponded well to former trial results obtained in patients exclusively infected by HBV. Serum aminotransferase levels decreased or normalized in seroconverted children. In chronic HBV infection with associated hepatitis D (HDV) infection--compared to the spontaneous course of the disease--IFN-alpha therapy reduced inflammatory activity by earlier seroconversion to anti-HBe in responding patients. Moreover, viral replication and infectivity of hepatitis B was markedly reduced, but no effect on replication of HDV could be documented. Although long-term effects cannot be exactly estimated, at present IFN-alpha remains the only available treatment for HBeAg and anti-HDV positive children and seems to be of benefit for responding patients.

Serum immunoglobulin M antibody to hepatitis D as a surrogate marker of hepatitis D in interferon-treated patients and in patients who underwent liver transplantation

The kinetics of the immunoglobulin (Ig) M type antibody to the hepatitis D virus (IgM anti-HD) were investigated in hepatitis B surface antigen (HBsAg) carriers with chronic hepatitis D treated with interferon (IFN) and in patients with terminal hepatitis delta virus (HDV) cirrhosis who underwent liver transplantation. The IgM antibody disappeared in each of 8 patients who responded to IFN therapy with the persistent normalization of aminotransferases and with the clearance of serum HBsAg and HDV-RNA. The IgM reactivity did not decline in the 45 treated patients who did not respond to the cytokine or who experienced a relapse after responding while on therapy. The antibody rapidly disappeared from serum post-transplantation in each of 10 examined patients with HDV who underwent transplantation. In 5 patients who underwent transplantation and who became reinfected with HDV, the antibody remained undetectable during the early reinfection phase, as marked by HDV replication and by the absence of liver damage; however, it rapidly raised to pre-transplantation levels with the recurrence of hepatitis D (HD) in the liver graft. Monomeric 7S IgM anti-HD predominated over pentameric 19S antibody in each of the two patients examined for IgM anti-HD molecular species. The IgM antibody to HDV raises in response to HDV-induced damage and represents a valid surrogate marker of liver damage which is immunopathologically related to HDV infection. Besides providing diagnostic information, it provides the best predictor of impending resolution of chronic HDV disease, whether spontaneous or IFN-induced.

Impact of interferon-alpha therapy on the development of hepatocellular carcinoma in patients with liver cirrhosis: results of an international survey

Clinico-epidemiological data show that the most severe forms of hepatitis C virus (HCV) associated liver disease occur in patients with multifactorial liver damage. We found that the prevalence of hepatitis B virus (HBV) markers in anti-HCV positive patients with cirrhosis complicated by hepatocellular carcinoma (HCC) is higher than in cirrhotics with comparable age and disease history, but without HCC. HBV can persist in integrated forms in HBsAg negative, anti-HBc positive individuals and we may speculate that in such patients concurrent liver pathogens, as HCV, could cause HCC more easily than in patients without previous exposure to HBV. Analysing the relations between age at HCC diagnosis and the different risk factors in consecutive HCC patients we found that patients with single hepatitis virus infections (HBsAg and/or anti-HCV positive) were of an older median age than patients with multiple hepatitis virus infections. We also studied patients with compensated cirrhosis and hepatitis virus infections. untreated or treated with interferon-alpha. The independent effect of treatment was analysed by matching groups with regard to all the other significant HCC risk factors. The overall relative HCC risk was three times higher (risk ratio 3.1) in untreated vs treated anti-HCV positive patients and more than six times higher (risk ratio 6.2) in untreated vs treated anti-HCV positive/anti-HBc negative patients. The difference between treated and untreated patients was not statistically significant in hepatitis B surface antigen carriers and in anti-HCV positive/anti-HBc positive patients. The evidence that HBV coinfection may worsen the course of liver cirrhosis in patients with chronic hepatitis C is intriguing, but it has important practical consequences. It warrants the identification of high risk patients with chronic hepatitis C who need to be treated as early as possible and patients who can still benefit from interferon-alpha therapy once cirrhosis has already been diagnosed.

Current therapeutic trends in therapy for chronic viral hepatitis

Hepatitis B virus (HBV), hepatitis C virus (HCV) and hepatitis delta virus (HDV) are associated with clinically significant chronic infection that may lead to the development of cirrhosis or even hepatocellular carcinoma (HCC). Intervention at the earliest possible stage is needed to prevent such untoward sequelae. Currently, interferon (IFN) is the only approved and widely used agent for the treatment of these infections, including in HBV patients with precore mutant hepatitis or decompensated cirrhosis, but its efficacy is far from satisfactory. Corticosteroid priming has been shown to increase the efficacy of IFN therapy in HBV patients with low abnormal serum transaminase levels, but only a few responders will clear serum hepatitis Bs antigen (HBsAg). Ongoing randomized controlled trials of thymosin alpha 1, lamivudine and famcyclovir have demonstrated encouraging preliminary results. Therapeutic vaccines, such as polypeptides with human leucocyte antigen (HLA)-specific hepatitis B core antigen (HBcAg) epitopes, are under phase II/III clinical trial. For HDV infection, the use of IFN in the early phase of acute superinfection tends to prevent chronic progression. For HCV infection, IFN used at higher doses for a longer period of time is associated with a higher sustained response, but overall it is still not satisfactory. The combined use of ribavirin or corticosteroid priming may improve the effect of IFN therapy by enhancing the durability of the response. Interferon in the acute phase of HCV infection may also prevent chronic progression. There is evidence to suggest that IFN therapy, when associated with response, tends to reduce the risk of cirrhosis or HCC and prolongs survival. There is no doubt that satisfactory treatment of chronic viral infection will require more effective agents and demand optimal treatment strategies, many of which are yet to be found.

Management of viral hepatitis: clinical and public health perspectives--a consensus statement. CASL Hepatitis Consensus Group. Canadian Association for Study of the Liver

The Canadian Liver Foundation convened a two-day conference in September 1996, at which experts from across Canada were invited to discuss various aspects of viral hepatitis and to issue guidelines to assist practitioners in caring for patients with these diseases. The proceedings of this conference were transcribed and submitted to all participants for approval before being submitted for publication. The views expressed in this article represent the consensus opinion of the group. Where there was significant difference of opinion this is explicitly stated, and opposing points of view are given.

Management of chronic viral hepatitis

Chronic viral hepatitis is a leading cause of death worldwide. Four of the six identifiable hepatitis viruses are associated with chronic disease. Until recently, the only accepted treatment has been injected interferon alfa. New antiviral medications currently hold promise in the treatment of hepatitis B. Hepatitis C remains more difficult to treat than hepatitis B, but involving the patient in selecting the treatment and identifying patients with better responses to interferon may help the physician direct the management of such patients more successfully.

Viral hepatitis: how to manage type C and D infections

Hepatitis C and D are relative newcomers to the study of viral hepatitis. Their transmission is mainly parenteral. The 0.5 to 2.2% prevalence of hepatitis C in the United States does not vary by patient age. Often, hepatitis C is asymptomatic. In older patients, symptomatic infection has a cholesteatic appearance, and progress to chronic hepatitis and cirrhosis is more rapid than in younger adults. Hepatitis D virus is a defective single-stranded RNA that presents as a co-infection or superinfection of hepatitis B. Prevalence varies by geographic region. The rate of progression to chronic disease and cirrhosis is high in superinfection.

A practical guide to the use of interferons in the management of hepatitis virus infections

The recommended interferon dosage for patients with chronic hepatitis and typical hepatitis B virus (HBV) infection is 10 MU 3 times weekly for 4 to 6 months; with such a regimen sustained alanine aminotransferase (ALT) normalisation, liver histology improvement, clearance of HBV DNA and seroconversion from hepatitis B e antigen (HBeAg) to anti-HBe are obtained in about 40% of treated patients. Patients with elevated disease activity (high ALT values, active chronic hepatitis, low HBV DNA levels) tend to respond better to therapy; Oriental patients and immunocompromised patients are not ideal candidates for interferon. Patients with chronic hepatitis B and the HBeAg-negative variant should be given intermediate dosages (6 to 9 MU thrice weekly) of interferon for prolonged periods (12 months); however, even with this approach, the relapse rate is high (> 60%) during the follow-up. In chronic hepatitis D virus (HDV) infection, therapy with 9 to 10 MU of interferon 3 times weekly for 12 months induces a transient remission in disease (ALT normalisation, HDV RNA clearance) in more than 50% of treated patients, but a sustained response is found in less than 20% of patients. In such disease, baseline predictive factors of long term response are still unknown. In chronic hepatitis C, treatment with 3 to 5 MU of interferon given 3 times weekly for 6 to 12 months induces a sustained remission in no more than 30% of treated patients. Probable predictive factors of long term response are: low viraemia, genotype other than 1, absence of cirrhosis, low intrahepatic iron content, low nucleotide diversity of the envelope 2 gene of the hepatitis C virus. Prolonged (> 12 months) therapeutic courses seem to enhance the sustained response rate; in nonresponders/relapsers, combined therapy (interferon plus indomethacin, interferon plus ketoprofen, interferon plus ribavirin) is promising but randomised controlled trials are needed in order to establish the real efficacy and safety of such therapeutic regimens.

Comparison of clinico-pathological features in hepatitis B virus-associated hepatocellular carcinoma with or without hepatitis D virus superinfection

BACKGROUND/AIMS

Hepatitis D virus superinfection in hepatitis B virus carriers produces additional damage in an already injured liver. Earlier reports noted that the development of hepatocellular carcinoma may be accelerated in hepatitis D virus-superinfected patients. This study aimed to investigate the impact of hepatitis D virus on the clinical course of hepatitis B virus-associated hepatocellular carcinoma.

METHODS

A total of 42 consecutive hepatocellular carcinoma cases seropositive for antibody against hepatitis D virus antigen (anti-HDV) were found from 1986 to 1994; the clinical manifestations, treatment and outcomes were compared with 255 consecutive hepatocellular carcinoma cases seropositive for hepatitis B virus surface antigen but seronegative for anti-HDV.

RESULTS

The mean age was 60 years in both groups of patients. Other features, including sex, duration of follow-up, presence of cirrhosis or ascites, serum biochemistry, status of HBV-e antigen, and gross and microscopic tumor appearance, were not significantly different between the two groups. Though more patients in the anti-HDV-positive group underwent active treatment (operation or transcatheter arterial chemoembolization) than those in the anti-HDV-negative group (54.8% in 42 versus 34.9% in 255 cases, p = 0.02), the cumulative 4-year survival rates (9.5% versus 9.8%) were similar. For the anti-HDV-positive hepatocellular carcinoma patients, tumor size < 5 cm and active treatment were favorable prognostic predictors associated with survival > 18 months.

CONCLUSION

Hepatitis D virus superinfection does not accelerate the development of hepatocellular carcinoma. The clinical manifestations were similar, and the outcome in anti-HDV-positive patients was not worse than in the general HBV-associated hepatocellular carcinoma patients, as long as they were diagnosed at an early stage and actively treated.

HLA typing in chronic type B, D and C hepatitis

AIMS

We aimed to test the hypothesis that susceptibility to chronic HBV, HDV and HCV infections or their pathology is influenced by host genetic factors.

METHODS

The Human Leukocyte Antigens (HLA) (A, B, DR and DQ) were determined by microlymphocytotoxicity assay in patients with chronic C (n = 117), B (n = 97) or D (n = 27) hepatitis and their frequencies were compared with those of 489 healthy controls.

RESULTS

No statistically significant association was found between any HLA antigen and chronic B or D hepatitis. A significantly higher frequency of HLA-B14 was observed in patients with chronic persistent or active C hepatitis (16.7% of 90 versus 5.9% of 489, chi(2) = 10.9, pc < 0.05, Relative Risk = 3.17, Etiological Fraction = 0.11). The frequency of HLA-DR5 was lower in HCV positive patients (24.8%) than in controls (45%, chi(2) = 15.1, pc < 0.005, RR = 0.4, EF = -0.37).

CONCLUSIONS

No correlation could be observed between clearance of HBV or HDV and HLA phenotype. Immunogenetic factors may have a role in determining susceptibility to chronic HCV hepatitis, and in Italian patients HLA-DR5 is a protective factor.

Role of hepatitis C virus in dual and triple hepatitis virus infection

Hepatitis B virus (HBV), hepatitis C virus (HCV), and hepatitis delta virus (HDV) share same transmission routes, thus dual or triple infection may occur and even persist in the same patients. A significant amount of literature has accumulated since the advent of HCV assays. It is pertinent to review and evaluate the clinical and virological significance of HCV in multiple hepatotropic viral infection. The reported series on seroprevalence of HCV indicate that HCV is found in more than 10% of HBV- or HDV-infected patients worldwide. Of the patients with dual or triple infection involving HCV, those having coreplication of viruses tend to have severe and progressive liver disease that is resistant to interferon therapy, in contrast with patients having a single virus infection. Paradoxically, dual or triple hepatitis virus infections are associated with viral interference. In particular, HCV exerts a suppressive effect on HBV and HDV and may enhance seroclearance of HBV antigens or even usurp the role of preexisting virus as the agent for continuing hepatitis. Although HBV and HDV may also suppress HCV, it appears to be less effective. These findings clearly suggest the necessity of monitoring patients with HBV or HDV infections. In view of complex dynamism of viral interaction in multiple hepatotropic virus infection, the importance of HCV assay in the clinical studies can not be overemphasized. The basic mechanisms that regulate the viral interactions, in particular the impact of HCV in dual or triple virus infections, remain to be investigated.

[Interferons as therapy in viral hepatitis: are promises kept?]

Due to their antiviral and immunomodulatory properties, interferons constitute the only efficacious therapy against chronic viral hepatitis. Type-1 interferons are used for therapy with doses ranging between 3 and 10 million units on three days a week. Duration and dose vary with the various forms of viral hepatitis and have not been defined for all instances. In chronic hepatitis B, continued suppression of viral replication can be achieved in 40 to 50% of patients and leads to loss of HBV-DNA and HBe in the serum. 10 to 15% of patients also loose HBs-Ag later on. By carefully selecting patients, even higher success rates can be achieved; however, good selection criteria do not exist for chronic hepatitis C. With this hepatitis, interferons normalize aminotransferases frequently, but sustained elimination of viral infection is still a rare event. Finally, most patients have a relapse of their hepatitis when interferon therapy is terminated. Thus, only 20% of patients with chronic hepatitis C have a sustained benefit from their interferon treatment. Interferon therapy of chronic hepatitis D is even more difficult. Side effects increase with dose and duration of therapy. Fortunately, they only rarely require discontinuation of interferon and are fully reversible, when interferon is stopped. In conclusion, as there exist no therapeutic alternatives, patients with chronic hepatitis B and hepatitis C should be treated with interferon, even though only 20 to 40% of treated patients benefit in the long term.

[The problem of the interferon therapy of patients with chronic viral hepatitis]

In this work the results of the clinico-immunological evaluation of the therapeutic effectiveness of alpha-interferon preparations are presented and criteria suitable for use in screening patients with chronic virus hepatitis, sensitive to interferon therapy, are discussed. The study revealed that the use of alpha-interferon preparations in single doses of 1-3 x 10(6) in a prolonged course of treatment (6-12 months) facilitated essential improvement in the clinical course of the disease and ensures correction of the immune status in 55.6% of patients with chronic active hepatitis (CAH) resulting in cirrhosis of the liver and 57.9% of patients with CAH moderate activity. Indications for the use of alpha-interferon preparations in patients with CAH-induced cirrhosis were high activity of the cytolytic process, the presence of immunodeficiency, faintly pronounced autoimmune process and the presence of protein shifts.