Xiaomin Yan

Soluble CD40 ligand-activated human peripheral B cells as surrogated antigen presenting cells: A preliminary approach for anti-HBV immunotherapy

BackgroundWe aimed to clarify whether soluble CD40 ligand (sCD40L) activated B cells may be loaded with HBcAg18-27 peptide and served as antigen-producing cells (APCs) to induce HBV-specific cytolytic T lymphocytes (CTLs).ResultsHuman B cells could be cultured in the presence of sCD40L up to 54 days, and the proportion of B cells in the S phase increased from 0% to 8.34% in the culture. The expression of CD80, CD86, major histocompatibility complex (MHC) classes I and II molecules on the sCD40L-activated B cell was significantly increased after long-time culture. Cytometry and fluorescence microscopy showed that more than 98% sCD40L-activated B cells were loaded by the HBcAg peptide. Furthermore, the peptide-pulsed activated B cells could induce HBcAg18-27 specific CTLs.ConclusionsOur results demonstrate that sCD40L-activated B cells may function as APCs and induce HBV-specific CTLs.

Gamma-glutamyl-transpeptidase to platelet ratio is not superior to APRI,FIB-4 and RPR for diagnosing liver fibrosis in CHB patients in China

The gamma-glutamyl transpeptidase to platelet ratio (GPR) is a novel index to estimate liver fibrosis in chronic hepatitis B (CHB). Few studies compared diagnostic accuracy of GPR with other non-invasive fibrosis tests based on blood parameters. We analyzed diagnostic values of GPR for detecting liver fibrosis and compared diagnostic performances of GPR with APRI (aspartate aminotransferase-to-platelet ratio index), FIB-4 (fibrosis index based on the four factors), NLR (neutrophil-to-lymphocyte ratio), AAR (aspartate aminotransferase/alanine aminotransferase ratio) and RPR (red cell distribution width-to-platelet ratio) in HBeAg positive CHB and HBeAg negative CHB. We found AUROCs of GPR in predicting significant liver fibrosis, advanced liver fibrosis and liver cirrhosis were 0.732 (95% CI 0.663 to 0.801), 0.788 (95% CI 0.729 to 0.847) and 0.753 (95% CI 0.692 to 0.814), respectively. Further comparisons showed the diagnostic performance of GPR was not significantly different with APRI, FIB-4 and RPR in identifying significant fibrosis, advanced fibrosis and cirrhosis, but it was significantly superior to AAR and NLR in both HBeAg positive CHB and HBeAg negative CHB. In conclusion, GPR does not show advantages than APRI, FIB-4 and RPR in identifying significant liver fibrosis, advanced liver fibrosis and liver cirrhosis in both HBeAg positive CHB and HBeAg negative CHB in China.

A scoring model for predicting prognosis of patients with severe fever with thrombocytopenia syndrome

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging epidemic infectious disease caused by the SFTS bunyavirus (SFTSV) with an estimated high case-fatality rate of 12.7% to 32.6%. Currently, the disease has been reported in mainland China, Japan, Korea, and the United States. At present, there is no specific antiviral therapy for SFTSV infection. Considering the higher mortality rate and rapid clinical progress of SFTS, supporting the appropriate treatment in time to SFTS patients is critical. Therefore, it is very important for clinicians to predict these SFTS cases who are more likely to have a poor prognosis or even more likely to decease. In the present study, we established a simple and feasible model for assessing the severity and predicting the prognosis of SFTS patients with high sensitivity and specificity. This model may aid the physicians to immediately initiate prompt treatment to block the rapid development of the illness and reduce the fatality of SFTS patients.

A novel predictive model using routinely clinical parameters to predict liver fibrosis in patients with chronic hepatitis B

Objectives Noninvasive models have been established for the assessment of liver fibrosis in patients with chronic hepatitis B(CHB). However, the predictive performance of these established models remains inconclusive. We aimed to develop a novel predictive model for liver fibrosis in CHB based on routinely clinical parameters. Results Platelets(PLT), the standard deviation of red blood cell distribution width(RDW-SD), alkaline phosphatase(ALP) and globulin were independent predictors of significant fibrosis by multivariable analysis. Based on these parameters, a new predictive model namely APRG(ALP/PLT/RDW-SD/globulin) was proposed. The areas under the receiver-operating characteristic curves(AUROCs) of APRG index in predicting significant fibrosis(≥F2), advanced fibrosis(≥F3) and liver cirrhosis(≥F4) were 0.757(95%CI 0.699 to 0.816), 0.763(95%CI 0.711 to 0.816) and 0.781(95%CI 0.728 to 0.835), respectively. The AUROCs of the APRG were significantly higher than that of aspartate transaminase(AST) to PLT ratio index(APRI), RDW to PLT ratio(RPR) and AST to alanine aminotransferase ratio(AAR) to predict significant fibrosis, advanced fibrosis and cirrhosis. The AUROCs of the APRG were also significantly higher than fibrosis-4 score (FIB-4) (0.723, 95%CI 0.663 to 0.783) for cirrhosis(P=0.034) and better than gamma-glutamyl transpeptidase(GGT) to PLT ratio(GPR) (0.657, 95%CI 0.590 to 0.724) for significant fibrosis(P=0.001). Materials and Methods 308 CHB patients who underwent liver biopsy were enrolled. The diagnostic values of the APRG for liver fibrosis with other noninvasive models were compared. Conclusions The APRG has a better diagnostic value than conventionally predictive models to assess liver fibrosis in CHB patients. The application of APRG may reduce the need for liver biopsy in CHB patients in clinical practice.OBJECTIVES Noninvasive models have been established for the assessment of liver fibrosis in patients with chronic hepatitis B(CHB). However, the predictive performance of these established models remains inconclusive. We aimed to develop a novel predictive model for liver fibrosis in CHB based on routinely clinical parameters. RESULTS Platelets(PLT), the standard deviation of red blood cell distribution width(RDW-SD), alkaline phosphatase(ALP) and globulin were independent predictors of significant fibrosis by multivariable analysis. Based on these parameters, a new predictive model namely APRG(ALP/PLT/RDW-SD/globulin) was proposed. The areas under the receiver-operating characteristic curves(AUROCs) of APRG index in predicting significant fibrosis(≥F2), advanced fibrosis(≥F3) and liver cirrhosis(≥F4) were 0.757(95%CI 0.699 to 0.816), 0.763(95%CI 0.711 to 0.816) and 0.781(95%CI 0.728 to 0.835), respectively. The AUROCs of the APRG were significantly higher than that of aspartate transaminase(AST) to PLT ratio index(APRI), RDW to PLT ratio(RPR) and AST to alanine aminotransferase ratio(AAR) to predict significant fibrosis, advanced fibrosis and cirrhosis. The AUROCs of the APRG were also significantly higher than fibrosis-4 score (FIB-4) (0.723, 95%CI 0.663 to 0.783) for cirrhosis(P=0.034) and better than gamma-glutamyl transpeptidase(GGT) to PLT ratio(GPR) (0.657, 95%CI 0.590 to 0.724) for significant fibrosis(P=0.001). MATERIALS AND METHODS 308 CHB patients who underwent liver biopsy were enrolled. The diagnostic values of the APRG for liver fibrosis with other noninvasive models were compared. CONCLUSIONS The APRG has a better diagnostic value than conventionally predictive models to assess liver fibrosis in CHB patients. The application of APRG may reduce the need for liver biopsy in CHB patients in clinical practice.

Association of serum gamma-glutamyl transferase with treatment outcome in chronic hepatitis B patients.

AIM To investigate the association of serum gamma-glutamyl transferase (GGT) levels with chronic hepatitis B infection and hepatitis B e antigen (HBeAg) seroconversion. METHODS A retrospective study was performed on clinical data collected from patients who had been positive for hepatitis B surface antigen for > 6 mo and who were antiviral-treatment naïve (n = 215) attending the Hepatitis Clinic at Nanjing Drum Tower Hospital between August 2010 and December 2013. Healthy individuals without liver disease (n = 83) were included as controls. Patients were categorized into four groups based on disease status as recommended by the European Association for the Study of the Liver: immune tolerance (IT; n = 47), HBeAg-positive hepatitis (EPH; n = 93), HBeAg-negative hepatitis (ENH; n = 20), and inactive carrier (IC; n = 55). Prediction of complete response (CR) based on serum GGT was also examined in EPH patients (n = 33) treated for 48 wk with nucleos(t)ide analogue (NA) therapy, including lamivudine plus adefovir combination therapy (n = 20) or entecavir monotherapy (n = 13). CR was defined as a serum hepatitis B virus DNA level < 500 copies/mL and HBeAg seroconversion by 48 wk of treatment. RESULTS Serum GGT levels were significantly increased in EPH and ENH patients relative to the IT, IC, and healthy control groups (P < 0.01 for all). However, no significant difference in serum GGT levels was found between the EPH and ENH groups. Baseline serum GGT levels were significantly higher in patients who achieved CR (7/33; 21.2%) compared to patients in the non-CR group (26/33; 78.8%; P = 0.011). In addition, the decline in serum GGT was greater in CR patients compared to non-CR patients after 24 wk and 48 wk of treatment (P = 0.012 and P = 0.008, respectively). The receiver operating characteristic curve yielded a sensitivity of 85.71% and a specificity of 61.54% at a threshold value of 0.89 times the upper limit of normal for baseline serum GGT in the prediction of CR following NA therapy. CONCLUSION Serum GGT is significantly elevated in EPH and ENH patients and is a potential biomarker for the prediction of HBeAg seroconversion following NA therapy.

Emodin Alleviates Liver Fibrosis of Mice by Reducing Infiltration of Gr1hi Monocytes

Emodin, as a major active component of Rheum palmatum L. and Polygonum cuspidatum, has been reported to have antifibrotic effect. However, the mechanism of emodin on antifibrotic effect for liver fibrosis was still obscure. In the present study, we aimed to investigate whether emodin can alleviate carbon tetrachloride- (CCl4-) induced liver fibrosis through reducing infiltration of Gr1hi monocytes. Liver fibrosis was induced by intraperitoneal CCl4 injection in mice. Mice in the emodin group received emodin treatment by gavage. Pretreatment with emodin significantly protected mice from liver inflammation and fibrosis revealed by the decreased elevation of serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST), as well as reduced hepatic necrosis and fibrosis by analysis of hematoxylin-eosin (HE) staining, Masson staining, α-smooth muscle actin (α-SMA), and collagen-I immunohistochemistry staining. Further, compared to CCl4 group, mice in the emodin group showed significantly less intrahepatic infiltration of Gr1hi monocytes. Moreover, emodin significantly inhibited hepatic expression of interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), transforming growth factor-β1 (TGF-β1), granulin (GRN), monocyte chemoattractant protein 1 (MCP-1), and chemokine ligand 7 (CCL7), which was in line with the decreased numbers of intrahepatic Gr1hi monocytes. In conclusion, emodin can alleviate the degree of liver fibrosis by reducing infiltration of Gr1hi monocytes. These results suggest that emodin is a promising candidate to prevent and treat liver fibrosis.

Letter: lipid‐lowering effect of tenofovir disoproxil fumarate in chronic hepatitis B—more evidence is needed

and the stressors in Cuba have evolved as well. We know from murine models that chronic psychological stress can disrupt the composition of colonic microbiota and accelerate intestinal inflammation in pre-disposed mice (ie, knockout mice). However, while some studies find a relationship between stress and self-reported disease activity, a direct association between stress and the onset of inflammatory bowel disease is less clear. We agree with the authors that this remains an important area of research to pursue. We hope our future studies in this patient population will be able to answer these insightful questions.

Letter: need to re-evaluate non-invasive markers for staging fibrosis in chronic delta hepatitis

SIRS, We read with great interest the article by Takyar et al. In this study, they evaluated the utility of serum fibrosis markers, including fibrosis-4 score (FIB-4), aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio, aspartate aminotransferase ratio (AAR), age-platelet index (API), AST-toplatelet-ratioindex (APRI) and Hui score for staging liver fibrosis in hepatitis delta virus (HDV) infection and they also compared these non-invasive fibrosis biomarkers across hepatitis B virus (HBV), hepatitis C virus (HCV) and HDV infection. They found that serum fibrosis markers had lower performance accuracy in chronic HDV-infected patients compared to HBV and HCV patients. They also found that FIB-4 performed better than APRI in identifying advanced liver fibrosis (Ishak ≥ 4) and cirrhosis (Ishak = 6) in chronic HBV infection. We appreciated the efforts made by the authors to compare these non-invasive fibrosis biomarkers for staging fibrosis in HBV, HCV and HDV infection. However, several issues deserve further discussion. Firstly, most of the non-invasive fibrosis biomarkers in the study included platelets (four of five biomarkers) as the component. Nevertheless, platelets may also be affected by many factors such as infections, chronic inflammatory diseases, some haematological disorders and drug use. Therefore, when evaluating these noninvasive biomarkers that may affect the components of the non-invasive fibrosis biomarkers particular comorbidities need to be taken into consideration. However, the authors only excluded the patients with co-existing non-viral hepatitis liver diseases. The patients were not evaluated for the existence of comorbidities such as infections, chronic inflammatory diseases, haematological disorders or drug use, which might have affected the results. Secondly, in the study, chronic HBV infection was defined as presence of hepatitis B surface antigen (HBsAg) in serum at time of liver biopsy and positive staining for HBsAg or HBcAg in hepatocytes. However, according to current guidelines, 7 chronic HBV infection is defined as HBsAg seropositive status at 6 months or beyond. Thus, acute HBV infection might have been included in the study according to their criteria. Thirdly, FIB-4 performed the best across all chronic viral hepatitis cohorts in detecting advanced fibrosis and cirrhosis in the study by Takyar et al. However, FIB-4 is not recommended in WHO guidelines because it has been developed and validated for the detection of fibrosis stages ≥F3 but not cirrhosis. Instead, APRI is recommended as the most cost-effective non-invasive test to assess liver fibrosis in chronic HBV infection. Thus, the superiority of FIB-4 to assess liver fibrosis deserves further investigation. Finally, as the authors mentioned, only a relatively small number of patients with HDV infection (n = 62) were included in the study. Lack of a validation cohort was another weakness. Thus, large-scale research with well-defined inclusion and exclusion criteria is required to re-evaluate the utility of serum non-invasive fibrosis markers in patients with chronic viral hepatitis, especially in HDV infection. Furthermore, we believe that better results could be achieved using a combination of non-invasive fibrosis markers in HDV infection.

Letter: the potential risk of HBV reactivation in patients with resolved HBV infection during direct-acting antiviral therapy

SIRS, We read with great interest the article by M€ ucke et al. They investigated the possibility of hepatitis B virus (HBV) reactivation in hepatitis C virus (HCV) patients during anti-HCV therapy in a large European single-centre cohort. No HBV reactivation was observed in HBsAg-negative/HBcAb-positive HBV/HCV co-infected patients during anti-HCV treatment. Five of nine (56%) HBsAg-positive/ HBcAb-positive patients experienced HBV reactivation during or after direct-acting antivirals (DAAs)-based treatment. Although these data provide more evidence about the risk of HBV reactivation during DAAs-based treatment, several issues deserve discussion. The rate of HBV reactivation varies among different studies. One important interpretation is that the definitions of virological HBV reactivation are different among these studies. In the study by Londo~ no et al., virological HBV reactivation was defined as an increase in HBV-DNA levels ≥1 log as compared to previous value. Belperio et al. defined virological HBV reactivation as a >3 log increase in HBV DNA or the detection of HBsAg in a person who was previously HBsAg negative. Ogawa et al. defined HBV reactivation as a quantifiable HBV DNA level >20 IU/mL. However, in the study by M€ ucke et al., the definition of virological HBV reactivation is not clearly described. As the author mentioned, they did not detect the HBV DNA levels at baseline of DAA therapy. Thus, patients with occult hepatitis B infection could not be excluded in the study. Moreover, any change in HBV DNA levels during and after treatment is not known. Ogawa et al. evaluated the risk of HBV reactivation during treatment with sofosbuvir-based regimens in 63 patients with resolved HBV infection (negative for HBsAg and undetectable HBV DNA but positive for HBcAb). Four patients (6.3%) with resolved HBV infection came to have detectable HBV DNA during treatment. One patient with resolved HBV infection developed HBV reactivation at week 4 (HBV DNA 80 IU/mL). However, HBV DNA was not detected after week 8 without nucleos(t)ide analogue treatment. This study indicates that patients with resolved HBV infection may developed transient HBV replication with a very low-level of HBV DNA load during DAA-based treatment. Thus, the HBV reactivation rate might have been underestimated in the study by M€ ucke et al. Thus, large-scale prospective studies are needed to confirm the risk of HBV reactivation in patients with resolved HBV infection treated with DAAs. ACKNOWLEDGEMENTS

A novel index using routine clinical parameters for predicting significant liver inflammation in chronic hepatitis B

Identifying the degree of liver inflammation is critical for therapeutic judgement of patients with chronic hepatitis B (CHB). However, we lack indexes which can accurately predict significant liver inflammation in patients with CHB. This study aimed to develop a simple predictive index for liver inflammation in CHB using routine clinical parameters. A total of 519 patients with CHB who underwent liver biopsy were enrolled and randomly divided into training (n = 346) and validation cohorts (n = 173). Based on routine clinical parameters, gamma‐glutamyl transpeptidase (GGT; P = 0.031) and platelets (PLT; P < 0.001) were identified as independent predictors of significant inflammation by multivariable analysis in the training cohort. Accordingly, the GGT to PLT ratio (GPR) was developed to amplify the opposing effects for predicting liver inflammation. In the training cohort, the AUCs of GPR in predicting significant inflammation were 0.791 (95% CI: 0.742‐0.839), 0.783 (95% CI: 0.717‐0.849) and 0.791 (95% CI: 0.716‐0.867) in the entire patients with CHB, HBeAg‐positive CHB patients and HBeAg‐negative CHB patients, respectively. The diagnostic performance of GPR for significant inflammation was significantly superior to that of alanine aminotransferase (ALT), aspartate transaminase (AST) and GGT in all patients with CHB and HBeAg‐positive CHB patients, but was comparable with ALT, AST and GGT in HBeAg‐negative CHB patients. In the validation cohort, the diagnostic performance of GPR in assessing significant liver inflammation was also superior to other indexes in all patients with CHB and HBeAg‐positive CHB patients, but was comparable with GGT in HBeAg‐negative CHB patients. Thus, GPR can be a novel and simple index for predicting significant liver inflammation in CHB, especially for HBeAg‐positive CHB.