Viral and immune factors associated with successful treatment withdrawal in HBeAg-negative chronic hepatitis B patients

BACKGROUND & AIMS

Factors associated with a successful outcome upon nucleos(t)ide analogue (NA) treatment withdrawal in HBeAg-negative chronic hepatitis B (CHB) patients have yet to be clarified. The objective of this study was to analyse the HBV-specific T cell response, in parallel with peripheral and intrahepatic viral parameters, in patients undergoing NA discontinuation.

METHODS

Twenty-seven patients without cirrhosis with HBeAg-negative CHB with complete viral suppression (>3 years) were studied prospectively. Intrahepatic HBV-DNA (iHBV-DNA), intrahepatic HBV-RNA (iHBV-RNA), and covalently closed circular DNA (cccDNA) were quantified at baseline. Additionally, serum markers (HBV-DNA, HBsAg, HBV core-related antigen [HBcrAg] and HBV-RNA) and HBV-specific T cell responses were analysed at baseline and longitudinally throughout follow-up.

RESULTS

After a median follow-up of 34 months, 22/27 patients (82%) remained off-therapy, of whom 8 patients (30% of the total cohort) lost HBsAg. Baseline HBsAg significantly correlated with iHBV-DNA and iHBV-RNA, and these parameters were lower in patients who lost HBsAg. All patients had similar levels of detectable cccDNA regardless of their clinical outcome. Patients achieving functional cure had baseline HBsAg levels ≤1,000 IU/ml. Similarly, an increased frequency of functional HBV-specific CD8+ T cells at baseline was associated with sustained viral control off treatment. These HBV-specific T cell responses persisted, but did not increase, after treatment withdrawal. A similar, but not statistically significant trend, was observed for HBV-specific CD4+ T cell responses.

CONCLUSIONS

Decreased cccDNA transcription and low HBsAg levels are associated with HBsAg loss upon NA discontinuation in patients with HBeAg-negative CHB. The presence of functional HBV-specific T cells at baseline are associated with a successful outcome after treatment withdrawal.

LAY SUMMARY

Nucleos(t)ide analogue therapy can be discontinued in a high proportion of chronic hepatitis B patients without cirrhosis. The strength of HBV-specific immune T cell responses may contribute to successful viral control after antiviral treatment interruption. Our comprehensive study provides in-depth data on virological and immunological factors than can help guide individualised therapy in patients with chronic hepatitis B.

South African guideline for the management of chronic hepatitis B: 2013

Hepatitis B remains a significant yet preventable health issue in South Africa. The introduction of the hepatitis B vaccine into the country some 18 years ago has demonstrated benefit, but the exposure to, and prevalence of chronic HBsAg positivity remain unacceptably high. Those with chronic hepatitis B virus infection have an elevated risk of developing cirrhosis with end-stage liver disease and a markedly elevated risk of hepatocellular carcinoma, independent of the presence of cirrhosis. The challenge in South Africa remains prevention through the universal vaccination coverage of all children and the identification of those with chronic hepatitis B virus infection. Over the last decade our understanding of hepatitis B and its behaviour and natural history in those with chronic infection has significantly improved. This understanding is key to identifying those who warrant further evaluation and therapy. A number of global societies have updated their guidelines in recent years. This document draws on these guidelines and serves to contextualise, for South Africa, practice guidelines for the management of chronic hepatitis B.

[Possibility of detecting HBsAG in bloodstains on evidential objects by solid-phase immunoenzyme assay]

This study was designed to detect HBsAg in bloodstains on evidential objects by solid-phase immunoenzyme assay and to characterize its sensitivity, specificity, and reproducibility as well as effect of various external factors on the results of HBsAg measurements. Both whole blood from 25 HBsAg carriers and its stains were available for analysis. HBsAg was detected in all blood stains regardless of the time of their formation. However, HBsAg was absent in 25 stains of blood from control subjects and in 27 extracts from carrier objects. A highly specific, sensitive, and well-reproducible method was developed for determining HBsAg in traces of blood after its preliminary extraction from the stain. The method allows HBsAg to be detected in a stain containing 4 x 10(-6) ml of blood.

Chronic hepatitis B and C infection in children in New South Wales

OBJECTIVE

To characterise epidemiological, clinical and laboratory features of children in New South Wales with chronic hepatitis B (HBV) or C (HCV) infections.

DESIGN AND SETTING

Retrospective record review of epidemiological, clinical, laboratory, liver biopsy and treatment data for children (aged < 18 years) referred to tertiary referral paediatric and refugee clinics in NSW with chronic HBV or HCV during 2000-2007; and comparison with NSW Health notification data for the same period.

MAIN OUTCOME MEASURES

Numbers and characteristics of referred children with HBV and HCV, and notifications to NSW Health.

RESULTS

During 2000-2007, 79 children with chronic HBV and 29 with HCV infection were referred to specialist clinics, while 930 children with HBV and 777 with HCV infection were reported to NSW Health. Most of the referred children with HBV were born overseas, while most with HCV were born in Australia to mothers with a history of intravenous drug use. Of the 79 HBV-infected children, 56 were e-antigen positive. Most HCV-infected children (23/29) had alanine aminotransferase levels < or = 2 times the upper limit of normal, and more than half of those who had genotype determined had type 2 or 3. Fibrosis was evident in liver biopsies performed for both HBV and HCV.

CONCLUSIONS

Although advanced liver disease was uncommon in children referred with HBV or HCV infection, a large number of infected children in NSW were not referred for specialist medical care, indicating that opportunities to intervene early in the natural history of these infections, particularly HCV, are being missed.

Clinical and virological responses to clevudine therapy in chronic hepatitis B patients: results at 1 year of an open-labelled prospective study

BACKGROUND

A previous clinical study of oral clevudine monotherapy for 24 weeks demonstrated that it has potent sustained antiviral effects without inducing drug resistance. The aim of this study was to evaluate the antiviral effects and safety of clevudine monotherapy for 12 months.

METHODS

In this open-labelled prospective study, 45 treatment-naive chronic hepatitis B patients treated with 30 mg clevudine once daily for 12 months were monitored at baseline and at 3-month intervals during treatment.

RESULTS

At baseline, the mean age of patients was 42 years, 32 were hepatitis B e antigen (HBeAg)-positive and 15 had liver cirrhosis. After 12 months of clevudine therapy, the mean serum hepatitis B virus (HBV) DNA level in HBeAg-positive patients had decreased by 4.6 log(10) IU/ml. Serum HBV DNA was undetectable in 68.7% of patients. HBeAg loss or seroconversion was observed in five patients (15.6%) and serum alanine aminotransferase (ALT) level had normalized after 12 months of treatment in 75% of patients. In all 13 HBeAg-negative patients, serum HBV DNA level was undetectable after 12 months of therapy and ALT level was normal in 61.5% of patients. Viral breakthrough occurred in one patient after 9 months of clevudine treatment. This patient had an HBV polymerase mutation, rtM204I. There were no serious adverse events.

CONCLUSIONS

One-year clevudine therapy is effective for suppressing serum HBV DNA level and for normalization of ALT level. Viral breakthrough associated with the rtM204I mutation in the HBV polymerase gene occurs during long-term clevudine treatment.

[Molecular virology of the hepatitis B virus]

The hepatitis B virus (HBV) belongs to the hepadnavirus family. The genome of the virus, formed by a small DNA molecule with 3,200 base pairs, has 4 strongly overlapping protein coding regions: ORF preS/S, corresponding to the envelope proteins that constitute the HBV surface antigen (HBsAg); ORF preC/C, which encodes the viral capsid component (core antigen or HBcAg) and a non-structural protein that, after postranslation modification, is secreted and constitutes the "e" antigen (HBeAg); ORF P, which encodes the viral polymerase (polyprotein with DNA polymerase activity, reverse transcriptase and RNAase), and ORF X, which encodes a protein that acts as a multifunctional regulator for both the viral and cell cycles. HBV has a mutation rate of 1.4-3.2 x 105 substitutions/nucleotide/year. As a result of this variability, the virus circulates as a complex mixture of genetic variants, constituting a semi-species, that evolves throughout the infection depending on the evolutionary pressure of factors such as the immune response and antiviral treatments. Based on this variability, HBV has been classified into 8 genotypes (A-H) defined by a difference of more than 8% in the sequences of the complete viral genome. This variability is also responsible for HBV resistance to antiviral treatments with nucleotide and nucleoside analogs. Diagnosis of HBV infection includes determination of virological markers: viral antigens (HBsAg, HBeAg), specific antibodies (anti-HBc, anti-HBe, anti-HBs) and study of HBV-DNA for its detection and quantification and determination of genotypes and viral variants.

Fatal hepatic failure associated with hepatitis B virus reactivation in a hepatitis B surface antigen-negative patient with rheumatoid arthritis receiving low dose methotrexate

A 66-year-old female patient with rheumatoid arthritis, who had been HBsAg-negative and anti-HBs-positive, developed hepatic dysfunction following low-dose methotrexate therapy. Serologic testing for HBsAg, HBeAg, IgM HBc and HBV DNA were positive. Despite antiviral therapy with lamivudine, the hepatic condition gradually deteriorated until the patient died. Since HBV replication persists in the liver even in individuals with resolved HBV infection (i.e., HBsAg-negative, anti-HBs-positive), HBV reactivation may occur in these patients with immunosuppression. Therefore, especially in endemic areas, all patients being considered for immunosuppressive therapy should be closely monitored with liver function tests and evaluated for HBV reappearance even when HBsAg-negative.

Kurzfassung der aktualisierten S3-Leitlinie „Diagnostik und Therapie der Hepatitis B”

Therapeutic option for hepatitis B virus infection have significantly improved in recent years. Moreover, new insights in the natural history of hepatitis B required an update of current national guidelines. Therefore, the German network of competence on viral hepatitis (Hep-Net) has revised guidelines on diagnosis and treatment og HBV incetion in cooperation with the national societies for Gastroenterology, Pathology, Virology, and Pediatric Gastroenterology. Important alterations concern the indication for antiviral therapy considering an HBV viremia of 104 copies/ml (2000 IU/ml) as a critical level. Moreover, specific recommendations how to prevent and to treat antiviral drug resistance are given. Finally, the importance of HBV in the context of organ and bone marrow transplantation, treatment of coinfections and children and prophylaxis of HBV is covered.

[The histopathologic and clinical analysis of viral chronic hepatitis patients with negative serological viral markers]

OBJECTIVE

To analyze the histopathological and clinical features of viral chronic hepatitis patients with negative serological viral markers.

METHODS

62 hepatitis patients with negative serological markers were assayed with serological viral hepatitis markers, liver function test and liver biopsies were enrolled in the study. Serum HBV DNA of HBV cases was analyzed by PCR. Liver specimens were examined by immunohistochemistry for HBsAg and HBcAg.

RESULTS

The fit rate of histopathological diagnosis with clinical diagnosis is 53.2%, the fit rate is 69.1% in moderate chronic hepatitis group. The immunohistochemistry showed that HBsAg and/or HBeAg positive rate was 45.2%, 53.6% had moderate chronic hepatitis and 25% had mild hepatitis. 13 (46.4%) had G1 hepatitis, 10 (35.7%) had G2 hepatitis, 3 (10.8%) had G3 hepatitis and 2 (7.1%) had G4 hepatitis, and serum HBV DNA positive rate was 35.7%. There were no differences in HBV DNA levels between different hepatitis group and fibrosis stage group (P > 0.05). There were no differences in all indexes between HBV DNA negative group and HBV DNA positive group (P > 0.05). There were no differences in all indexes between HBV patients and other patients (P > 0.05).

CONCLUSION

Occult HBV infection may account for a high proportion of the cases with chronic hepatitis of unknown etiology. Most patients are chronic mild hepatitis, but they still have HBV replication and can progress to liver cirrhosis. Serum PCR test, liver biopsy and immunohistochemistry are helpful for the diagnosis.

Administration of hepatitis B vaccine in winter as a significant predictor of the poor effectiveness of vaccination in rural Mongolia: evidence from a nationwide survey

BACKGROUND

Universal hepatitis B (HB) immunisation is the most effective means for prevention of hepatitis B virus (HBV) infection worldwide. Maintaining the vaccine cold chain is an essential part of a successful immunisation programme. Our recent nationwide survey in Mongolia has observed significant urban-rural differences in the prevalence of HBV infection among vaccinated cohorts.

OBJECTIVE

To examine whether the administration of HB vaccine in winter contributes to these residential discrepancies on the effectiveness of vaccination.

DESIGN AND SETTING

In 2004, a nationwide serosurvey was carried out covering both urban and rural areas of Mongolia. Sampling was multistage, with random probability from all public schools in the country.

PARTICIPANTS

A random sample of 1145 children (51.7% boys; aged 7-12 years), representative of Mongolian elementary school children.

RESULTS

Multivariate logistic regression analysis identified that total (past and current) HBV infection (OR 2.31, 95% CI 1.20 to 4.42; p = 0.012) was independently associated with the administration of all HB vaccines in winter. An increased OR for current HBV infection was also observed (OR 2.58, 95% CI 0.87 to 7.68; p = 0.089), but without significance. Interestingly, after stratifying by residence, the association between winter vaccination and total HBV infection was evident for rural (p = 0.008) but not for urban areas (p = 0.294). The frequency of vaccine-induced immunity was significantly (p = 0.007) lower for those who received HB vaccine at birth during winter in rural areas.

CONCLUSION

Administration of HB vaccine during winter is an important predictor of the low effectiveness of vaccination in rural Mongolia. To improve the effectiveness of HB vaccination in remote areas, cold chain control should be addressed with particular attention to the winter season.

Immuno-prophylaxis of babies borne to hepatitis B carrier mothers

OBJECTIVES

To examine the efficacy of current hepatitis B immuno-prophylaxis and estimate the prevalence of S-mutant infections among local newborn babies.

DESIGN

Prospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

A total of 137 newborn babies delivered between the period of November 2000 and 30 June 2001 inclusive, whose mothers were chronic hepatitis B surface antigen carriers.

RESULTS

Of the 121 infants who were followed up for 12 months, three were found to be chronic hepatitis B virus carriers, giving a vertical transmission rate of 2.5%. One (0.8%) was suspected to be infected by the S-mutant. All the three hepatitis B virus carrier babies were born to mothers with hepatitis B e antigen, but none to the eight mothers suspected to have S-mutants. Of 119 (98.3%) infants who developed hepatitis B surface antibody upon follow-up at 12 months, 35 were found to have hepatitis B e antigen at birth. All were born to hepatitis B e antigen-positive mothers. Only three of the 35 babies were found to be hepatitis B virus carriers. Most babies lost the hepatitis B e antigen by 6 months of age; only the infected babies had the antigen persisting at 1 year of age. The non-infected infants' hepatitis B e antigen is likely transplacental.

CONCLUSIONS

Our hepatitis B virus prophylaxis programme was effective at preventing perinatal infection and the non-infected infants' hepatitis B e antigen was likely transplacental.

Inhibition of the replication of hepatitis B virus in vitro by emodin

BACKGROUND

Emodin (1, 3, 8-trihvdroxy-6-methylanthraquinone) is derived from herbal medicines and proved to have a strong antimicrobial activity. However, its anti-virus effects are less known. The aim of the present study was to investigate the effects of emodin, interferon alpha (IFNalpha), and lamivudine (3TC) on hepatitis B virus (HBV) in vitro.

MATERIAL/METHODS

The human hepatoma G2.2.15 cell line stably expresses hepatitis B virus particles in culture. The cells were exposed to different concentrations of emodin, IFNa, and lamivudine triphosphate, respectively. MTT (methyl thiazolyl tetrazolium) assay was used to evaluate the cytotoxicity of the drugs and real-time PCR was applied to quantify extracellular HBV DNA. HIBsAg and HBeAg were assessed by enzyme-linked immurnosorbent assay (ELISA).

RESULTS

The results showed that exposure of HepG2.2.15 cells to emodin resulted in a time- and concentration-dependent inhibition of HBV DNA replication and HBsAg secretion. After exposed to three different concentrations of emodin for 3, 6, and 9 days, the inhibition rates of extracellular HBV DNA, HBsAg, and HBeAg of each concentration decreased significantly (P < 0.05). After 9 days of treatment, the inhibition rates of extracellular HBV DNA of the different concentrations differed greatly (P < 0.001). IFNalpha and 3TC had similar inhibition results to HBV DNA replication to those previously found.

CONCLUSIONS

These findings suggest that mnodin may prove to be a new modality to treat hepatitis B infection.

Meta-analysis: anti-viral therapy of hepatitis B virus-associated glomerulonephritis

BACKGROUND

Hepatitis B virus-associated glomerulonephritis is an infrequent complication of chronic hepatitis B virus (HBV) with significant morbidity. A causal association between hepatitis B virus infection and the development of glomerulonephritis remains controversial. Also, the optimal therapy is undefined although several approaches have been made.

AIM

To evaluate the efficacy and safety of anti-viral therapy (interferon or lamivudine) in HBV-associated glomerulonephritis by a systematic review and meta-analysis of clinical trials.

METHODS

The primary outcome was clinical response (as a measure of efficacy); the secondary outcomes were drop-out rate (as a measure of tolerability), and virological response. We used the random effects model of DerSimonian and Laird, with heterogeneity, sensitivity and meta-regression analyses.

RESULTS

We identified six clinical trials (84 unique patients); three had controlled design. The overall estimate for proteinuria remission was 65.2% (95% confidence intervals: 52.7-75.9%), Q-test for heterogeneity = 7.731, P = 0.172, I(2) = 35.327. The overall estimate for hepatitis B e antigen clearance was 62.0% (95% confidence intervals: 50.5-72.2%). The overall estimate for drop-out rate was 12.7% (95% confidence intervals: 6.4-23.6%). Meta-regression analysis showed a significant link between hepatitis B e antigen clearance and logit rate of proteinuria remission after interferon therapy [coefficient -2.585 (S.E. 1.089), P = 0.017].

CONCLUSION

Remission of the nephrotic syndrome is accompanied by clearance of HBV replication, supporting the role of the virus in the pathogenesis of the disease.

Inhibition of hepatitis B virus by D-fraction from Grifola frondosa: synergistic effect of combination with interferon-alpha in HepG2 2.2.15

In this study, D-fraction extracted from Grifola frondosa (GF-D) and its combination with human interferon alpha-2b (IFN) were investigated for the inhibitory effect on hepatitis B virus (HBV) in HepG2 2.2.15 cells (2.2.15 cells). HBV DNA and viral antigens were analyzed by a quantitative real-time polymerase chain reaction and end-point titration in radioimmunoassays, respectively. The results showed that GF-D or IFN alone could inhibit HBV DNA in 2.2.15 cells with the 50% inhibitory concentration (IC50) of 0.59 mg/ml and 1399 IU/ml, respectively. We further investigated the combination of GF-D and IFN for anti-HBV activity and found that they synergistically inhibited HBV replication in 2.2.15 cells. In combination with 0.45 mg/ml GF-D, the apparent IC50 value for IFN was 154 IU/ml. This 9-fold increase in antiviral activity of IFN suggested that GF-D could synergize with IFN. These results indicate that GF-D, in combination with IFN, might provide a potentially effective therapy against chronic HBV infections.

A retrospective study of the pattern of sexually transmitted diseases during a ten-year period

BACKGROUND

Proper knowledge of the patterns of sexually transmitted diseases (STDs) in different geographical regions is necessary for evolving proper strategies for control of these diseases.

AIMS

To study the pattern of STDs and to analyze the changes during a ten-year period from 1990 among patients attending Medical College Hospital, Kottayam.

METHODS

Case records of 686 patients with STDs who attended the outpatient wing of the Department of Dermatology and Venereology were studied.

RESULTS

There were 504 males and 182 females in the total of 686 patients. Marital contact alone was reported by 123 (67.6%) female patients. Genital ulcer diseases (GUDs) accounted for the maximum number of STDs, with 504 cases (73.5%), followed by condyloma acuminatum (17.5%) and gonorrhea (10.1%). Forty-three patients had multiple infections. The total number of patients during the first year of study was 129, while it was 41 during the last year. Bacterial STDs showed a striking reduction in numbers. The decline was less marked in the case of viral STDs.

CONCLUSION

The majority of patients had genital ulcer diseases. Spouses were the most common source of infection for female patients. There was a marked decline in the number of patients with various STDs during the ten-year period. The decline was more evident in the bacterial STDs resulting in an apparent increase of the viral STDs towards the end of the period of study.

New amperometric and potentiometric immunosensors based on gold nanoparticles/tris(2,2′-bipyridyl)cobalt(III) multilayer films for hepatitis B surface antigen determinations

Two generic, fast, sensitive and novel electrochemical immunosensors have been developed. Initially, a layer of plasma-polymerized Nafion film (PPF) was deposited on the platinum electrode surface, then positively charged tris(2,2'-bipyridyl)cobalt(III) (Co(bpy)(3)(3+)) and negatively charged gold nanoparticles were assembled on the PPF-modified Pt electrode by layer-by-layer technique. Finally, hepatitis B surface antibody (HBsAb) was electrostatically adsorbed on the gold nanoparticles surface. Electrochemical behavior of the {Au/Co(bpy)(3)(3+)}(n) multilayer film-modified electrodes was studied. Cyclic voltammetry, electrochemical impedance spectroscopy (EIS) were adopted to monitor the regular growth of the multilayer films. The performance and factors influencing the performance of the resulting immunosensors were studied in detail. The multilayer film-modified immunosensor was used for hepatitis B surface antigen (HBsAg) determination via the amperometric and potentiometric immunosensor systems, and both systems provided the same linear ranges from 0.05 to 4.5 microg/mL with different detection limits for the amperometric system 0.005 microg/mL and for the potentiometric system 0.015 microg/mL. The immunosensors were used to analyse HBsAg in human serum samples. Analytical results of clinical samples show that the developed immunoassay is comparable with the enzyme-linked immunosorbent assays (ELISAs) method, implying a promising alternative approach for detecting HBsAg in the clinical diagnosis. In addition, the multilayer films also showed better stability for 1 month at least.

Prevention of hepatitis B in nonresponders to initial hepatitis B virus vaccination

Although vaccination against hepatitis B virus (HBV) is highly successful, 5% to 10% of individuals do not experience a response with an adequate antibody level to hepatitis B surface antigen (anti-HBs). Contributing causes for nonresponse to the vaccine are genetic predisposition, immunosuppression, and certain chronic illnesses. The distinction between true nonresponse (after adequate immunization) and waning anti-HBs levels is important. The latter is not uncommon in populations in areas of the world with low endemicity for HBV infection. Data from subjects with waning anti-HBs levels show that immunologic memory may still protect these individuals against acute HBV infection or may prevent chronic infection with HBV for < or =10 years after immunization. Recent reports from Asia and Alaska describe cases of chronic HBV infection 15 years after immunization in subjects who have very low levels of anti-HBs. Thus, nonresponders or those with waning immunity who may be at risk of HBV infection in subsequent years may require a booster dose. Clinical algorithms to reimmunize nonresponders have been described and are discussed in this article. Experimental hepatitis B vaccines have shown some promise in nonresponders but are not commercially available in the United States.

Genotype C hepatitis B virus infection is associated with a higher risk of reactivation of hepatitis B and progression to cirrhosis than genotype B: a longitudinal study of hepatitis B e antigen-positive patients with normal aminotransferase levels at baseline

BACKGROUND/AIMS

Longitudinal studies on the relationship between hepatitis B virus (HBV) genotypes and reactivation of hepatitis B and progression to cirrhosis were very rare.

METHODS

Liver biochemistry, virological markers and ultrasound were monitored in 202 hepatitis B e antigen (HBeAg)-positive patients with normal alanine aminotransferase (ALT) at baseline for 3-20 (average 10.8) years, and the outcome was correlated with HBV genotypes.

RESULTS

There were 150 genotype B and 52 genotype C patients. Hepatitis activity during the HBeAg-positive phase showed no significant difference. However, genotype B was associated with a significantly earlier and higher rate of HBeAg seroconversion. HBeAg seroconversion correlated with age at entry for genotype B and with ALT levels for genotype C. Reactivation of hepatitis B was significantly more common in genotype C patients. Five genotype B and 10 genotype C patients progressed to cirrhosis. Multivariate analysis revealed that genotype C (P = 0.03) and reactivation of hepatitis B (P = 0.0004) were independent factor predictive of cirrhosis.

CONCLUSIONS

Rate and factors of HBeAg seroconversion, and rate of reactivation of hepatitis B differed between genotype B and genotype C patients. Genotype C and reactivation of hepatitis B were associated with increased risk of cirrhosis.

Evaluation of viral replication in children with chronic hepatitis B with and without interferon treatment

BACKGROUND

In chronic infection with hepatitis virus B the fact that HBeAg becomes negative does not always mean suppression of viral replication.

METHOD

HBV replication was assessed in 74 patients with chronic hepatitis or viral B cirrhosis, in whom diagnosis was made according to clinical, biological, and histological criteria. The patients were divided into two groups: group I (36 patients with interferon- therapy, 3 million U/m 2/ dose, 3 doses/week over a period of 4-6 months) and group II (control group of 38 patients who did not undergo interferon therapy). After a follow up period of 6 years in which patients underwent clinical, biochemical and serologic monitorization, HBV DNA was detected by the hybridization method on solid medium.

RESULTS

During evolution the levels of transaminases became normal in both groups. The HBe Ag/Ab seroconversion rate at the end of the interferon therapy was 52.8% and the spontaneous HBe Ag/Ab seroconversion rate was 72.7% in group II after an average evolution of 6 years. HBs Ag/Ab seroconversion was not detected in any patient. Assessment of viral replication by HBV DNA testing at the end of the follow up period showed higher levels as compared to the HBeAg testing (69.4% vs. 25% in group I, 55.2% vs. 7.9% in group II). The absence of viral replication (HBV DNA negative) had similar rates in both groups (30.6% in group I vs. 44.8% in group II, p>0.9) and HBV DNA titers in the two groups were not significantly different at the end of the follow up period. In both groups, HBV DNA titers were significantly higher in patients with positive HBeAg. The concordance between the two viral markers was 100%.

CONCLUSION

Because of the fluctuating evolution, long-term follow up and monitorization (including HBV DNA testing) of patients with chronic hepatitis B and of inactive HBsAg carriers are necessary.

Contamination with hepatitis B virus DNA in gastrointestinal endoscope channels: risk of infection on reuse after on-site cleaning

BACKGROUND AND STUDY AIMS

The incidence of viral contamination in the air, water and suction/accessory channels of gastrointestinal endoscopes was examined in order to evaluate the risk of infection.

MATERIALS AND METHODS

After endoscopic examinations, including biopsy procedures, in 17 patients who were positive for hepatitis B virus surface antigen and eight patients who were positive for hepatitis C virus antibody, the endoscopes were cleaned on site by suctioning and flushing the air and water channels with an enzyme detergent. First samples were then collected by flushing 5 ml of sterile water through each channel. After mechanical reprocessing, second samples were collected in the same way. Virological studies were carried out with real-time polymerase chain reactions for hepatitis B virus DNA and hepatitis C virus RNA.

RESULTS

Hepatitis B virus DNA was detected in five of the first samples recovered from the suction/accessory channels of the endoscopes (titers of 1.3 x 10 (4) to 2.5 x 10 (5) copies/ml), while no contamination was detected after reprocessing ( P = 0.0445). The first samples from one water channel and three air channels were also positive for hepatitis B virus DNA, but were negative after reprocessing ( P > 0.5, P = 0.227, respectively). No hepatitis C virus RNA was detected in any of the samples.

CONCLUSIONS

These results indicate that all of the channels were potential sources of viral infection.

[Laboratory diagnosis of viral hepatitis B and C]

Accurate diagnosis of viral hepatitis is based on determination of specific viral markers. In HBV infection they include HBsAg, anti-HBs, HBeAg, anti-HBe, anti-HBc, IgM anti-HBc, and HBV DNA. There are patients with HBV marker constellation indicating serologic recovery, but with HBV DNA in the liver indicating continuous viral replication. Mutations have been described in all four HBV genes. It is important to take into account the main precore mutation which leads to a decrease or complete inhibition of HBeAg production (HBeAg negative HBV infection). Diagnostically most important are surface gene mutations because they can result in the false diagnosis or delay in diagnosis in important groups of patients. Anti-HCV and HCV RNA are found in sera of patients with HCV infection. A false positive result is possible with ELISA, especially in patients with low c/o ratio and in all individuals with a low risk of HCV infection. It is necessary to confirm ELISA positivity with confirmation techniques (western blot, immunoblot). There are qualitative and quantitative assays for HCV RNA determination. HCV genotyping should be done, since different viral genotypes respond differently to therapy and therapeutic protocols are different. It is possible to determine HCVAg free or complexed with the antibody. Determination of free HCVAg could enable the diagnosis of acute HCV infection. There are some clinical situations where the interpretation of HBV and HCV markers is difficult because of ambiguous interpretation and "unusual" constellation. Attention should be focused on simultaneous infection within other hepatitis viruses or other viruses like HIV. Replication of one virus could have a direct influence on the replication and expression of another virus.

[Monitoring patients with chronic hepatitis during and after therapy]

Hepatitis C is a major public health problem. General screening is not advisable and should be limited to risk groups. The gold standard for the assessment of disease severity is liver biopsy. AST and ALT do not correlate with histology. Serum HCV RNA by qualitative assay and HCV genotype should be determined prior to therapy. Response to antiviral therapy should be assessed by testing AST, ALT and qualitative HCV RNA. Repeat liver biopsy is not necessary. The incidence of HCC related to HCV infection is rising. Early detection by a cost effective screening program is essential. In patients with liver cirrhosis caused by hepatitis C, alpha fetoprotein and liver sonography should be done every 6 months. Upper GI endoscopy is recommended every 1-4 years in cirrhotic patients. Over 350 000 000 people are infected with HBV worldwide, and chronic HBV infection is the leading cause of liver cancer and tenth leading cause of death. HBs Ag, HBeAg and HBV DNA positive patients should be monitored for 6 months before treatment. Patients treated with antiviral therapy should be tested for HBAg, HBeAg and HBV DNA at the end of treatment and every 6 months thereafter to assess virologic response. Monitoring of serum HBV DNA is done by PCR. Patients treated with lamivudine should be tested for YMDD mutation. Ultrasound and AFP monitoring are recommended for detection of HCC, but results are not always reliable. Approximately 40% -70% of HIV infected patients have coinfection with HCV, HBV and HDV. HIV/HCV coinfected patients have an increased risk of progressive liver disease and should be treated accordingly.

Prevention of perinatal hepatitis B transmission in a health authority area: an audit

The aim of this audit was to provide baseline measurement of antenatal hepatitis B virus (HBV) screening uptake, coverage of HBV vaccination in infants born to high- and low-risk HBsAg carrier mothers, completion of post-vaccination serological testing, outcome for vaccinated infants, and an assessment of the factors that influenced the effectiveness of the whole programme. Methods included identifying HBV positive pregnancies by laboratory results, and follow up of at-risk infants by a GP survey. Uptake of antenatal HBV screening was 99.9%. Thirty-one HBV positive pregnancies were identified, and twenty-nine infants were followed up. The overall HBV vaccination completion rate was 93%. Fifty per cent of eligible infants were tested for hepatitis carriage, the majority of whom were high-risk infants. None had acquired HBV infection and all had gained adequate immunity. We conclude that, although the local screening programme has been implemented effectively, there is inconsistency in the follow up of infants at high and low risk of acquiring HBV.

Dynamic analysis of hepatitis B virus DNA and its antigens in 2.2.15 cells

The 2.2.15 cells-derived from HepG2 cells transfected with a plasmid containing hepatitis B virus (HBV) DNA secrete surface antigen (HBsAg) particles, nucleocapsids and virions (Proc Natl Acad Sci U S A 1987; 84: 1005-1009). The latter elicit acute hepatitis in chimpanzees (Proc Natl Acad Sci U S A 1987; 84: 4641-4644). We studied the presence of intracellular and extracellular HBV covalently closed circular (ccc) DNA in this culture system by polymerase chain reaction (PCR), kinetically analysed HBsAg and hepatitis B e antigen (HBeAg) released in the culture media by quantitative enzyme-linked immunosorbent assay and quantitated by real-time PCR but HBV DNA from intracellular and extracellular HBV-DNA. HBV cccDNA was found both intracellularly and extracellularly. A significant correlation was seen between the extracellular HBV DNA levels and virus antigens (r = 0.833; P = 0.01 and r = 0.939; P < 0.01 for HBsAg and HBeAg, respectively), whereas there was no statistical correlation between intracellular HBV DNA levels and virus antigen levels (r = 0.024; P = 0.955 and r = 0.177; P = 0.625 for HBsAg and HBeAg, respectively). These data would be valuable in studies of the HBV life cycle and of potential anti-viral agents.

Role of hepatitis B virus infection in pathogenesis of IgA nephropathy

AIM: To investigate the role of hepatitis B virus (HBV) in the pathogenesis of IgA nephropathy (IgAN).

METHODS: HBV antigens (HBAg, or HBsAg, HBcAg, and HBeAg) in renal tissues with IgAN were detected by immunohistochemical technique. The distribution and localization of HBV DNA were observed by using in situ hybridization. Southern blot analysis was performed to reveal the state of renal HBV DNA.

RESULTS: Among 100 patients with IgAN, HBs antigenemia was detected in 18 patients (18.00%). HBAg in renal tissues was detected in 31 patients (31.00%), the positive rate of HBAg, HBsAg and HBcAg was 64.52% (20/31), 32.26% (10/31), 32.26% (10/31), respectively in glomeruli. HBcAg was also found in tubular epithelia and interstitia, which was 45.16% (14/31) and 6.45% (2/31), respectively. Five out of six cases with positive HBV DNA by in situ hybridization were proved to be HBV DNA positive by Southern blot analysis, and all were of the integrated form. Eight specimens were demonstrated to be HBV DNA positive by in situ hybridization, which was localized in the nuclei of tubular epithelial cells and glomerular mesangial cells as well as in infiltrated interstitial lymphocytes.

CONCLUSION: There is a relationship between HBV infection and IgAN. In addition to the humoral immune damage mediated by HBAg-HBAb immune complex, the cellular mechanism mediated by HBV originating from renal cells in situ may be also involved in the pathogenesis of IgAN.

Short interfering RNA-directed inhibition of hepatitis B virus replication

RNA interference (RNAi) is the process by which double-stranded RNA directs sequence-specific degradation of mRNA. In mammalian cells, RNAi can be triggered by 21-nucleotide duplexes of short interfering RNA (siRNA). We examined effects of siRNA on hepatitis B virus (HBV) replication. Human hepatoma cells were transfected with HBV DNA and siRNA against HBV-pregenome RNA. Transfection experiments demonstrated that the siRNA reduced the amount of HBV-pregenome RNA and resulted in reduction of the levels of replicative intermediates and viral protein. Our results indicate that siRNA-mediated gene silencing inhibits HBV replication through suppression of viral RNA, which may be useful as a potential therapeutic modality.

Effects of hepatitis B virus infection on human sperm chromosomes

AIM: To evaluate the level of sperm chromosome aberrations in male patients with hepatitis B, and to directly detect whether there are HBV DNA integrations in sperm chromosomes of hepatitis B patients.

METHODS: Sperm chromosomes of 14 tested subjects (5 healthy controls, 9 patients with HBV infection, including 1 with acute hepatitis B, 2 with chronic active hepatitis B, 4 with chronic persistent hepatitis B, 2 chronic HBsAg carriers with no clinical symptoms) were prepared using interspecific in vitro fertilization between zona-free golden hamster ova and human spermatozoa, and the frequencies of aberration spermatozoa were compared between subjects of HBV infection and controls. Fluorescence in situ hybridization (FISH) to sperm chromosome spreads was carried out with biotin-labeled full length HBV DNA probe to detect the specific HBV DNA sequences in the sperm chromosomes.

RESULTS: The total frequency of sperm chromosome aberrations in HBV infection group (14.8%, 33/223) was significantly higher than that in the control group (4.3%, 5/116). Moreover, the sperm chromosomes in HBV infection patients commonly presented stickiness, clumping, failure to staining, etc, which would affect the analysis of sperm chromosomes. Specific fluorescent signal spots for HBV DNA were seen in sperm chromosomes of one patient with chronic persistent hepatitis. In 9 (9/42) sperm chromosome complements containing fluorescent signal spots, one presented 5 obvious FISH spots, others presented 2 to 4 signals. There was significant difference of fluorescence intensity among the signal spots. The distribution of signal sites among chromosomes was random.

CONCLUSION: HBV infection can bring about mutagenic effects on sperm chromosomes. Integrations of viral DNA into sperm chromosomes which are multisites and nonspecific, can further increase the instability of sperm chromosomes. This study suggested that HBV infection can create extensively hereditary effects by alteration genetic constituent and/or induction chromosome aberrations, as well as the possibility of vertical transmission of HBV via the germ line to the next generation.

[Role of hepatitis B virus infection in pathogenesis of IgA nephropathy]

OBJECTIVE

To clarify the relationship between hepatitis B virus (HBV) infection and IgA nephropathy (IgAN).

METHODS

HBV antigen (HBAg) in renal tissues of the patients with IgAN was detected by immunohistochemical technique, the carrier status and localization of HBV DNA in renal tissues were determined by Southern blot analysis and in situ hybridization.

RESULTS

Serum HBsAg was detected in 18 of the 100 patients with IgAN (18%), HBAg was detected in 31 of 100 patients (31%) in their renal tissue and in 20 of 31 patients (65%) in their glomeruli, and both HBsAg and HBcAg were detected in 10 of 31 patients (32%), respectively. HBcAg was also found in tubular epithelia (45%, 14/31) and renal interstitium (6%, 2/31), respectively. Five of six cases were proved to be positive of integrated-form HBV DNA in their renal tissue by Southern blot analysis. In situ hybridization demonstrated that HBV DNA was 8/8 and 6/8 positive in their renal tubules and glomeruli of all eight specimens, localized in the nucleus of tubular epithelial cells, glomerular mesangial cells, as well as infiltrated interstitial lymphocytes.

CONCLUSION

HBV infection closely related with IgAN and HBV infection might be involved in pathogenesis of IgAN.

Woodchuck hepatitis virus replication and antigen expression gradually decrease in preneoplastic hepatocellular lineages

BACKGROUND/AIMS

Hepatocellular carcinomas elicited in woodchucks by the woodchuck hepatitis virus (WHV) emerge gradually from parenchymal areas of minimal structural deviation via two predominant preneoplastic hepatocellular lineages, composed of either glycogenotic/basophilic or amphophilic/basophilic cell foci. In this study we analyzed WHV replication during neoplastic development in both lineages.

METHODS

In minimal deviation areas, preneoplastic hepatocellular foci, and hepatocellular neoplasms, developing in 16 WHV-carriers 31-38 months after WHV-inoculation, the proportion of hepatocytes containing WHV replicative intermediates (as detected by in situ hybridization for WHV DNA) and immunoreactive for WHV core and surface antigens was assessed.

RESULTS

Appearance of WHV replicative intermediates and expression of antigens were limited to the cytoplasm of hepatocytes and were strongly correlated (P<0.0001), both showing high levels in minimal deviation areas, but markedly reduced amounts in all types of preneoplastic hepatic focus (P<0.0001), and in hepatocellular adenomas. Most hepatocellular carcinomas were negative for WHV replicative intermediates and antigens.

CONCLUSIONS

In both the glycogenotic-basophilic and the amphophilic-basophilic preneoplastic hepatocellular lineage, WHV replication and antigen expression gradually decrease early during the preneoplastic phase. The close correlation of these changes with metabolic aberrations characterizing preneoplastic hepatocellular lineages suggests that oncogenic effects mimicking insulin/glucagon imbalances may be responsible for the repression of hepadnaviral replication.

Lamivudine/interferon combination therapy in anti-HBe positive chronic hepatitis B patients: a controlled pilot study

BACKGROUND/AIMS

In this study, lamivudine-interferon (LAM/IFN) combination therapy was compared to LAM monotherapy to verify if the combination treatment might improve efficacy and reduce the emergence of LAM-resistant mutants.

METHODS

Fifty patients with anti-HBe-positive chronic hepatitis B were treated for 12 months with LAM at 100mg/day (26 pts) or with IFN at 5MU t.i.w.+LAM 100mg/day (24 pts). Serum ALT, HBV DNA and IgM anti-HBc were monitored during treatment and a 6-month follow-up. The polymerase gene was amplified by PCR and the region coding for YMDD motif was directly sequenced.

RESULTS

All patients normalized ALT and cleared HBV DNA during treatment. The response was maintained until the end of therapy in the LAM/IFN group, while in 5/26 initial responders treated with LAM alone, a virological and biochemical breakthrough was observed after 6-10 months, and selection for YMDD variants resulted. After therapy discontinuation, most patients relapsed; the response rate after 6 months was 17% in the LAM/IFN group and 19% in the LAM group.

CONCLUSIONS

In anti-HBe-positive chronic hepatitis B, a 12-month course of LAM/IFN combination therapy is as beneficial as LAM monotherapy, however, the combination regimen appeared to prevent or delay the emergence of YMDD variants.

[Expression of hepatitis B virus antigen in brain tissue from liver cirrhosis patients with hepatitis B and its significance]

OBJECTIVE

To investigate the expression of hepatitis B virus (HBV) antigen in brain tissue from liver cirrhosis patients with hepatitis B and explore its significance.

METHODS

HBsAg and HBcAg were detected in the brain tissue from 70 liver cirrhosis dead patients with hepatitis B by S-P immunohistochemical assay, and the relationship between the expression of HBV antigen in brain tissue testing and clinic and pathology was analyzed.

RESULTS

30 patients (42.89%) were positive for HBV antigen. Among them, 24 patients (34.29%) were positive for HBsAg and 18 patients (25.71%) were positive for HBcAg. HBV antigen was mainly found in cytoplasm and distributed in neurons, neurogliocytes and vascular endothelial cells. The positive cells were distributed separately, scatteredly or focally. The expression of HBV antigen was not associated with the serum level of HBV replication but associated with the occurrence of hepatic encephalopathy (HE) and the severity of brain tissue pathologic lesions of HE.

CONCLUSIONS

The results indicate that HBV infection develop in brain tissue from liver cirrhosis patients with hepatitis B and HBV may replicate in it. HBV infection in brain tissue may p lay an important role in occurrence and development of HE from liver cirrhosis patients with hepatitis B.

Subcellular localisation of the X protein in HBV infected hepatocytes

Hepatitis B virus X protein (HBx) is a multifunctional protein that exerts its effects primarily by acting as a transcriptional transactivator of viral and multiple host cell genes. HBx is thought to be essential for maintaining viral replication and has been implicated in the development of hepatocellular carcinoma in patients chronically infected with hepatitis B virus. Very little is known about its functional mechanisms and although interactions with several nuclear and cytoplasmic proteins have been demonstrated in vitro, there is no clear consensus as to where HBx localises in infected hepatocytes. In this study, the expression and intracellular distribution of HBx were examined in human liver biopsies using an anti-HBx rabbit polyclonal antiserum. HBx was detected in a high proportion (69%) of samples from patients with chronic HBV infection. Detection of HBx correlated with the absence of cirrhosis and the presence of serum e-antigen. HBx was detected predominantly in the cytoplasm; however, it was also found in the nuclei of up to 20% of positively stained hepatocytes, either exclusively nuclear or localised both in the nucleus and cytoplasm within the same cell. Furthermore, the intracellular distribution of HBx was analysed in transfected Huh-7 cells by confocal microscopy, using the monoclonal antibody 16F1. In these experiments, a substantial nuclear detection was confirmed in a significant proportion of HBx expressing cells. The data indicate a high functional significance of nuclear HBx, consistent with the concept that transactivation may involve interactions with nuclear proteins.

Virologic and biochemical changes and prognosis after liver resection for hepatitis B virus-related hepatocellular carcinoma

BACKGROUND/AIMS

During the natural course of hepatitis B virus (HBV) infection, clearance of HB e antigen (HBeAg) and HB surface antigen (HBsAg) occurs with remission of liver disease. We investigated the effects of postoperative changes in virologic and biochemical parameters on the prognosis after liver resection for HBV-related hepatocellular carcinoma (HCC).

METHODS

We investigated the relationship between postoperative changes in virologic and biochemical parameters and the incidence of intrahepatic recurrence and the outcome during a 3-year period following surgery in 30 HCC patients with HBsAg.

RESULTS

The incidence of intrahepatic recurrence of HCC was significantly higher in patients with acute postoperative exacerbation of hepatitis (p = 0.0084), a sustained high serum concentration of HBV DNA (> or = 5.0 mEq/ml, p = 0.001), and sustained expression of HBsAg after surgery (p = 0.0421). A high serum concentration of HBV DNA was significantly associated with a shorter survival time (p = 0.0447) and the cause of death was recurrence of HCC.

CONCLUSION

Patients with acute postoperative exacerbation of hepatitis, sustained HBsAg expression, and sustained high serum concentrations of HBV DNA after surgery may require more intensive postoperative monitoring for HCC recurrence.

Reactivation of viral replication after liver resection in patients infected with hepatitis B virus

OBJECTIVE

To investigate the mechanisms and risk factors underlying postoperative reactivation of hepatitis after liver resection for hepatitis B virus-related hepatocellular carcinoma.

SUMMARY BACKGROUND DATA

Although risk factors for acute hepatic failure after liver resection have been reported in patients with chronic liver disease, the issue of reactivation of hepatitis B virus replication after liver resection is unresolved.

METHODS

Fifty-five patients with hepatocellular carcinoma and hepatitis B surface antigen underwent liver resection. In 25 of these 55 patients, serum levels of hepatitis B virus DNA and the type of hepatitis B virus were determined before and after surgery.

RESULTS

Postoperative hepatitis occurred in 13 of the 55 patients (24%). Reactivation of viral replication occurred after liver resection in 7 of the 25 patients tested, and alanine aminotransferase activity increased in 6 of these 7 patients. High preoperative alanine aminotransferase activity, high levels of hepatitis B virus DNA, presence of wild-type DNA, and detection of hepatitis B core antigen in hepatocytes, all features of the immune clearance phase in the natural course of hepatitis B virus infection with no surgery, were more likely to be found in patients with reactivation than in patients without reactivation.

CONCLUSIONS

During the immune clearance phase of hepatitis B virus infection, especially the period of acute exacerbation, changes in serum hepatitis B virus DNA level should be monitored for early warnings of reactivation of viral replication, likely to cause severe postoperative hepatitis and acute hepatic failure.

A randomised controlled trial of intradermal hepatitis B vaccination and augmentation of response with erythropoietin

AIM

Intradermal administration of Hepatitis B vaccine (HBV) achieves better seroconversion in patients on dialysis compared to intramuscular administration. The aim of the study was to determine whether twice weekly intradermal injections of the vaccine can further augment the vaccine response as compared to once weekly injections. Patients with end stage renal failure on haemodialysis were randomly allocated over a period of 22 months to receive 20 mu gms of recombinant HBV by intradermal injections once a week (group 1) or twice a week (group 2) for 6 weeks. The patients recruited during the first 12 months of the study did not receive recombinant human erythropoietin (Epo) as it was not available (phase 1). During the last 10 months of study all patients received Epo (phase 2) in addition to HBV.

RESULTS

A total of 85 patients were enrolled of whom 77 completed the study. There were 41 patients in group 1 and 36 patients in group 2. Seroprotection (anti HBs > 10 mIU/ml in the absence of HBs Ag and anti HBc) was achieved in 56.1% patients of group I compared to 77.8% of group 2 (p < 0.05). The seroprotection rate was 78.1% among patients receiving Epo (phase 2) compared to 60% among 45 who did not receive Epo (phase 1). Anti HBs titre in responders was 308.5 +/- 148.7 mIU/ml in patients of phase 2 compared to 198 +/- 112.8 mIU/ml in patients of phase 1 (p < 0.05). The subgroup receiving both Epo and twice weekly vaccine (group 2 of phase 2) had the highest seroprotection rate of 86.7%.

CONCLUSION

Twice weekly intradermal vaccination is more effective than once weekly regime in achieving rapid seroconversion. The vaccine response may be augmented by use of Epo probably due to reduction in transfusion requirement and concomitant immunosuppression.

Churg-Strauss syndrome with perforating ulcers of the colon

We report a case of a 72-year-old woman with Churg-Strauss syndrome, who presented with intestinal perforation. She has had bronchial asthma with peripheral blood eosinophilia for 30 years. Gross findings of a resected colon showed multiple ulcers with perforation. Histologic findings demonstrated transmural inflammation infiltrated with large numbers of eosionophils, neutrophils and lymphoplasma cells, and characteristic extravascular granuloma in the subserosa. There were multifocally-distributed transmural vasculitis showing all stages of activity in medium and small-sized arteries and veins located in the submucosa, and proper muscle and subserosal layers of the colon, some of which revealed granulomatous inflammation. Histologic finding of liver showed chronic viral hepatitis B with mild inflammatory activity and macronodular cirrhosis. Immunohistochemical findings, acid fuschin orange G staining and electromicroscope found no evidence of hepatitis B virus infection contributing to the pathogenesis of this lesion.

Hepatitis B immunoglobulin discontinuation followed by hepatitis B virus vaccination: A new strategy in the prophylaxis of hepatitis B virus recurrence after liver transplantation

It is widely agreed that hepatitis B virus immunoglobulin (HBIG) should be administered for at least 12 months to patients transplanted for hepatitis B virus (HBV)-related diseases to prevent HBV recurrence. No data are available, however, on how long this treatment should be used, and most centers currently administer HBIG on a life-long basis. Herein, we report the results of a new prophylactic strategy aiming at the discontinuation of HBIG treatment and consisting of the administration of double dose recombinant HBV vaccine (0, 1-, and 6-month schedule) to liver transplant recipients fulfilling the following criteria: (1) liver transplantation for conditions related to nonreplicative HBV infection (hepatitis B surface antigen [HBsAg] positive, hepatitis B e antigen [HBeAg] negative, and HBV DNA negative); (2) at least 18 months of HBIG administration; and (3) no HBV infection recurrence, normal or slightly altered liver graft function, and low-grade immunosuppression at the time of vaccination. Seventeen patients received HBV vaccination and 14 of them (82%) developed protective serum titers of anti-HBs (>10 IU/L). Six patients seroconverted after a first course of vaccination, whereas 8 patients required a second course (3 additional doses of vaccine). Responding patients were followed for a median of 14 months (range, 3-50) after seroconversion. During this period no HBV recurrence occurred and in only 2 patients a decrease of anti-HBs titers below 10 UI/L was observed. Our data suggest that in selected liver transplant recipients, posttransplantation HBV vaccination may be a useful and cost-effective strategy in the prophylaxis of HBV recurrence, allowing the discontinuation of life-long HBIG treatment.

Which patients with hepatitis C develop liver complications?

To identify variables that are independent predictors of adverse outcomes in chronic hepatitis C, we analyzed a cohort of 455 patients followed for a median of 4.7 years. Associations were sought between demographic and behavioral factors, hepatitis C virus (HCV) genotype, liver histology and liver tests at entry, and development of liver complications, hepatocellular carcinoma (HCC), hepatic transplantation and liver-related death. Independent predictors were identified by multivariate analysis. The following were associated with a significantly higher rate of liver complications: age; birth in Asia, Europe, Mediterranean region, or Egypt; transmission by blood transfusion or sporadic cases; HCV genotypes 1b and 4 (compared with 1/1a); fibrosis stage 3 or 4 (cirrhosis); serum albumin; bilirubin; prothrombin time; and alpha-fetoprotein. However, the only independent predictors of liver-related complications were sporadic transmission (P <.001), advanced fibrosis (P =.004), and low albumin (P <.001). The corresponding independent risk factors for HCC were male gender (P =. 07), sporadic transmission (P <.001), and albumin (P <.001); bilirubin (P =.02) was an additional predictor of transplantation or liver-related death. It is concluded that only patients with advanced hepatic fibrosis or cirrhosis, are at risk of developing hepatic complications of chronic hepatitis C during 5-year follow-up. Among such patients, abnormalities in serum albumin, bilirubin, or prothrombin time indicate a high probability of complications. Patients without definite risk factors for HCV (sporadic cases) are at higher risk of complications, possibly because of interaction between older age, duration of infection, country of birth, and HCV genotypes 1b and 4.

Latent hepatitis B virus infection in healthy individuals with antibodies to hepatitis B core antigen

Several recent reports have shown that hepatitis B virus (HBV) could be frequently transmitted to the recipients from donors who have antibodies to hepatitis B core antigen (anti-HBc) through liver transplantation. We provide here the molecular evidence of latent HBV infection accompanied with ongoing viral replication in the liver tissue of anti-HBc-positive healthy individuals. HBV DNA was detectable in 13 of 14 healthy donors who were positive for both anti-HBc and antibodies to hepatitis B surface antigen (anti-HBs), but in none of 3 who were positive for anti-HBs alone. The detected HBV genomes from these subjects included covalently closed circular DNA and pregenomic RNA, the replication intermediate of HBV. Notably, 5 of 7 cases tested were predominantly infected with wild type HBV strains without any mutations in the precore and core promoter regions under the presence of circulating antibody to hepatitis B e antigen. Interestingly, a predominant clone detected in one donor showed a 63-nucleotide deletion in the precore region including an encapsidation signal sequence. Our findings indicate that the majority of healthy individuals positive for anti-HBc, which had been assumed to denote a past history of transient HBV infection, were latently infected with the episomal form of HBV accompanied by ongoing viral replication and few nucleotide mutations in the precore and core regions.

Long-term ganciclovir therapy for hepatitis B virus infection after liver transplantation

BACKGROUND/AIMS

Hepatitis B virus (HBV) disease on a liver graft is associated with florid viral replication and graft failure. The aim of this study performed between 1992 and 1995 was to investigate the safety and efficacy of long-term intravenous ganciclovir for HBV infection in liver transplant recipients.

METHODS

Twelve patients with HBV re-infection and four with de novo HBV infection were studied. HBV DNA was positive in all (median titer: 437.5 pg/ml) and HBeAg was positive in seven. Intravenous ganciclovir was started after a median of 14.5 months from HBsAg positivation and continued for a median of 10 months.

RESULTS

A complete response with HBV DNA negativation was seen in ten cases, a partial response with a decrease of more than 50% of initial HBV DNA levels in four and no response in two. Overall tolerance was good. Among the ten complete responders, two seroconverted for both HBsAg and HBeAg and one for HBsAg alone. Among these ten patients, three were re-transplanted for liver failure: two of them are alive; three had a viral breakthrough during treatment; and four remained HBV DNA negative: two are alive and two died. Partial responders and nonresponders were treated with other antiviral agents and three were re-transplanted, two of them are alive. Overall 12 out of 16 patients (75%) survived with a median follow up of 46 months.

CONCLUSIONS

Long-term intravenous ganciclovir can persistently inhibit HBV DNA replication in liver transplant recipients and is well tolerated. Further evaluation should be encouraged, especially for HBV recurrence after first-line treatments.