HBeAg-negative Chronic Infection Research Articles

Genetic variability of hepatitis B virus in acute and in different phases of chronic infection in Brazil

The selection pressure imposed by the host immune system impacts on hepatitis B virus (HBV) variability. This study evaluates HBV genetic diversity, nucleos(t)ide analogs resistance and HBsAg escape mutations in HBV patients under distinct selective pressures. One hundred and thirteen individuals in different phases of HBV infection were included: 13 HBeAg-positive chronic infection, 9 HBeAg-positive chronic hepatitis, 47 HBeAg-negative chronic infection (ENI), 29 HBeAg-negative chronic hepatitis (ENH) and 15 acute infected individuals. Samples were PCR amplified, sequenced and genetically analyzed for the overlapping POL/S genes. Most HBV carriers presented genotype A (84/113; 74.3%), subgenotype A1 (67/84; 79.7%), irrespective of group, followed by genotypes D (20/113; 17.7%), F (8/113; 7.1%) and E (1/113; 0.9%). Clinically relevant mutations in polymerase (tL180M/M204V) and in the Major Hydrophilic Region of HBsAg (sY100C, T118A/M, sM133T, sD144A and sG145R) were observed. Our findings, however, indicated that most polymorphic sites were located in the cytosolic loops (CYL1-2) and transmembrane domain 4 (TMD4) of HBsAg. Lower viral loads and higher HBV genetic diversity were observed in ENI and ENH groups (p < 0.001), suggesting that these groups are subjected to a higher selective pressure. Our results provide information on the molecular characteristics of HBV in a diverse clinical setting, and may guide future studies on the balance of HBV quasispecies at different stages of infection.

Characterization of BCP/PreC/C region quasispecies in treatment-naive patients with different phases of HBV infection using next-generation sequencing

BackgroundTo analysis of quasispecies (QS) changes and high-frequency mutations in the BCP/PreC/C region of patients at different phases of hepatitis B virus (HBV) infection and provides novel biomarkers for the diagnosis of chronic hepatitis B (CHB) patients. MethodsWith the application of next-generation sequencing technology, we were able to sequence the HBV BCP/PreC/C regions in 40 patients, each at different phases of the HBV infection. The heterogeneity of QS and the frequency of mutations were calculated using MEGA 7 software. ResultsOur results show that the complexity and diversity of the BCP/PreC/C QS in HBeAg-positive CHB patients are significantly higher than those in HBeAg-positive chronic infection patients, while HBeAg-negative chronic infection patients had significantly higher QS complexity and diversity than HBeAg-negative CHB patients. In addition, HBeAg-negative patients showed reduced complexity but increased diversity compared with HBeAg-positive patients. Receiver operating characteristic curves showed that G1764A, C2102T, dN and complexity of QS could be used as potential biomarkers for diagnosing HBeAg-positive CHB, while the A2189C, dS and complexity of QS could be used as potential biomarkers for diagnosing HBeAg-negative chronic hepatitis. Finally, our study also found that G1896A and A2159G may be hotspot mutations affecting HBeAg seroconversion. ConclusionOur research elucidates the evolution of HBV by analyzing QS heterogeneity and mutation patterns, offering novel serum biomarkers for enhancing clinical diagnosis and disease prognosis. This comprehensive approach sheds light on the intricate dynamics of HBV progression and paves the way for more precise medical interventions.

Detection of serum large and middle hepatitis B virus surface proteins: A novel potential diagnostic and prognostic biomarker for chronic hepatitis B

BackgroundThe significance of large (LHB) and middle (MHB) HBV surface proteins in chronic hepatitis B (CHB) remains uncertain. This study investigates the role of LHB and MHB in different infection phases and liver diseases. MethodsSerum samples from 217 patients with HBV chronic infection, CHB, liver cirrhosis (LC), and hepatocellular carcinoma (HCC) were subjected to quantification of LHB and MHB using ELISA. ResultsPositive correlations were observed among LHB, MHB, and LHB/HBsAg, with HBV serum markers including HBsAg, HBeAg, and HBV DNA. (P < 0.0001). In HBeAg-positive chronic infection, LHB and MHB were higher than in HBeAg-positive CHB (P < 0.01). In HBeAg-negative chronic infection, LHB and MHB were lower than in HBeAg-negative CHB (P < 0.01). ROC analysis identified LHB and MHB as potential discriminators of CHB and chronic infection. LC and HCC exhibited lower LHB, MHB, and MHB/HBsAg than CHB (P < 0.05). Multivariate analysis found that age and the MHB/HBsAg serve as independent factors for the progression of CHB to end stage of liver disease. ConclusionsLHB and MHB emerge as novel biomarkers distinguishing chronic infection and CHB. MHB/HBsAg shows promise as a predictor for CHB progression.

Fetuin A and fetuin B as an indicator of liver fibrosis in hepatitis B

Abstract Objectives The aim of this study is to investigate the diagnostic and prognostic characteristics of fetuin A and fetuin B in chronic hepatitis B (CHB) and HBe Ag-negative chronic infection (HCI) and the relationship between the levels of these proteins and fibrosis in CHB. Methods In this study, we examined 98 patients with CHB, 58 with HCI and 42 control groups. Fetuin A and B levels were determined via ELISA. Results Serum fetuin A and B levels were significantly higher in the control group than the hepatitis B cases (p=0.001). No significant difference in fetuin A and B levels between patients in the CHB and HCI. In the CHB, fetuin A level was significantly lower in patients with significant fibrosis than those with mild fibrosis (p=0.007). Fetuin B was lower in patients with significant fibrosis than in with mild fibrosis; however, this difference was not significant. In predicting the absence of significant fibrosis, the area under the curve was estimated as 0.855 for fetuin A and 0.866 for fetuin B using the ROC curve. Conclusions Fetuin A and B were lower in CHB and HCI compared to the control group and there was no difference between the two groups suggests that these proteins may be effective in the pathogenesis of hepatitis B-induced liver damage. Fetuin A and B, which are found to be lower in patients with significant fibrosis in CHB, can be used as non-invasive markers in the early detection of fibrosis and in the follow-up of progression to significant fibrosis.

Eligibility for antiviral therapy and treatment uptake in chronic hepatitis B patients referred to a European tertiary care center.

Treatment indications for chronic hepatitis B (CHB) differ among recommendations by European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD) and World Health Organization (WHO). We aimed to assess treatment eligibility and linkage to therapy at a large tertiary care center. All CHB patients who were evaluated for treatment at the Vienna General Hospital between January 2010 and December 2020 were retrospectively included. Clinical, virological, and long-term treatment efficacy data were analyzed. A total of 751 CHB patients were included (53.3% male; median age: 39.5years; HBeAg-positive: 10.8%). The median Hepatitis B Virus (HBV)-DNA and HBsAg levels were 569 (68-11,750)IU/mL and 3467.65 (620.05-11,935.43)IU/mL, respectively. Overall, 9.2% of patients had severe fibrosis/cirrhosis, and 5.7% were coinfected with hepatitis D virus (HDV), which was highly prevalent in cirrhosis. According to the recent EASL nomenclature, 3.2% of patients had HBeAg-positive chronic infection, 7.6% had HBeAg-positive chronic hepatitis, 58.9% had HBeAg-negative chronic infection, and 30.4% had HBeAg-negative chronic hepatitis. At the time of evaluation, 36.4% had HBV-DNA >2000IU/mL, and 37.3% showed alanine aminotransferase >40U/L. Ultimately, 26.9% (EASL), 29.0% (AASLD) and 23.4% (WHO) met the treatment criteria. Treatment was initiated in most patients, mainly with tenofovir (61.8%) or entecavir (34.9%). Treatment efficiently suppressed HBV-DNA in all patients; however, HBsAg loss was observed only in 2.8% at 5years of therapy. Severe fibrosis/cirrhosis was found in 9.2% of CHB patients at presentation, and 23.4%-29.5% met current treatment recommendations with a high treatment uptake of 79.8%-89.2% among eligible patients.

Clinical and virological features of chronic hepatitis B in the French national surveillance program, 2008–2012: A cross-sectional study

Background & AimsAmong people living with HBV, only a subset of individuals with chronic hepatitis is in need of treatment, and this proportion varies according to the population, region, and setting. No estimates of the proportion of people who are infected with HBV and meet the treatment eligibility criteria in France are available.Methods552 treatment-naïve individuals with chronic HBV infection referred for the first time to a hepatology reference centre between 2008 and 2012 were prospectively included. Demographic, clinical, and laboratory data were analysed.ResultsIn total, 61.1% of patients were males, with a median age of 37.5 years. Moreover, 64% were born in an intermediate- or high-HBV endemicity country, and 90% were HBeAg-negative. At referral, median HBV DNA and HBsAg levels were 3.3 and 3.6 log IU/ml, respectively; 37.8% of patients had alanine aminotransferase >40 U/L, and 29.0% had moderate or severe fibrosis (≥F2), including 9.4% with cirrhosis. The most prevalent genotypes were D (34.7%), E (27.4%), and A (25.7%). Coinfections were rare: 2.4% were HIV-positive, 4.0% were HCV-positive, and 6.0% were HDV-positive. According to the 2017 EASL Clinical Practice Guidelines, using a single time point analysis, 2.7% of patients were classified as HBeAg-positive chronic infection, 6.1% as HBeAg-positive chronic hepatitis B, 26.5% as HBeAg-negative chronic hepatitis B, and 61.1% as HBeAg-negative chronic infection, whereas 3.6% patients could not be classified. The performance of HBsAg level quantification to identify individuals with HBeAg-negative chronic hepatitis B was poor. A total of 29.1% met the criteria for initiation of antiviral treatment, whereas 66.5% remained under routine clinical surveillance. Most eligible patients initiated recommended first-line therapies, including tenofovir (45.3%), entecavir (36.8%), or pegylated interferon alpha (11.6%).ConclusionsOf all cases, 9.4% had cirrhosis at presentation and 29.1% met the 2017 EASL Clinical Practice Guidelines treatment criteria. HBsAg levels failed to accurately identify individuals with HBeAg-negative chronic infection.Lay summaryAmong French adults chronically infected with HBV referred for the first time to hepatology reference centres, about one-third had a significant liver disease. Approximately one-third of individuals met criteria for initiation of antiviral treatment based on entecavir or tenofovir or, occasionally, pegylated interferon alpha.

THU399 - Parameters related to ALT elevation in patients with HBeAg negative chronic infection

THU399 - Parameters related to ALT elevation in patients with HBeAg negative chronic infection

Оцінювання фіброзу печінки в дітей з хронічною HBV-інфекцією неінвазивними методами

Purpose — to assess liver fibrosis in children with chronic HBV infection with nonEinvasive methods: instrumental (shear wave elastography) and serological (APRI score). Materials and methods. 70 children with HCV aged 2–17 years were examined. The stage of liver fibrosis was determined by the APRI index and the method of shear wave elastography. Results. The majority (82.8%; n=58) of children were diagnosed with HBeAgEpositive HBV infection: HBeAg-positive chronic hepatitis occurred in 54.3% (n=38) of children, HBeAg-positive chronic infection in 28.6% (n=20). 15.7% (n=11) of children had HBeAg-negative chronic infection, and only one (1.4%) patient had HBeAg-negative chronic hepatitis. According to the results of shear wave elastography, in 64.3% (n=45) the stage of liver fibrosis F0-1 was diagnosed; in 35.7% (n=25) — stage of fibrosis &gt;F2. According to APRI score, 63.0% (n=44) had liver fibrosis F0-1, and liver fibrosis stage &gt;F2 was diagnosed in 37.2% (n=26). According to liver elastography, 42.0% of patients with HBeAg-positive chronic hepatitis were diagnosed with liver fibrosis stage &gt;F2. According to APRI score, almost 66% (n=46) of children with HBeAg-positive chronic hepatitis had progressive liver fibrosis &gt;F2. According to the correlation analysis results, a direct correlation was found between liver enzymes levels and APRI score — ALT (τ=0.67; p&lt;0.05), AST (τ=0.72; p&lt;0.05) and GGT (τ=0.26; p&lt;0.05). Conclusions. Most children with chronic HBV infection had stage F0-1 liver fibrosis according to both elastography and APRI score (64% and 63%, respectively). Elastography fibrosis stage &gt;F2 was diagnosed in 42% of HBeAg-positive chronic hepatitis, while APRI index fibrosis stage &gt;F2 was diagnosed in 66% of patients with HBeAg-positive chronic hepatitis. Thus, the results of the liver fibrosis evaluation according to the liver elastography and APRI score in children with chronic HBV infection are similar and can be used in clinical practice to select patients who require antiviral therapy. The APRI score depends on the activity of hepatitis and its use in children with HBeAg-positive chronic hepatitis has certain limitations. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: children, chronic HBV infection, fibrosis, shear wave elastography, APRI.

Забезпеченість вітаміном D дітей з хронічним вірусним гепатитом В

Purpose — to investigate the vitamin D supply in children with chronic viral hepatitis B (HBV) depending on the activity of hepatitis and the stage of liver fibrosis. Materials and methods. Fifty children with HBV were examined. All children underwent a comprehensive examination according to the recommendation and elastography of the shear wave of the liver parenchyma to determine the stage of fibrosis. Serum 25(OH)D concentration was determined to verify the diagnosis of vitamin D deficiency. The peculiarities of vitamin D supply in children with HBV, depending on gender, age, hepatitis activity and stage of liver fibrosis, were evaluated. The study included children who did not receive calcium and vitamin D for 6 months. Results. Children of senior scholl age predomnanted among the surveyed. HBV was more often registered in boys 66.0% (n=33), while in girls — only 34.0% (n=17) (χ2=10.24; p=0.01). Among the examined children significantly more often 66.0% (n=33) we observed HBeAg-positive chronic hepatitis, 18.0% (n=9) children were diagnosed with HBeAg-positive chronic infection, HBeAg-negative chronic infection were determined in 14.0% (n=7) of children. In the vast majority (70.0%) of patients with HBV, the concentration of vitamin D in the serum was reduced (χ2=16.0; p=0.01). The average concentration of 25(OH)D was 59.85 [13.4–181] nmol/l and was in the zone of insufficiency. The optimal concentration of 25(OH)D was found in 30.0% (n=15) of children, insufficiency in 42.0% (n=21), vitamin D deficiency was diagnosed in 14 children (28.0%). Gender, age and biochemical activity of hepatitis do not affect the level of vitamin D in the examined children with HBV (p&gt;0.05). The analysis of vitamin D supply depending on the stage of fibrosis did not reveal differences in the median concentration of 25(OH)D between groups of children, but in all groups the number of patients with low concentrations of vitamin D prevailed. Conclusions. HBV in children is characterized mainly by a chronic course, with a predominance of the parenteral route of infection. In most patients with HBV, the concentration of 25(OH)D in the serum is reduced. There was no statistically significant difference between the levels of vitamin D in children with HBV depending on gender, age, and biochemical activity of hepatitis. All children with cirrhosis of the liver were deficient in vitamin D. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of all participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: chronic viral hepatitis B, children, vitamin D, hepatitis activity, stage of fibrosis.

Association of anti-HBc and liver inflammation in HBeAg-negative chronic hepatitis B virus-infected patients with normal ALT and detectable HBV DNA.

Serum hepatitis B core antibody (anti-HBc) is associated with liver inflammation in chronic hepatitis B patients. This study aimed to investigate whether anti-HBc could serve as a predictor of significant liver inflammation in hepatitis B e antigen (HBeAg)-negative chronic hepatitis B virus (HBV) infected patients with normal alanine aminotransferase (ALT) and detectable HBV DNA. Treatment-naïve HBeAg-negative chronic HBV infected patients with normal ALT and detectable HBV DNA who underwent liver biopsy were retrospectively included from two medical centers. Liver inflammation grade was evaluated using the Scheuer scoring system and significant liver inflammation was defined as ≥G2. Serum anti-HBc levels were measured by commercial immunoassays (Abbott GmbH & Co. KG). A total of 117 patients were included and 50 (42.7%) patients showed significant liver inflammation. Serum anti-HBc levels in patients with significant liver inflammation were significantly higher than patients with no or mild liver inflammation (<G2) (p < 0.001). High serum anti-HBc (odds ratio 1.562, 95% confidential interval 1.157-2.110, p = 0.004) was an independent risk factor of significant liver inflammation. The area under the receiver operating characteristic curve of serum anti-HBc in predicting significant liver inflammation was 0.769 and the optimal cut-off value was 10.87 S/CO, with a sensitivity of 59.2% and a specificity of 87.9%. Our data revealed that a substantial of HBeAg-negative chronic infection patients with normal ALT and detectable HBV DNA showed significant liver inflammation. Serum anti-HBc can predict significant liver inflammation in these patients.

O-27 IMPACT OF HBV GENOTYPE F IN THE DIAGNOSIS AND EVOLUTION OF PATIENTS WITH HBEAG-NEGATIVE CHRONIC HBV INFECTION

The quantitative hepatitis B surface antigen (qHBsAg) threshold of 1,000 IU/ml has been proposed to distinguish HBeAg-negative chronic infections from HBeAg-negative chronic hepatitis, to assess risk of liver disease progression, and to predict HBsAg clearance. There is evidence that qHBsAg vary significantly among genotypes, however, there is scarce data on genotype F, the most prevalent in Latin America. To analyze the impact of HBV genotype F on qHBsAg inpatients with HBeAg-negative chronic infection and to describe clinical and virological outcomes. HBV-DNA and qHBsAg serum levels of 141 patients with HBeAg-negative chronic infection were correlated with HBV genotype, who were followed for 10.6±7.4 years. The overall genotype distribution was as follows: F 46.8%, D 26.1%, A 25.2%, and B 0.7% and C 0.7%. While no impact of the HBV genotype on HBV DNA levels was observed, qHBsAg differed significantly among genotypes (p<0.001). The highest HBsAg levels were observed in genotype F (4.0±1.1 Log10IU/ml) followed by genotype A (3.9±0.6 Log10IU/ml) and genotype D (2.4±0.9 Log10IU/ml). In genotype A and F, qHBsAg <3.0 Log10IU/ml were only observed in 10.7% and 11.5% respectively. Regardless of the HBV genotype, spontaneous clearance of HBsAg was observed in 17 cases. Of these, 12 patients presented qHBsAg <100 IU/ml one year before clearance. Despite, 101 (71.6%) patients showed qHBsAg >3.0 Log10IU/ml, no cases of advanced liver disease or hepatocellular carcinoma were observed at the end of follow-up. This study provides new insights into the impact of HBV genotypes on serum HBsAg levels, emphasizing the need to implement genotype-specific cut-off to achieve diagnostic certainty in the identification of HBeAg-negative chronic infection and the risk of liver disease progression, particularly on infections with genotypes A and F. Moreover, HBsAg serum levels can became a reliable biomarker to predict HBsAg clearance.

Prevalence of sero-markers and non-invasive assessment of liver cirrhosis in patients with Hepatitis B virus infection in Freetown, Sierra Leone: a cross-sectional study

BackgroundHepatitis B virus (HBV) is a major global health problem. Although sub-Saharan Africa has a high proportion of the global burden of HBV, the epidemiology and clinical features of HBV in this region are poorly characterized, and access to diagnostic and treatment services remain limited.MethodsWe conducted a retrospective study of HBV-infected children and adults of all age groups who were evaluated at public and private health facilities in Freetown, Sierra Leone between January 2017 and January 2019. We assessed their clinical presentation, HBV sero-markers, stages of liver disease, prevalence of cirrhosis by non-invasive tools, and the proportion of treatment eligible patients using the criteria recommended by the World Health Organization’s 2015 treatment guidelines for HBV. Logistic regression was used to identify predictors of liver cirrhosis.Results163 HBV patients included in the study, with mean age 32.6 years and 65.0% (106) being males. Most (84.0%) were asymptomatic at presentation. The majority (69.9%) were classified as having HBeAg-negative chronic infection (or inactive HBsAg carrier phase), 24.5% were in the HBeAg-negative immune active phase, 3.1% had HBeAg positive hepatitis, and 2.5% were HBsAg negative. The median Aspartate aminotransferase to Platelet Ratio (APRI) and Fibrosis-4 (FIB-4) scores were 0.37 and 0.80, respectively. The prevalence of cirrhosis was 7.6% and 6.2%, estimated by the APRI and FIB-4 scores, respectively. About 20.0% of patients were eligible for treatment with antiviral agents. Based on APRI scores, the presence of any symptom [adjusted odds ratio (aOR) 20.0, 95% confidence interval (CI) (4.1–85.9); p < 0.001], elevated direct bilirubin [aOR 12.1, 95% CI (1.9–63.0); p = 0.003], and elevated total bilirubin [aOR 16.1, 95% CI (3.2–80.8); p = 0.001] were independent predictors of cirrhosis.ConclusionAlthough most patients with HBV infection were asymptomatic, the prevalence of liver cirrhosis and proportion of patients requiring antiviral treatment were substantial. This small study from a hyperendemic setting in Sierra Leone suggests that routine population-based screening may increase early detection and linkage of HBV patients to care before development of complications. Larger studies are needed to confirm our findings.

High L-Carnitine Levels Impede Viral Control in Chronic Hepatitis B Virus Infection.

Persistent antigen exposure during chronic hepatitis B infection leads to exhausted immune responses, thus impeding viral control. In recent years, immunometabolism opens new therapeutic possibilities for the modulation of immune responses. Herein, we investigated the immunomodulatory effect of L-carnitine (L-Cn) on immune cells in chronic HBV infection. In this study, 141 treatment-naïve patients with chronic HBV infection, 38 patients who achieved HBsAg loss following antiviral treatment, and 47 patients who suffered from HBV-related HCC from real-life clinical practice were recruited. The plasma L-Cn levels were measured by ELISA. RNA sequencing was conducted to define the transcriptional profiles of peripheral blood mononuclear cells after L-Cn stimulation. In vitro assays were performed to assess the effect of L-Cn on immune cells; the frequencies and function of immune cells were analyzed by flow cytometry. We found that compared with patients with HBsAg loss, patients with HBsAg positivity and patients who suffered from HBV-related HCC had higher levels of L-Cn, and the plasma levels of L-Cn in the HBeAg-positive chronic hepatitis patients who had elevated ALT were significantly higher than that of HBeAg-negative chronic infection and HBsAg loss groups. Moreover, a positive correlation between plasma levels of L-Cn and HBsAg levels was found. Additionally, RNA sequencing analysis demonstrated that L-Cn altered the transcriptional profiles related to immune response. In vitro assays revealed that L-Cn suppressed the proliferation of and IFN-γ production by CD4+ and CD8+ T cells. It also down-regulated the proliferation and IgG production of B cells. Notably, L-Cn enhanced IL-10 secretion from regulatory T cells and up-regulated the expression of inhibitory receptors on T cells. Moreover, a variant in CPT2 (rs1799821) was confirmed to be associated with L-Cn levels as well as complete response in CHB patients following Peg-IFNα antiviral therapy. Taken together, the immunosuppressive properties of L-Cn may hinder the control of HBV in chronic HBV infection, implicating that L-Cn manipulation might influence the prognosis of patients with HBV infection.

Inter-method variability of hepatitis B surface antigen quantification in a cohort of Egyptian patients with chronic hepatitis B virus

Background and study aimsHepatitis B (HB) surface antigen (HBsAg) levels can predict clinical and treatment outcomes in chronic HB virus (HBV) infection. We aimed to compare the performance of two different assays [Elecsys® (Roche) and Architect™ (Abbott)] for HBsAg quantification and evaluate HBsAg levels in the various immune phases in a cohort of Egyptian patients with chronic HBV. Patients and methodsQuantitative HBsAg by Elecsys® and Architect™ assays, measurement of routine biochemical and serological markers, and transient elastography were performed in 92 patients with chronic HBV. Results of the two assays and other tests were compared. ResultsNinety-two treatment-naive patients with chronic HBV, (70% males; mean age, 36.1 ± 10.5 years) were recruited from Cairo Fatemic Hospital. Patients were categorized as HBeAg positive (n = 22) and HBeAg negative (n = 70). The Architect™ and Elecsys® assays were significantly correlated (intraclass correlation coefficient: 0.913; 95% CI: 0.870–0.943; p < 0.001). However, Deming regression, Passing and Bablok, and Bland–Altman statistical analyses showed discordance among the assays. HBsAg levels by both assays were significantly higher in the HBeAg positive than patients with HBeAg-negative (p = 0.033 and 0.013, respectively). HBsAg levels in the Architect™ and Elecsys® assays were significantly higher in HBeAg-negative chronic hepatitis than in HBeAg-negative chronic infection (p = 0.002 and 0.004, respectively) ConclusionBoth assays for qHBsAg were found to be simple and reproducible tests that could classify patients and provide additional evidence on the natural history of HBV.

HBV RNA Profiles in Patients With Chronic Hepatitis B Under Different Disease Phases and Antiviral Therapy.

Large-scale comprehensive studies on HBV RNA in chronic hepatitis B are lacking. We aimed to study the HBV RNA profile and its correlation with other viral markers in patients with chronic hepatitis B who are treatment-naïve and patients receiving nucleos(t)ide analogues (NA). Biomarkers, including HBV RNA and hepatitis B core-related antigen (HBcrAg), were measured in 388 patients. Of these, 246 were treatment-naïve and were categorized into HBeAg-positive chronic infection (n=41), HBeAg-positive chronic hepatitis (n=81), HBeAg-negative chronic infection (n=39), HBeAg-negative chronic hepatitis (n=66), and HBsAg seroclearance (n=19). These biomarkers were also measured in 142 patients who were NA-treated receiving tenofovir or entecavir at baseline, week 48, and week 96. The pattern of serum HBV RNA levels mirrored HBV DNA (1-2 logs higher than HBV RNA) and HBcrAg in patients who were treatment-naïve. HBV RNA correlated best with HBcrAg (r=0.84) and to a lesser extent with HBV DNA (r=0.737) (both P<0.001). In patients with HBsAg seroclearance, 15.8% and 15.8% had detectable serum HBV RNA and HBcrAg, respectively. NA treatment reduced serum HBV RNA by 1.46 logs and 1.77 logs at weeks 48 and 96, respectively. At week 96 of NA therapy, only 19.1% patients who were tenofovir-treated and 25.7% patients who were entecavir-treated had unquantifiable HBV RNA (P>0.05). In patients who were treated and had undetectable HBV DNA, 77.5% and 30% had quantifiable HBV RNA and HBcrAg, respectively. HBV RNA showed distinct and corresponding profiles in patients with HBV in different disease phases. HBV RNA and HBcrAg could be used to monitor residual transcriptional activities in patients with HBsAg seroclearance. NA led to reduction of serum HBV RNA. Monitoring of viral activities can still be achieved in patients with undetectable HBV DNA by serum HBV RNA.

Clinical utility of quantifying hepatitis B surface antigen in African patients with chronic hepatitis B.

The clinical utility of quantifying hepatitis B surface antigen (qHBsAg) levels in African subjects with chronic hepatitis B virus (HBV) infection has been poorly documented. From a multicentre cohort of 944 HBV-infected African patients, we aimed to assess whether qHBsAg alone can accurately identify i) those in a HBeAg-negative chronic HBV infection phase at low risk of liver disease progression and ii) those in need of antiviral therapy according to the 2017 EASL guidelines. We analysed 770 HBV mono-infected treatment-naïve patients, mainly males (61%) from West Africa (92%), median age 35years (IQR: 30-44), median HBV DNA: 95.6IU/ml (10.0-1,300.0), median qHBsAg 5,498IU/ml (1,171-13,000) and HBeAg-pos 38 (5%). A total of 464/770 (60.2%) patients were classified as HBeAg-negative chronic infection (median age 36years (31-46), median ALT 23IU/l (18-28), median HBV-DNA 33.5IU/ml (3.8-154.1), median LSM 4.8kPa (4.1-5.8)) and qHBsAg levels had poor accuracy to identify these subjects with an AUROC at 0.58 (95%CI: 0.54-0.62), sensitivity 55.0% and specificity 55.6%; 118/770 (15.3%) patients were eligible for treatment according to the 2017 EASL criteria. qHBsAg correlated poorly with HBV DNA and had poor accuracy to select patients for antiviral therapy with an AUROC at 0.54 (0.49-0.60), sensitivity 46.6% and specificity 46.9%. In African treatment-naïve HBV-infected subjects, the clinical utility of qHBsAg to identify subjects in HBeAg-negative infection phase or subjects eligible for antiviral therapy seems futile. Whether qHBsAg levels can be used as a predictor of long-term liver complications in Africa needs to be further investigated.

Letter to the Editor: The Differences Between the Reverse Transcriptional Efficiency of HBV Pregenomic RNA and Transcriptional Efficiency of HBV Covalently Closed Circular DNA

We read with great interest the article entitled "HBV RNA profiles in chronic hepatitis B patients under different disease phases and anti-viral therapy" authored by Mak et al(1). The authors proposed that the reverse transcription efficiency in HBeAg-positive patients was significantly higher than that in HBeAg-negative patients, based on the RNA: DNA ratio in the two groups of patients (0.79 vs. 0.53; p< 0.001). We had found that a higher ratio of serum HBV RNA to HBV DNA was inversely related with reverse transcription efficiency of HBV pgRNA(2), and HBeAg-positive patients had a lower reverse transcription efficiency of HBV pgRNA than HBeAg-negative patients did. We here suggest that the ratio of serum HBV DNA: (HBV DNA + HBV RNA) is more reliable to assess the reverse transcriptional efficiency of pgRNA. The medians of ratio in our cohort were 0.56 (n = 54), 0.56 (n = 23), 0.69 (n = 64) and 0.66 (n = 4), for patients with HBeAg-positive chronic infection, HBeAg-positive chronic hepatitis, HBeAg-negative chronic infection, and HBeAg-negative chronic hepatitis, respectively. Inconsistent with the report by Mak et al., our data showed that the reverse transcriptional efficiency was lower in HBeAg-positive patients than in HBeAg-negative patients (0.56 vs. 0.68; p< 0.001). A schematic diagram for illustrating the efficiencies of covalently closed circular DNA (cccDNA) transcription and reverse transcription of pgRNA are shown in Figure 1.

From the Editor’s Desk...

From the Editor’s Desk...

Chronic hepatitis B: the demise of the 'inactive carrier' phase.

Chronic hepatitis B (CHB) remains a global healthcare burden. Although the recent developments in the field have led to a reduction in incidence, the morbidity and mortality including liver cirrhosis and hepatocellular carcinoma (HCC) remain a formidable challenge. Advances in understanding the immunopathogenesis of CHB have led to a recent change in clinical categorization. EASL introduced the term hepatitis B 'e' antigen (HBeAg)-negative chronic infection, to replace the historical term 'inactive carrier' disease phase, the commonest CHB phase. Although this disease phase is associated with a favorable prognosis, it is not a truly 'inactive' disease phase with no ostensible liver disease, as inferred by the previous anachronistic terminology, and the risk of spontaneous reactivation and the potential risk of disease progression and HCC development are not negligible. Likewise, the APASL also uses the term "Incidentally Detected Asymptomatic Hepatitis B surface antigen (HBsAg)-positive Subject (IDAHS)", comprising all HBsAg-positive subjects who are incidentally detected during routine tests, without any previous or present symptoms of liver disease. This entity includes HBV infection with varied stages of liver disease. Antiviral treatment is generally reserved for patients with active inflammation and/or at risk of disease progression and HCC development. HBsAg loss is considered an optimal treatment endpoint, and may also be achievable in HBeAg-negative chronic infection and IDAHS. In light of this, andthe emerging novel HBV therapies, lowering the treatment threshold and a 'Treat All' approach should now be considered. In this review, we summarize the literature and guidance on HBeAg-negative chronic infection, and we make a concerted effort to present the reasons why the one-dimensional term 'inactive carrier' should be abandoned.

Sophisticated viral quasispecies with a genotype-related pattern of mutations in the hepatitis B X gene of HBeAg-ve chronically infected patients

Patients with HBeAg-negative chronic infection (CI) have not been extensively studied because of low viremia. The HBx protein, encoded by HBX, has a key role in viral replication. Here, we analyzed the viral quasispecies at the 5′ end of HBX in CI patients and compared it with that of patients in other clinical stages. Fifty-eight HBeAg-negative patients were included: 16 CI, 19 chronic hepatitis B, 16 hepatocellular carcinoma and 6 liver cirrhosis. Quasispecies complexity and conservation were determined in the region between nucleotides 1255 and 1611. Amino acid changes detected were tested in vitro. CI patients showed higher complexity in terms of mutation frequency and nucleotide diversity and higher quasispecies conservation (p < 0.05). A genotype D-specific pattern of mutations (A12S/P33S/P46S/T36D-G) was identified in CI (median frequency, 81.7%), which determined a reduction in HBV DNA release of up to 1.5 log in vitro. CI patients showed a more complex and conserved viral quasispecies than the other groups. The genotype-specific pattern of mutations could partially explain the low viremia observed in these patients.