乙型肝炎病毒感染者肾移植前肝穿刺活检与预后分析

背景:乙肝病毒感染者肾移植手术国内有较多报道,但乙肝病毒感染者肾移植前肝穿刺活检观察有限.目的:对慢性肾功能衰竭合并不同程度慢性乙型病毒性肝炎患者进行肾移植前肝穿刺活检,移植后2年随访观察转归情况.方法:对接受肾移植的21例乙型肝炎病毒感染的尿毒症患者进行肝穿刺活检.根据肝活检组织病理学改变,分为轻度(n=9)、中度(n=7)、重度(n=5)3组.肾移植后随访观察2年.3组中各有2例进行重复肝活检组织病理学检查.结果与结论:轻度慢性乙型肝炎组在随访2年中各项观察指标均无明显变化.中度慢性乙型肝炎组从移植后3个月开始谷氨酰转肽酶活性明显高于正常水平,随访至终点时,2例重复肝活检病理显示已处于重度病变.重度慢性乙型肝炎组从移植后3个月开始谷氨酰转肽酶活性持续高于正常水平;18个月开始,血清白蛋白水平低于正常值,球蛋白水平高于正常值;随访至终点时,有4例呈肝硬化改变.提示不同程度的慢性乙型病毒性肝炎患者肾移植后预后不同,肝活检是评价肝脏病变程度的重要手段,具有指导肾移植选择的作用.     

乙型肝炎病毒感染者肾移植前肝穿刺活检与预后分析

背景：乙肝病毒感染者肾移植手术国内有较多报道,但乙肝病毒感染者肾移植前肝穿刺活检观察有限。目的：对慢性肾功能衰竭合并不同程度慢性乙型病毒性肝炎患者进行肾移植前肝穿刺活检,移植后2年随访观察转归情况。方法：对接受肾移植的21例乙型肝炎病毒感染的尿毒症患者进行肝穿刺活检。根据肝活检组织病理学改变,分为轻度（n=9）、中度（n=7）、重度（n=5）3组。肾移植后随访观察2年。3组中各有2例进行重复肝活检组织病理学检查。结果与结论：轻度慢性乙型肝炎组在随访2年中各项观察指标均无明显变化。中度慢性乙型肝炎组从移植后3个月开始谷氨酰转肽酶活性明显高于正常水平,随访至终点时,2例重复肝活检病理显示已处于重度病变。重度慢性乙型肝炎组从移植后3个月开始谷氨酰转肽酶活性持续高于正常水平;18个月开始,血清白蛋白水平低于正常值,球蛋白水平高于正常值;随访至终点时,有4例呈肝硬化改变。提示不同程度的慢性乙型病毒性肝炎患者肾移植后预后不同,肝活检是评价肝脏病变程度的重要手段,具有指导肾移植选择的作用。     

De novo hepatitis B infection acquired during liver transplantation

Although the use of donor organs from patients negative for hepatitis B surface antigen (HBsAg) but positive for hepatitis B core antibody (HBcAb) is well known to have the potential to transmit hepatitis B to the recipient, routine screening of organ donors for HBcAb is not yet implemented in the UK. We investigated whether current organ donor screening for hepatitis B infection is effective in preventing de novo hepatitis B infection after liver transplantation. The database of the liver transplant unit at the Queen Elizabeth Hospital, Birmingham, was searched for all cases of de novo hepatitis B after liver transplantation between January 1982 and July 2000. Four cases were identified from a population of 1354 (0.3%) adult liver transplant recipients. In all cases, the likely source of hepatitis B in the recipient was the donated organ. De novo acquisition of hepatitis B after liver transplantation occurs within the UK. This problem is likely to be resolved by the institution of HBcAb testing in all liver donors. Continuing the current practice in the UK of incomplete donor hepatitis B testing (HBsAg serology only) can no longer be justified. De novo acquired infection has potentially life-threatening implications to the liver recipient and their contacts.     

Hepatocellular carcinoma: molecular biology of its growth and relationship to hepatitis B virus infection

Hepatocellular carcinoma is a very common tumor worldwide and is associated with high mortality rates. Evidence that the development of hepatocellular carcinoma is related to chronic HBV infection has accumulated from epidemiologic studies, information from animal and cell culture models, and molecular biologic evidence that HBV components can be found within hepatocellular carcinoma tissue. Integration of HBV DNA within host liver cell chromosomes may be a crucial step in the development of hepatocellular carcinoma. Integration is associated with disruption of both structure and function of DNA at the site of integration. The study of individual examples of HBV DNA integration in hepatocellular carcinoma tissue illustrates possible mechanisms of hepatocarcinogenesis by HBV. In many cases, activation of various growth factors has been found in association with HBV DNA integration including IGF II, oncogenes such as c-myc, and novel growth factors such as the retinoic acid receptor. A clearer understanding of the mechanisms involved may allow for possible therapeutic interventions in the future, or perhaps even the prevention of hepatocellular carcinoma.     

Intrafamilial spread of hepatitis B virus infection

Summary Two hundred and forth household contacts of 85 chronic HBsAg carriers were studied to assess the relationship between liver histology and ‘e’ antigen or antibody positivity in the index carrier, and evidence of HBV infection within the family. Liver biopsy results were available in 54 index carriers. The prevalence of HBsAg and anti-HBs in the families of 29 carriers with chronic hepatitis and 25 carriers with either a normal liver or minimal inflammatory changes was not significantly different. Serum from 72 index carriers was available for HBeAg and anti-HBe testing. The prevalence of HBsAg and anti-HBs in the families of 5 HBeAg positive carriers, 59 anti-HBe positive subjects, and 8 carriers negative for both HBeAg and anti-HBe was again not significantly different. Infectivity of a carrier thus does not appear to correlate either with histological evidence of liver damage or with the ‘e’ antigen or antibody positivity of the carrier.     

Risk factors for de novo hepatitis B during solid cancer treatment

BACKGROUNDReactivation of hepatitis B virus (HBV) during anticancer treatment is a critical issue. When treating patients with solid tumors, it is unclear whether specific cancer types or treatments affect HBV reactivation in hepatitis B surface antigen (HBsAg)-negative and hepatitis B core antibody (HBcAb)-positive patients, so-called de novo hepatitis B patients. The risk of de novo hepatitis B may vary based on different background factors.AIMTo determine the frequency and risk factors for de novo hepatitis B during solid tumor treatment.METHODSThis retrospective cohort study comprised 1040 patients without HBsAgs and with HBcAbs and/or hepatitis B surface antibodies (HBsAbs). The patients were treated for solid cancer from 2008 to 2018 at the National Kyushu Cancer Center and underwent HBV DNA measurements. Patient characteristics and disease and treatment information were investigated. HBV DNA measurements were performed using TaqMan polymerase chain reaction (PCR). To identify the risk factors associated with HBV DNA expression, the age, sex, original disease, pathology, treatment method, presence or absence of hepatitis C virus (HCV), and HBsAb and/or HBcAb titers of all subjects were investigated. In patients with HBV DNA, the time of appearance, presence of HBsAgs and HBsAbs at the time of appearance, and course of the subsequent fluctuations in virus levels were also investigated.RESULTSAmong the 1040 patients, 938 were HBcAb positive, and 102 were HBcAb negative and HBsAb positive. HBV DNA expression was observed before the onset of treatment in nine patients (0.9%) and after treatment in 35 patients (3.7%), all of whom were HBcAb positive. The HBV reactivation group showed significantly higher median HBcAb values [9.00 (8.12-9.89) vs 7.22 (7.02-7.43), P = 0.0001] and significantly lower HBsAb values (14 vs 46, P = 0.0342) than the group without reactivation. Notably, the reactivated group showed a significantly higher proportion of cancers in organs related to digestion and absorption (79.0% vs 58.7%, P = 0.0051). A high HBcAb titer and cancers in organs involved in digestion and absorption were identified as independent factors for HBV reactivation (multivariate analysis, P = 0.0002 and P = 0.0095). The group without HBsAbs tended to have a shorter time to reactivation (day 43 vs day 193), and the frequency of reactivation within 6 mo was significantly higher in this group (P = 0.0459) than in the other group.CONCLUSIONA high HBcAb titer and cancers in organs involved in digestion and absorption are independent factors that contribute to HBV reactivation during solid tumor treatment.     

Chronic hepatitis B virus infection: issues in treatment

As research continues to define the optimal management of chronic hepatitis B virus (HBV) infection, clinicians must deal with a number of yet unresolved issues: Should we treat all patients with HBV infection to prevent liver cancer, even if they have no evidence of active disease? Which is the best treatment strategy? What do we do with patients who develop resistance to our current drugs? Should we treat patients with HBV infection who have already developed cirrhosis?     

Hepatitis B virus genotypes in Korea: an endemic area of hepatitis B virus infection

OBJECTIVES: It has been reported that distribution of hepatitis B virus (HBV) genotypes shows geographic difference and are associated with clinical outcomes of HBV infection, including response to antiviral therapy and progression of chronic liver diseases. In this study, we analyzed the distribution of HBV genotypes according to the various clinical outcomes of chronic HBV infection in Korea, which is one of the most endemic areas of HBV infection. METHODS: A total of 200 patients with chronic HBV infection were enrolled. Clinical diagnoses of the 200 patients with chronic liver diseases were as follows: hepatitis B e antigen (HBeAg)-positive healthy carrier (defined as HBeAg(+), anti-HBe(-), HBV DNA(+) by hybridization, normal transaminase; n = 40); inactive HBsAg carrier (n = 40); chronic hepatitis B (n = 40); liver cirrhosis (n = 40); hepatocellular carcinoma (n = 40). HBV genotypes were determined by nested polymerase chain reaction using genotype-specific primers. RESULTS: All patients except 2 (inactive HBsAg carriers) were positive for nested PCR and they have genotype C regardless of clinical outcomes. CONCLUSIONS: HBV genotype was genotype C regardless of various clinical outcomes of chronic HBV infection in Korea. Considering that HBV genotypes have clinical relevance, distribution of HBV genotype in each area should be monitored when management for chronic HBV infection is planned.     

Surface gene mutations of hepatitis B virus among high-risk patients with occult hepatitis B virus infection

Surface gene mutants of hepatitis B virus (HBV) have been reported in a variety of patient groups. Because of limited data regarding these mutations in patients with occult HBV infections; we aimed to determine these mutations among high-risk patients with occult HBV infection. The presence of HBV-DNA was determined in patients with isolated anti-HBc by real-time polymerase chain reaction (PCR). Then, surface gene region was amplified by nested PCR and mutations were analyzed after sequencing. The mutations that resulted in nonfunctional hepatitis B surface antigen (HBsAg) were insertion of single nucleotide in 2 cases, which causes frameshift and single-nucleotide replacement, and premature stop codons at Leu15 and Gly10 in the other 2 cases. Amino acid substitution at amino acid position 207(S207N) was found in the other isolates. Our study suggested that “a” region mutations did not play a major role in HBsAg detection, and other genetic and nongenetic factors may be responsible for failure to detect HBsAg by routine laboratory tests.     

In situ analysis of intrahepatic virological events in chronic hepatitis B virus infection

Persistent hepatitis B virus (HBV) infection is established by the formation of an intranuclear pool of covalently closed circular DNA (cccDNA) in the liver. Very little is known about the intrahepatic distribution of HBV cccDNA in infected patients, particularly at the single-cell level. Here, we established a highly sensitive and specific ISH assay for the detection of HBV RNA, DNA, and cccDNA. The specificity of our cccDNA probe set was confirmed by its strict intranuclear signal and by a series of Southern blot analyses. Use of our in situ assay in conjunction with IHC or immunofluorescence uncovered a surprisingly mosaic distribution of viral antigens and nucleic acids. Most strikingly, a mutually exclusive pattern was found between HBV surface antigen–positive (HBsA-positive) and HBV DNA– and cccDNA-positive cells. A longitudinal observation of patients over a 1-year period of adeforvir therapy confirmed the persistence of a nuclear reservoir of viral DNA, although cytoplasmic DNA was effectively depleted in these individuals. In conclusion, our method for detecting viral nucleic acids, including cccDNA, with single-cell resolution provides a means for monitoring intrahepatic virological events in chronic HBV infection. More important, our observations unravel the complexity of the HBV life cycle in vivo.     

Phylogenetic analysis of hepatitis GB virus type C/hepatitis G virus in Spanish patients with chronic hepatitis B or C virus infection.

The nucleotide sequence of hepatitis GB virus type C (HGBV-C)/hepatitis G virus (HGV) NS3/helicase and 5'-untranslated regions from 23 Spanish patients were analyzed to assign the HGV isolates one of the proposed HGBV-C/HGV genotypes. The analysis of the evolutionary distance frequency showed that the distances among all sequences in NS3/helicase region were distributed around a single peak of 0.20, suggesting that all included sequences belonged to the same HGBV-C/HGV genotype. By contrast, in the 5'-untranslated region, all the distances corresponding to our sequences and those of the HGBV-C/HGV types 2 and 3 were distributed around a major peak of 0.03. The remaining distances corresponding to the HGBV-C/HGV type 1 sequences were distributed around a minor peak of 0.11. The phylogenetic tree and pairwise comparison of evolutionary distances among the 5'-untranslated region of the infected patients and each HGBV-C/HGV genotype demonstrated that our HGBV-C/HGV isolates belonged to subtype 2a (17/23; 78%) and 2b (5/23; 22%). No relation was found between HGBV-C/HGV subtype and hepatitis B or C virus infection.     

Precore wild-type hepatitis B virus with G1896 in the resolution of persistent hepatitis B virus infection

OBJECTIVE: Factors influencing the resolution of persistent hepatitis B virus (HBV) infection were sought for. METHODS: The loss of hepatitis B surface antigen (HBsAg) from serum was correlated with mutations in HBV DNA for a hepatitis B e antigen (HBeAg)-minus phenotype in patients infected with HBV genotype C and positive for HBeAg at presentation. RESULTS: HBeAg turned negative in all the 22 patients in whom HBV infection resolved, but only in 11 of the 25 patients with severe liver diseases (100 vs. 44%, p = 0.0001). The precore wild type (G1896) persisted significantly more frequently in the 22 patients in whom HBV infection resolved than in the 11 patients who developed decompensated liver cirrhosis or hepatocellular carcinoma (15/22 or 68% vs. 1/11 or 9%, p = 0.005). The double mutation in the core promoter (T1762/A1764) was comparably frequent in the two groups of patients at presentation (14/22 or 64% vs. 7/11 or 64%) and >15 years thereafter (18/22 or 82% vs. 10/11 or 91%). CONCLUSION: The precore wild type (G1896) would seem to facilitate the resolution of HBV infection, while the precore mutant (A1896) may induce severe liver diseases in patients with HBeAg-positive chronic hepatitis who have lost HBeAg from serum.     

Immunomodulatory therapy for chronic hepatitis B virus infection

Hepatitis B virus (HBV) is one of the most prevalent viral pathogens of man with around 350 million chronically infected patients. It has been postulated that in persistently infected individuals the HBV-specific immune response is too weak to eliminate HBV from all infected hepatocytes, but sufficiently strong to continuously destroy HBV-infected hepatocytes and to induce chronic inflammatory liver disease. The primary aim in the treatment of chronic hepatitis B is to induce sustained disease remission and prevent serious complications like liver failure and/or hepatocellular carcinoma. The recent emergence of drug-resistant HBV mutants and post-treatment relapse as a consequence of nucleoside analogue monotherapy emphasizes that the principal goal should be to stimulate a successful immune response. In this paper we will focus on the immune response to HBV and we will review reported data on immunotherapeutic strategies like immunomodulatory drugs (cytokines and Thymic derivates) and vaccine therapies using currently available recombinant anti-HBV vaccines, lipopeptide-based T cell vaccine and newly developed genetic vaccines.     

Liver-specific autoantibodies in chronic hepatitis B virus infection

Anti-liver-specific protein (LSP) antibody and liver membrane autoantibody (LMA) have been evaluated in 88 patients with hepatitis B virus (HBV)-induced chronic liver disease by means of radioimmunoprecipitation and immunofluorescence. Among our patients, 38 presented circulating HBe antigen while 43 had HBe antibody and seven were negative for both. Anti-LSP was mainly found in HBeAg positive chronic active hepatitis (CAH), anti-HBe in positive CAH and in anti-HBe positive chronic persistent hepatitis (CPH). Similar prevalences of LMA (range 13-33%) were detected in the various groups studied. Taking into account the histological diagnosis of disease activity (periportal inflammation and piecemeal necrosis) no significant differences were found between active and inactive patients. Taking into account the HBeAg/anti-HBe status, no significant differences were found between the patients positive for 'e' antigen or 'e' antibody. Humoral autoimmune reactions may also play a role in HBV-induced chronic (active) liver disease irrespective of HBeAg/anti-HBe status and hence of the viral replication activity of the patients.     

Antiviral L-nucleosides specific for hepatitis B virus infection

A unique series of simple "unnatural" nucleosides has been discovered to inhibit hepatitis B virus (HBV) replication. Through structure-activity analysis it was found that the 3'-OH group of the beta-L-2'-deoxyribose of the beta-L-2'-deoxynucleoside confers specific antihepadnavirus activity. The unsubstituted nucleosides beta-L-2'-deoxycytidine, beta-L-thymidine, and beta-L-2'-deoxyadenosine had the most potent, selective, and specific antiviral activity against HBV replication. Human DNA polymerases (alpha, beta, and gamma) and mitochondrial function were not affected. In the woodchuck model of chronic HBV infection, viral load was reduced by as much as 10(8) genome equivalents/ml of serum and there was no drug-related toxicity. In addition, the decline in woodchuck hepatitis virus surface antigen paralleled the decrease in viral load. These investigational drugs, used alone or in combination, are expected to offer new therapeutic options for patients with chronic HBV infection.     

Current therapies for chronic hepatitis B virus infection

Patients who are chronically infected with the hepatitis B virus are at an increased risk of developing cirrhosis, hepatic decompensation and hepatocellular carcinoma. Therapeutic intervention offers the only means of interrupting this progression. Currently there are three licensed agents for the treatment of chronic hepatitis B virus infection. These are interferon-α, an immunomodulator, and two synthetic nucleos(t)ide analogs, namely lamivudine (Epivir^®, GlaxoSmithKline) and adefovir dipivoxil (Hepsera^®, Gilead Sciences). This review aims to summarize current experience with these drugs in the treatment and management of patients with chronic hepatitis B virus infection, their efficacy, and current problems of drug resistance. An outline of future treatment perspectives is also included.     

Antiviral beta-L-nucleosides specific for hepatitis B virus infection

Three simple, related nucleosides, beta-L-2'-deoxycytidine (LdC), beta-Lthymidine (LdT), and beta-L-2'-deoxyadenosine (LdA), have been discovered to be potent, specific and selective inhibitors of the replication hepatitis B virus (HBV), as well as the closely related duck and woodchuck hepatitis viruses (WHV). Structure-activity relationship analysis indicates that the 3'-OH group of the beta-L-2'-deoxyribose of the beta-L-2'-deoxynucleoside confers specific anti-hepadnavirus activity. The simple nucleosides had no effect on the replication of 15 other RNA and DNA viruses, and did not inhibit human DNA polymerases (alpha, beta and gamma) or compromise mitochondrial function. The nucleosides are efficiently converted intracellularly into active triphosphate metabolites that have a long half-life. Once-daily oral administration of these compounds in the woodchuck efficacy model of chronic HBV infection reduced viral load by as much as 10(8) genome equivalents/ml serum and there was no drug-related toxicity. In addition, a decline in WHV surface antigen (WHsAg) paralleled the decrease in viral load. This class of nucleosides displays an excellent overall safety profile. The first compound, LdT, has already entered clinical trials and LdC, currently being developed as a prodrug, is expected to enter the clinic in the near future. These compounds have the potential for use in combination therapy with the goal of achieving superior viral suppression and diminishing the onset of resistance.     

siRNA drug development against hepatitis B virus infection

Introduction: Hepatitis B virus (HBV) infection is the worldwide leading cause of liver cirrhosis and hepatocellular carcinoma. Currently available medication can suppress viral replication in the majority of patients, but clearance of the viral antigens can be achieved in only about 10%.

Areas covered: RNA interference is a very attractive therapeutic option since a well-designed compound could possibly inhibit all HBV mRNA and thus synthesis of all its antigens, which could combine antiviral and immunomodulatory modes of action. The aim of the article is to provide current knowledge on possible use of small interfering RNA (siRNA) molecules in the treatment of chronic HBV infection.

Expert opinion: Based on the current status of clinical trials, we should expect that within the coming five years at least one siRNA molecule will be registered for clinical use. However, most important at this stage of development will be the safety profile, improving the route of administration, selection of the optimal combination with other anti-HBV drugs (nucleoside analogues, interferons) and finally selection of the optimal system introducing siRNA molecules into infected cells. Current therapeutic options for HBV, the siRNA mechanism of action, as well as preclinical and clinical studies with siRNA molecules are presented in this article.