J. van Hattum

Relation between laboratory test results and histological hepatitis activity in individuals positive for hepatitis B surface antigen and antibodies to hepatitis B e antigen

BACKGROUND Hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B e antigen (anti-HBe) commonly coexist, and laboratory tests are often requested to assess histological hepatitis activity. An optimum panel of tests has not been found and the usefulness of hepatitis B virus (HBV) DNA assays in this context has not been established. We assessed various blood tests to find which best predicted hepatitis activity. METHODS Routine plasma biochemical liver tests and serum HBV DNA (hybridisation and PCR assays) were assessed prospectively in 123 patients positive for HBsAg and anti-HBe. We scored histological hepatitis activity (hepatitis activity index) and determined whether chronic active hepatitis (chronic hepatitis with portal and periportal lesions) was present. We analysed the relation between laboratory data and the hepatitis activity index or risk of chronic active hepatitis by multiple regression and multiple logistic regression, respectively. FINDINGS The analyses provided models for predicting either the hepatitis activity index or the risk of chronic active hepatitis. Aspartate aminotransferase was the most important test in the two models. The contribution of HBV DNA and other assays, especially alanine-aminotransferase activity, were of no practical importance. INTERPRETATION Because screening by aspartate-aminotransferase activity could not be improved by the addition of other assays or HBV DNA, patients positive for HBsAg and anti-HBe could be screened for chronic active hepatitis with a single assay and counselling of patients can be improved if proper reference values are used.

A prospective study of in vitro anti-HBs producing B cells (spot-ELISA) following primary and supplementary vaccination with a recombinant hepatitis B vaccine in insulin dependent diabetic patients and matched controls.

A prospective study of the immune response after hepatitis B vaccination was carried out in 32 insulin dependent diabetes mellitus (IDDM) patients and their age and sex matched healthy controls. A sensitive, immunoenzymatic technique was used, able to detect in vitro specific antibody production by mitogen stimulated individual B cells.

Immunogencity of two versus three injections of inactivated hepatitis A vaccine in adults

AIM To investigate the immunogenicity of two versus three injections of inactivated strain CR326F-derived hepatitis A vaccine in healthy adults. METHODS Healthy adult volunteers (n = 105) at Utrecht University Hospital, The Netherlands, were randomly assigned to receive intramuscular injections (deltoid muscle) of 25 Units (U) at 0 and 6 months (group A, n = 53), or at 0, 2 and 6 months (group B, n = 52). Blood was drawn before and at various time points after vaccination for determination of serum antibody to hepatitis A (anti-HAV). RESULTS One month after the first injection, the seroconversion rates (> or = 10 mIU/ml, international units) were 88% for group A and 90% for group B. Only 2/ 103 (one in each group) showed IgM anti-HAV. One month after the second injection, seroconversion rates were 100% in both groups. At months 3, 6 and 7, anti-HAV geometric mean titers were significantly different because of the different vaccination schedules, but they were similar at months 1, 2 and 12. The anti-HAV geometric mean titer increase after the second injection was higher when the interval between the two doses was of longer duration. Anti-HAV titers of females were significantly higher than those of males and vaccinees < or = 30 years had higher titers than those > 30 years. CONCLUSIONS Two 25 U doses of the vaccine investigated given at 0 and 6 months, induce adequate anti-HAV titers in all adult healthy vaccinees and are as immunogenic as three doses given at 0, 2 and 6 months.

A survey of liver pathology in needle biopsies from HBsAg and anti-HBe positive individuals

Aims—To use laboratory data and liver biopsies, prospectively obtained from hepatitis B surface antigen (HBsAg) and anti hepatitis B e antigen (anti-HBe) positive patients, for the assessment of: (1) the relation between biopsy length/number of portal tracts and sampling error; (2) the relation between the severity of piecemeal necrosis and the new grading terminology (minimal, mild, moderate, and severe chronic hepatitis); and (3) liver pathology, which has not been studied in patients with this specific serological profile. Methods—The study group (n = 174) included 104 patients with normal aminotransferase concentrations and no cases with clinically apparent cirrhosis. The specimen length and number of portal tracts were measured at light microscopy examination. Sampling error analysis was related to the discrepancies between aminotransferase concentrations versus histological grade. Detailed histological scorings were undertaken by the reference pathologist and compared with laboratory and hepatitis B virus (HBV) DNA precore sequence data. Results—Sampling error seemed to be a constant feature, even for biopsies ≥ 20 mm, but increased dramatically in biopsies < 5 mm long and/or containing less than four portal tracts. Between 25% and 30% of biopsies, graded as “mild” or “moderate” activity showed features of moderate and severe piecemeal necrosis, respectively. Ten per cent of the patients with normal aminotransferase values had stage III–IV hepatic fibrosis, and 20% had piecemeal necrosis. Only cytoplasmic, not nuclear, core antigen expression was a strong predictor of high hepatitis B viraemia. There was no association between precore stop codon mutations, grade/stage of liver disease, and hepatitis B core antigen (HBcAg) expression. Conclusions—The specimen available for light microscopical examination should be > 5 mm long and should contain more than four portal tracts. In addition, the new grading terminology might give the clinician an inappropriately mild impression of the severity of piecemeal necrosis. Furthermore, even in the presence of normal aminotransferase concentrations, considerable liver pathology can be found in 10–20% of HBsAg and anti-HBe positive individuals; such pathology is not associated with the occurrence of precore stop codon mutations.

GB Virus Type C Viremia and Envelope Antibodies among Population Subsets in The Netherlands

Background and Objectives: Two new flaviviruses, hepatitis G virus and GB virus type C (GBV–C), are possible causative agents for non–A–E hepatitis. In this study we established the prevalence of GBV–C markers in various population subsets in The Netherlands by assays for GBV–C antibodies and GBV–C nucleic acid. Materials and Methods: We tested specimens from groups of patients with hepatitis of various causes, intravenous drug users (IVDUs), and blood donors for GBV–C RNA (LCx® GBV–C assay, Abbott Laboratories), and for antibodies to the GBV–C envelope E2 protein (GBV–C anti–E2) with an enzyme immunoassay (Abbott Laboratories). Patients and donors were represented in one group only. Results: GBV–C RNA and GBV–C anti–E2 prevalence were, respectively, 2/34 (6%) and 3/34 (9%) among patients with non–A–E hepatitis, 2/10 (20%) and 0/10 (0%) among hepatitis B virus patients, 10/40 (25%) and 19/40 (48%) among hepatitis C virus (HCV) patients, 1/8 (13%) and 0/8 (0%) among patients with autoimmune hepatitis (AIH), 24/102 (24%) and 72/102 (71%) among IVDUs, 1/34 (3%) and 2/34 (6%) among blood donors with indeterminate anti–HCV recombinant immunoblot assay reactivity, and 3/250 (1.2%) and 8/250 (3.2%) among first–time blood donors. The profile of simultaneous GBV–C RNA positivity plus GBV–C anti–E2 positivity was found in 2/40 (5%) HCV patients, 4/102 (4%) IVDUs, and 1/250 (0.4%) first time blood donors. Conclusion: GBV–C infection appears not to be a major cause of non–A–E hepatitis and AIH, but is associated with parenteral risk. The prevalence of GBV–C viremia in first time blood donors is higher than that of HCV (1.2 vs. 0.04%), but GBV–C viremia in IVDUs is lower than HCV (24 vs. 59%). Most IVDUs have probably previously been exposed to GBV–C given the very high prevalence of GBV–C anti–E2 (71%). Most persons with GBV–C markers are GBV–C RNA–negative and anti–E2–confirmed positive, suggesting that GBV–C infection is transient.

Co-occurrence of HBsAg and heterotypic anti-HBs

Co-occurrence of HBsAg and anti-HBs is said to be rare and is usually explained by assuming two consecutive infections with incomplete immunity following the first infection. In order to determine the frequency of co-occurrence of HBsAg and anti-HBs and to validate the two-infection hypothesis, a group of 89 Dutch patients of North-European local race with HBsAg(+) biopsy-documented chronic hepatitis were tested for the presence ofanti-HBs and risk factors for hepatitis B. HBsAg and anti-HBs were determined using radio immuno assay (AUS.RIA II, AUSAB); subtyping was also done with RIA after neutralization with a panel of specific antigen or antibody subtypes according to the method of Hoofnagle et al. (1977). Anti-HBs was found in 32 patients (36 %). In 19 out of 25 patients with a reliable subtyping of HBsAg and anti-HBs, the co-occurrence of HBsAg/ad and antiy was found; the combination HBsAg/ay and anti-d was present in one patient; the other 5 patients exhibited complex patterns of antibody. Comparison between anti-HBs(+) and anti-HBs(-) patients revealed no differences in various categories of risk factors for hepatitis B infection (transfusion, medical profession, homosexual contacts, drug abuse, etc.) but a significant correlation was found between the prevalence of anti-HBs and the histologic progression of the liver disease (antiHBs positivity in carriers: 3/23; CPH : 4/20; CAH :20/41 ; cirrhosis: 5/5). Thus, co-occurrence of HBsAg and anti-HBs is not rare, but its frequency depends on the histologic stage of the liver disease. No support could be found for the two-infection hypothesis. We, therefore, believe that d and y antigens are present on HBsAg-bearing proteins and that one or the other of these subdeterminants is hidden in HBsAg-bearing particles dependent on the virus strain. The masked subdeterminant becomes antigenic after degradation of liver cells in advanced disease.