Chi-Hang Tse

A longitudinal study on the natural history of serum hepatitis B surface antigen changes in chronic hepatitis B.

Serum hepatitis B surface antigen (HBsAg) quantification has been suggested to reflect the concentration of covalently closed circular DNA in the liver. We aimed to investigate the HBsAg levels at different stages of chronic hepatitis B and the changes in HBsAg level during the natural progression of disease. One hundred seventeen untreated patients with chronic hepatitis B were studied with longitudinal follow‐up for 99 ± 16 months. HBsAg quantification was performed at the first visit, the last visit, and three visits at each quartile during the follow‐up. At the first visit, HBsAg level was higher among patients who were hepatitis B e antigen (HBeAg)‐positive (N = 49) than those who were HBeAg‐negative (N = 68) (4.01 ± 0.91 log IU/mL versus 2.73 ± 1.25 log IU/mL, P < 0.001). HBsAg level was persistently high at approximately 5 log IU/mL among patients in the immune tolerance phase (N = 7). The HBsAg levels among patients with HBeAg‐positive active disease (N = 25) or sustained HBeAg seroconversion (N = 17) were comparable at approximately 3‐4 log IU/mL. The HBsAg levels among patients who were HBeAg‐negative tended to be higher among patients with active (N = 46) than those with inactive disease (N = 22). The median HBsAg levels decreased in HBeAg‐negative patients with active and inactive disease by 0.041 log IU/mL/year and 0.043 log IU/mL/year, respectively. Twenty‐two (17%) patients had HBsAg reduction >1 log IU/mL at the last visit; most of them showed reduced hepatitis B virus DNA, and eight had HBsAg loss. Conclusion: HBsAg remained stable in HBeAg‐positive patients and tended to reduce slowly in HBeAg‐negative patients. Reduction of HBsAg for >1 log IU/mL could reflect improved immune control. (HEPATOLOGY 2010)

Viral genotype and hepatitis B virus DNA levels are correlated with histological liver damage in HBeAg-negative chronic hepatitis B virus infection.

OBJECTIVES:We aimed to study the relationship between the hepatitis B virus (HBV) genotypes, core promoter/precore stop codon mutations, and histological liver damage among hepatitis B e antigen (HBeAg)-negative patients.METHODS:Liver biopsy specimens of 55 HBeAg-negative chronic HBV-infected patients were studied. A histological activity index was scored for degree of necroinflammation (HAI-NI) and fibrosis (HAI-F) as described by Knodell et al. HBV DNA was determined by a cross-linking assay and polymerase chain reaction (PCR) at the core promoter/precore region and the S region. PCR-positive samples were directly sequenced for core promoter and precore mutations and examined by restriction fragment length polymorphism for genotyping.RESULTS:Forty-one males and 14 females at a median age of 43 were studied. HBV DNA was detectable in 32 (58%) and 37 (67%) patients by the cross-linking assay and PCR, respectively, at the time of liver biopsy. The median (range) HAI-NI and HAI-F scores were 5 (1–10) and 2 (0–4), respectively. HBV DNA detectable by either the cross-linking assay or PCR was associated with a higher HAI-NI score. Eleven and 31 patients had genotypes B and C HBV, respectively. Genotype C HBV was associated with higher HAI-NI than genotype B HBV. Core promoter mutations and precore stop codon mutation were detected in 74% and 40% patients, respectively, but they were not associated with higher HAI-NI or HAI-F scores.CONCLUSIONS:Detectable HBV DNA and genotype C HBV, but not core promoter or precore stop codon mutations, are associated with more severe liver damage in HBeAg-negative patients.

Molecular Characterization of the Fecal Microbiota in Patients with Nonalcoholic Steatohepatitis - A Longitudinal Study

Background The human gut microbiota has profound influence on host metabolism and immunity. This study characterized the fecal microbiota in patients with nonalcoholic steatohepatitis (NASH). The relationship between microbiota changes and changes in hepatic steatosis was also studied. Methods Fecal microbiota of histology-proven NASH patients and healthy controls was analyzed by 16S ribosomal RNA pyrosequencing. NASH patients were from a previously reported randomized trial on probiotic treatment. Proton-magnetic resonance spectroscopy was performed to monitor changes in intrahepatic triglyceride content (IHTG). Results A total of 420,344 16S sequences with acceptable quality were obtained from 16 NASH patients and 22 controls. NASH patients had lower fecal abundance of Faecalibacterium and Anaerosporobacter but higher abundance of Parabacteroides and Allisonella. Partial least-square discriminant analysis yielded a model of 10 genera that discriminated NASH patients from controls. At month 6, 6 of 7 patients in the probiotic group and 4 of 9 patients in the usual care group had improvement in IHTG (P = 0.15). Improvement in IHTG was associated with a reduction in the abundance of Firmicutes (R2 = 0.4820, P = 0.0028) and increase in Bacteroidetes (R2 = 0.4366, P = 0.0053). This was accompanied by corresponding changes at the class, order and genus levels. In contrast, bacterial biodiversity did not differ between NASH patients and controls, and did not change with probiotic treatment. Conclusions NASH patients have fecal dysbiosis, and changes in microbiota correlate with improvement in hepatic steatosis. Further studies are required to investigate the mechanism underlying the interaction between gut microbes and the liver.

Durability of peginterferon alfa‐2b treatment at 5 years in patients with hepatitis B e antigen–positive chronic hepatitis B

Approximately 30%‐40% of patients with hepatitis B e antigen (HBeAg)‐positive chronic hepatitis B treated with peginterferon and/or lamivudine achieve HBeAg seroconversion 6 months after the end of treatment. The durability and long‐term effect of treatment are unknown. In this study, 85 HBeAg‐positive patients who received peginterferon alfa‐2b 1.5 μg/kg/week for 32 weeks and lamivudine 100 mg/day for 52 or 104 weeks were prospectively followed for 6.1 ± 1.7 years posttreatment. Twenty‐five (29%) patients had virologic response (HBeAg seroconversion and HBV DNA <10,000 copies/mL) at 5 years. The rate of HBeAg seroconversion rose progressively from 37% at the end of treatment to 60% at 5 years. Twenty‐seven (32%) and 11 (13%) patients had undetectable HBV DNA (<100 copies/mL) at the end of peginterferon treatment and at 5 years, respectively. Two (2.4%) patients achieved hepatitis B surface antigen (HBsAg) seroclearance at 2.6 and 84 months posttreatment. Among virologic responders at the end of treatment, 82% and 57% and sustained HBeAg seroconversion and virologic response at 5 years. End‐of‐treatment serum quantitative HBsAg was significantly lower in patients with sustained virologic response at 5 years (median 1,431 IU/mL versus 2,689 IU/mL [P = 0.041]). At the last follow‐up, the liver stiffness measurement by transient elastography was 5.8 ± 2.7 kPa. Only two patients had liver stiffness suggestive of advanced fibrosis. Week 16 HBV DNA, end‐of‐treatment HBeAg seroconversion, and undetectable HBV DNA were independent factors associated with virologic response at 5 years. The duration of concomitant lamivudine treatment had no impact on any long‐term response. Conclusion: Peginterferon has high durability in HBeAg‐positive chronic hepatitis B patients with end‐of‐treatment virologic response. (Hepatology 2010;)

Viral Determinants of Hepatitis B Surface Antigen Seroclearance in Hepatitis B e Antigen-Negative Chronic Hepatitis B Patients

BACKGROUND We studied whether quantification of serum HBsAg and HBV DNA levels could predict spontaneous HBsAg clearance in patients with negative hepatitis B e antigen (HBeAg). METHODS Serum HBsAg and HBV DNA levels were measured at baseline among a longitudinal cohort of 103 HBeAg-negative patients recruited since 1997. RESULTS Twelve (12%) patients developed HBsAg seroclearance after 88 ± 26 months (range, 21-139) of follow-up. At baseline, the serum HBsAg level among patients who cleared HBsAg (1.30 ± 1.27 log IU/mL) was significantly lower than those who did not clear HBsAg (2.96 ± 0.84 log IU/mL; P < .001). The area under receiver operating characteristics (ROC) curve for serum HBsAg to predict HBsAg seroclearance was 0.90 (95% confidence interval [CI], 0.83-0.97; P < .001). Nine (75%) of 12 patients who had HBsAg seroclearance versus 8 (9%) of 91 who remained HBsAg-positive had serum HBsAg ≤100 IU/mL at the baseline (P < .001). An HBsAg cutoff of ≤100 IU/mL had 75% sensitivity and 91% specificity to predict HBsAg seroclearance. Baseline serum HBV DNA could not predict HBsAg seroclearance; the area under ROC curve was 0.64 (95% CI, 0.46-0.81; P = .13). CONCLUSIONS Single-point serum HBsAg level can predict the chance of HBsAg seroclearance in chronic hepatitis B patients with negative HBeAg.

Occult HBV infection in cryptogenic liver cirrhosis in an area with high prevalence of HBV infection

OBJECTIVES:Hepatitis B surface antigen (HBsAg) is often used as the serological marker to screen for hepatitis B virus (HBV) infection in the investigation of liver cirrhosis. In Hong Kong, where HBV infection is endemic, some patients may have persistent viral infection after the loss of HBsAg. We aimed to investigate 1) the prevalence of occult HBV infection in cryptogenic liver cirrhosis in Hong Kong and 2) the role of HBV “a” determinant mutations among these patients.METHODS:Twenty-eight patients with cryptogenic liver cirrhosis (group I), 49 subjects with no liver disease (group II), and 26 patients with HBV-related cirrhosis (group III) were studied. HBV DNA was determined by the cross-linking assay (sensitivity = 0.5 mEq/ml) and polymerase chain reaction (PCR). Occult HBV infection was defined as HBV DNA detectable by PCR among patients with negative HBsAg.RESULTS:Eighty-nine percent and 92% of patients in groups I and II, respectively, had positive anti-HBs and/or anti-hepatitis B core. Nine (32%), no (0%), and 14 (54%) patients in groups I, II, and III, respectively, had detectable HBV DNA by PCR (group I vs group II, p < 0.001; group I vs group III, p = 0.36). Four patients in group I had HBV DNA detectable by the cross-linking assay (median = 5.98 mEq/ml, range = 3.1–8.01). “a” determinant mutations were detected in two patients in group I (K122N and G145R, C125A) and one patient in group II (I126N).CONCLUSIONS:Occult HBV infection is common among patients with cryptogenic liver cirrhosis, and it cannot be explained by mutations in the HBV “a” determinant.

On-treatment alpha-fetoprotein is a specific tumor marker for hepatocellular carcinoma in patients with chronic hepatitis B receiving entecavir.

Alpha‐fetoprotein (AFP) is the most widely used biomarker for hepatocellular carcinoma (HCC) surveillance, which is criticized as neither sensitive nor specific in active hepatitis and liver cirrhosis. The aim of this study was to determine the performance of AFP as a tumor marker for HCC in entecavir‐treated patients with chronic hepatitis B (CHB). This was a retrospective‐prospective cohort study of 1,531 entecavir‐treated patients under regular HCC surveillance with AFP and ultrasonography. Mean age was 52 ± 12 years; 1,099 (72%) patients were male and 332 (21.7%) had clinical evidence of cirrhosis. At a mean follow‐up of 51 ± 13 months, 57 (2.9%) patients developed HCC (median size: 3.3 cm). AFP fluctuated with alanine aminotransferase (ALT) and peaked at the time of starting entecavir, then gradually decreased after. AFP started to increase 6 months before the diagnosis of HCC. The receiver operator characteristic curve (AUROC) of AFP was highest at the time of HCC diagnosis (0.85; 95% confidence interval [CI]: 0.73‐0.98) and remained satisfactory at 3 (0.82; 95% CI: 0.73‐0.91) and 6 months (0.79; 95% CI: 0.69‐0.89) before the diagnosis. Using the conventional AFP cut‐off (20 μg/L) at month 0, the sensitivity and specificity to diagnose HCC were 38.6% and 98.9%, respectively. Adopting the lower cut‐off value (6 μg/L) of AFP level at month 0, sensitivity was increased to 80.7%, whereas specificity was decreased to 80.4%. Conclusion: On‐treatment AFP is a specific tumor marker for HCC in CHB patients receiving entecavir therapy. Adopting a lower cut‐off value of AFP level at 6 μg/L would significantly increase the sensitivity for HCC detection. (Hepatology 2014;59:986–995)

Relationship of clinical and virological factors with hepatitis activity in hepatitis B e antigen-negative chronic hepatitis B virus-infected patients.

To investigate the factors associated with active disease among hepatitis B surface antigen (HBsAg) positive/hepatitis B e antigen (HBeAg)‐negative chronic hepatitis B virus (HBV) infection we studied chronic HBV infected patients who had undetectable HBeAg at the first visit. HBV DNA was determined by the cross‐linking assay (NAXCOR) and polymerase chain reaction (PCR). Mutations in the core promoter and precore regions and viral genotypes were studied. Clinical outcome of these patients were followed and categorized as: (i) relapse (ALT > 200 IU/L or three times the previous levels); (ii) active hepatitis (elevated ALT < 200 IU/L with concomitant detectable HBV DNA); or (iii) remission. A total of eighty‐five patients were followed up for 5.5 ± 1.0 years. At first visit, 31 (36.5%) patients had elevated ALT levels, 12 (14.1%) had measurable HBV DNA by the cross‐linking assay and 26 (30.6%) by PCR. Sixteen (18.8%) patients had hepatitis relapse, 13 (15.3%) had active hepatitis, and 56 (65.9%) remained in remission. Core promoter and precore stop codon mutants were found in 27 and 12 patients, respectively. Eleven and 20 had genotype B and C HBV, respectively. Initial elevated ALT and detectable HBV DNA were associated with active liver disease. Patient demographics, viral mutants or genotypes failed to predict disease activity. Hence, serum ALT and HBV DNA levels offer the best prediction of natural course of HBeAg‐negative chronic HBV infection.

Prevalence of the TM6SF2 variant and non-alcoholic fatty liver disease in Chinese

To the Editor: Non-alcoholic fatty liver disease (NAFLD) is currently the most common chronic liver disease worldwide and may progress to cirrhosis and hepatocellular carcinoma [1–3]. A recent exomewide association study identified the TM6SF2 variant (encoding p.Glu167Lys) as a novel locus associated with higher liver fat level [4]. The variant is associated with decreased hepatic secretion of very-low-density lipoprotein and higher risk of myocardial infarction [4,5]. Since Asians were underrepresented in the exome-wide association studies [4,5], here we report the prevalence of the TM6SF2 variant in a well-characterized Chinese cohort. In the HK-MRS Study, 922 randomly selected community subjects underwent non-invasive assessment of liver fat and fibrosis by protonmagnetic resonance spectroscopy and transient elastography, respectively [3]. All subjects were ethnic Chinese. Genotyping was performed using a TaqMan assay (dbSNP rs58542926; Applied Biosystems, C_89463510_10) in 920 subjects with adequate blood samples. Overall, the TM6SF2 variant was detected in 4 subjects (0.4%, 95% CI 0–0.9%). Subjects carrying the variant had significantly lower total cholesterol and low density lipoprotein-cholesterol levels than those without (Table 1). None of them were taking lipid-lowering drugs at the time of assessment. Though limited

Genotype B hepatitis B virus is associated with severe icteric flare-up of chronic hepatitis B virus infection in Hong Kong

OBJECTIVE:We aimed to investigate the association of viral genotype and the development of icteric flare-up (IF) in chronic hepatitis B virus (HBV) infection.METHODS:Twenty-one consecutive patients suffering from IF of chronic HBV infection, defined as elevation of ALT over five times the upper limit of normal, together with either bilirubin >50 IU/L or elevated bilirubin plus PT >3 s prolonged, were studied. Patients from three stages of HBV-related chronic liver disease were studied as controls: 1) asymptomatic carriers (31 patients), defined as persistent normal ALT for at least 2 yr; 2) active early cirrhosis (49 patients), defined as Childs A liver cirrhosis plus HBV DNA >106 Eq/ml; and 3) decompensated cirrhosis (31 patients), defined as Childs B or C liver cirrhosis with complications. Restriction fragment length polymorphism was used for genotyping.RESULTS:Only genotype B and C HBV were identified in our studied cohort. Ninety-one percent of patients suffering from IF were infected by genotype B HBV (p <0.001vs asymptomatic carriers, early cirrhosis patients, and decompensated cirrhosis patients). On the contrary, genotype C HBV was the predominant strain at different stages of chronic liver disease; no statistical difference was found on the relative prevalence of genotype B/C HBV among asymptomatic carriers, early cirrhosis patients, and decompensated cirrhosis patients.CONCLUSIONS:Genotype B HBV is associated with IF among chronic HBV-infected patients in Hong Kong, whereas genotype C HBV is more prevalent at all stages of chronic liver disease. Our findings suggested that the two different HBV genotypes might have different pathogenic mechanisms of liver damage.