HBeAg-negative Hepatitis Research Articles

Chronic Hepatitis B: A Critical Appraisal of Current Approaches to Therapy

Treatment of chronic hepatitis B (CHB) involves a number of complex and controversial issues. Expert opinions may differ from those of practicing hepatologists and gastroenterologists. We aimed to explore this issue further after a critical review of the literature. A panel of 14 international experts graded the strength of evidence for 16 statements addressing 3 content areas: patient selection, therapeutic end points, and treatment options. Available data relating to the statements were reviewed critically in 3 small work groups. After discussion of each statement with the entire panel, the experts voted anonymously to accept or reject statements based on the strength of evidence and their experience. A total of 241 members of the American Association for the Study of Liver Diseases (AASLD) responded to the same statements and their responses were compared with those of the experts. A discordant response was defined as a difference of more than 20% in any of the 5 graded levels of response (accept or reject) between the 2 groups. With the exception of 2 statements, the experts' responses were relatively uniform. However, the responses of the AASLD members were discordant from the experts in 12 statements, spanning all 3 content areas. Several areas of disagreement on the management of CHB exist between experts and AASLD members. Our results indicate a potential knowledge gap among practicing hepatologists. Better educational efforts are needed to meet the challenge of managing this complex disorder in which even expert opinion occasionally may disagree.

Chronic hepatitis B in children after e antigen seroclearance: Final report of a 29-year longitudinal study

Chronic hepatitis B is usually a benign disease in Caucasian children; however, the long-term prognosis remains unsettled. This report describes the results of a 29-year longitudinal study including 99 white children with chronic hepatitis B, mainly acquired horizontally: 91 were hepatitis B e antigen (HBeAg) positive (4 had cirrhosis), and 8 were HBeAg negative at presentation. Of the 91 HBeAg-positive children, 89 underwent HBeAg seroconversion after a mean period of 5.2 +/- 4.0 years and were included in the study. Of the 85 children without cirrhosis, one had HBeAg-negative hepatitis and the other 84 became inactive carriers. During a mean follow-up of 14.5 +/- 6.1 years after HBeAg seroclearance, 4 carriers experienced reactivation, and 3 of them had HBeAg-negative hepatitis at the last follow-up. Of the 8 initially HBeAg-negative children, 2 had HBeAg-negative hepatitis, and 6 were inactive carriers. Of the 4 children with cirrhosis, 2 had hepatocellular carcinoma (HCC) and remained alive and 2 lost the histological features of cirrhosis in adulthood. Two patients with HBeAg-negative hepatitis and 1 with cirrhosis had experienced drug abuse. At the end of follow-up, 15 of the 89 initially HBeAg-positive patients and 2 of 8 initially HBeAg-negative children had cleared hepatitis B surface antigen. In conclusion, the overall prognosis for chronic hepatitis B in horizontally infected Caucasian children is favorable; however, some patients progress to HCC and HBeAg-negative hepatitis. Long-term monitoring is important, as is counseling on cofactors of liver damage, such as alcohol and drug abuse.

Emergence and takeover of precore-stop mutant prior to exacerbation of e antigen-negative chronic hepatitis B after withdrawal of lamivudine therapy

Although hepatitis B virus (HBV) precore-stop mutant (nonsense mutation at codon 28) is usually isolated from patients with hepatitis B e antigen (HBeAg)-negative hepatitis, it is unclear whether the mutant is the cause of the hepatitis flare or it is a consequence of necroinflammation. Using the amplification-created restriction site method, the ratios of precore-stop mutant were measured in serial serum samples obtained from three patients experiencing HBeAg-negative hepatitis after withdrawal of lamivudine therapy. In all three patients, the precore-stop mutant emerged and took over the viral population at least 2 months prior to the hepatitis exacerbations. After the onset of exacerbation, transient elevation of serum HBV-DNA was observed, which was followed by progressive decrease of the ratio of precore-stop mutant as well as normalization of serum transaminases. The present data indicate that at least in some patients, the precore-stop mutant is the cause but not the consequence of the flare of HBeAg-negative hepatitis.

Clinical characteristics of patients with hepatocirrhosis after HBeAg-negative hepatitis B

Clinical characteristics of patients with hepatocirrhosis after HBeAg-negative hepatitis B

Natural Course, Therapeutic Options and Economic Evaluation of Therapies for Chronic Hepatitis B

Chronic hepatitis B virus infection afflicts 400 million people worldwide and untreated will progress to cirrhosis in 15-40% of individuals, with an associated increased risk for the development of hepatocellular carcinoma. The 'inactive carrier state' carries a benign prognosis with a very low risk of cirrhosis or hepatocellular carcinoma. However, the hepatitis B e antigen (HBeAg)-positive chronic hepatitis state is an active disease state with increased risk for progressing to cirrhosis and hepatocellular carcinoma. The HBeAg-negative mutant variety of chronic hepatitis B has been associated with a higher incidence of cirrhosis at initial presentation and more frequent progression to hepatocellular carcinoma compared with the wild-type hepatitis B. Five medications are currently approved by the US FDA for the treatment of chronic hepatitis B: interferon-alpha, lamivudine, adefovir dipivoxil, entecavir and peginterferon-alpha-2a. Interferon-alpha therapy has been shown to increase the rate of HBeAg and hepatitis B DNA loss with a small chance of hepatitis B surface antigen loss, but has significant adverse effects and is ineffective against the HBeAg-negative mutant. Lamivudine is a safely used, orally administered drug with good efficacy, but is associated with the development of a lamivudine-resistant (Lam-R) mutant in a large proportion of patients after long-term therapy. High relapse rates after lamivudine therapy make this medication less effective in the HBeAg-negative mutant also. Adefovir dipivoxil is a safely used, orally administered drug, which is effective against the Lam-R mutant. Adefovir dipivoxil is effective against the wild-type and HBeAg-negative hepatitis B and has a very low incidence of resistance development. Entecavir is a highly potent and selective new oral drug against hepatitis B. It has demonstrated no resistance development in treatment-naive patients, but a low incidence of resistance in patients infected with prior Lam-R mutants. Peginterferon-alpha-2a is administered once weekly and has improved efficacy compared with standard interferon-alpha and lamivudine. However, it has a similar adverse-effect profile to standard interferon-alpha. Pharmacoeconomic studies have demonstrated a cost benefit in treating chronic hepatitis B patients compared with no therapy. However, results have been conflicting, with earlier studies showing a cost advantage of lamivudine over interferon-alpha and a more recent, comprehensive study favouring interferon-alpha monotherapy in HBeAg-negative patients and adefovir dipivoxil 'salvage' after lamivudine resistance development in HBeAg-positive patients.

Biochemical response to lamivudine treatment in HBeAg negative chronic hepatitis B patients in Iran

To study the effect of a one-year lamivudine regimen in patients with chronic hepatitis B. Medical records of HBeAg negative hepatitis B patients who attended a hepatitis clinic in Tehran between March 2002-March 2004 were evaluated. The patients received 100 mg lamivudine tablets once daily for at least 12 mo. Liver enzymes and complete blood count were checked at baseline and the end of treatment (12th mo) and 6 mo after discontinuation of treatment. Of all patients, 24 were excluded. Of 71 patients left, 58 (81.7%) were men. Mean age of the patients was 38 +/- 14 years. Mean level of ALT in serum was 1437 +/- 205 nkat/L at baseline with a significant reduction at the end of treatment to a mean level of 723 +/- 92 nkat/L (P = 0.002). In 38 patients (53.5%), the ALT level was normal after one-year treatment. Five patients (7.3%) relapsed (biochemically) within 6 mo after discontinuing lamivudine therapy (the patients with good end of treatment response). Mean level of AST in serum was 1060 +/- 105 nkat/L at baseline which decreased significantly to 652 +/- 75 nkat/L at the end of treatment (P = 0.002). Over half (53.5%) of chronic hepatitis B patients with HBeAg negative have normal liver enzyme level at 12-mo lamivudine therapy.

Long-Term Lamivudine Treatment is Associated with a Good Maintained Response in Severe Acute Exacerbation of Chronic Hbeag-Negative Hepatitis B

Hepatitis B e antigen (HBeAg)-negative chronic hepatitis B is difficult to treat and there is little long-term data for lamivudine treatment of severe acute exacerbation. We report a prospective, consecutive cohort of severe acute exacerbation of HBeAg-negative chronic hepatitis B patients treated by lamivudine between 1999 and 2004. All patients had respectively increased alanine aminotransferase and serum bilirubin to at least 10 and 2 times the upper limit of laboratory normal. Thirty-two patients were treated with lamivudine for 130 +/- 58 (range 48-217) weeks. Five patients had evidence of virological breakthrough (HBV DNA >10,000 copies/ml) during lamivudine treatment. The cumulative probability of maintained response without any virological breakthrough was 94% (95% confidence interval [CI], 86-100%) at year 1, 94% (95% CI, 82-100%) at year 2 and 71% (95% CI, 41-100%) at year 3. At the last follow-up visit, 31 (97%) lamivudine patients had HBV DNA <10,000 copies/ml. The prevalence of lamivudine resistance mutation was 1 in 32 patients (3%; 95% CI, 0-9%) at year 1, 1 in 17 patients (6%; 95% CI, 0-17%) at year 2, 1 in 9 patients (11%, 95% CI, 0-32%) at year 3 and 1 in 4 patients (25%; 95% CI, 0-67%) at year 4 of lamivudine treatment. In conclusion, extended lamivudine treatment is associated with a high maintained virological response and a low rate of drug resistance in severe acute exacerbation of HBeAg-negative chronic hepatitis B.

Interferon-α plus lamivudinevslamivudine reduces breakthroughs, but does not affect sustained response in HBeAg negative chronic hepatitis B

The HBeAg negative form of chronic hepatitis B (CHB) predominates in the Mediterranean area and has a rising frequency in Europe and North America. At present there are three approved therapies for patients with CHB: interferon-alpha (IFN-alpha), lamivudine and adefovir dipivoxil. Unfortunately, none of these drugs are effective in achieving a sustained response in patients with HBeAg negative CHB. Therefore, new therapeutic approaches have been examined. Our aim was to investigate the efficacy of combination treatment of IFN-alpha and lamivudine compared to lamivudine monotherapy, after 24 mo of administration in HBeAg-negative hepatitis B patients. Fifty consecutive patients were randomly assigned to receive IFN-alpha-2b (5 MU thrice per week, n = 24) plus lamivudine (100 mg daily) or lamivudine only (n = 26) for 24 mo. Patients were followed up for further 6 mo. The primary outcome was the proportion with sustained virological response (undetectable serum HBV DNA concentrations) and or sustained biochemical response (transaminase levels within normal range) at 30 mo (6 mo after the end of therapy). Secondary end-points were timed from initial virological (biochemical) response to VBR (BBR, respectively) and the emergence of YMDD mutants across the two arms. Five of twenty-four (21%) patients in the combination arm vs 3/26 (12%) in the lamivudine arm had sustained response (i.e., normal serum transaminase levels and undetectable HBV DNA by PCR assay) 6 mo after treatment discontinuation. A reduction in the emergence of YMDD mutants and in the development of virological breakthroughs was observed in patients receiving combination treatment (10% vs 46%, P = 0.01 and 14% vs 46%, P = 0.03, respectively). Time from initial virologic response to virologic breakthrough (VBR) was greater among initial responders receiving combination treatment compared to those receiving lamivudine (22.9 mo vs 15.9 mo, respectively; P = 0.005). Our results demonstrate that IFN-alpha plus lamivudine combination therapy did not increase the sustained response, compared to lamivudine. However, combination therapy reduces the likelihood of VBR due to YMDD mutants and prolongs the time period until the breakthrough development.

Does the addition of lamivudine to peginterferon α-2a sustain response rates in HBeAg-negative hepatitis B?

BACKGROUND HEPATITIS B e ANTIGEN (HBeAg)-NEGATIVE CHRONIC HEPATITIS B has a poor prognosis because sustained remission is hard to achieve with current treatments. The optimal therapy or combination of therapies for this condition has not been determined. OBJECTIVES To determine the efficacy and safety of peginterferon α-2a monotherapy, peg interferon α-2a in combination with lamivudine, and lamivudine monotherapy for the treatment of HBeAg-negative chronic hepatitis B.

Histologic activity of childhood chronic hepatitis B related to viremia levels, genotypes, mutations, and epidemiologic factors.

Despite high viral load, children with chronic hepatitis B virus (HBV) infection may lack significant biochemical signs of liver dysfunction. Failure to develop abnormal liver chemistriesis is probably due to immunologic hyporeactivity. Despite the absence of biochemical abnormalities in these patients, there is still a risk for long-term complications. The pathogenic importance of viral load and genetic variability is less well studied in children than in adults. We evaluated viremia levels, genotypes, and mutations related to histologic evidence of liver damage in 71 HBV carriers, aged 2 to 18 years, all of non-Swedish origin. None of the of 22 children who were hepatitis B e antigen (HBeAg) negative had severe liver disease or had HBV DNA levels greater than 10 copies/mL (mean 10 ); 3 (14%) of them had increased alanine aminotransferase (ALT). The 49 HBeAg-positive children had a mean HBV DNA level of 10 copies/mL, and increased ALT was seen in 28 (55%). Core promoter mutations (at nt 1764) or precore mutations (at codon 1, 2, or 28) were rare; they were seen in four and one HBeAg-positive children, and in four and nine HBeAg-negative children, respectively, without association to liver damage. C-1858 was associated with more liver inflammation. Genotype did not significantly influence liver damage. Children with horizontal transmission had a faster rate of seroconversion and more inflammation of the liver. Severe HBeAg-negative hepatitis with high HBV DNA levels and mutations in the core promoter or precore regions seems to be less common in children than in adults. C-1858 strains may be more pathogenic, but this requires further study. Epidemiologic factors influence the course of infection.

Influence of precore and core promoter mutations on disease course of chronic HBeAg-negative hepatitis

Influence of precore and core promoter mutations on disease course of chronic HBeAg-negative hepatitis

Outcome of patients with HBeAG negative hepatitis B awaiting liver transplantation (OLT) treated with lamivudine

Outcome of patients with HBeAG negative hepatitis B awaiting liver transplantation (OLT) treated with lamivudine

Outcome of patients with HBeAG negative hepatitis B awaiting liver transplantation (OLT) treated with lamivudine

Outcome of patients with HBeAG negative hepatitis B awaiting liver transplantation (OLT) treated with lamivudine

ALT normalization and loss of HBV DNA among HBeAG negative hepatitis B patients treated with lamivudine in a clinic setting

ALT normalization and loss of HBV DNA among HBeAG negative hepatitis B patients treated with lamivudine in a clinic setting

Reversion From Precore/Core Promoter Mutants to Wild-Type Hepatitis B Virus During the Course of Lamivudine Therapy

The effect of lamivudine administration on the evolution of precore/core promoter mutation is unknown. The aim of this study was to determine the changes of precore/core promoter sequences in chronic type B hepatitis patients treated with lamivudine. Serial sera were obtained from 11 patients before, at the beginning of, and during therapy. Serum samples were polymerase chain reaction-amplified, and nucleotide sequences of hepatitis B virus (HBV) were analyzed. At baseline, precore and core promoter mutations were found in 6 and 4 of 11 patients, respectively. A precore stop codon mutant was replaced by a wild-type virus in all 6 patients infected with precore mutant at a median treatment of 12 months (vs. before therapy; P = .011). Mutations in the core promoter appeared in only 1 of 10 patients (vs. before therapy; P = .021). However, precore and core promoter mutations appeared in 5 and 7 of 10 patients at a median treatment of 21 months, respectively. Acute exacerbation occurred after lamivudine withdrawal in 2 patients who had hepatitis B e antigen (HBeAg) loss or seroconversion. The serum remained HBeAg-negative throughout the study period, and each of 2 patients had precore wild-type virus during acute exacerbation. HBV mutants with core gene deletions are not eliminated completely during prolonged therapy in 2 patients in whom the HBV genomes had core gene deletions at baseline. In conclusion, lamivudine therapy resulted in reversion from precore/core promoter mutants to wild-type. However, mutations in the precore and core promoter region reappeared during prolonged therapy. HBeAg-negative wild-type precore hepatitis B virus could be selected after lamivudine withdrawal in patients who had HBeAg loss or seroconversion. (Hepatology 2000;32:1163-1169.)

Mutations of the core promoter and response to interferon treatment in chronic replicative hepatitis B

In chronic replicative hepatitis B the significance of mutations in the basic core promoter (BCP), core upstream regulatory sequences (CURS) and negative regulatory element (NRE) for response to interferon (IFN) is unknown. A sequence analysis of the NRE, CURS, BCP, and precore region was performed from sera of 96 patients with chronic replicative hepatitis B (64 hepatitis B e antigen [HBeAg]-positive patients and 32 HBeAg-negative patients) treated with alfa-IFN (IFN-alpha). The overall sustained response (SR) rate to IFN was 30% with no significant difference between HBeAg-positive and HBeAg-negative patients. IFN responsiveness correlated to hepatitis B virus (HBV)-DNA levels, hepatitis B surface antigen (HBsAg) levels, the number of mutations in the complete BCP, especially nucleotide (nt) region 1753 to 1766 and mutations at nt 1762 and 1764. In HBeAg-positive hepatitis, SR to IFN was associated with a high number of mutations in the BCP (P <.04) and nucleotide region 1753 to 1766 (P <.015) as well as mutations at nucleotide 1764 (P <.007). In HBeAg-negative hepatitis, SR to IFN correlated with a low number of mutations in the BCP (P <.04) and nucleotide region 1753 to 1766 (P <.02) and a wild-type sequence at nt 1764 (P <.003). Prediction of IFN response was possible on the basis of nt 1764 in 77% of HBeAg-positive patients and 78% of HBeAg-negative patients. IFN response did not correlate with the occurrence of the 1896 mutation, mutations in the CURS or NRE, disease duration, ethnic origin of the patient, alanine transaminase (ALT) levels and HBV genotype. Our data suggest that HBV genome mutations located within the BCP are determinants of a response to IFN therapy.

Changes in the prevalence of HBeAg-negative mutant hepatitis B virus during the course of chronic hepatitis B.

Hepatitis B virus with a G-to-A point mutation at nucleotide 83 in the precore region (mutant hepatitis B virus 83), which cannot produce HBeAg, is commonly found in HBe antibody-positive hepatitis B virus carriers. We analyzed the consecutive changes in the prevalence of mutant hepatitis B virus 83 during the course of chronic hepatitis B virus infection. Forty-five patients with chronic hepatitis B who were followed up for more than 2 yr in our hospital were studied by polymerase chain reaction in combination with a restriction fragment length polymorphism assay. Mutant hepatitis B virus 83 was found in 14 of 18 (78%) HBe antibody-positive patients and in 8 of 27 (30%) HBeAg-positive patients at baseline. Eighteen of the 22 patients who had mutant hepatitis B virus 83 (82%) showed mixed viral populations of wild-type hepatitis B virus and mutant hepatitis B virus 83, whereas 4 (18%) had only mutant hepatitis B virus 83 and were positive for HBe antibody. During a 2 yr follow-up period, mutant hepatitis B virus 83 was newly detected in 9 of 23 (39%) patients who had wild-type hepatitis B virus alone at baseline. The proportion of mutant hepatitis B virus 83 to whole hepatitis B virus in the serum of 18 patients with mixed viral populations at baseline fluctuated during follow-up. In contrast, wild-type hepatitis B virus was never detected throughout the study in all four patients who had only mutant hepatitis B virus 83 at baseline.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in the prevalence of HBeAg-negative mutant hepatitis B virus during the course of chronic hepatitis B

Hepatitis B virus with a G-to-A point mutation at nucleotide 83 in the precore region (mutant hepatitis B virus 83), which cannot produce HBeAg, is commonly found in HBe antibody-positive hepatitis B virus carriers. We analyzed the consecutive changes in the prevalence of mutant hepatitis B virus 83 during the course of chronic hepatitis B virus infection. Forty-five patients with chronic hepatitis B who were followed up for more than 2 yr in our hospital were studied by polymerase chain reaction in combination with a restriction fragment length polymorphism assay. Mutant hepatitis B virus 83 was found in 14 of 18 (78%) HBe antibody-positive patients and in 8 of 27 (30%) HBeAg-positive patients at baseline. Eighteen of the 22 patients who had mutant hepatitis B virus 83 (82%) showed mixed viral populations of wild-type hepatitis B virus and mutant hepatitis B virus 83, whereas 4 (18%) had only mutant hepatitis B virus 83 and were positive for HBe antibody. During a 2 yr follow-up period, mutant hepatitis B virus 83 was newly detected in 9 of 23 (39%) patients who had wild-type hepatitis B virus alone at baseline. The proportion of mutant hepatitis B virus 83 to whole hepatitis B virus in the serum of 18 patients with mixed viral populations at baseline fluctuated during follow-up. In contrast, wild-type hepatitis B virus was never detected throughout the study in all four patients who had only mutant hepatitis B virus 83 at baseline.(ABSTRACT TRUNCATED AT 250 WORDS)

Replication of a molecularly cloned HBeAg negative hepatitis B virus variant in transfected HepG2 cells.

Transient expression in a hepatoma cell line of an HBV variant with a defective pre-C region suggested its ability to undergo full replication cycles except for the lack of HBeAg synthesis.