100例丙氨酸氨基转移酶正常的慢乙肝病毒感染者的肝组织病理研究

目的探索100例丙氨酸氨基转移酶（ALT）正常的慢乙肝病毒感染者的肝组织病理改变影响的可能因素及ALT相应的正常界限。方法收集100份乙肝病毒携带者的血清和肝穿病理标本分别行生化、乙肝标记物、乙肝病毒DNA（HBVDNA）检测和常规HE染色,光镜下观察其病理变化并评分。结果26例肝脏组织学有显著改变,HBeAg状态、ALT水平这二种因素对慢乙肝病毒携带者肝组织病理有影响。结论目前ALT正常值上限应下调为宜;持续ALT正常的慢性HBV感染者,应将肝活检作为判断肝病活动性和是否抗病毒治疗的主要依据。     

A novel noninvasive algorithm for the assessment of liver fibrosis in patients with chronic hepatitis B virus infection

Several noninvasive blood biomarkers have been established for the assessment of liver fibrosis in patients with chronic hepatitis B virus (HBV) infection, but their clinical performance remains inconclusive. Here, we compared the diagnostic performance of these biomarkers and developed a novel algorithm for assessing liver fibrosis. Six hundred and sixteen chronically HBV‐infected and treatment‐naïve patients who underwent liver biopsy were enrolled and randomly divided into training (N=410) and internal validation cohorts (N=206). One hundred and fifty‐nine patients from another centre were recruited as an external validation cohort. Receiver operating characteristic (ROC) curves were used to analyse the performance of the gamma‐glutamyltransferase‐to‐platelet ratio (GPR), red cell volume distribution width‐to‐platelet ratio (RPR), FIB‐4 index, aspartate aminotransferase‐to‐platelet ratio index (APRI) and HBV DNA level against liver histology, and a novel algorithm was developed using the recursive partitioning and regression tree (RPART) method. In the training cohort, the area under the ROC curve of FIB‐4 was significantly higher than that of APRI (P=.038) but was comparable to those of GPR, RPR and HBV DNA; however, the performance of the biomarkers was similar among the validation cohort. The established RPR‐HBV DNA algorithm performed better in the training cohort than any individual blood biomarker, and the corresponding sensitivity, specificity, positive predictive value and negative predictive value were 63%, 90%, 72% and 80%, respectively. In the internal and external validation cohorts, the performance of the algorithm in assessing liver fibrosis was also superior to that of other biomarkers. These results suggest that the established RPR‐HBV DNA algorithm might improve the diagnostic accuracy of liver fibrosis in treatment‐naïve patients with chronic HBV infection, although additional studies are warranted to confirm these findings.     

Occult hepatitis B virus infection in patients with autoimmune liver diseases

Background: Occult hepatitis B virus (HBV) infection is characterized by undetectable serum HBV surface antigen (HBsAg) but detectable HBV‐DNA in serum or liver. Aims: To determine the prevalence and clinical impact of occult HBV in autoimmune liver diseases as similar data are missing. Methods: One hundred and ninety‐six sera samples from HBsAg‐negative patients, including 66 autoimmune hepatitis (AIH), 93 primary biliary cirrhosis (PBC) and 37 primary sclerosing cholangitis (PSC), were investigated for HBV‐DNA using the polymerase chain reaction (PCR) before treatment initiation. One hundred and three serial samples from 38 AIH patients under immunosuppression and 282 selected blood donors (HBsAg negative; antibodies to HBV‐core antigen positive) were also investigated. Fourteen available paraffin‐embedded AIH liver samples were also investigated for HBV‐DNA by nested‐PCR. Results: Hepatitis B virus DNA was detected in the serum of 24/196 patients (12.2%) and 0/282 donors (P=0.0000). Nine patients had AIH (13.6%), eight had PBC (8.6%) and seven had PSC (18.9%) (P=0.0000 vs healthy). HBV‐DNA detection in AIH livers was higher than in serum. HBV‐DNA was associated neither with HBV markers nor with epidemiological, laboratory and clinical data. Serial testing of AIH patients revealed two HBV‐DNA‐negative patients before treatment becoming positive during treatment, while all HBV‐DNA‐positive patients before immunosuppression became negative. Conclusion: Based mainly on serum HBV‐DNA, we found a significant proportion of autoimmune liver disease patients with occult HBV compared with donors. However, taking into account our results in a small number of liver tissues, it should be emphasized that occult HBV could be even higher when both serum and liver specimens are investigated. Occult HBV does not seem to affect the clinical and laboratory features of the diseases, while AIH patients with occult HBV under immunosuppression do not deteriorate during follow‐up.     

Serum lincRNA‐p21 as a potential biomarker of liver fibrosis in chronic hepatitis B patients

Serum long non‐coding RNAs (lncRNAs) are emerging as promising biomarkers for various human diseases. The aim of this study was to investigate the feasibility of using serum long intergenic non‐coding RNA‐p21 (lincRNA‐p21) as a biomarker for chronic hepatitis B patients. Serum lincRNA‐p21 levels were quantified using real‐time PCR in 417 CHB patients and 363 healthy controls. The promoter methylation level of lincRNA‐p21 was detected using bisulphite‐sequencing analysis in primary hepatic stellate cells (HSCs). Sera from hepatitis B‐infected patients contained lower levels of lincRNA‐p21 than sera from healthy controls. Serum lincRNA‐p21 levels negatively correlated with stages of liver fibrosis in infected patients. Receiver operating characteristic (ROC) curve analyses suggested that serum lincRNA‐p21 had a significant diagnostic value for liver fibrosis in these patients. It yielded an area under the curve of ROC of 0.854 with 100% sensitivity and 70% specificity in discriminating liver fibrosis from healthy controls. There was additionally a negative correlation between serum lincRNA‐p21 level and the markers of liver fibrosis including α‐SMA and Col1A1. However, there was no correlation of serum lincRNA‐p21 level with the markers of viral replication, liver inflammatory activity, and liver function. Notably, during primary HSCs culture, loss of lincRNA‐p21 expression was associated with promoter methylation. Serum lincRNA‐p21 could serve as a potential biomarker of liver fibrosis in CHB patients. Down‐regulation of lincRNA‐p21 in liver fibrosis may be associated with promoter methylation.     

The usefulness of transient elastography in the assessment of patients with HBeAg‐negative chronic hepatitis B virus infection

Histological severity is often mandatory for the management of HBeAg‐negative chronic HBV patients. We evaluated the performance of transient elastography (TE) in this setting. We included 357 untreated HBeAg‐negative patients with ≥1 reliable liver stiffness measurement (LSM‐kPa) by TE: 182 inactive carriers with HBV‐DNA < 2000 (n = 139) or 2000–19 999 IU/mL (n = 43) and 175 patients with chronic hepatitis B (CHB). In carriers, HBV‐DNA > 2000 and/or LSM > 6.5 were considered as biopsy indications. LSMs did not differ between carriers with low and high viremia, but were lower in carriers than in patients with CHB (5.8 ± 1.7 vs 9.0 ± 5.6, P < 0.001) offering moderate differentiation between these two groups (AUROC: 0.705). LSMs did not change significantly in carriers after 16 (12–24) months. In carriers with a liver biopsy, Ishak's staging scores were similar between cased with low and high viremia but higher in cases with LSM > 6.5 than ≤6.5 kPa. Moderate fibrosis (stages: 2–3) was detected in 0/10 carriers with only HBV‐DNA > 2000 IU/mL, 2/10 (20%) carriers with only LSM > 6.5 and 5/10 (50%) carriers with both HBV‐DNA > 2000 and LSM > 6.5 (P = 0.009). In patients with CHB, LSMs correlated significantly with grading and staging scores and offered excellent accuracy for ≥moderate, ≥severe fibrosis or cirrhosis (AUROC ≥ 0.919–0.950). TE can be helpful for the noninvasive assessment of HBeAg‐negative chronic HBV patients. In conclusion, LSMs offer excellent accuracy for fibrosis severity in HBeAg‐negative patients with CHB and can identify carriers with high risk of moderate fibrosis, which may be present in up to 35% of carriers with LSM > 6.5 kPa and 50% of carriers with LSM > 6.5 kPa and HBV‐DNA > 2000 IU/mL.     

Comparative serum proteomic analysis of patients with acute‐on‐chronic liver failure: alpha‐1‐acid glycoprotein maybe a candidate marker for prognosis of hepatitis B virus infection

Summary. The acute‐on‐chronic liver failure (AoCLF) caused by hepatitis B virus (HBV) infection remains to be a challenge in clinics with a high mortality rate in China, and it is important to identify biomarkers to foresee the prognosis of patients with HBV. The current study analysed serum proteome changes of acute‐on‐chronic liver failure as a result of acute exacerbation of chronic hepatitis B infection. Serum samples were collected from normal subjects (NS, n = 8), patients with chronic hepatitis B (CHB, n = 12) and patients with AoCLF (n = 12). After removal of albumin/IgG and ultramembrane centrifugation, serum proteins were separated by two‐dimensional gel electrophoresis. Differentially expressed spots were identified by matrix‐associated laser desorption ionization time‐of‐flight tandem mass spectrometry. Through the removal of albumin/IgG and ultramembrane centrifugation, the well‐resolved and reproducible two‐dimensional gel electrophoresis (2‐DE) profiles were obtained. A total of 23 proteins were identified on 2‐DE profiles by their differential expression between the three cohorts. Mass spectrometry analysis resulted in the identification of 12 proteins unambiguously. Western blot analysis confirmed the proteomics results that the α1‐acid glycoprotein (α1‐AGP) levels decrease significantly in plasma of patients with AoCLF, but somewhat decreased in patients with chronic HBV. Further α1‐AGP levels in bulk serum samples were measured by immune turbidimetry including normal subjects group (n = 25), acute hepatitis group (n = 36), chronic hepatitis group (n = 52) and AoCLF group (n = 48), the level of α1‐AGP in AoCLF groups sharply decrease than other groups. Our study shows that α1‐AGP may be a potential plasma biomarker for AoCLF diagnosis because of acute exacerbation of chronic hepatitis B infection.     

Eighteen‐month lamivudine prophylaxis on preventing occult hepatitis B virus infection reactivation in patients with haematological malignancies receiving immunosuppression therapy

This study evaluated the long‐term efficacy and safety of an 18‐month lamivudine prophylaxis in 68 HBsAg‐negative/anti–HBc‐positive patients with oncohaematological disease. All 68 consecutive HBsAg‐negative/anti–HBc‐positive patients with an oncohaematological disease and naïve for chemotherapy observed from April 2008 to December 2012 at 2 Hematology Units in Naples were treated with lamivudine for 18 months after stopping chemotherapy and monitored for HBsAg at months 1 and 3 during chemotherapy and then every 3 months after its discontinuation. During follow‐up, 13 (19.1%) of the 68 patients died of complications related to their oncohaematological disease, and 3 (4%) showed a virological HBV reactivation (retroconversion to HBsAg positivity) 1‐7 months after the discontinuation of lamivudine prophylaxis (2 treated for chronic lymphocytic leukaemia and one for Waldenstrom's disease); of these, 2 showed a biochemical reactivation. Comparing the demographic and clinical characteristics of the 3 patients with a virological HBV reactivation to the 65 without, the former were older (median age and range: 67 years [75‐78] vs. 61 [24‐88]; P = .05) and were less frequently treated for B‐cell non‐Hodgkin lymphoma (B‐NHL) (0 vs. 70.7%, P = .03). In conclusion, a 18 months of lamivudine prophylaxis was effective in preventing HBV reactivation in HBsAg‐negative/anti–HBc‐positive patients treated for B‐NHL. However, in patients with chronic and severe immunodepression, such as those with chronic lymphocytic leukaemia and Waldenstrom's disease, prophylaxis should be continued for an indefinite period.     

Occult hepatitis B virus infection in Greek patients with chronic hepatitis C and in patients with diverse nonviral hepatic diseases

Occult hepatitis B virus (HBV) infection has been reported in patients with chronic hepatitis C who are negative for HBV surface antigen (HBsAg). However, the significance of 'silent' HBV in hepatitis C virus (HCV) infection is unknown. We investigated 540 subjects for the presence of occult HBV in Greek HCV patients, patients with nonviral liver diseases and healthy donors in an attempt to determine the frequency and importance of this phenomenon. One hundred and eighty-seven anti-HCV(+)/HBsAg(-) patients' sera were investigated for the presence of HBV-DNA by polymerase chain reaction. Two hundred and eighty-two selected blood donors (positive for antibodies to HBV core antigen) and 71 patients with various nonviral hepatic diseases consisted the control groups [both controls were anti-HCV(-)/HBsAg(-)]. HBV-DNA was detected in 26.2% of HCV-infected patients vs 8.5% of patients with nonviral diseases (P = 0.003) and 0/282 of donors (P = 0.0000). HBV-DNA was neither associated with HBV markers, nor with the clinical status of HCV and nonHCV patients. Neither epidemiological, histologic and virologic data nor the response to therapy were associated with the HBV-DNA detection. Hence one quarter of HCV-infected patients had occult HBV infection. Similar findings were not found in both control groups. Occult HBV infection in Greek patients with chronic hepatitis C does not seem to modify the progression of chronic liver disease. Further studies of longer duration are needed in order to clarify the role of 'silent' HBV infection in HCV-infected patients.     

Exposure to HAV infection in patients with chronic liver disease in Italy, a multicentre study

We carried out a multicentre study on 2830 patients with chronic liver disease from 79 liver units (25 in northern, 24 in central and 30 in southern Italy) to evaluate naturally acquired immunity against hepatitis A virus (HAV) in relation to age, sex, geographical area of origin and entity of liver disease, and to define the strategy for specific vaccination. Antibody to HAV (anti-HAV) was detected in 1514 (53.5%) of the 2830 patients tested; the prevalence was 50.4% in males and 59.1% in females. Both in central and southern Italy the prevalence of anti-HAV positive subjects increased with increasing age from 43.3 and 44.7%, respectively, in the 0-30-year-old subjects to 80.1 and 68.3%, respectively, in those aged over 60 years. The overall prevalence was much lower in northern Italy, as were the variations from one age group to another, from 28.4% in the 0-30-year-old subjects to 38% in those aged over 60 years. 40.6% of patients with cirrhosis lacked naturally acquired protection against HAV; this percentage was higher in northern (60.5%) than in central (34.9%, P < 0.0001) and southern Italy (27.6%, P < 0.0001). The high prevalence of patients in Italy with chronic hepatitis or cirrhosis who lack naturally acquired immunity to HAV warrants the implementation of vaccination programmes against hepatitis A in such patients.