23rd Annual Conference of APASL March 12-15, 2014, Brisbane, Australia.

Hepatol Int (2014) 8:S1–S405 DOI 10.1007/s12072-014-9519-7

ABSTRACTS

23rd Annual Conference of APASL March 12–15, 2014, Brisbane, Australia

Asian Pacific Association for the Study of the Liver 2014

Topic: 1 Acute Liver Failure Absno: 22 Acute liver failure in Sapporo, Japan: clinical features according to the aetiologies Jong-Hon Kang, Takeshi Matsui, Hajime Yamazaki, Kazumasa Nagai, Kunihiko Tsuji, Yoshihisa Kodama, Yasuo Sakurai, Hiroyuki Maguchi

of useful arms against hepatic encephalopathy in Japan where chronic donor shortage for LT has persisted. Keywords: Acute liver failure, Etiology, Clinical feature

Topic: 1 Acute Liver Failure Absno: 35

Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo, Japan

Adherence to surveillance poor in chronic liver disease presenting as acute on chronic liver failure: single centre experience

Background/aims: As for acute liver failure (ALF), not all patients need liver transplantation (LT), because clinical outcome is different by every etiology. Artificial liver support (ALS) including hemodiafiltration has started to treat ALF with encephalopathy in 2000. Our study was aimed to clarify the clinical impact of etiology for ALF. Methods: A total of 102 ALF patients (52 females, median age 48 years) referred from all Hokkaido areas in Japan during 1997 through June 2013 were enrolled, and etiological assessment underwent. ALF was defined to be 1.5 or more in INR. When hepatic coma was diagnosed, intensive care including ALS started using antivirals and/ or corticosteroid, if necessary. LT underwent for the patients showed refractory. Results: The distribution of etiologies for ALF was viral infection 48, circulatory disturbance 12, autoimmune hepatitis 9, drug-induced liver injury 7, metabolic diseases 4, infiltration of liver by malignant cells 2 and miscellaneous 20. Among 48 cases of viral infection, hepatitis B virus (HBV), HEV, HAV or others was causative in 26, 15, 5, and 2, respectively. Out of 53 patients presented hepatic encephalopathy, 25 (47.2 %) had viral infection, 6 (11.3 %) AIH 5 (9.4 %) drug-induced, 6 (11.3 %) others, and 11 (20.7 %) miscellaneous. Non-comatose 46 and comatose 29 including 8 undergone LT survived. 37 of 48 patients with viral infection were saved by antivirals and/or ALS, and 11 of 12 caused by circulatory disturbance survived after the treatment for underlying disorders, whereas all 4 with HBV reactivation and 2 caused by malignancy were died, despite of intensive therapy. Conclusions: In Japan, infections of hepatotropic viruses have significant impact for the etiologies of ALF. According to the different etiologies, the optimal treatments should be prepared, and ALS is one

Rajneesh Kumar, Thinesh Lee Krishnamurthy, Hiang Keat Tan, Hock Foong Lui, Wan Cheng Chow Department of Gastroenterology, Singapore General Hospital, Singapore Introduction: Acute on chronic liver failure is increasingly being recognised as a condition which results in acute deterioration of patients leading to liver transplant or mortality. The causes for this deterioration have been variable and in spite of varied etiology. Early recognition of this condition has resulted in early intervention and GSF has been shown to improve survival in acute on chronic liver failure (ACLF). Prevalence and demographics for such group of patients is not known in Singapore. Aim: This retrospective study in prospective was done to assess the disease burden, know the demographics and the triggering event for ACLF. Method: 1835 discharge summaries of liver related condition was scrutinised to assess of the patients fulfilled the APASL diagnostic criteria for ACLF i.e. Observation: 55 patients were identified who fulfilled the above criteria. Records of 53 patients was available at the time of reporting Mean age of presentation was 55.89 ± 1.46 years with 73.5 % being male 74.5 % were Chinese, 20 % Indians and 1.8 % others. The common cause of underlying chronic liver disease was Hepatitis B in 63.6 % of patients and 23.6 % had alcoholic liver disease. The most common cause of Acute deterioration was spontaneous hepatitis B flare seen in 24.5 % of patients, while Alcoholic hepatitis was seen on 18.9 %. Cirrhosis was seen in 66 % of patients with ACLF. Non adherence to regular follow-up was seen in 69.8 % of patients. All the

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S2 patients diagnosed as chronic liver disease were aware of underlying liver problem, however as they were asymptomatic they did not have regular follow-up. Of the patients who were noncompliant to regular follow-up 67.5 % had cirrhosis of liver. Conclusion: High rate (69.8 %) of non-adherence to regular followup was seen in patients with ACLF in spite of being aware of chronic liver disease and 66 % of patients had liver cirrhosis at presentation. Patient education and regular follow-up may reduce the chances of developing liver cirrhosis in subjects with chronic liver disease and may improve overall survival of patients with chronic liver disease As ACLF represents the potential severe manifestation of Chronic liver disease requiring hospitalisation, there may be a huge population of undiagnosed liver cirrhosis in community who are asymptomatic.

Topic: 1 Acute Liver Failure Absno: 79 Predictors of adverse events at 60 days in acute on chronic liver failure: a single tertiary centre experience Rajneesh Kumar, Thinesh Lee Krishnamurthy, Hock Foong Lui, Hiang Keat, Wan Cheng Chow Department of Gastroenterology and Hepatology, Singapore General Hospital Introduction: Acute on chronic liver failure (ACLF) is characterised by sudden deterioration of underlying chronic liver disease which results in increased mortality and need for liver transplant. Identifying the patients at risk of mortality is essential for accurate prognosis of patients with ACLF.

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Hepatol Int (2014) 8:S1–S405 Material and methods: 1835 hospital inpatient discharge summaries of patients admitted between Januar 2001 to April 2013 were scrutinized. ACLF was defined as per Asiapacific association of liver disease (APASL) criteria. 55 subjects fulfilled the above criteria, data was available for 53 subjects at time of reporting. Clinical and laboratory variables were analysed using multivariate analysis done and logistic regression model using ROC curve used for prediction of mortality at 60 days. Laboratory parameters were recorded at the time of presentation and the peak values during the course of disease. Observation: Mortality at 60 days was 36 % while 4 (7.5 %) had liver transplant done. Model for end stage liver disease (MELD), high WBC had significant area under ROC, 0.921 and 0.736 respectively with 95 % CI for prediction of mortality. Encephalopathy was associated with Odds Ratio of 6.25 and RR of 2.5 for mortality or transplant. MELD score of more than 29 was 76 % specific and 96 % sensitive in predicting mortality at 60 days. Of Patients whose MELD score worsened over 2 weeks 67.8 % either died or required liver transplant. 79 % sensitive and 69 % specific for predicting mortality or liver transplant, with negative predictive value of 80 %. Cirrhosis at the time presentation was not associated with mortality or liver transplant (p = 0.29). Conclusion: MELD score is good predictor of mortality in ACLF, however it underestimates prognosis as these patients have higher mortality at shorter time. Encephalopathy and high White blood cell count needs to be added in the scoring system for evaluating prognosis of Acute on chronic liver failure. Presence of Childs A to B cirrhosis does not affect the mortality in ACLF. Worsening of MELD at 2 weeks portends poor prognosis.

Hepatol Int (2014) 8:S1–S405

S3

Topic: 1 Acute Liver Failure Absno: 256 Usefulness of serum T3, and TSH as prognostic indicators for patients of acute-on-chronic liver failure with hepatitis B virus infection Yichen Wu, Zhihong Wan, Shaoli You, Shaojie Xin Liver Failure Treatment and Research Center, Beijing 302 Hospital, 100 Xisihuan Middle Road, Beijing 100039, China

Topic: 1 Acute Liver Failure Absno: 254 Serum level of cystatin C as a predictor for acute kidney injury in HBV-related acute-on-chronic liver failure patients Zhihong Wan, Shaoli You, Hongling Liu, Bing Zhu, Hong Zang, Shaojie Xin Liver Failure Treatment and Research Center, Beijing 302 Hospital, 100 Xisihuan Middle Road, Beijing 100039, China Aim: To investigate whether serum cystatin C levels can be used as an early biomarker to predict acute kidney injury (AKI) in acuteon-chronic liver failure (ACLF) patients. Methods: Fifty-six consecutive patients, with Hepatitis B virus (HBV)related ACLF who had normal serum creatinine (Cr) levels (\1.2 mg/dL in male, or \1.1 mg/dL in female), were enrolled in the Liver Failure Treatment and Research Center of Beijing 302 Hospital between August 2011 and October 2012. Thirty patients with chronic hepatitis B (CHB) and thirty healthy controls in the same study period were also enrolled. Measurement of serum CysC was performed by a particle-enhanced immunonephelometry assay using the BN Prospec nephelometer system. The ACLF patients were followed up during their hospitalization period. Results: In ACLF group, the serum level of CysC was 1.1 ± 0.4 mg/L, which was significantly higher (P\0.01) than that of the healthy controls (0.6 ± 0.3 mg/L) and CHB patients (0.7 ± 0.2 mg/L). Meanwhile, the CysC level was positive correlated with MELD score (r = 0.746, P\ 0.001), but not with the Cr level (r = 0.193, P[ 0.05) in ACLF patients. During the hospitalization period, eight of ACLF patients developed acute kidney injury (AKI). Logistic regression analysis indicated that CysC level was the independent risk factor for AKI development (OR = 1.8; 95 % CI, 1.4–2.3; P = 0.021). The cutoff value of serum CysC for prediction of AKI in ACLF patients was 1.21 mg/L. The baseline CysCbased estimated GFR (eGFRCysC) was significantly lower than Cr-based estimated GFR (eGFRC&G and eGFRMDRD) in ACLF patients with AKI, suggesting basal eGFRCysC more early represented renal function of ACLF patients while the Cr levels were still within the normal ranges. Conclusion: Our results suggested that serum CysC provides an early prediction of renal dysfunction in ACLF patients with a normal serum Cr level.

Objective: Previous studies have demonstrated that chronic liver diseases induce several abnormalities in thyroid function tests. And serum T3 level may be a useful indicator for assessing the severity of patients with cirrhosis. However, data from patients with acute-onchronic liver failure (ACLF) are not available. In this study, we investigated the thyroid function in patients with ACLF caused by hepatitis B virus infection. Method: Seventy-five patients with ACLF, 42 patients with chronic hepatitis B (CHB) were enrolled in the study. Serum samples of all patients were collected at admission For ACLF patients, continual serum samples were collected during their hospitalization. All samples were stored at -80 C until analysis. Levels of serum thyroid hormones (T3, T4, FT3, FT4 and TSH) were measured by using chemiluminescence. The patients with ACLF were followed up for 1 year. Results: Patients with ACLF showed significantly lower values of serum T3 (0.8 ± 0.38 nmol/L, p \ 0.001), T4 (64.7 ± 32.7 nmol/L, p \ 0.001), FT3/FT4 (0.2 ± 0.1, p \ 0.001) and TSH (0.7 ± 0.7 IU/ ml, p \ 0.001) than those in patients with CHB. The levels of serum T3 and TSH in patients with ACLF were correlated negatively with the MELD score (r = -0.431, p \ 0.001 for T3; r = -0.574, p \ 0.001 for TSH), suggesting that the serum levels of thyroid hormone reflect the disease severity. During the follow up period (one year), thirty-one patients with ACLF died. Serum levels of T3 (0.6 ± 0.2 nmol/L, p \ 0.01), T4 (39.4 ± 18.9 nmol/L, p \ 0.008), and TSH (0.2 ± 0.3 IU/ml, p\0.003) in non-survivors were significantly lower than those in survivors. The optimal cutoff values were 0.46 nmol/L for T3, and 0.38 IU/ml for TSH to predict mortality of ACLF patients. The cumulative survival rate were decreased significantly while serum T3 levels of \0.46 nmol/L (21.1 %, p \ 0.001) or serum TSH levels of \0.38 IU/ml (39.2 %, p \ 0.001). Conclusion: Our results suggested that serum levels of T3 and TSH may be useful indicators for assessing the severity and prognosis of patients with ACLF.

Topic: 1 Acute Liver Failure Absno: 317 Evaluation of Curative Effect of Bilirubin Adsorption with Plasma Perfusion and Plasma Exchange in the Treatment of Patients with Liver Failure Juan Wang, Hong Tang, Ping Feng, Xue-Zhong Lei, Fang Chen, Yan Xu, Li-Yue Chen, Jing Chen Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu 610041, China Background: To observe the efficacy of artificial liver support system (ALSS) bilirubin adsorption with plasma perfusion and plasma exchange in the treatment of patients with liver failure.

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S4 Methods: There were 110 patients with liver failure as the treatment group were treated with ALSS bilirubin adsorption with plasma perfusion and plasma exchange (1500 ml). Before and after the treatment, the liver function, cholinesterase, blood ammonia and prothrombin time were tested and analysed difference by paired T test. And then the curative effect was compared with in nonsynchronous plasma exchange (3000 ml) for 80 patients as the control group. The outcomes of the patients were tracted for about 1 month. Results: The indexes before and after treatment were significant differences (P \ 0.01) both the treatment group and the control group, except for albumin of the control group. Comparing the two groups, the indexes after the treatment had no significant difference (P[0.05). In the treatment group, the mortality rate was 35.45 % and the improvement rate was 61.82 %. Liver transplantation accounted for 2.73 % patients. In the control group, the mortality rate was 41.25 % and the improvement rate was 55 %. Liver transplantation accounted for 3.75 % patients. Conclusions: ALSS bilirubin adsorption with plasma perfusion and plasma exchange (1500 ml) can significantly improved the patients liver function and blocked deterioration. The effect can be equivalent to the plasma exchange (3000 ml), but can save a lot of plasma.

Topic: 1 Acute Liver Failure

Hepatol Int (2014) 8:S1–S405 treatment was stopped because of higher levels of AST (573 U/L), ALT (256 U/L), ALP (201 U/L), GGT (378 U/L) and triple therapy treatment was stopped. New treatment with gentamicin 160 mg q24h IV and ceftriaxone 1 g q12h IV was started. Fresh frozen plasma was given for four days with INR follow-up. Hematology consultation and bone marrow biopsy were performed due to progression of neutropenia (336/ mm3) and thrombocytopenia (27,400/mm3).There was increased megakaryocytes, conglomeration dysmegakaryopoiesis and small conglomerations of histiocyte groups in aspiration material. Also increased histiocytes, macrophages which fagocytosing thrombocytes, erythrocytes and erythroblasts, prominent decreased erythrocyte series with 2–3 % blasts were seen in aspiration film and touch imprint. With these findings, patient was codiagnosed as hemophagocytic syndrome. Intraveno¨z immunglobuline treatment (400 mg/kg/day) was implemented for five days. Erythrocyte suspensions were given during hemoglobin level follow up the fourth day of IVIG treatment the patient’s neutropenic state recovered; liver enzyme levels normalized on the 11th day of treatment and triple brucellosis treatment was started again. Due to improvement of the patient’s clinical symptoms, treatment was continued for three months. Conclusion: Brucellosis can mimic many diseases. Persistent thrombocytopenia, decreased hemoglobin should be considered in patients with hemophagocytic syndrome and IVIG treatment should be administered in the early period.

Absno: 341 A brucellosis case with hepatitis and concomitant hemaphagocytic syndrome Meltem Is¸ ıkgo¨z Tas¸ bakan, Tansu Yamazhan, Hu¨snu¨ Pullukçu, Esra Erdem Kıvrak, Serhat Uysal, Og˘uz Res¸ at Sipahi, Sercan Ulusoy Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Bornova, Izmir, Turkey Introduction: Brucellosis is a zoonotic disease that persists and replicates within phagocytic cells of the reticuloendothelial system. Brucellosis is endemic in Turkey. Despite the high prevalence of bone marrow suppression, clinical hepatitis and hemaphagocytic syndrome due to involvement of RES is rare. Case report: A twenty-seven years old, male patient without any known disease with fever, malaise, generalized body pain complaints for two months admitted to our hospital. Because of additional symptoms like nausea, vomiting, cough and weight loss (5 kg), the patient was hospitalized. On physical examination; his body temperature fever 39.5 C, pulse 114/minute, blood pressure 110/70 mmHg. His liver was palpable one cm under his rib and Castell’s sign on traube’s space was positive. Blood Laboratory parameters were found as follows: white blood cells 1240/mm3; neutrophil 650/mm3; platelet 54,000/mm3; hemoglobin 11.6 mg/dL; CRP 16.06 mg/dL; sedimentation 6 mm/h; ALT 79 U/L; AST 177 U/L; ALP 139 U/L; GGT 245 U/L; T. Bilirubin 1.99 mg/dL; D. Bilirubin 1.55 mg/dL; LDH 2111 U/L; PT 15.9 sn; aPTz 41.5 sn; INR 1.4. His complete urine analysis parameters were found as follows: protein 150 mg/dL; urobilinogen 12 mg/dL; bilirubin 3 mg/dL. Findings of abdominal ultrasound were plastering style fluid in the right perirenal region, minimally free fluid in the pelvis as well as hepatosplenomegaly and perihepatitis. On his serological tests only HAV IgG was positive. His serology was negative for hepatitis B, hepatitis C, syphilis, HIV, EBV, CMV. Meanwhile his Rose Bengal test was found to be positive, the standard Wright 1/640 positive, 2 Mercapto Ethanol 1/160 positive, Brucella IgM was positive (10:48), and Brucella IgG was negative. Than doxycycline 100 mg q12h PO, rifampicin 600 mg q24h PO and ciprofloxacin 750 mg q12h PO treatment was started. But,

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Topic: 1 Acute Liver Failure Absno: 438 Severe hepatic manifestations associated with systemic juvenile idiopathic arthritis M. Kawamoto1, A. Inui1, K. Iwasawa1, T. Kondo1, T. Tsunoda1, T. Sogo1, H. Komatsu2, Y. Ito3, M. Mori4, S. Yokota5, T. Fujisawa1 1

Department of Pediatric Hepatology and Gastroenterology, and Endoscopy Center, Saiseikai Yokohama City Tobu Hospital, Yokohama, Japan. 2Department of Pediatrics, Sakura Medical Center, Toho University, Chiba, Japan. 3Department of Pediatrics, Nagoya University Hospital, Nagoya, Japan. 4Department of Pediatrics, Yokohama City University Medical Center, Yokohama, Japan. 5 Department of Pediatrics, Yokohama City University School of Medicine, Yokohama, Japan Backgrounds and aims: Hepatic manifestations associated with systemic juvenile idiopathic arthritis (S-JIA) are not so common, but these hepatic involvements are sometimes very critical. We investigate the etiologies of severe forms of liver disorders in children with S-JIA. Materials and methods: Seven children with S-JIA who had severe liver involvements (T-Bil ] 2.0 mg/dl and transaminase ]700 U/l) were enrolled in this study. They were 4 males and 3 females, with a median age of 8 years (range 4–;14 years). We retrospectively evaluated the associations of the herpes virus infections (Epstein-Barr virus (EBV), cytomegalovirus, human herpesvirus 6), autoimmune hepatitis (AIH), drug induced liver injuries (DILI), and macrophage activation syndrome (MAS). Herpes virus infections were diagnosed with real-time PCR, AIH with AIH score 1999, DILI with DDW-J 2004 scores, and MAS with Hemophagocytic lymphohistiocytosis (HLH) score. Results: Table 1. Conclusion: EBV, drug injuries, associated AIH, their acute liver failure, and MAS should be considered in S-JIA children with severe


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Table 1 Treatment and outcome of liver involvement Case no. Diagnosis

Age Sex Treatment

Outcome

has to be adapted to each treatment and each patient. MARS like a ‘‘personal therapy’’.

9

M

m-PSL?PSL?m-PSL ?DEX?PSL

Alive

AIH

4

F

m-PSL+AZA?PSL+UDCA ?m-PSL?PSL

Alive

3

ALF with DILI

7

F

m-PSL?PSL+CSP?PE + continuous hemofiltration ?m-PSL?PSL

Alive

4

DILI

8

F

UDCA

Alive

5

DILI

10

M

UDCA?PE ?cglb? m-PSL?PSL+CSP

Alive

6

ALF with MAS in liver

5

M

PE?mPSL?DEX+CSP?PSL Alive

Shivaram Prasad Singh1, Girish Kumar Pati1, Bijay Misra1, Debasis Misra1, Ayaskanta Singh1, Haribhakti Seba Das1, Chitta Ranjan Panda1

7

ALF with MAS 14 in liver

M

cglb?m-PSL?DEX+CSP? m-PSL?DEX

1

1

Liver disorder associated with EBV

2


Alive

ALF acute liver failure, m-PSL pulse methylprednisolone (30 mg/kg for 3 days), PSL prednisolone, DEX dexamethasone-palmitate, UDCA ursodeoxycholic acid, CSP cyclosporin A, PE plasma exchange, cglb gamma-globulin

liver disorders. The evaluation of liver histology is the most helpful measure for the accurate diagnosis, which leads to prompt therapeutic strategies and good outcome without liver transplantation.

Topic: 1 Acute Liver Failure Absno: 443 Evolution of artificial liver MARS application: a new concept V. Morabito1, S. Novelli2, L. Poli1, P. B. Berloco1, G. Novelli1 1

Department ‘‘Paride Stefanini’’, Sapienza University of Rome. Department of Mechanical and Aerospace Engineering, Sapienza University of Rome, Italy

2

Introduction: The aim of this study is to show the evolution of MARS application and the real detoxification of single substances following the engineering model indications. Materials and methods: Two hundred-twenty ACLF patients treated with MARS in waiting list for transplant, were enrolled in this study. Sample collections of liver parameters and cytokines targets were performed before and at different times after the beginning of the treatment in blood circuit and in the 4 points of albumin circuit. The patients were divided in two groups following the MELD score. In the first groups, patients with a MELD range 20–27, in the second one, patients with MELD range 28–36. Than the findings were inserted in an engineering model to evaluate detoxification efficiency (g), defined as the fractional reduction of the toxin concentration respect to volume blood pump, volume albumin circuit and Delta between patient albumin and circuit albumin. Results: The MARS application was divided in three different era. In the first era, from 1999 to 2004, we used the MARS only, in the second era, from 2005 to 2008, we started the study about engineering model in vitro and in vivo. In the third era, from 2009–2012, the MARS therapy with model application. Following the model, we highlighted an improvement of detoxification efficiency (g), with an increase of Responders to treatment and survival, based on the albumin concentration and the change of adsorbents after few hours. Conclusions: The engineering model can help us to set the flows rate, membrane pressure, albumin concentration predicting the time course of bound toxin removal. The correct application of artificial MARS

Absno: 658 Acute-On-Chronic Liver Failure (ACLF) in coastal eastern India: a single centre experience

Department of Gastroenterology, S.C.B. Medical College, Cuttack, Odisha, India

Background and aim: Acute-on-chronic liver failure (ACLF) is an emerging entity. There is limited data on ACLF in the literature. The present study was undertaken to analyze the clinical profile and natural course of ACLF patients. Patients and Methods: ACLF was defined as per Asian Pacific Association for the Study of Liver (APASL) consensus criteria. Patients fulfilling the APASL criteria were prospectively evaluated for clinical profile, etiologies of acute decompensation and underlying chronic liver disease, and short term natural course [three months]. Results: Out of 123 patients with ACLF (mean age 45.83 ± 12.05 years; male: female 109:14), 45.53 % cases had prior history of decompensation, and 54.47 % presented for the first time as ACLF. The mean CTP and MELD score were 12.28 ± 1.23 and 27.52 ± 6.46 respectively. Etiologies of cirrhosis were alcohol, cryptogenic and chronic hepatitis B virus infection in 65.04, 23.57 and 11.38 % cases respectively. Recent history of alcohol intake (within 4 weeks) [42.27 %] followed by bacterial infection [36.58 %] were the common etiologic precipitants for acute decompensation. Only 87 (70.73 %) out of 123 cases could be followed up for a duration of 3 months; 62 (71.26 %) cases died by 3 months. Majority of deaths were among those with alcoholic liver disease compared to other etiology [(43/53) 81.13 % vs. (19/34) 55.88 %; p = 0.011]. No significant difference in mortality rate was observed between patients with prior decompensation compared to newly diagnosed ACLF cases [30/40 (75 %) vs. 32/47 (68.09 %); p = 0.477]. The prognostic markers [MELD, MELD-Na, CTP] were not significantly different between survivors and non-survivors. Conclusion: ACLF patients in our population had high short term mortality rates with majority of death in alcoholics. Alcohol intake and bactertial infection were mainly responsible for acute decompensation in our study.

Topic: 1 Acute Liver Failure Absno: 676 UPLC-MS-based metabolomic analysis of livers in a Dgalactosamine (D-GalN)-induced rat model of acute hepatic failure and regeneration CaiYun Nie1,2, Tao Han2,3,4, Lei Zhang5, XinHua Nie2, FuShuang Ha2 1

The Third Central Clinical College of Tianjin Medical University, Tianjin, China. 2Department of Hepatology, Tianjin Third Central Hospital, Tianjin, China. 3Tianjin Institute of Hepatobiliary Disease,

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S6 Tianjin, China. 4Tianjin Key Laboratory of Artificial Cells, Tianjin, China. 5Department of Clinical Laboratory, Tianjin Third Central Hospital, Tianjin, China Introduction: D-galactosamine (D-GalN)-induced liver injury is a well-known experimental model used to develop acute hepatic failure (AHF) as a result of massive hepatocyte death. Materials and methods: In the present study, for induction of AHF, 25 rats were intraperitoneally injected with D-GalN (1,400 mg/kg), and every 5 rats were sacrificed at 12, 24, 36, 48 and 72 h respectively, while 5 healthy rats served as controls. Ultra-performance liquid chromatography–mass spectrometry (UPLC/MS) based metabolomic analysis of livers was used to investigate the metabolites changes in the process of progression and regeneration of D-GalNinduced rat model of AHF. Characteristic metabolites were screened and identified to clarify the possible mechanism of AHF and liver regeneration on metabolic level. Liver tissues were extracted for histopathological and metabolomics analysis, and serum samples were used in biochemical determination. Results: Metabolomic analysis of liver tissues was consistent with conventional biochemical and histopathological results, and meanwhile, a number of metabolites involved in biochemical pathways such as energy metabolism, lipid biosynthesis and others, were valuable in monitoring the process of progression and regeneration of a D-GalN-induced rat model of AHF. Conclusions: UPLC-MS-based metabolic profiling provides new insight into the mechanism of liver injury and regeneration, and suggests putative metabolic biomarkers for the monitoring of process of progression and regeneration of AHF.

Topic: 1 Acute Liver Failure Absno: 760 A 5 year single centre experience of hepatitis E virus infection during pregnancy Premashis Kar1, Rajib Kishore Hazam1, Jayanta Borkakoti1, Ashok Kumar2 1

Department of Medicine, Maulana Azad Medical College, University of Delhi, 2Department of Obstetrics and Gynaecology, Maulana Azad Medical College, University of Delhi Objective: Viral hepatitis in pregnancy has been a subject of controversy. Reports from Europe and United States suggest that the course and outcome of acute liver failure during pregnancy is in no way different from non-pregnant women. The study was designed to examine the hypothesis whether pregnancy influences the course and severity of the disease in acute viral hepatitis (AVH) and acute liver failure (ALF). Method: 768 AVH and 320 cases of ALF patients were analysed. This included 411 AVH and 139 ALF cases associated with pregnancy. Results: The mortality in pregnancy associated Acute liver failure cases was 83.45 % (116/139) pregnancy associated AVH cases was 3.16 % (13/411), while the mortality observed in non pregnant group was 16.6 % in ALF cases and no mortality in AVH cases (p \ 0.001). Hepatitis E Virus was the most common etiological agent in both the groups. Conclusion: Mortality in pregnant women was found to be significantly higher than non-pregnant cohort. Hepatitis E has a high incidence and severe course in pregnancy. This study further substantiates the observation that mortality in ALF and AVH with HEV infection during pregnancy is higher compared to cases without pregnancy.

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Topic: 1 Acute Liver Failure Absno: 850 Do nucleotide substitutions in the hepatitis E Virus genome play a key agent in acute liver failure? Jayanta Borkakoti1,2, Giasuddin Ahmed2, Premashis Kar1 1

PCR Hepatitis Laboratory, Department of Medicine, Maulana Azad Medical College and Associated Lok Nayak Jai Prakash Hospital, University of Delhi, New Delhi, India, 2Department of Biotechnology, Gauhati University, Assam, India Introduction: Preliminary studies suggest that the genotype of Hepatitis E virus influence the severity of hepatitis E. Viral capsid proteins play widespread role in interacting cellular proteins during capsid assembly and virus entry. Studies at the molecular level of the capsid protein of the HEV genome are limited. We aimed to study the molecular alterations in the HEV genome in patients with acute liver failure and acute viral hepatitis. Materials and methods: A total of 32 patients with acute liver failure and 155 patients with acute viral hepatitis were screened for the study during the years 2011–2013. HEV IgM was detected by anti HEV IgM ELISA. HEV RNA was detected using Viral RNA extraction kit. The Open Reading Frame 2 (ORF 2) region of the HEV genome was amplified using Reverse Transcriptase PCR. Representative samples were directly sequenced. Full length nucleotide sequences of HEV isolates were retrieved from the Gen Bank /EMBL/DDBJ databases and compared with the strains. Sequences were aligned by CLUSTAL W software. Results: The mean age of the AVH and ALF patients were 23.85 ± 3.68 years and 24.6 ± 3.32 years respectively. HEV RNA was detected in 84 (54.19 %) AVH and 24 (75 %) ALF patients respectively. A total of 15 nucleotide substitutions at various positions of the ORF 2 were observed after aligning the obtained sequence of 5 ALF patients with the other reference sequences. The nucleotide substitutions obtained were mainly silent substitutions with some conserved substitutions, one deletion and only a single amino acid change from lysine to cysteine in all the patients. Conclusion: Substitutions encompassing these regions may play a crucial role in enhancing HEV replication through interactions with other proteins thus leading to disease severity. The single amino acid substitution and the silent substitutions may be associated with the poor outcome in ALF patients.

Topic: 1 Acute Liver Failure Absno: 880 Ultra-deep sequencing analysis of the HAV 50 -untranslated region among HAV-outbreak patients associated with a revolving sushi bar Tatsuo Kanda, Shuang Wu, Shingo Nakamoto, Xia Jiang, Masato Nakamura, Tatsuo Miyamura, Hiroshi Shirasawa, Osamu Yokosuka Chiba University, Graduate School of Medicine, Chiba, Japan Aim: Hepatitis A virus (HAV) is a causative agent of acute viral hepatitis for which an effective vaccine has been developed. Here we describe ultra-deep pyrosequences (UDPSs) of HAV 50 -untranslated region (50 UTR) among cases of the same outbreak, which arose from a single source, associated with a revolving sushi bar.

Hepatol Int (2014) 8:S1–S405 Methods: We determined the reference sequence from HAV-derived clone from an attendant by the Sanger method. Sixteen UDPSs from this outbreak and one from another sporadic case were compared with this reference. Results: Nucleotide errors yielded a UDPS error rate of \1 %. This study confirmed that nucleotide substitutions of this region are transition mutations in outbreak cases, that insertion was observed only in non-severe cases, and that these nucleotide substitutions were different from those of the sporadic case. Conclusion: Analysis of UDPSs detected low-prevalence HAV variations in 50 UTR, but no specific mutations associated with severity in these outbreak cases. Analysis of HAV UDPSs might give us new information about the association between the disease severity of hepatitis A and HAV genome substitutions.

Topic: 1 Acute Liver Failure Absno: 884 Identification of eight serum microRNA from a genome-wide serum microRNA expression profile serves as potential noninvasive biomarkers for acute on chronic liver failure Peng Wang, Ruidong Mo, Xiaogang Xiang, Rongtao Lai, Qing Xie Department of Infectious Diseases, Ruijin Hospital 65292; School of Medicine 65292; Shanghai Jiao Ton Identification: Of eight serum microRNA from a genome-wide serum microRNA expression profile serves as potential noninvasive biomarkers for acute on chronic liver failure. Introduction: Prognosis of patients with acute on chronic liver failure (ACLF) is generally poor due to the lack of non-invasive tools for ACLF detection. The purpose of present study was to identify a serum microRNA (miRNA) expression profile that can serve as a novel diagnostic biomarker for ACLF detection and to assess its clinical applications in monitoring disease progression.

S7 Methods: Serum samples were taken from 80 ACLF patients and 80 age and gender matched healthy controls. MiRNA expression by Exiqon LNA miRNAs chip analysis was performed using serum samples pooled from 6 ACLF patients and 6 healthy controls, respectively. Differential expression was validated using quantitative reverse transcription polymerase chain reaction (qRT-PCR) in individuals samples. Results: Exiqon LNA miRNAs chip results demonstrated that 12 serum miRNAs were markedly upregulated and 136 serum miRNAs were markedly downregulated in the ACLF patients compared to the controls (p \ 0.05). The qRT-PCR analysis further identified a profile of eight serum miRNAs (miR-122, miR-130a-3p, miR-142-3p, miR142-5p, miR-221, miR-200b, miR-300 and miR-595) as a biomarker for ACLF detection (p \ 0.0001). The analysis results showed that the expression level of eight serum miRNAs was correlated to disease stage and associated with the prognosis of disease. Conclusions: We identified eight-miRNA signature for ACLF diagnosis by genome-wide serum miRNA expression profiling. Expression levels of the serum miRNA-based biomarker also indicate liver failure progression stages and prognosis (Fig. 1). References 1. Hu Z, Chen X, Zhao Y, Tian T, Jin G, Shu Y, Chen Y, Xu L, Zen K, Zhang C, Shen H. Serum microRNA signatures identified in a genome-wide serum microRNA expression profiling predict survival of non-small-cell lung cancer. J Clin Oncol 2010;28(10):1721–1726 2. Liu R, Chen X, Du Y, Yao W, Shen L, Wang C, Hu Z, Zhuang R, Ning G, Zhang C, Yuan Y, Li Z, Zen K, Ba Y, Zhang CY. Serum microRNA expression profile as a biomarker in the diagnosis and prognosis of pancreatic cancer. Clin Chem 2012;58(3):610–618

Topic: 1 Acute Liver Failure Absno: 887 Role of Dynamic PELD and PRISM III scores for prognostication in pediatric acute liver failure (PALF) Rajeev Khanna, Vikrant Sood, Seema Alam, Dinesh Rawat Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India

Fig. 1 The relative expression of hsa-miRNAs was normalized to expression of the internal control (miR-39) in 80 liver failure patients versus 80 health control, 20 CHB and 20 liver cirrhosis. The P values were calculated by t test. Liver significant (p \ 0.0001). * p \ 0.05, ** p \ 0.01, *** p \ 0.001

Background and aims: Pediatric end-stage liver disease (PELD) and Pediatric risk of mortality (PRISM III) scores are routinely used in chronic liver disease and PICUs, respectively, but need validation in the setting of pediatric acute liver failure (PALF). The present study evaluated the prognostic utility of King’s College criteria (KCC), PELD and PRISM III scores at admission and at 72 h for prediction of mortality or need for LTx in PALF in a living donor liver transplant center. Methods: All children aged 0–18 years fulfilling the PALF study group (PALFSG) definition were included. KCC, PELD (or MELD for above 12 years of age) and PRISMIII scores were calculated at admission and at 72 h. AUROC curves were obtained and binary logistic regression analysis was done with regard to poor outcome (mortality or need for LTx at Day 30 of admission). Results: There were 52 children (34 males). Overall, 30 (58 %) had poor outcome (22 deaths and 8 LTx-14 within 72 h of admission). KCC, PELD and PELD72 scores had significantly higher AUROCs

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S8


(0.940, 0.936 and 0.886, respectively; p \ 0.001) with regard to poor outcome than PRISMIII (p = NS) or PRISM72 (p = 0.001). KCC C 3, PELD C 30 and PELD72 C 26 had a sensitivity of 83.3, 80 and 87.5 %, specificity of 86.4, 90.9 and 95.5 % and positive likelihood ratio of 6.1, 8.8 and 19.4, respectively for prediction of poor outcome. On multivariate analysis, admission values of KCC and PELD, whereas 72 h value of PELD72 as well as change in PRISMIII (C0) determine mortality or need of LTx (p \ 0.001). Conclusions: KCC, PELD and PELD72 better predict poor outcome than PRISMIII score in PALF, however the dynamicity of latter is more helpful than of PELD score.

Topic: 2 Alcoholic Liver Disease


1

Absno: 911 Acquired hemophagocytic lymphohistiocytosis (HLH) presenting as acute liver failure in a dedicated liver ICU: our experience of 17 cases Ankur Jindal, Naveen Kumar, S. K. Sarin Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi-110070 Background: HLH is frequently fatal (overall mortality [50 %) and often underdiagnosed. It involves a final common pathway of hypercytokinemia. A timely diagnosis is imperative to facilitate immunosuppressive therapy and decrease mortality. HLH presenting as severe acute viral hepatitis or acute-on-chronic liver failure is extremely rare. We present our experience with HLH in a dedicated liver ICU presenting mainly for severe acute hepatic insult. Methods: Retrospective analysis of admitted patients with systemic inflammatory response (SIRS) fulfilling diagnostic HLH criteria (C5/8). Results: Seventeen patients [Male: Female 14:3; Adults: Child— 14:3; median age—26 years (range—1 month to 66 years) were diagnosed with acquired HLH at our hospital from year 2010 to 2012. Twelve (70.6 %) patients presented clinically as ACLF (7) and AVH (5) at admission. Viral associated HLH (8 patients; 47.1 %) was most common (HAV-3, HEV-2, EBV-1, Dengue-1, Parvovirus-1). Although etiology remained undiagnosed in 7 (41.2 %) patients, one patient each had lymphoma and visceral leishmaniasis. While fever [16 patients (94.2 %); median duration—30 days (4–90 days)] and jaundice [14 patients; mean bilirubin—20.34 ± 8.6 mg/dl] were most common symptoms at presentation, clinical signs such as presence of enlarged liver (76.4 %), spleen (76.4 %) and ascites (58.8 %) were most frequent. 5 patients also had AKI (serum creatinine [1.5 mg/dl) at admission. Important biochemical parameters included hyperferritinemia [all patients; mean—16064.7 ± 7652 ng/dl], hypertriglyceridemia (10 patients (58.9 %); mean—354.7 ± 145.1 mg/dl), raised LDH (mean—2952.66 ± 726) and low fibrinogen (12 patients (70.6 %); mean—146.1 ± 32.4) levels. Bone marrow aspiration was done in 12 patients of which 11 showed presence of hemophagocytosed histiocytes. 10 patients (58.8 %) had in-hospital mortality and the main cause was eventual sepsis and multiorgan failure. 12 patients (70.6 %) received specific immunosuppressive therapy (steroids-4, IV IG-4, Plasmapheresis-4, cyclosporine-1) but it made no difference in clinical outcome (In hospital mortality, Treated vs. non-treated 66.67 vs. 62.25 % respectively; p [ 0.05). Conclusions: HLH may masquerade as acute hepatic insult and hence it is important to suspect and recognise this entity early enough in patients with ACLF. Prognosis is poor despite immunosuppressive therapy and hence newer criteria need to be developed for early detection.

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Absno: 36 Pilot study of granulocytapheresis and leukocytapheresis for the treatment of severe alcoholic hepatitis Atsushi Naganuma1, Takashi Hoshino1, Tsuyoshi Ogashiwa1, Eri Hayashi1, Sanae Uehara1, Naomi Miyamae1, Tomohiro Kudo1, Hiroshi Ishihara1, Shuichi Saito2, Mitsuo Toyoda3, Toshiyuki Otsuka4, Norio Horiguchi5, Yuichi Yamazaki5, Ken Sato5, Satoru Kakizaki5, Hitoshi Takagi1 Takasaki General Medical Center, National Hospital Organization, Takasaki, 2Public Tomioka General Hospital, Tomioka, 3Maebashi Red Cross Hospital, Maebashi, 4Numata Hospital, National Hospital Organization, Numata, 5Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan Introduction: SAH is an inflammatory response with multiple morbidity factors like leukocytosis, jaundice, hepatomegaly, hepatic encephalopathy, gastrointestinal bleeding, renal failure, endotoxemia and its prognosis is usually poor. The standard therapy for SAH remains controversial. We retrospectively evaluated the efficacy of GCAP and LCAP for the treatment of SAH. Methods: Eleven patients (M/F = 9/2) of SAH from November 1999 to August 2013 were enrolled. Clinical severity of SAH was evaluated by Maddrey’s index (discriminant function; DF), MELD score and Japan alcoholic hepatitis score (JAS) for alcoholic hepatitis. Clinical course and prognosis of SAH patients were compared with those treated by GCAP or LCAP (CAP group) and those treated by the other therapy (non-CAP group). Clinical outcomes were analyzed by Kaplan–Meier curve and log-rank test. Results: Average age of patients was 45.1 years-old. All of patients had a DF greater than 32. The average value of MELD and JAS was 25.4 and 10.8, respectively. Most patients had received one or more of the following treatments, corticosteroids, plasma exchange and hemodiafiltration. Four patients had died and 7 patients had survived at least within 100 days of hospitalization. Three patients were treated by GCAP or LCAP (CAP group) and 8 patients were treated by other therapy (non-CAP group). Although white blood cells (WBC) of CAP group showed higher than those of non-CAP group (28433 ± 5862 vs. 13471 ± 7477; p = 0.052), no statistical difference was obtained. Survival rates at 100 days estimated were 66.7 and 71.4 % in CAP group and non-CAP group, respectively (p = 0.339). In CAP group, 2 patients who started CAP within ten days from diagnosis could recover from hepatic failure, the rest one patient who started GCAP at the 26th day after diagnosis died in 36th day after the diagnosis. Conclusions: Although LCAP or GCAP could not demonstrate significant usefulness as a treatment modality for SAH, they may improve the survival when initiated at an early stage from diagnosis. Randomized controlled trial would be necessary to evaluate the efficacy of CAP for SAH.

Topic: 2 Alcoholic Liver Disease Absno: 75 High frequency of dopamine receptor D2 TaqIA polymorphisms and lifestyle factors are associated to alcoholism in Mexico A. Zepeda-Carrillo Eloy2, Roman Sonia1, H. Hernańdez-Nazara´ Zamira1, A. Fierro Nora1, Escobedo-Meleńdez Griselda1, Torres-Valade´z Rafael1, Panduro Arturo1

Hepatol Int (2014) 8:S1–S405 1

Department of Molecular Biology in Medicine, University of Guadalajara, Guadalajara, Jalisco, Mexico. 2Health Sciences, University Autonomous of Nayarit, Tepic, Nayarit, Mexico

Introduction: Alcoholic liver disease (ALD) is a health problem with variable prevalence rates worldwide. A strong association between the TaqIA polymorphisms (rs1800497) of the dopamine receptor D2 (DRD2) and alcohol abuse or dependence has been described. Although Mexico is the number one leading country for mortality due to ALD and has a high pattern of drinking score, little is known about DRD2 polymorphisms, the pattern of alcohol intake and the genetic-sociocultural factors that are related to alcoholism among the Mexican population. Materials and methods: A cross-sectional study was conducted in 680 unrelated adults from two rural Amerindian groups (Huicholes and Nahuas) and two urban mestizo populations (Tepic, Nayarit and Guadalajara, Jalisco). The pattern of alcohol intake and sociocultural factors were registered by a medical history questionnaire. Liver function tests were determined by enzymatic methods. The allelic and genotypic frequencies for DRD2 were analyzed by PCR-RFLP. Statistical differences between groups were analyzed by ANOVA and t-student test. Qualitative variables and Hardy–Weinberg Law were analyzed by chisquare test. The study protocol was approved by the hospital’s Research and Ethics Committee and patients signed informed consent. Results: Beer and tequila were the main consumed alcoholic beverages. Three stages of chronic alcohol consumption were identified. In the first stage, the average alcohol intake was 99 g/day during the weekends; later 365 g/day, three times a week and lastly 511 g/day, four or more times per week. The duration of each stage was 4, 14 and 10 years, respectively. Different patterns of alcohol intake were found. The Huicholes drank at their homeland religious ceremonies for almost 100 days per year, whereas in the urban mestizos, alcohol intake was related to weekend family celebrations and religious festivities, including birthdays, christenings and weddings. The Huicholes had the lowest values of AST and ALT (19 ± 9 U/L and 13 ± 7.8 U/L, respectively) compared to all other groups. The overall distribution of the DRD2 genotypes was A1/A2 (56 %), A1/A1 (26 %) and A2/A2 (18 %) and allele frequencies were A1 (54 %) and A2 (46 %). The A1 allele frequency in the Nahuas and Huicholes was 67 and 65 %, respectively, and 57 and 47.3 % among the mestizos from Tepic and Guadalajara, respectively. A higher alcohol intake was associated to the A1 allele carriers than to A2 carriers (392 vs. 203 g/day, p = 0.019). Conclusions: The pattern of alcohol intake is different among the Mexican mestizos and Amerindian populations. To date, the Mexican population has the highest frequency of A1 allele reported worldwide. A high alcohol intake was associated with the DRD2 A1 allele in the study groups. These results suggest a plausible interaction between genetic, environmental and socio-cultural factors involved in alcohol intake that are related to alcohol dependence, alcohol abuse and severity of liver disease.

Topic: 2 Alcoholic Liver Disease Absno: 318 Up-regulation of IL-13 by invariant natural killer T cells (iNKT) correlates with disease progression in alcoholic liver patients Juanjuan Zhao, Z. Heng Zhang Research Center for Biological Therapy, Beijing 302 Hospital, Beijing 100039, China Objectives: Invariant natural killer T cells (iNKT) have been demonstrated to participate in the pathogenesis of alcoholic liver disease in mouse model; however, little is known regarding their immune-

S9 pathogenic roles in patients with alcoholic cirrhosis. The aim of this study was to evaluate whether they are related to disease progression in alcoholic cirrhosis patients, and also to explore the possible mechanisms. Methods: The frequencies of circulating iNKT subsets were analyzed in alcoholic cirrhosis. The expression levels of activation marker, chemokine receptors and Th1 and Th2 cytokine production by iNKT cells were detected by flow cytometry in alcoholic cirrhosis patients (n = 40) as well as healthy controls (n = 20). Results: The total number of iNKT cells was reduced, but the ratio of the CD4+iNKT/CD4-iNKT was significantly increased in patients with alcoholic cirrhosis and closely associated with alcohol intake in alcoholic hepatitis (AH) and alcoholic liver cirrhosis (ALC) patients. In addition, iNKT cells from these patients were characterized by the increased expression of activation markers and chemokine receptors; in particular in livers from the patients, the activated iNKT were more enriched. Finally, the increased IL-13 production by peripheral iNKT is found to be positively closely associated with liver pathogenesis, indicated by liver HAI scores and MELD score in these alcoholic liver disease patients. Conclusion: Peripheral and intrahepatic iNKT cells are activated and exhibit a concomitant increase of IL-13 production in AH and ALC patients, which was subsequently associated with liver immunepathogenesis of chronic ALD.

Topic: 2 Alcoholic Liver Disease Absno: 454 Diagnostic Sensitivity of Carbohydrate Deficient Transferrin in Heavy Drinkers Kevin Fagan1, Katharine Irvine2, Brett McWhinney3, Linda Fletcher1, Leigh Horsfall1, Lambro Johnson3, Peter O’Rourke4, Jennifer Martin1, Ian Scott1, Carel Pretorius3, Jacobus Ungerer3, Elizabeth Powell 1

Princess Alexandra Hospital, 2University of Queensland, TRI, Pathology Queensland, 4Queensland Institute of Medical Research

3

Background: Carbohydrate deficient transferrin (CDT) is the most specific biomarker of heavy alcohol consumption, defined as C350–420 g alcohol/week. Despite introduction of a standardised reference measurement technique, widespread use of CDT remains limited due to low sensitivity. The aim of this study was to determine the factors that affect diagnostic sensitivity in patients with sustained heavy alcohol intake. Methods: Patients with a self-reported history of sustained heavy alcohol consumption were recruited from the hepatology outpatient department or medical wards at the Princess Alexandra Hospital, Brisbane, Australia. Each patient was interviewed with a structured questionnaire of alcohol consumption including validated alcohol screening tools: AUDIT and BMAST. CDT analysis, using the standardised reference measurement technique with high performance liquid chromatography, was performed on serum collected at time of interview. %CDT[1.7 is considered specific for sustained heavy alcohol consumption. Results: 52 heavy drinkers were recruited: 19 from the hepatology outpatient department and 33 from general medical wards. Median alcohol intake was 1013 (range 366–5880) g/week over the preceding two week period. 26 patients had a diagnostic CDT (%CDT [1.7), yielding a sensitivity of 50 %. Overweight/obesity (defined as body mass index (BMI) C 25 kg/m2 in Caucasians and C23.0 kg/m2 in Asians), female gender and presence of cirrhosis were independently associated with non-diagnostic %CDT (B1.7). (Fig. 1) Conclusion: CDT has limited sensitivity as a biomarker of heavy alcohol consumption. Caution should be applied when ordering and interpreting %CDT results, particularly in women, patients with cirrhosis and those with an elevated BMI.

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Seoul National University Boramae Medical Center, Seoul, Republic of Korea; 1Seoul National University Hospital, Seoul, Republic of Korea Introduction: Acute kidney injury (AKI) is progressive and associated with mortality in cirrhosis. Although AKI network(AKIN) criteria was shown to be useful in alcoholic hepatitis (AH) [1], detailed features of AKI in AH remain elusive. The aim was to investigate characteristics and relevant prognosticators of AKI in Asian patients with AH. Methods: We conducted a hospital-based, retrospective cohort study for 405 AH patients between 1999 and 2012. Multivariable logistic regression analysis was conducted to identify factors associated with mortality. Cox proportional hazard model was applied to identify predictive factors for survival. Results: Median age was 51 years, and 348 were male (85.9 %). Median clinical scores were discriminant function = 33, MELD = 14.3, and ABIC = 7.44. AKI was diagnosed in 115 patients (28.4 %). Initial AKIN stages were 0 in 27 (23.5 %), 1 in 62 (53.9 %), 2 in 12 (10.4 %) and 3 in 14 (12.2 %), and stage progression was observed in 70 (60.9 %). Peak stages were 1 in 49 (42.6 %), 2 in 21 (18.3 %), and 3 in 45 (39.1 %). Ninety-day survival probability was 45.4 %. Mortality was higher in patients with AKI (P \ 0.001), peak AKIN stage 2/3 (P\0.001), higher Child-Pugh score (P\0.001) and cirrhosis on imaging (P = 0.003). No difference in clinical characteristics was found except duration of hospitalization between patients with or without AKIN-stage progression (24.3 vs. 40.7 days; P = 0.002). Creatinine (P = 0.010) and C-reactive protein (P = 0.014) were associated with mortality. Initial AKIN stage 1 (hazards ratio (HR) = 2.551, P \ 0.001) or 2/3 (HR = 3.016, P = 0.001) and peak stage 2/3 (HR = 3.048, P \ 0.001) were predictive factors for survival. Conclusion: AKI significantly reduced survival in hospitalized AH patients. In addition to the initial AKIN stage, peak stage was a significant prognostic factor. Early recognition of AKI and prevention of progression may improve outcomes of AH. Reference 1. Altamirano J, Fagundes C, Dominguez M, Garcia E, Michelena J, Cardenas A, Guevara M, et al. Acute kidney injury is an early predictor of mortality for patients with alcoholic hepatitis. Clin Gastroenterol Hepatol 2012;10:65–71 e63

Topic: 2 Alcoholic Liver Disease Fig. 1 Correlation of alcohol consumption (g/week/kg LBW) and %CDT for: (a) lean vs. overweight/obese subjects; (b) non cirrhotic vs. cirrhotic subjects; and (c) men vs. women (# identifies the 2 patients with moderately decreased renal function (eGFR 30–59)). (LBW = Lean body weight)

Topic: 2 Alcoholic Liver Disease

Absno: 718 Berberine with alfa lipoic acid (ALA) in non alcoholic steatohepatitis (NASH). A randomized double blinded placebo control trial. A clinical pilot: the BANISH trial P. Patrick Basu1,3, Mark M. Aloysius3, Niraj James Shah2, Robert S. Brown Jr.1 1

Absno: 687 Outcome of acute kidney injury in hospitalized patients with alcoholic hepatitis Hwi Young Kim1, Junsu Byun1, Sae Kyung Joo1, Yong Jin Jung1, Byeong Gwan Kim1, Kook Lae Lee1, Jeong-Hoon Lee2, Su Jong Yu2, Yoon Jun Kim2, Jung-Hwan Yoon2, Hyo-Suk Lee2, Won Kim1

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College of Physicians and Surgeons, Columbia University, New York, NY, 2James J. Peters VA Medical Center, Icahn School of Medicine at Mount Sinai, NY, 3King’s County Hospital Medical Center, NY Objective: Therapeutic modalities for NASH have not yet been fully established. Anti-oxidants and insulin sensitizers altering insulin resistance, inhibiting intra hepatic oxidative stress with inhibition of formation of free radicals and blocking inflammatory cytokines to prevent fibrosis. Berberine is a natural substance extracted from plants like Berberis which is found to up-regulate intra hepatic pathways as


S11

insulin sensitizer, via GLP-1 up regulation and Acyl palmotyl mechanism on fatty acid oxidation, induction of PPAR gama; all of which blocks the terminal inflammatory Cytokine release TNF Alfa to prevent fibrosis that prevents End stage liver disease (ESLD) and liver cancer. Methods: Hundred and twenty patients (n = 120) with NASH were recruited. Mean BMI 29.9 % (29–32 %) with 69 males and 51 females. Hispanic 46, Caucasians 34, Asian Pacific 15, Black 11, Asian 14. Mean HbA1C 6.2 (5.9–6.8), Mean HOMA 2.7 (2.1–3.6), ALT 54 (38–79), Triglyceride 287 (233–344), LDL c 163 (129–176), Leptin 63 (43–98), Adiponectin 0.9 (0.1–1.1), RBP 4 of 5.8 (4.0–6.8), TNF Alfa 3.8 (2.1–4.8), IL 12 of 5.3 (3.9–7.8), Serum Fibrotic and Steatotic scores were measured at 0 and then at 6 months. Results:

% Change

Group A

Group B

Group C

TB

66.7

78.6

60

Albumin

34.7

52.3

73.7

Creatinine

44.4

45.8

37.5

AST

82.9

86.8

90.4

ALT

76

83.6

81.3

TNF

87

42.9

65.4

IL6

64.7

67.6

72.7

IL8

62.1

62.1

50

MELD

51.5

50

42.1

Topic: 2 Alcoholic Liver Disease ALT

Group A

HOMA

TG

Adiponectin

TNF-a

Leptin

Steatotic score

0.001

0.004

\0.001

0.090

0.005

0.003

0.021

Group B \0.001

0.003

\0.001

0.03

0.012

0.015

0.034

Group C \0.001

0.003

\0.001

0.001

\0.001

0.003

\0.001

Group D

0.001

\0.001

0.001

\0.001

0.016

0.002

0.006

Absno: 721 Role of mycophenolate mofetil (MMF) in steroid non responsive severe acute alcoholic hepatitis: a randomized open label placebo control prospective clinical pilot trial P. Patrick Basu1,3, Niraj James Shah2, Mark M. Aloysius3, Robert S. Brown Jr.1 1

Conclusion: All the study arms showed statistically significant (p \ 0.05) post interventional change except for Adiponectin in group A (p = 0.09).

Topic: 2 Alcoholic Liver Disease Absno: 720 Role of intravenous N-acetyl cysteine (NAC) with steroid in acute alcoholic hepatitis (AAH) with high morbidity score: a randomized open label prospective clinical pilot trial: RENAISSANCE trial P. Patrick Basu1,3, Mark M. Aloysius, Niraj James Shah2, Robert S. Brown Jr.1 1

College of Physicians and Surgeons, Columbia University, New York, NY, 2James J. Peters VA Medical Center, Icahn School of Medicine at Mount Sinai, NY, 3King’s County Hospital Medical Center, NY Objective: AAH is a severe clinical state with significant morbidity with impending mortality in 28 days of about 49 %. Standard of care (SOC) is absolute abstinence and nutrition with restricted use of corticosteroids and pentoxyphilline. Method: Forty five (n = 45) patients with AAH, Age 32–58 (mean 46), mean BMI 24 %, Mean Alcohol consumption 80 grams/day. DF [32 %, Lilies score [ 0.67, ABCI (Albumin, Total Direct Bilirubin, creatinine and INR) [ 9, mean MELD 24 and mean HOMA 0.9. Group A (n = 15): I.V Methyl Prednisolone, i.v. Vitamin C 500 mg + Pentoxifylline 400 mg orally for 4 days followed by Prednisone 60 g orally for 30 days. Group B (n = 15): I.V NAC + IV Vitamin C + Pentoxifylline for 4 days followed by Prednisone for 30 days. Group C (n = 15): IV Methyl Prednisolone + IV NAC + Pentoxifylline for 4 days followed by Prednisone for 30 days. Results: Conclusion: This study postulates effects of IV NAC to the SOC in AAH is safe, efficacious with faster recovery time.

College of Physicians and Surgeons, Columbia University, New York, NY, 2James J. Peters VA Medical Center, Icahn School of Medicine at Mount Sinai, NY, 3King’s County Hospital Medical Center, NY Objective: Severe alcoholic hepatitis (SAH) still remains a clinical challenge with mortality of 47 % with steroid non-responsiveness immunosuppressives remains SOC. MMF is a immunosuppressive reduces B and T lymphocytic recruitment and immune injury. This study evaluates the role of MMF in steroid unresponsive SAH, reduction of necro-inflammation, acute liver decompensation needs transplantation which remains controversial. Methods: Thirty patients aged 25–60 diagnosed with steroid unresponsive SAH, with severity score criteria (DF [ 32 %, ABCI [ 12, Lile [ 0.45, MELD [ 26. Exclusion: Hepatitis A,B, C, GI bleed, Hepatic Encephalopathy or sepsis. Group A MMF 500 mg bid with Ptx 400 mg and Placebo orally for 30 days. Group B Prednisolone 30 mg plus Placebo (Vit D) and Ptx 400 mg orally 30 days. Group C Prednisolone plus NMF and PTX orally for 30 days. Results: Group A Day 0

Group B Day 90

Day 0

Group C Day 90

Day 0

Day 90

T.bilirubin

14

1.3

13

8

15

2.1

INR

2.1

0.9

2.1

1

2.3

0.8

Albumin

2.3

3.3

2.4

3

1.9

3.1

Creatinine

1.8

0.7

1.5

0.8

2.4

1

WBC

5.7

8.6

3.8

5.4

9.2

5.2

Hemoglobin

9.7

11.8

9.4

12

9.1

12

Platelets

138

303

121

251

98

187

MELD

22

4

20

10

24

10

AST ALT

321 187

31 23

341 157

39 25

421 299

34 36

TNF

9.7

0.4

8.9

1.1

12.2

0.3

IL-6

7.9

0.2

6.7

1

9.8

0.1

IL-8

5.3

0.03

4.9

0.6

11.4

0.8

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S12 Conclusion: This study postulates MMF is well tolerated, safe, and effective. MMF independently and precipitously reduced the necroinflammatory score compared with the SOC. A larger trial needs to validate the singular role of MMF in AAH.

Topic: 2 Alcoholic Liver Disease Absno: 724 Effects of Korean red ginseng (Panax ginseng), urushiol (Rhus vernicifera Stokes), and probiotics on gut-liver axis of alcoholic liver disease in mice Ki Tae Suk1, Dong Joon Kim1, So Hyung Hong2, Myoung Jo Kim3, Seung-Woo Kim1 1

Department of Internal Medicine, Hallym University College of Medicine, 2Department of Molecular Medicine, Hallym University, 3 College of Agriculture and Life Science, Kangwon National University, Cuncheon, Korea Introduction: lipopolysaccharide (LPS) and toll like receptor-4 (TLR4) in the pathogenesis of alcoholic liver disease (ALD) has been widely established. We evaluated effect of natural products (urushiol and Korean red ginseng [KRG]) and probiotics (Lactobacillus rhamnosus R0011 and Lactobacillus acidophilus R0052), which were known as therapeutic candidates in ALD, on gut-liver axis. Materials and methods: One hundred C57BL/6 mice were divided into normal (N) and saturated fat (H) diet groups. Each group was divided into five sub-groups: control, alcohol (L, 5 g/kg/day of alcohol [9 weeks]), alcohol+probiotics (LL, alcohol [7 weeks]+1 mg/mL/day of probiotics [2 weeks]), alcohol+KRG (LK, alcohol [7 weeks] + 200 mg/ kg/day of KRG [2 weeks]), and alcohol+urushiol (LU, alcohol [7 weeks] + 0.128 mg/mL/day of urushiol [2 weeks]). A liver function test, histologic and electron-microscopic finding, cytokines (IL-1b, TNF-a, IL-6, and IL-10), and TLR4 were evaluated and compared. Results: The TNF-a was decreased in the NLL, NLK, and NLU (12.30 ± 1.54, 13.42 ± 1.18, and 12.08 ± 1.35 vs. 27.87 ± 4.37 pg/ mL [NL]) (p \ 0.05). The IL-1b was decreased in NLK (63.88 ± 14.92 vs. 149.37±13.13 pg/mL [NL]) (p \ 0.05). The IL10 was increased in HLL (25.33 ± 4.18 vs. 7.58 ± 2.10 pg/mL [HL])(p \ 0.01). In the pathology, hepatitis was significantly decreased by treatment. TLR4 in the NLL and NLU were decreased compared with NL ([0.63 ± 0.14 and 0.76 ± 0.08] vs. [0.90 ± 0.15]) (p \ 0.05). In the HLL, TLR4 was 0.66 ± 0.14 which was significantly lower than HL (0.93 ± 0.20). Conclusions: Probiotics, KRG, and urushiol are effective in the treatment of ALD by anti-inflammatory effect in gut-liver axis. Grant: Cooperative Research Program for Agriculture Science and Technology Development (PJ 009859) Rural Development Administration, Republic of Korea.

Topic: 2 Alcoholic Liver Disease Absno: 885 Clinical factors correlated to alcohol withdrawal in patients with alcoholic liver disease Dong Wook Choi, Dae Hee Choi, Sang Hyuk Lee, Dong Gyu Lee, Kyoung Ree Lim, Tae Suk Kim, Wonho Lee, Eun Ju Cho, Sung Chul Park, Chang Don Kang, Sung Joon Lee

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Hepatol Int (2014) 8:S1–S405 Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, South Korea Background: Alcohol related diseases including alcohol withdrawal(AW) are still big social and medical problems. But the studies about clinical factors associated with the development and prognosis of alcohol withdrawal are lacking. Therefore, the aim of this study was to evaluate the clinical factors associated with AW in patients who were admitted to a general hospital with alcoholic liver disease. Method: This retrospective case-control study targeted the patients with alcoholic liver diseases, such as alcoholic hepatitis and alcoholic liver cirrhosis, who were admitted in the Kangwon national university hospital between January 2008 and October 2013. We divided two groups, AW and non-AW, and analyzed alcohol consumption habits, comorbidities, laboratory findings and hospital courses by medical record. Results: We analyzed 212 cases out of 602 admitted cases, 390 cases were excluded due to alcohol abstinence for more than 1 month before admission. In AW group, 54 cases (25.4 %) were included and median age was 49.7 years old. Presence of previous alcohol withdrawal history (p = 0.036), higher diastolic pressure (82.3 ± 10.7 mmHg vs. 76.6 ± 13.1 mmHg, p = 0.003), more elevated MCV (101.4 ± 9.4 fL vs. 97.1 ± 11.1 fL, p = 0.021), and GGT (796.5 ± 538.7 mg/dL, vs. 435.3 ± 468 ± 3 mg/dL, p = 0.000) and less PT(INR) (1.212 ± 0.256, vs. 1.386 ± 0.489, p = 0.030) were statistically significant variables between two groups. In addition, AW patients needed a longer ICU stay and length of hospitalization compared to the patients without AW, but there were no differences in complications and mortality rates between two groups. Conclusion: Several clinical findings, such as prior alcohol withdrawal history, MCV, GGT, and PT (INR) were associated with AW. And there were no significant differences in mortality rates between two groups, but longer ICU stay and length of hospitalization were required for management of AW. Therefore, a proper evaluation and treatment is needed as soon as they are admitted.

Topic: 2 Alcoholic Liver Disease Absno: 918 Spur cell anaemia in alcoholic liver disease: does more spur cells really matter Lovkesh Anand1, Naveen Kumar1, Ashok Choudhry1, Chagan Bihari2, Ajeet Singh bhaduria3, Chandan Kumar Kedarishetty1, Shiv Kumar Sarin1 Department of Hepatology, 2Department of Hematology, Department of Biostatistics and Epidemiology, Institute of Liver and Biliary Sciences, New Delhi

1

3

Aim: Spur cell anemia (SCA) is a form of acquired hemolytic anemia seen in patients with advanced liver disease and particularly in patients with alcoholic etiology. This study was performed to study the prevalence of spur cell anemia and its correlation with liver disease severity, impact of spur cell percentage, association with various complications of end stage liver disease and overall prognosis. Materials and methods: Retrospective and prospective analysis of patients admitted to the hospital for alcoholic liver disease was done. Peripheral blood picture was studied and correlated with biochemical and clinical markers of liver disease. Results: Of the 1507 alcoholic cirrhotics, 135 (9 %) had spur cells in the peripheral blood. Of these 135 patients 100 patients were having spur cell anemia with Hb\10 gm/dl. These patients were further analyzed. They were subdivided into two groups on the basis of percentage of spur cells seen on peripheral smear—one group having spur cells between 1


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Table 1 Clinical characteristics in alcoholic cirrhotic patients with spur cells less than and more than 5 % Characteristics

Reticulocyte count 1–4 % (n = 84)

Reticulocyte count C5 % (n = 16)

p value

CTP—median (IQR)

11.0 (11–12)

11.5 (10.25–13)

0.41

MELD—median (IQR)

25 (20.25–30.75)

27.5 (22–31.75)

0.22

Alcoholic hepatitis

26 (31 %)

7 (43.8 %)

0.32

GI Bleed

38 (45.2 %)

5 (31.3 %)

0.30

Sepsis

44 (52.4 %)

7 (43.8 %)

0.52

Hepatic encephalopathy

57 (67.9 %)

Death

20 (23.9 %)

12 (75 %) 5 (31.3 %)

0.57

serum bilirubin (p = 0.003) and DF score (p = 0.001). SIRS, HE, and serum creatinine at baseline were significant predictors on univariate analysis for AKI development. On multivariate analysis, SIRS predicted both AKI development (p\0.001, OR 2.7, 95 % CI 1.5–4.6) and AKI progression (p = 0.05, HR 2.1, 95 % CI 1.1–4.6). Resolution of AKI was also significantly associated with SIRS (p = 0.05). High MELD score (C18) (p = 0.008, HR 2.1, 95 % CI 1.2–3.6), in-hospital progression of AKI (p = 0.01, HR 1.8, 95 % CI 1.1–2.9) and SIRS (p = 0.001, HR 2.9, 95 % CI 1.5–5.7) were significant predictors of short-term mortality at 1 and 3 months. Conclusion: SIRS at admission predicts both development and in-hospital progression of AKI as well as short-term mortality in patients with SAH. This could definitely have a therapeutic and prognostic implication.

0.64

to 4 % and the other group having spur cells C5 %. The median CTP and MELD score was 11 (IQR 11–12) and 25.5 (IQR 21–31). The 30 day mortality of patients presenting with spur cell anemia was 25 % (n = 25). The presence of spur cell anemia correlated strongly with the presence of hepatic encephalopathy 69 % (n = 69), sepsis 51 % (n = 51), GI bleed 43 % (n = 43) and alcoholic hepatitis 33 % (n = 33). The mean hemoglobin level of patients with spur cell anemia was 7.9 gm/dl, platelet-92,000/mm3, total bilirubin—10.9 mg/dl, indirect bilirubin—5.7 mg/dl and an INR of 2.2. There was no statistical difference in any parameters tested in the group of patients having 1–4 % and equal to or more than 5 % spur cells. Conclusion: This study shows that the presence of spur cell anemia is associated with a severe liver disease and with high mortality without any significance of the percentage of spur cells present as shown by few studies conducted previously. Very high association with hepatic encephalopathy argues for some common factor being responsible for causation of spur cell anemia and hepatic encephalopathy. Patients with spur cell anemia should be urgently worked up for liver transplantation and should be aggressively evaluated and managed for GI bleed, sepsis and hepatic encephalopathy. (Table 1)

Topic: 2 Alcoholic Liver Disease Absno: 935 SIRS at admission is a predictor of AKI development and mortality in hospitalized patients with severe alcoholic hepatitis Rakhi Maiwall, Muralikrishnan Shashthry, Manoj Kumar Sharma, Shiv Kumar Sarin ILBS Background: Systemic Inflammatory response syndrome (SIRS) is associated with an increased risk of hepatic encephalopathy (HE), renal failure and poor outcome in patients with acute liver failure, however this is not reported for severe alcoholic hepatitis (SAH). Aim: To look at SIRS at baseline as a predictor of AKI development and progression including mortality in patients with SAH. Methods: Consecutive in-patients with SAH (DF C 32) without AKI at baseline were included and followed for the development and progression of AKI (AKIN criteria). Results: Of the 427 patients (mean age 45.5 ± 9.5, 416 males), SIRS at baseline was present in 312 (73 %). AKI developed in 143 (33.5 %) of which 62 (14.5 %) had progression of AKI. Presence of SIRS significantly correlated with serum creatinine (p = 0.001), Na (p = 0.01),

Topic: 2 Alcoholic Liver Disease Absno: 940 Alcoholic liver cirrhosis and bacterial infections A. Babameto, J. Basho, B. Resuli, L. Cuko, K. Xhaferri, E. Shagla, I. Bibolli, F. Kuqi, M. Sina, S. Taci, I. Tafaj, B. Kraja, S. Prifti Department of Gastroenterology & Hepatology, University Hospital Center ‘‘Mother Theresa’’, Tirana, Albania Introduction: Bacterial infections (BI) are known as a major, frequent and severe complication of liver cirrhosis (LC) also as an important cause of death. In fact, up to 25 % of cases of death in cirrhotic patients are believed to be related to bacterial infections. And alcohol seems to be a predisposing factor to infections in such patients. Aim: The aim of this study was to compare the frequency and influence of bacterial infection among alcoholic and nonalcoholic cirrhotic patients. Method: The study was a retrospective one and included a cohort of 462 inpatients in a single terciary medical center, with an established diagnosis of LC. From whom, 249 patients (53.90 %) were alcoholic cirrhosis (alcohol intake [or = 80 g/day for [or = 10 years) and 213 (46.1 %) were nonalcoholic ones. Results: Infection upon hospitalization was present in a total of 148 patients (32.3 %), 90 (60.8 %) of whom were alcoholic and 58 (39.2 %) of whom were nonalcoholic (p = 0.03). A total of 189 cases of infection were diagnosed and related to the frequency it was found spontaneous bacterial peritonitis (SBP) as the most prevalent one in 98 cases (51.8 %), followed by respiratory tract infections (mostly pneumonia and bronchopneumonia) in 38 cases (20.1 %), infection of the soft parts in 23 patients (12.2 %), and urinary tract infections in 18 patients (9.5 %). The study revealed that in Child-Pugh C group of patients the frequency of infections and deaths were significantly more than in Child-Pugh A and B ones (respectively p = 0.002 and p = 0.004). For the group Child-Pugh A and B it was found that alcoholic patients were more susceptible to infection compared to nonalcoholic patients (p = 0.02), but no difference was found related to the death, except the cases of Child-Pugh B with SBP (p = 0.04). For the patients with Child-Pugh C, was found statistical difference for the infections or deaths among alcoholics and nonalcoholics only when SBP was present (p = 0.05), while it was not found in total between alcoholics and nonalcoholics ones (p = 0.06). Conclusion: Our study revealed that bacterial infections are more common in cirrhotic alcoholics than in nonalcoholic ones. Despite this its seems that the mortality rate is associated more with the severity than with the etiology of the hepatic disease, except the cases of SBP presence.

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Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease

Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease

Absno: 19

Absno: 81

The miRNA profiling as a novel marker to predict clinical course of patients with primary biliary cirrhosis: comprehensive analysis with deep sequencing

Study of laboratory tests and clinical features of primary biliary cirrhosis

T. Katsumi1, M. Ninomiya2, K. Mizuno, K. Tomita1, C. Sato1, K. Okumoto1, Y. Nishise1, H. Watanabe1, T. Saito1, T. Shimosegawa2, Y. Ueno1 1 Department of Gastroenterology, Yamagata University Faculty of Medicine, Yamagata,Japan, 2Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan

Background: PBC is considered to be an autoimmune disease, although its pathogenesis remains to be unclear. PBC is largely classified into 3 subtypes by clinical course; (i) a major part of patients gradually progressing and staying within the asymptomatic stage for a long period (Gradual progress type), (ii) other proportion of patients developing portal hypertension without presenting jaundice (Portal hypertension type), and (iii) a minor part of patients rapidly presenting jaundice and hepatic failure (Hepatic failure type). Recently, several studies have reported that microRNAs (miRNAs), demonstrate specific expression patterns in a variety of diseases. In this study, we aimed to evaluate miRNA expression patterns among three distinct clinical course of PBC using comprehensive deep sequencing technique. Methods: Each 3 subgroup of PBC (Gradual progress type, Portal hypertension type, Hepatic failure type), and healthy subjects as a control were enrolled in this study (n = 5, respectively). The international criteria (Poupon criteria or Barcelona criteria) were used for the judgments of responses to the treatment during the clinical course. Total RNA was extracted from individual serum samples with Trizol LS (Invitrogen). The library was prepared and we detected circulating miRNAs using Illumina Genome Analyzer IIx. After mapping to the database (miRBase and UCSC: hg19), we could successfully identified the reads of miRNAs. Cluster analysis was performed to create a heat map. Quantitative RT-PCR with Taqman miRNA assay was conducted for validating the expression levels of the miRNAs obtained from deep sequencing. Furthermore, the quantified expression levels of miRNAs were compared between the initiation and 2 years after the therapy. Results: We obtained approximately 11 million of 32 mer shortreads on average per sample. The expression levels of 97 miRNAs were found to be statistically significant between 4 groups (p \ 0.05). The heat map and hierarchical clustering demonstrated that the miRNA profiles from both Hepatic failure type and Portal hypertension type differently clustered from those of Gradual progress type and healthy controls. Furthermore, quantitative RTPCR revealed that particular down-regulated miRNAs predicted the favorable outcomes in Gradual progress type after drug interventions. Conclusion: There were characteristic expression profiles of miRNA among clinical subgroup of PBC by comprehensive analysis using deep sequencer. The current study demonstrated that specific miRNAs profiling could serve as a clinical prognostic biomarker for distinguishing the clinical course of PBC.

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Yongkang Wu1, Chunfang Jin1, Linxin Li1, Jing Hu1, Bin Yang1, Zhuochun Huang1, Lanlan Wang1 1 Department of Laboratory Medicine, West China Hospital affiliated Sichuan University, Chengdu, China

Objective: We aimed to investigate the characteristics of the laboratory tests and clinical features of primary biliary cirrhosis (PBC). Method: All patients were enrolled according to the inclusion and exclusion criteria during Jan,2013 to June, including 3 groups as PBC, virus hepatitis and healthy controls. Tests of liver function and autoantibodies were detected and compared the laboratory tests and clinical features of each group. Result: The positive rate of anti-mitochondrial antibody 2 (AMAM2), anti-Sp100 and anti-gp210 in PBC patients were 85.71 %, 19.05 % and 38.10 % respectively, significantly higher than the virus hepatitis and healthy controls (P \ 0.05). Anti-sp100 or anti-gp210 in one of 21 (4.8 %) PBC patients was positive while the AMA-M2 negative. The concentration of alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), direct bilirubin (DBIL) and indirect bilirubin (IBIL) were significantly higher than the healthy controls(P \ 0.05), but lower than virus hepatitis group. The red blood cell count (RBC), hemoglobin (HGB), platelet count (PLT) levels of PBC were significantly decreased than healthy controls (P \ 0.05). The positive rates of portal hypertension (42.9 %), gastrointestinal bleeding (50.0 %), osteoporosis (28.6 %) were significantly higher than the other 2 groups. Conclusion: The positive rate of AMA-M2 is high and can be a sensitive indicator of PBC, Anti-sp100 and anti-gp210 was useful as a complementary diagnosis test for PBC although with lower sensitivity. PBC as a chronic disease impaired with liver function and severe anemia, in addition ALP with universal increase can provide some clues for PBC. Clinical features such as hypertension, gastrointestinal bleeding and osteoporosis should be concerned about in diagnosis of PBC. Keywords: Primary Biliary Cirrhosis; AMA-M2; autoantibodies; clinical features

Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease Absno: 83 Emodin attenuates bile acid-induced and palmitate-induced hepatocyte apoptosis by suppressing JNK activation Yun Bin Lee1, Jung-Hwan Yoon1, Eun Ju Cho2, Dong Hyeon Lee1, Yuri Cho1, Su Jong Yu1, Jeong-Hoon Lee1, Yoon Jun Kim1, Chung Yong Kim1, Hyo-Suk Lee1


Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea, 2Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea Background/aim: Emodin,1,3,8-trihydroxy-6-methyl-anthraquinone, is an anthraquinone derivative contained in the rhizome of Rheum palmatum L., which is traditionally used in Chinese medicine. It has been reported that Emodin possesses biological activities such as antiinflammatory or hepatoprotective effects. Thus, we aimed to investigate if Emodin may attenuate hepatocyte apoptosis induced by bile acid or saturated fatty acid. Methods: We performed in vitro studies using human hepatocellular carcinoma cell line, SNU761, which contains bile acid transporter and thereby, susceptible to bile acid-induced apoptosis. Deoxycholate (DC) and palmitate were used to induce apoptosis. Endoplasmic reticulum (ER) stress was induced by tunicamycin or thapsigargin. Cell growth and apoptosis were assessed using MTS assay, and apoptotic and kinase signaling pathways were explored by immunoblot analysis. Results: Emodin diminished DC- and palmitate-induced JNK activation, which in turn lead to attenuation of caspase-dependent hepatocyte apoptosis. However, Emodin did not affect tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)-induced and ER stress-induced apoptosis, indicating that it had no effects on death receptor- and ER stress-mediated pro-apoptotic signalings. Conclusions: Emodin attenuates bile acid-induced hepatocyte apoptosis and palmitate-induced hepatocyte lipoapoptosis by suppressing JNK activation. Therefore, Emodin may exhibit hepatoprotective activities against cholestatic liver injury and steatohepatitis. Keywords: Emodin; Hepatocyte apoptosis; Lipoapoptosis; c-Jun N-terminal kinase (JNK); Endoplasmic reticulum stress; Death receptor

S15 Patients and Methods: We compared long-term prognosis, efficacy and safety between the combination therapy with BF and UDCA and UDCA monotherapy for patients showing refractory responses to UDCA monotherapy in a prospective, multicenter, randomized controlled study. Total consecutive 27 patients were enrolled. Results: Serum ALP levels were significantly reduced and creatinine levels were significantly increased by the combination therapy than UDCA monotherapy throughout the study duration. Besides, platelet levels were significantly increased and total birilubin levels were significantly decreased by the combination therapy compared to the corresponding basal levels, and these effects were more evident at 8 years after the start of therapy. Serum IgM levels were also significantly decreased by the combination therapy and there were a trend towards decreasing of serum IgM levels with time. However, there were no significant differences of the survival and the severity of PBC between both the therapy groups. We observed dose reduction or discontinuation of administration of BF, but not UDCA. The combination therapy also significantly decreased serum IL-18 levels at 12 months after the start of therapy. Conclusions: Long-term combination therapy significantly improved important biochemical responses other than serum ALT levels compared to UDCA monotherapy. However, the survival and severity of PBC were not significantly different between both the therapy groups. Based on our results, we should closely pay attention to incidence of renal dysfunction during the long-term combination therapy because BF had the nephrotoxic potential. Large prospective studies should be examined to confirm our results.

Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease Absno: 261 Predictability of the incidence of complications in patients with primary biliary cirrhosis

Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease Absno: 260 Long-term prognosis of combination therapy with ursodeoxycholic acid and bezafibrate for primary biliary cirrhosis: A prospective, multicenter, randomized controlled study Ken Sato1, Kenichi Hosonuma1, Yuichi Yamazaki1, Masatoshi Yanagisawa1, Hiroaki Hashizume1, Norio Horiguchi1, Satoru Kakizaki1, Motoyasu Kusano2, Masanobu Yamada1 1

Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan, 2 Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Maebashi, Gunma, Japan Introduction: Ursodeoxycholic acid (UDCA) is reported to be effective for primary biliary cirrhosis (PBC) and has been established as a standard therapy for PBC. In fact, long-term UDCA therapy reportedly ameliorates the prognosis of PBC particularly in patients with non-advanced disease. However, there still remain some patients showing refractory responses to UDCA. Bezafibrate (BF), a fibric acid derivative alone or in combination with UDCA, effectively ameliorates biochemical findings and serum IgM levels. However, the long-term prognosis of PBC patients who treated with the combination therapy has not been reported.

Y. Fujinaga1, T. Nakatani1, Y. Sawada1, S. Saikawa1, N. Shimozato1, S. Nagamatsu1, H. Matsuo1, E. Kikuchi1 1 Department of Gastroenterology, Nara Prefectural Nara Hospital, Nara, JAPAN

Introduction: The prognosis of primary biliary cirrhosis (PBC) is affected by its complication such as portal hypertension (PH) or hepatocellular carcinoma (HCC). Although gp210 and anti-centromere antibody are known as useful predictive markers for its prognosis, it is practically difficult to estimate them in all cases. Thus, the predictability for the prognosis of PBC was assessed using routinely available parameters. Methods: Thirty two patients (male/female 4/28, average age at diagnosis 57.8 ± 9.2, median observation period 112 months) diagnosed as PBC either histologically or clinically during the period between 1994 and 2012 were enrolled in this study. The relation between the change in serum parameters (ALT, ALP, gamma-GTP, T.Bil, PLT) and the incidence of complications (HCC, PH such as Gastro-esophageal varix etc.) was evaluated. Liver biopsy was conducted in 21 patients, consisting of 8/8/5/0 patients in Scheuer staging 1/2/3/4, respectively. Ursodeoxycholic acid with or without bezafibrate was administered for treatment. Results: Each parameter such as ALT, ALP and gamma-GTP (before treatment/3 months after treatment) was 76.3 ± 92.3/ 32.8 ± 21.2 IU/l, 702.8 ± 375.9/451.6 ± 197.8 IU/l, 274.2 ± 219.7/92.5 ± 69.1 IU/l, respectively, indicating statistically significant amelioration (p \ 0.01). On the other hand, no significant change was observed in PLT and T.Bil after medication. However,

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S16 when focusing on symptoms, the number of PLT was gradually declining with time in the symptomatic population in contrast to the asymptomatic one. The total number of life-threatening complications was 12 in 6 patients (2 cases with HCC, 4 with gastroesophageal varix, 1 with GAVE, 1 with portal hypertensive gastropathy, 2 with hepatic encephalopathy, 2 with ascites). In the univariate analysis, the symptomatic PBC as well as the high level of parameters (ALT, T.Bil, ALP, gamma-GTP) after commencement of the treatment was significantly associated with the incidence of the complication. Next, when patients were divided into 2 groups according to the number of PLT (group A: PLT [ 150,000; group B: PLT \ 150,000), the mortality rate after 6 months based on the predictive formula of prognosis by Japanese Liver Transplantation Society was higher in group B (P \ 0.05). In addition, more complications were observed in group B as well (A/B, 13 %(3/24)/38 %(3/8)). All the 3 patients with complications in group A showed the declining of PLT by more than 50,000 from the beginning of treatment, while those without complications in group A did not. Thus, the low number of PLT at the diagnosis or significant declining of PLT after treatment could be associated with the higher incidence of complications. Conclusions: In patients with PBC, the state of symptoms as well as the number of PLT at the diagnosis, and the level of PLT declining as well as the change in hepatic function after treatment could be useful markers for predicting the incidence of subsequent developing complications.

Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease Absno: 321 Frequency of circulating CD4+CXCR5+TFH cells are associated with disease severity and treatment outcome in primary biliary cirrhosis patients Juanjuan Zhao, Lifeng Wang, Zheng Zhang, Ying Sun, Fu-Sheng Wang Research Center for Biological Therapy, Beijing 302 Hospital, Beijing 100039, China Objectives: Primary biliary cirrhosis (PBC) is a progressive autoimmune liver disease that characterized by the immune-mediated destruction of small and medium-sized bile ducts. Although there have been significant advances in the dissection of the innate and adaptive immune response in the disease progression, but the detail mechanisms are still not clear. Human follicular helper T (Tfh) cells, characterized by high expression of CXCR5 and CD4, have been reported to relate with a lot of autoimmune diseases. The purpose of this study was to examine the roles of Tfh in PBC patients. Methods: Forty-five patients with PBC were enrolled and compared with 20 classical autoimmune hepatitis (AIH), and 20 Healthy patients as controls. Peripheral CD4+CXCR5+ T cells frequency and their cytokines secretion ability were detected by flow cytometry and intracellular staining (ICS) separately. The proportion and location of CD4+CXCR5+ T cells in the liver tissue was also examined by immunohistochemistry. Finally, the association between frequency changes of Tfh and UDCA treatment effect was also analyzed by retrospective and prospective studies. Results: We found that the frequency of circulating and intrahepatic Tfh cells in PBC patients was significantly higher than that of AIH, and HC. The Tfh cell frequency is also accompanied by the level of ALP and IgM in PBC patients. Moreover, the severity in PBC patients correlated with the frequency of circulating Tfh cells. In addition,

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Hepatol Int (2014) 8:S1–S405 significantly decreased frequency of Tfh was observed during the 1 year follow up in patients who completely response to Ursodeoxycholic acid (UDCA) treatment, but not in incomplete responders. Conclusion: These data indicate that Tfh cells may participate in the PBC-related immune responses and that the frequency of CD4(+)CXCR5(+) Tfh cells may be a biomarker to the evaluation of therapeutic effect of UDCA .

Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease Absno: 394 Comparative analysis of expression and gene polymorphisms TNF-alpha in autoimmune liver diseases and chronic hepatitis C L. K. Palgova1, N. V. Marchenko1, V. E. Karev2, K. L. Raikhelson1, A. Yu. Baranovsky1 1 North-Western State Medical University named after I.I Mechnikov, Department of Gastroenterology and Dietology, Saint-Petersburg, Russia, 2Research Institute of Children’s Infections of Federal Medico-Biology Agency, Saint-Petersburg, Russia

Introduction: The impact of tumor necrosis factor alpha (TNFa) on development and maintenance of a chronic inflammation at autoimmune liver diseases (AiLD), such as autoimmune hepatitis (AIH) and primary biliary cirrhosis (PBC) is discussed. At the same time, TNF-a is an important cytokine in generating an immune response against infection with hepatitis C virus (HCV). The aim of this study was to examine serum TNFa level and its expression in a liver tissue in AiLD compared with CHC and assessed TNF-a gene polymorphisms -308 G/A and -238 G/A in patients with PBC and AIH. Materials and methods: Serum TNFa level was quantified using ELISA at 41 patients (13—autoimmune hepatitis (AIH), 18—primary biliary cirrhosis (PBC), 10—chronic hepatitis C (CHC)). We processed liver biopsies for immunohistochemical cell characterization from 37 patients (15—PBC, 12—AIH, 10—CHC). The expression of TNFa in nonparenchymal liver cells (NPCs) was quantified as a percent positive cells rather CD68 as a whole. The number of CD68-positive macrophages and TNFa were counted in 15 HPF (9400). TNFa gene polymorphisms -238 G/A and -308 G/A were assessed by polymerase chain reaction and restriction fragment length polymorphism in AiLD groups and 146 controls. Activity scores were similar in all groups (METAVIR A2-A3). Results: Serum TNFa level in all groups were less than normal limit. The expression of TNFa in a liver tissue was significantly higher in patients with CHC in comparison with AIH and PBC (p \ 0.5; p \ 0.01, respectively). On the other hand, there was not found statistically significant difference in the expression of TNFa in AIH patients in comparison with PBC patients (p[0.05). The number of CD68 was significantly higher in patients with CHC in comparison with AIH and PBC (p \ 0.005; p \ 0.05, respectively). We did not observed statistically significant differences in CD68 expression in groups of AIH and PBC (p[0.05). The TNFa-308 G/A genotype was found more frequently in AIH patients (46.1 %) compared with control (9.6 %, p \ 0.5). There was not difference between TNFa-308 G/A genotype frequency in PBC (22.2 %) and control group. The distribution of -238 G/A genotype did not differ either between patients with PBC (11.1 %) or AIH (7.7 %) and control group (11.28 %). Conclusions: We have not found high serum levels of TNFa in patients with PBC, AIH, CHC, and it does not reflect this cytokine synthesis in the liver. We also found a low level of expression of TNFa in liver tissue in AiLD in comparison with CHC. Our results

Hepatol Int (2014) 8:S1–S405 may reflect different mechanisms of pathogenesis in that disease. TNFa-308 G/A polymorphism are important in the development of the AIH, but not PBC. References 1. Tilg H, Kaser A, Moschen AR. How to modulate inflammatory cytokines in liver diseases. Liver Int. 2006; 26(9):1029–1039. 2. Tacke F, Luedde T, Trautwein C. Inflammatory pathways in liver homeostasis and liver injury. Clin Rev Allergy Immunol. 2009; 36(1):4–12.

Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease Absno: 516 Hepatic granulomas in Turkey: a seven year experience Memduh Sahin1, Mehmet Arhan1, Guldal Yilmaz2, Ibrahim Dogan1, Harun Erdal1, Mehmet Ibis1, Selahattin Unal1 Gastroenterology, Gazi University, Ankara, Turkey, 2Pathology, Gazi University, Ankara, Turkey 1

Background: Hepatic granulomas is not uncommon finding on liver biopsy. It is commonly associated with systemic diseases. Aim: This study performed to evaluate underlying etiologies in patients with hepatic granulomas in Turkey between 2005 and 2011. Materials and methods: A total of 2662 liver biopsy obtained from January 2005 to December 2011 in the Gazi University Gastroenterology Department were reviewed. Patients were from different regions of Turkey. Results: Hepatic granulomas were found in 35 (1.3 %) cases out of 2662 biopsy samples. Twenty seven of patients were female, with a mean age of 51.6 years (range 28–82). The most common causative etiology of hepatic granulomas was primary biliary cirrhosis in 15 cases (42.8 %). There were 6 cases of sarcoidosis (17.1 %). Other underlying etiologies were as follows: hepatitis C (5.7 %, n = 2), hepatitis B (5.7 %, n = 2), autoimmune hepatitis (5.7 % %, n = 2), fasciola hepatica (5.7 %, n = 2), tuberculosis (5.7 %, n = 2), leishmaniasis (2.8 %, n = 1), Hodgkin lymphoma (2.8 %, n = 1) and immune cholangiopathy (2.8 %, n = 1). One case had both sarcoidosis and primary biliary cirrhosis coincidentally (2.8 %, n = 1). There were coincidental brucellosis in one of the patient with tuberculosis and rheumatoid arthritis in another patient with tuberculosis. In conclusion, the etiology of hepatic granulomas is distributed in a wide range in this study. The leading causes of hepatic granulomas were primary biliary cirrhosis and sarcoidosis in Turkey.

Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease Absno: 805 Co-incidence of autoimmune diseases in autoimmune hepatitis A. Cetinkaya1, B. Kantarceken1, K. Gisi1, M. S. Deniz2, H. Bolat2 1 Department of Gastroenterology, School of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey, 2 Department of Internal Medicine, School of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey

S17 Introduction: Autoimmune hepatitis is a chronic, progressive liver disease that responds well to immunosuppressive therapy. Although the origin is unknown, a characteristic feature is the association with immunological changes, such as hypergammaglobulinaemia, presence of auto-antibodies and interface hepatitis, on histological examination. On the other hand, autoimmune hepatitis may be associated with other autoimmune diseases. The aim of the present study, was to investigation clinical characteristics of patients with autoimmune hepatitis and accompanying autoimmune diseases. Materials and methods: A total of 11 patients with autoimmune hepatitis who were followed up in our clinic since 5 years, were enrolled to the study. The demographical characteristics, antibody positivity (type) and accompanying autoimmune diseases were investigated retrospectively. Results: All of the patients were female and the mean age of the patients was 41.5. 8 (73 %) were type I autoimmune hepatitis and 3 (27 %) were type II autoimmune hepatitis. Type I autoimmune hepatitis patients were positive for antinuclear antigen (ANA) and antismooth muscle antigen (ASMA). Liver kidney microsomal antigen (LKM-1) was positive in all type II autoimmune hepatitis patients. Also ANA and anti-mitocondrial antibody (AMA) were positive in one patients. 3 patients (27 %) had concomitant autoimmune diseases; Graves disease, discoid lupus erythematosus and type I diabetes mellitus. Conclusion: We aimed to investigate and present the some features and accompanying autoimmune diseases in our patients. Although the number of the patients was low to make a clear recommandation, the accompanying autoimmune diseases should be keep in mind while following or treating the patients with autoimmune hepatitis.

Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease Absno: 821 The etiology and demographical features of cholestatic conditions in our patients K. Gisi1, B. Kantarceken1, A. Cetinkaya1, S. Yilmaz2, B. Ganidagli2 1

Department of Gastroenterology, School of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey, 2 Department of Internal Medicine, School of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey Introduction: Cholestasis with ichterus is a common clinical problem. Firstly, definition of the cholestasis must be done for further approach. Cholestasis may be intrahepatic or extrahepatic and treatment modalities differs according to the etiology. We aimed to investigate and present the etiology and demographical features in our patients with cholestasis. Materials and methods: Our research includes 30 inpatients who have clinical and labaratory cholestasis. The datas of the patients were investigated retrospectively for age, gender and cholestasis etiology. Results: The mean age of the patients was 54.4 years and 16 (53 %) were female. Etiology of cholestasis were; Choledocholithiasis in 12 (40 %) patients, drug use in 6 (20 %) patients, pancreatic cancer in 5 (17 %) patients, pancreatitis in 3 (10 %) patients, cholangiocellular

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S18 cancer, lymphoma, post transplant choledochal stricture, and idiopathic in 1 (3.3 %) patient, respectively. Conclusion: In this study, the main type of the cholestasis was extrahepatic. But the points, that should be keep in mind were the fact that some drugs can be done severe cholestatic picture and asking the medical history is very important.

Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease Absno: 891 Liver and celiac disease: the need to exclude autoimmune hepatitis Vikrant Sood, Sanjeev Kumar Verma, Rajeev Khanna, Dinesh Rawat, Seema Alam Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi – India Background: Celiac disease (CD) has wide spectrum of multi organ involvement and liver is one of the frequently encountered involved organ. We aimed to study the spectrum of liver involvement in children with CD. Methods: All children below 18 years of age with positive IgA tissue trans-glutaminase antibody (tTG) serology were included. Diagnosis of celiac disease was established as per modified ESPHGAN criteria. Liver involvement was noted in the form of high transaminases ([40 IU/L), hepatomegaly, coarse liver on USG or evidence of portal hypertension (PHT). All cases with liver involvement were screened with autoimmune markers. Results: There were 44 cases with positive tTG serology with mean levels of 151 + 108 RU/mL; 36.8 % had levels [10 times of upper limit of normal. Duodenal biopsies were available in 36. Potential Celiac disease was in 8 (22.2 %) cases. There was partial, subtotal and total villous atrophy in 11, 9 and 8 cases, respectively. Liver involvement was seen in 20/36 cases (55.5 %) with Celiac hepatitis (Transaminitis) in 12 (33.3 %) and chronic liver disease (CLD) in 8 (22.2 %). Autoimmune hepatitis (AIH) was present in 7 (19.4 %) cases, whereas 1 case had hepatic venous outflow tract obstruction (HVOTO) with hepatocellular carcinoma. PHT was seen in 6/8 cases with CLD. Transaminase level elevation was unrelated to tTG levels or severity of villous atrophy (p = NS). Conclusion: More than half of CD patients have some form of liver involvement ranging from elevated transaminases to chronic liver disease with or without PHT. One-fifth of liver disease patients were accounted by Autoimmune Hepatitis. Serum tTG levels poorly correlate with extent of liver disease.

Topic: 3 Autoimmune Hepatitis and Cholestatic Liver Disease Absno: 916 Usefulness of diagnostic scoring systems for seronegative autoimmune hepatitis Dinesh Rawat, Rajeev Khanna, Seema Alam, Sanjeev Kumar, Vikrant Sood

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Hepatol Int (2014) 8:S1–S405 Institute of Liver & Biliary Sciences, New Delhi Introduction: Diagnosis of seronegative autoimmune hepatitis(AIH) poses challenge due to inadequacies of proposed diagnostic criteria and lack of gold standard diagnostic tests. This study was conducted to assess the utility of simplified AIH score in comparison to the revised criteria proposed by International Autoimmune Hepatitis Group (IAIHG) in 1999 for diagnosis of seronegative autoimmune hepatitis. Methods: Retrospective case records of patients who presented to a single centre between January 2011–June 2013 were analysed and data collected for clinical features, laboratory tests including IgG levels, autoimmune markers, viral serology, liver biopsy, imaging and endoscopy findings. Diagnosis of seronegative AIH was based on high IgG, typical liver histology, response to immunosuppression and exclusion of etiologies. A group of 23 children with liver diseases due to other etiologies were taken as controls . Results: 27 children included (16 boys) with median age of 11.5 years (range 3.3–18 years). Median IgG levels were 26 g/l (range 11–53) while autoantibodies were present in 15/27 (56 %). The commonest antibodies were ANA and (or) SMA in 48 % with LKM-1 & SLA in 1 patient each. 12/27(44 %) children were diagnosed as seronegative AIH. Decompensation was more common in seropositive AIH as compared to seronegative group (60 vs 16 %, p = 0.04, OR 2.18). while acute hepatitis like presentation was more common in seronegative AIH (50 vs 7 %). Associated autoimmune disorders were more common in seropositive group with a higher incidence of autoimmune hemolysis (40 vs 8 %). Celiac disease was seen in 3 and diabetes in 1 child. All seronegative children were categorised as probable AIH based on revised IAIHG criteria with a score greater than 10 (sensitivity 100 %, specificity 82 %, NPV 100 %) but only 58 % were correctly diagnosed by simplified AIH criteria (sensitivity 58 %, specificity 91 %, NPV 80 %). Likewise in seropositive group, simplified AIH score only diagnosed 73 % of cases. Conclusion: Revised IAIHG score is helpful in diagnosis of seronegative autoimmune hepatitis while simplified AIH score has limited utility and requires further modification. Patients should be carefully screened for presence of autoimmune disorders, especially autoimmune hemolysis and celiac disease.

Topic: 4 Cholangiocarcinoma and Other Liver Neoplasms Absno: 132 A comparison of smear cytology and cell-block according to acquisition order in biliary strictures Tae Hoon Lee1, Hyun-Deuk Cho1, Sang-Heum Park1, Joung-Ho Han2, Hyun Jong Choi1, Jong Ho Moon1, Sang Woo Cha1, Young Deok Cho1, Sun-Joo Kim1 1 Digestive Disease Center, Department of Internal Medicine and Pathology, Soonchunhyang University School of Medicine, Cheonan, South Korea, 2Department of Internal medicine, Chungbuk National University College of Medicine, Cheongju, South Korea

Introduction: There was few data supports diagnostic accuracy depending on the procedural order of cytological sampling and the location or shape of tumors in biliary strictures. This study was performed to investigate diagnostic yield and variation according to sampling acquisition sequence and tumor location. Materials and methods: Prospectively enrolled patients who had undergone ERCP with tissue sampling were analyzed from August


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Table 1 Sequential procedure outcomes Both procedures (smear cytology and cell-block)

Triple procedures (ERCP biopsy, smear cytology and cell-block)

Group A (C ? B)

Group B (B ? C)

P-value

Group A (C ? B)

Group B (B ? C)

Sensitivity (%)

18/32 (56.2)

30/46 (65.2)

18/29 (62)

Specificity (%)

5/5 (100)

0.525

10/13 (76.9)

9/10 (90)

[0.999

1/1 (100)

3/3 (100)

30/31 (96.7)

[0.999

10/10 (100)

18/18 (100)

P-value

0.485 –

PPV (%)

18/18 (100)

NPV (%)

5/18 (27.7)

9/25 (36)

0.570

1/4 (25)

3/14 (21.4)

[.9999

23/36 (63.8)

39/56 (69.6)

0.566

11/14 (78.5)

22/32 (68.7)

[.9999

Accuracy (%)

–

C, smear cytology; B, cell-block; PPV, positive predictive value; NPV, negative predictive value

2008 to July 2013. Group A was obtained smear cytology followed by cell-block sequentially, and Group B was examined in reverse order with or without biopsies. Outcome measurements were diagnostic accuracy and assessment for cellularity according to tumor type or location in the biliary tract. Results: A total of 138 patients were enrolled; among them, 92 patients were assessed using both smear cytology and cell-block preparations. There was no difference in the diagnostic yield between the two groups (P \ 0.566, Table 1). The cellularity of the samples from smear cytology was better than cell-block samples according to the location of the tumor (P \ 0.001). Conclusions: There were no differences in diagnostic accuracy depending on the sequence of acquisition order of the smear cytology and cell-block with or without biopsies. However, smear cytology showed a better cellularity for diagnosis.

and hepatitis C virus antibody were negative. Gd-EOB-DTPA enhanced MRI showed diffuse and multiple space-occupying lesions. An arterial phase image demonstrated scanty enhancement of the mass. A portal venous phase image showed rapid washout of contrast enhancement from the lesion, which was entirely hypointense in the delayed phase and hepatobiliary phase. Whole-body FDG-PET/CT fusion scanning confirmed metabolic activity with a maximum uptake value of 3.66 in the lesions. A liver biopsy revealed spindle-shaped tumor cells proliferating along sinusoids, with elongated and hyperchromatic nuclei. Immunohistochemical studies showed tumor cells that were positive for von Willebrand factor and CD34. The Ki-67 index of the tumor was 19.58 %, which confirms that the tumor was a well-differentiated low-grade angiosarcoma. Transmission electron microscopic study revealed well-formed neoplastic vessels lined by endothelium with focal proliferation and protrusion into the lumen and endothelial cells overlapping in a disordered manner, forming bridges along hepatic sinusoids. These findings were consistent with angiosarcoma of the liver. This case report is the first description of coregistered FDG-PET/CT images and Gd-EOB-DTPA MRI of primary hepatic angiosarcoma.

Topic: 4 Cholangiocarcinoma and Other Liver Neoplasms Absno: 330 A retrospective study of gemcitabine plus cisplatin as first-line therapy in advanced biliary tract cancer Dong Jun Kim, Byeong Jun Song, Su Bum Park, Hyung Wook Kim, Cheol Woong Choi, Kyung Won Koh, Dae Hwan Kang

Topic: 4 Cholangiocarcinoma and Other Liver Neoplasms

Division of Gastroenterology, Department of Internal Medicine, School of Medicine Pusan National University, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, South Korea

Absno: 158

Introduction: Gemcitabine-based chemotherapy has been used worldwide as the first-line treatment for advanced biliary tract cancer (BTC), and gemcitabine and cisplatin combination therapy have become the standard therapy. Recently, reports about first-line chemotherapy have increased, and the first-line chemotherapy treatment has gradually become more sophisticated. However, only limited studies have been reported. Materials and methods: Patients with previously untreated advanced BTC with first-line gemcitabine plus cisplatin between 2010 and 2013 were reviewed retrospectively. Eligibility criteria included previous chemotherapy, radiotherapy, or other investigation drug treatment for either (neo)adjuvant or advanced disease setting; no another cancer in 5 years. The primary endpoint of this study was objective response, and the secondary endpoints were progression-free survival (PFS), overall survival (OS) and toxicity. Results: A total 57 patients were enrolled. There was no complete remission. 14 (24.6 %) patients achieved partial response, 32 (56.1 %) stable disease, and 11 (19.3 %) progressive disease. The median PFS and OS were 174 and 399 days, respectively. Toxicity was generally mild but 27 patients (47.4 %) experienced grade 3 or 4 neutropenia. One patient died within 1 week of discontinuation of the treatment due to septic shock. Conclusions: Gemcitabine and cisplatin combination therapy showed a good anti-tumor effect and the median overall survival has reached above 1 year. But grade 3 or 4 neutropenia was a common major toxicity.

Coregistered PET/CT and Gd-EOB-DTPA-MRI features of multiple angiosarcoma of the liver: a case report Takashi Kamatani, Tomoyoshi Inoue, Hiroaki Yokomori Department of Internal Medicine, Kitasato University Medical Center, Saitama, Japan Introduction: Hepatic angiosarcoma, an extremely rare disease, accounts for only 2 % of primary liver malignancies in Western countries. We present a case of well differentiated diffuse and multiple hepatic angiosarcoma showing enhancement on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) enhanced MRI and fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT, which we also investigated using immunohistochemistry and electron microscopy. Case report: An 82-year-old man was admitted to our hospital because of jaundice and weight loss. Biochemical analysis of the blood yielded the following results: total bilirubin 2.7 mg/dL (normal range: 0.2–1.0), direct bilirubin 0.3 mg/dL (normal range 0.0–0.2), aspartate aminotransferase 132 IU/L (normal range 10–35), alanine aminotransferase 136 IU/L (normal range 5–40), alkaline phosphatase 736 IU/L (normal range 115–359), CEA 4.2 ng/ml (normal range \5.0), CA19-9 89.9 U/ml (normal range \37.0), and alpha fetoprotein 4.2 ng/ml (normal range \10.0). Hepatitis B s-antigen, e-antigen,

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Topic: 4 Cholangiocarcinoma and Other Liver Neoplasms Absno: 333 Is endoscopic sphincterotomy really harmful for SEMS insertion for malignant biliary stricture? Dong Jun Kim, Byeong Jun Song, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park, Kyung Won Koh, Dae Hwan Kang Division of Gastroenterology, Department of Internal Medicine, School of Medicine Pusan National University, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, South Korea Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) with biliary self-expanding metal stent (SEMS) placement is the primary choice of biliary drainage for unresectable pancreaticobiliary malignancies. Endoscopic sphincterotomy (ES) is more popular because of possibility of pancreatitis, facilitation of stent placement and another future procedure. But a study showed that ES is not necessary during transpapillary biliary SEMS placement because there is no risk of pancreatitis and instead, it may increase risk for complications (bleeding). However, considering the aspect of an intact or non-intact pancreatic duct, occurrence rate of pancreatitis can change. This study was performed to assess a safety of ES during SEMS placement. Materials and methods: In a retrospective analysis, from December 2008 to August 2013 outcomes of SEMS placement with ES and complication rates were evaluated. Results: There were 180 patients included in the study. Uncovered SEMS were placed in 153/180 patients (85 %). The incidence of acute pancreatitis was 5 % (9/180). 8 patients had cholangiocarcinoma and only 1 person had pancreatic head cancer. Postsphincterotomy bleeding was notified in only 2 patients. No patients who experienced bleeding required blood transfusion and all patients were successfully treated with hemostasis. Conclusions: Patients who undergo ES during SEMS insertion can experience bleeding than those who do not. But complication rates were very low and complications were tolerable.

Topic: 4 Cholangiocarcinoma and Other Liver Neoplasms Absno: 540 ZEB1 expression is a significant prognostic marker in intrahepatic cholangiocarcinoma Katsumi Terashita1, Makoto Chuma1, Kanako Hatanaka2, Yutaka Hatanaka2, Hideki Yokoo3, Takumi Ohmura4, Atsushi Nagasaka5, Koji Ogawa6, Hidenori Toyoda7, Takashi Kumada7, Goki Suda1, Mitsuteru Natsuizaka1, Toshiya Kamiyama3, Akinobu Taketomi3, Naoya Sakamoto1 1 Departments of Gastroenterology and Hepatology, 2Surgical pathology, and 3Gastroenterological Surgery I, Hokkaido University, Sapporo, Japan, 4Sapporo-Kosei General Hospital, Sapporo Japan, 5 Sapporo Municipal Hospital Sapporo Japan, 6Hakodate Municipal Hospital, Hakodate Japan, 7Ogaki Municipal Hospital, Ogaki Japan

Background/aim: Intrahepatic cholangiocarcinoma (ICC) is one of the most aggressive malignant tumors, so identification of useful biomarkers for ICC is an important issue. Zinc finger E-box binding

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Hepatol Int (2014) 8:S1–S405 homeobox 1 (ZEB1) is known as a key marker of epithelial-mesenchymal transition (EMT). The aim of this study was to examine the patterns of expression of EMT-related proteins in ICC and associations between expression of ZEB1 and EMT-related proteins. Methods: We immunohistochemically examined the expression of EMT-related proteins, namely ZEB1, vimentin, E-cadherin, and N-cadherin, in consecutive ICC specimens from 102 patients. The clinicopathological and prognostic values of these markers were also evaluated. Results: The frequency of acquisition of markers ZEB1 and vimentin, and loss of markers E-cadherin and N-cadherin in ICC were 46.1, 43.1, 44.1, and 47.1 %, respectively. ZEB1 expression showed a significant inverse correlation with E-cadherin expression (P = 0.004) and a positive correlation with vimentin expression (P = 0.022). Altered expression of ZEB1 was associated with aggressive tumor behavior, including lymph node metastasis (P = 0.024), undifferentiated-type histology (P = 0.017), portal vein invasion (P = 0.037) and advanced tumor stage (P = 0.037). Moreover, postoperative 3-year overall survival (OS) rates were significantly lower for patients with high ZEB1 expression (33.5 %) than for patients with low ZEB1 expression (64.9 %, P = 0.027). Kaplan-Meier analysis also identified prognostic impacts of E-cadherin expression (P = 0.041) and vimentin expression (P = 0.049) on OS. Conclusion: This study demonstrated that ZEB1 expression is associated with tumor progression and poor prognosis in patients with ICC through positive correlations with vimentin and negative correlations with E-cadherin.

Topic: 4 Cholangiocarcinoma and Other Liver Neoplasms Absno: 569 Diagnostic yield of MRI/MRCP surveillance in detecting hepatobiliary cancer in patients with primary sclerosing cholangitis N. Irani1, O. Arauz1, G. MacQuillan1, W. D. Reed3, G. P. Jeffrey1,2, G. Garas1, J Tibballs4, J. Ferguson4, L. A. Adams1,2 1 Department of Gastroenterology & Hepatology, Sir Charles Gairdner Hospital, WA, Australia, 2School of Medicine & Pharmacology, University of Western Australia, WA, Australia, 3Hollywood Private Hospital, Nedlands, WA, Australia, 4Department of Radiology, Sir Charles Gairdner Hospital, WA, Australia

Background and aims: Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease associated with an increased risk of hepato-biliary malignancy. Bi-annual or annual MRI / MRCP have been recommended as a surveillance strategy in these patients however the benefit of this is unclear. Therefore we wished to determine the diagnostic yield of six-monthly/annual MRI/ MRCP surveillance scans in patients with PSC and examine the relationship between MRI/ MRCP results and bilirubin/ CA19.9 levels. Methods: A retrospective cohort study of 89 PSC patients identified via Sir Charles Gairdner Hospital hepatology unit and a private gastroenterologist clinical database. Medical records and imaging results were reviewed to collect data on patient demographics, malignancy risk factors, laboratory results and imaging surveillance strategies. Results: A cohort of 89 patients were included in the study, and followed up for an average of 6.3 years. The mean age of patients was 57 years and 48 % (n = 43) of these were male. A total of 52 %


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Table 1 Patient demographics and MRI results in surveillance group versus none. Variables presented as mean (standard deviation) or percentage (number) MRI/MRCP surveillance (n = 36)

No surveillance (n = 53)

P value

Age

42 (17) years

46 (17) years

0.3

Gender (males)

47 % (n = 18)

50 % (n = 25)

0.6

Bilirubin at diagnosis

33 (44)

25 (42)

0.4

Alkaline phosphatase

337 (240)

337 (425)

0.9

Duration of follow up

6.4 (5) years

6.2 (4.8)

0.8

Inflammatory bowel disease Liver Transplants

53 % (n = 19)

51 % (n = 27)

0.9

33 % (n = 12)

26 % (n = 14)

0.6

Ursodeoxycholic acid

80 % (n = 29)

43 % (n = 23) \0.05

Cholangiocarcinoma

n=0

n = 4 (7.5 %)

Colorectal carcinoma

n=0

n = 2 (3.6 %)

0.5

Gall bladder polyp (HGD)

n = 1 (3 %)

n=0

0.4

0.1

(n = 46) had inflammatory bowel disease and 58 % (n = 52) were being treated with Ursodeoxycholic acid. 29 % (n = 26) underwent liver transplants in the course of their follow up. 42 % (n = 36) of the PSC patients enrolled in the study underwent regular MRI/MRCP surveillance scans. Four patients (4.5 %) in the non-surveillance group were diagnosed with cholangiocarcinoma (7.5 %) (Table 1). At the time of diagnosis of cholangiocarcinoma on MRI, this was associated with an elevated bilirubin and CA19.9. One patient in the surveillance cohort was diagnosed with an enhancing gall-bladder polyp on MRI which demonstrated with high-grade dysplasia on removal. Conclusion: A MRI/MRCP surveillance strategy for hepato-biliary cancer in PSC patients was not associated with improved detection of malignancy.

Fig. 1 . significantly lower in the resected group (p = 0.02, respectively). There was no significant difference between the two groups in the ratio of age, comorbidities, sex, T-stage and lymph node involvement. In the resection group, mean tumor size was 52 ± 16 mm, and the tumors were classified as TNM type III, IVa, and IVb in 13, 38, and 50 % of the patients, respectively. Median survival for patients submitted to resection for Stage III or IVa was 63 months, 15.4 months for patients submitted to resection for Stage IVb, versus 5.4 months for patients undergoing biopsy only (p = 0.05). Actuarial 1-year survival was 75, 50 versus 17 %, respectively (Fig. 1). Conclusion: Overall survival period of resected cases on Stage IVb is longer than non-resected cases. Surgical treatment for ICC with lymph node involvement is recommended.

Topic: 4 Cholangiocarcinoma and Other Liver Neoplasms Absno: 682 A long term survival case of primary adenosquamous carcinoma of the liver treated by radiofrequency ablation and chemotherapy Koki Sato, Takamasa Ohki, Kenji Ibukuro, Nobuo Toda, Kazumi Tagawa Department of Gastroenterology, Mitsui Memorial Hospital

Topic: 4 Cholangiocarcinoma and Other Liver Neoplasms Absno: 666 Intrahepatic cholangiocarcinoma : recommendation of surgical treatment for lymph node involved cases Daisuke Ito, Shojirou Hata, Kaoru Kobayashi, Masanori Teruya, Michio Kaminishi Showa general hospital Background: Intrahepatic cholangiocarcinoma (ICC) is a rare primary hepatic tumor of bile duct origin for which resection is the most effective treatment. (1) But resectability and outcomes after resection of ICC on Stage IVb have not been well described. Method: We retrospectively studied the records of 20 patients with hepatic tumors underwent exploration and were found to have pure ICC on pathologic analysis between January 2000 and September 2013 at the Showa general Hospital. Demographic data, tumor characteristics, and outcomes were analyzed. Result: 10 patients were unresectable for an overall resectability rate of 50 %. The ratio of remote metastasis (50 versus 84 %) was

Primary adenosquamous carcinoma of the liver is a very rare malignant tumor. The reported prognosis, even with resection, is a median survival rate of about 8 months. Here, we report a long-term survival case of primary adenosquamous carcinoma of the liver treated with radiofrequency ablation (RFA) and systemic chemotherapy. The patient was a 78-year-old man with a history of endoscopic resection for early gastric cancer and pancreaticoduodenectomy for bile duct cancer. In a post-operative periodic follow-up, a contrastenhanced computed tomography (CT) showed a nodular shadow measuring 5 cm in the lower portion of the right lobe of the liver, and multiple enlarged intra-abdominal lymph nodes, including the paraaortic lymph nodes. The patient underwent upper and lower endoscopy, however no neoplastic lesions were observed and recurrence of bile duct cancer was suspected. A biopsy of the liver tumor was carried out and a histological diagnosis of adenosquamous carcinoma was made. PET-CT showed nothing that indicated a primary lesion outside the liver, and primary adenosquamous carcinoma of the liver was diagnosed. Since surgical resection was not indicated, radio frequency ablation (RFA) was preformed for the primary liver lesion followed by FP chemotherapy (5-FU 800 mg/m2 + CDDP 80 mg/m2, every 5 weeks). On completion of 1 course of FP therapy, a post-RFA liver abscess developed, which was treated with percutaneous transhepatic abscess drainage and antibiotics. After the liver abscess healed, FP therapy was restarted, a total of 10 courses were

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S22 administered. During the course, renal dysfunction associated with CDDP (CTCAE v4.0 Grade 2) appeared, which necessitated the prolongation of dosage intervals. Up to 32nd months after diagnosis, CT/MRI showed no recurrence of primary lesion in the liver and the intra-abdominal lymph nodes exhibited a shrinking trend. At 34th months after diagnosis, the renal dysfunction associated with FP therapy became pronounced and the regimen was changed to F-CDGP therapy (5-FU 800 mg/m2 + CDGP 90 mg/m2, every 5 weeks). However, it became difficult to continue the treatment because of severe neutropenia (CTCAE v4.0 Grade 4) and thrombocytopenia (CTCAE v4.0 Grade 4). An MRI was performed in the 36th month after diagnosis, which showed sudden multiple recurrences in the liver, intra-abdominal lymph node enlargement, and bone metastasis. The patient’s general condition deteriorated rapidly due to progression of the underlying disease and he died in the 37th month after diagnosis. Currently, a standard treatment for primary adenosquamous carcinoma of the liver has not been established due to the small number of cases. In this case, we have demonstrated that long-term survival is possible for this difficult-to-treat cancer with a combination of chemotherapy based on the regimen for esophageal cancer and radical treatment of the primary liver lesion.

Topic: 4 Cholangiocarcinoma and Other Liver Neoplasms Absno: 790


Topic: 4 Cholangiocarcinoma and Other Liver Neoplasms Absno: 809 Aggressive surgical resection for five or more liver metastases M. Takahashi, A. Saiura, Y. Inoue, J. Arita, Y. Takahashi Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Cancer Institute Hospital Ariake, Tokyo, Japan Introdution: Surgical resection has been considered the only curable treatment for colorectal liver metastases (CLM). However, the usefulness of surgical resection for multiple liver metastases is still controversial. This study aimed to analyze prognostic factors in liver resection for multiple CLM with 5-year follow up data. Methods: A prospectively maintained our database was used. Clinicopathologic data of patients treated with liver resection for CLM in our institution between January 1997 and December 2008 were retrospectively reviewed. Overall survival rates were calculated. And prognostic factors of survival were analyzed. Results: There were 300 consecutive patients identified with 5-year follow-up. Five year overall and recurrent free survival rates were 58.6 and 27.8 %, respectively. There were 63 (21.0 %) patients who have 5 or more metastases. Of those, 26 patients survived more than 5 years and its five year overall survival rate was 43.5 %. Though 22 patients (84.6 %) experienced recurrence, hepatic re-resection was performed in 17 (77.2 %) patients.

A case of primary hepatic gastrinoma S. Ogawa1, M. Wada1, K. Hosotani1, T. Minamide1, H. Kitamoto1, K. Takashima1, H. Satake1, M. Fukushima1, N. Shimeno1, S. Inoue1, H. Tei1, M. Fujita1, Y. Suginoshita1, A. Okada1, T. Inokuma1, Y. Imai2, Y. Nakamoto3 1

Department of Gastroenterology and Hepatology, Kobe City Medical Center General Hospital, Kobe, Japan, 2Department of Pathology, Kobe City Medical Center General Hospital, Kobe, Japan, 3 Department of Diagnostic Imaging and Nuclear Medicine Graduate School of Medicine, Kyoto University, Kyoto, Japan Introduction: Gastrinoma usually occurs in the so-called ‘gasrinoma triangle’, which is defined by the junction of the cystic duct and common bile duct, the junction of the second and third portion of the duodenum, and the junction between the neck and body of the pancreas. It is rare that gastrinoma occurs outside this triangle, but then it is difficult to find and diagnose gastrinoma. Case report: We report a rare case of primary hepatic gastrinoma. A 28-year-old man was hospitalized for recurrent duodenal ulcers. After eradication of helicobacter pylori he suffered from diarrhea and heart burn, whenever he stopped taking proton pump inhibitor (PPI). Though taking PPI, his gastrin level was measured at 846 pg/mL. Abdominal ultrasound, endoscopic ultrasound (EUS), and CT couldn’t point out a tumor in the duodenum and pancreas. MRI detected a mass measuring 12 mm in a diameter in the right robe of the liver. So we performed selective intra-arterial calcium injection test (SACI test) and 68Ga-DOTATOC-PET CT. As results of these tests, we diagnosed as primary gastrinoma of the liver. Tumor enucleation was performed, and histopathological examination indicated gastrinoma. Four months postoperatively, he has no symptom without PPI and his gastrin level remains within normal range. Conclusion: Primary hepatic gastrinomas are very rare. Though the possibility of other primary locations missed by EUS and surgical exploration was not definitively excluded, SACI test and his clinical course strongly suggested that his tumor was primary hepatic gasrtinoma.

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Topic: 4 Cholangiocarcinoma and Other Liver Neoplasms Absno: 905 The survival outcomes of hepatic resection compared with transcatheter arterial chemoembolization for hepatocellular carcinoma with portal vein tumor thrombus J. M. Lee1, B. K. Jang1, W. J. Chung1, J. S. Hwang1, K. J. Kang1, Y. H. Kim1, Y. O. Kweon2, S. Y. Park2, W. Y. Tak2, B. S. Kim3, C. H. LEE3 1 Departments of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea, 2Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea, 3 Department of Internal Medicine, Catholic University of Daegu, School of Medicine Daegu, Korea

Introduction: The prognosis of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is very poor. However, the treatment of HCC with PVTT is still controversial. We analyzed the results of sorafenib compared with hepatic resection and transarterial catheter embolization (TACE) for treatment of HCC with PVTT. Methods: Between January, 2000 and December, 20011, HCC with portal vein tumor thrombosis patients who received sorafenib, hepatic resection or TACE were included. Of patients, who had the main portal vein tumor thrombosis, superior mesenteric vein tumor thrombosis or Child-Turcot-Pugh score C were excluded. Total 173 patients satisfied the inclusion criteria. Among them, 80 patients were received TACE, 41 patients were received hepatic resection and 52 patients were received sorafenib therapy. PVTT was classified to 2 types; involve segmental branch (type I), extending to involve the right/left portal vein (type II).

Hepatol Int (2014) 8:S1–S405 Results: From January 2000 to December 2011, the median survival for the hepatic resection, TACE group and sorafenib were 19.9 month, 6.6 month and 6.2 month (p \ 0.001). Considering the date of approval of sorafenib, the enroll periods were separated two group. The period A was decided from January 2000 to December 2007, and the period B was decided from January 2008 to December 2011. The median survival of period A for hepatic resection and TACE group were 19.3 month and 6.1 month (p = 0.008). And the median survival of the period B for hepatic resection, TACE group and sorafenib were 24.6 month, 9.5 month and 6.1 month (p = 0.001). Among the total period, 1-, 2- and 3-year overall survivals for the hepatic resection, TACE and sorafenib group were 63.6, 31.3 and 30.0 and 36.3, 9.8 and 8.6 and 32.3, 5.6, 0.0 % (p \ 0.001). In addition, another factors of tumor size, PVTT site type, presence of ascites and a-FP level were influenced the prognosis of HCC with PVTT. Conclusion: Hepatic resection can prolonged the survival of patients with HCC with involving the segmental branch of PVTT, compared with TACE or sorafenib. References 1. Tang Q, Li A, Yang G, Lai ECH, Zhou W, Jiang Z, Lau WY, Wu M. Surgical resection versus conformal radiotherapy combined with TACE for resectable hepatocellular carcinoma with portal vein tumor thrombus: a comparative study. World J Surg 2013; 37:1362–1370 2. Peng Z-W, Guo R-P, Zhang Y-J, Lin X-J, Chen M-S, Lau WY. Hepatic resection versus transcatheter arterial chemoembolization for the treatment of hepatocellular carcinoma with portal vein tumor thrombus. Cancer 2012; 118(19):4725–4736

Topic: 5 Cholelithiasis and Biliary Tract Disease Absno: 126 A case of IgG4-related disease accompanied by inflammatory pseudotumor of the liver Y. Ysuda1, Y. Osawa2, S. Sugiyama1, K. Yoshida1, H. Adachi1, T. Nakagawa1, K. Matsunaga3, H. Moriwaki4, H. Sugiyama1 1

Divisions of Gastroenterology, Kizawa Memorial Hospital, Minokamo, Japan, 2Departments of Pharmacology, Gifu University Graduate School of Medicine, Gifu, Japan, 3Divisions of Pathology, Kizawa Memorial Hospital, Minokamo, Japan, 4Departments of Gastroenterology, Gifu University Graduate School of Medicine, Gifu, Japan Introduction: Recently, much attention has focused on IgG4-related disease, which is an increasingly recognized syndrome of unknown etiology comprised of a collection of disorders that share specific pathologic, serologic, and clinical features characterized by abundant IgG4-positive plasma cell infiltration, high serum IgG4 levels, and variable degrees of fibrosis. IgG4-related disease sometimes manifests as tumorous lesions. We report the case of a 46-year-old man with a IgG4-related disease accompanied by inflammatory pseudotumor of the liver. Case report: A 46-year-old Japanese man was referred to Kizawa memorial hospital with upper abdominal discomfort. Abdominal contrast-enhanced CT and EOB-MRI revealed hypovascular liver tumors and a pancreas tumor which showed strong FDG accumulation in PET–CT. Laboratory data indicated liver damage (ALT 212 g/dl, T-Bil 4.42 mg/dl), and increases in the levels of IgG (3653 mg/ml) and IgG4 (2970 mg/ml). The liver tumors were histologically diagnosed as pseudotumor with IgG4-positive plasma cell infiltration, and

S23 the pancreas tumor was histologically diagnosed as autoimmune pancreatitis. Administration of prednisolone decreased tumor size with reduction of IgG and IgG4. Conclusion: Although it is difficult to diagnose the liver and pancreas tumors in IgG4-related disease, histological examination with IgG4 staining is effective tool for its diagnosis.

Topic: 5 Cholelithiasis and Biliary Tract Disease Absno: 131 Gallstone ileus in an elderly patient: a case report ¨ . B. Binicier1 I. S. Ertem1, C. Yıldız1, O 1 Department of Gastroenterology, Tepecik Training and Research Hospital, ˙Izmir, Turkey

Introduction: Gallstone ileus is a complication of cholelithiasis and an easily ignored medical condition in the elderly patients (1). It is mostly caused when a gallstone enters the intestinal system through a fistula between the gall bladder or bile ducts and certain localizations of the intestines, sometimes causing a life threatening obstruction. Gallstone ileus develops when the diameter of the stone exceeds 2.5 cm and is usually seen at the terminal ileum (70 %) and less commonly in other localizations of the intestinal system such as duodenum, jejunum (30 %) and colon (2.5 %). In this report, a rare case of gallstone ileus in sigmoid colon in an elderly patient is presented. Case history: Sixty-eight year old female patient admitted to the emergency room with the complaints of abdominal pain, nausea, vomiting and inability to pass gas and stools. She had been hospitalized three times due to acute cholecystitis and a year ago a 4 cm. gallstone was detected in her gall bladder. She told that she had rejected to have an operation for cholecystectomy. Routine blood tests revealed no pathology. Her physical examination revealed abdominal distension, defense and rebound in all four of the abdominal quadrants. Abdominal X-ray showed diffuse air in colonic loops and airfluid levels in small intestines. In abdominal computerized tomography (CT), a laminated hyperdense area with a diameter of 3.5 9 2.5 cm. in sigmoid colon level was observed. Wall thickening in the hepatic flexura and air extending to the superior of the gall bladder– bile duct area suggested a gall stone ileus in the sigmoid level and a fistula in the hepatic flexura level. Repeated trials to remove the stone with the endoscopic method (gallstone extraction balloon and lithotripsy basket) were unsuccessful because because it was impacted into the lumen . Eventually, the stone was removed with surgical operation. Cholecystectomy and fistula repair were planned to take place at a later date. Conclusion: In gallstone ileus cases, the mortality rate is reported to range between 12–18 % particularly in the elderly patients with comorbidities. So, gallstone ileus should always be considered when making the differential diagnosis of ileus cases, especially in elderly patients with cholecystitis attacks in the past. Because clinical signs and symptoms can be mild and nonspecific in most of the patients, abdominal CT findings are very helpful in reaching an accurate and early diagnosis (2). References 1. Chen-Wang C, Shou-Chuan S, Shee-Chau L, Cheng-Hsin C. A disease easily ignored in the elderly. Int J Gastoenterol. 2008;2(1):18–21 2. Elabsi M, Amraoui M, Errougani A, Chkof MR. Diagnosis and treatment: gallstone ileus. Dig Liver Dis. 2007;39:180–181

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Topic: 5 Cholelithiasis and Biliary Tract Disease


Absno: 199

Absno: 332

Efficacy observation of Chinese herbal drugs combined with ursodeoxycholic acid in the treatment of primary biliary cirrhosis

Comparison of nafamostat mesilate in 24-h versus 8-h infusion in the prevention of post-ERCP pancreatitis: a prospective study Dong Jun Kim, Byeong Jun Song, Hyung Wook Kim, Cheol Woong Choi, Su Bum Park, Jung Boom Hong, Dae Hwan Kang

S. Q. Luo, N. Zhang, M. Gong, YQ Sun, N. Du, F. Zhang Diagnosis and Treatment Research Center of Liver Disease by Integrated Traditional Chinese Medicine and Western Medicine. 302 Hospital of PLA, Beijing, China Introduction: Clinical efficacy of chinese herbal drugs combined with ursodeoxycholic acid (UDCA) was observed in the treatment of primary biliary cirrhosis (PBC), so that the advantages of chinese herbal drugs in treatment of PBC can be clarified as well as the possible adverse reaction. Methods: Retrospective analysis was done focused on the inpatients diagnosed as compensated PBC from May 2010 to May 2013 in our hospital, 72 patients met the inclusion criteria. According to the different treatments, the patients were divided into two groups. Patients in group one(experimental group) were treated with chinese herbal drugs and UDCA, while group two (control group) just UDCA only. All patients used liver-protective drugs The treatment duration was 24 weeks. Evaluation indexes included clinical efficacy, improvement of Traditional Chinese Medicine (TCM) symptoms and variation of liver biochemical indexes. t test was used to compare measurement data. Results: There was no significant difference between two groups in any of the variables before treatment. After treatment of 24 weeks, clinical efficacy in Group one was improved more significantly than Group two (P \ 0.05), the rates of TCM symptoms improvement were higher in Group one(P \ 0.05), symptoms such as fatigue, anorexia, dry mouth, pruritus, jaundice, fullness in chest and hypochondrium were improved more dramatically in Group one (P \ 0.05),,furthermore, the three bio-chemical indexes including Total bilirubin(TBIL), alkaline phosphatase (ALP), and c-glutamyl transpeptidase (c-GT) decreased more significantly. The results were illustrated in Table 1.

Division of Gastroenterology, Department of Internal Medicine, School of Medicine Pusan National University, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, South Korea Introduction: 24-h infusion of the protease inhibitor nafamostat mesilate effectively prevents post-ERCP pancreatitis (PEP). However, the appropriate duration of administration is unknown. 8-h infusion compared to 24-h infusion can respect the patient’s wish to avoid hospitalization and provide medical costs saving. We assessed and compared the incidence of PEP as a 8-h or 24-h infusion. Materials and methods: From February to August 2013, a total of 214 patients who underwent ERCP were analyzed. Patients were divided into 2 groups: 24-h infusion with nafamostat mesilate (group A), 8-h infusion (group B) (107 patients per arm). Serum amylase and lipase levels were checked before ERCP, 4 and 24 hours after ERCP, and when clinically indicated. The incidence of PEP was analyzed. Results: The overall incidence of acute pancreatitis was 5.6 % (12/ 214). There was no significant difference in the incidence of PEP as 24-h infusion or 8-h infusion (6.6 vs 4.6 % respectively; p = 0.768). Also there was no significant difference in the incidence of hyperamylasemia (8.4 vs 6.5 %, respectively; p = 0.796). Conclusions: Since both nafamostat mesilate infusion protocols had equal incidence of PEP, 8-h infusion of nafamostat mesilate is also helpful in preventing PEP.

Topic: 5 Cholelithiasis and Biliary Tract Disease Absno: 422 Bile deficiency induces the changes of intestinal Cl2 and HCO2 3 secretions in mice Penghong Song1, Yehui Du1, Wenfeng Song1, Xiaosun Liu2, Liangjie Hong1, Hui Li1, Haiyang Xie1, Lin Zhou1, Biguang Tuo3, Shusen Zheng1

Table 1 Comparison of bio-chemical indexes before and after treatment between two groups (x±s) Group one (n = 35)

Group two (n = 37)

t

P

109.61 ± 52.67

0.233 0.816

Pre-treatment TBIL(lmol/L) 106.53 ± 59.17 ALP(U/L) c-GT(U/L)

442.63 ± 275.28 464.78 ± 240.17 0.364 0.717 361.27 ± 112.18 354.37 ± 120.18 0.251 0.802

Post-treatment TBIL(lmol/L)

34.37±26.16*

63.44 ± 33.17

4.113 0.000 2.719 0.008

ALP(U/L)

216.24±70.49*

274.31 ± 99.15

c-GT(U/L)

170.65±84.48*

216.32 ± 105.64 2.019 0.047

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1

Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health; First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China, 2Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China, 3Department of Gastroenterology, Affiliated Hospital of Zunyi Medical College, Zunyi 563003, China Introduction: Biliary tract obstruction is a common clinical lesion, which induces the changes of some intestinal functions in addition to resulting in hepatic injury. The intestinal secretion is one essential function of intestine. However, the effect of biliary tract obstruction on intestinal secretion is not understood. In this study, we made secretions in an experiinvestigation on intestinal HCO3 and Cl mental model of murine biliary duct ligation. Methods: Murine intestinal mucosal HCO3 and Cl secretions were examined in vitro in using chambers by the pH stat and short circuit

Hepatol Int (2014) 8:S1–S405 current (Isc) techniques. The mRNA and protein expressions of cystic fibrosis transmember conductance regulator (CFTR) and Na+–K+– 2Cl- cotransporter (NKCC1) were analyzed by real time PCR and western blot. Results: Basal and forskolin-stimulated duodenal and jejunal mucosal secretions in mice with common biliary epithelial HCO3 and Cl duct ligation were markedly elevated, compared with controls (P\0.05 and P \ 0.01). Further experiments showed that basal and forskolin-stimulated duodenal and jejunal mucosal epithelial HCO3 and Cl- secretions in mice with external bile drainage were also markedly elevated, compared with controls (P \ 0.05 and P \ 0.01). The mRNA and protein expression levels of CFTR and NKCC1 in jejunal mucosae of mice with both biliary duct ligation and external bile drainage were markedly higher than those in controls (P \ 0.001). Conclusion: Bile deficiency in the intestine up-regulates the expressions of intestinal mucosal epithelial CFTR and NKCC1, and increases intestinal mucosal HCO3 and Cl secretion capacity, which contributes to the understanding of intestinal physiologic function for patients with biliary duct obstruction.


S25 inhomogeneous structure of pancreatic calcifications in the pancreas). Average values of glucose venous blood in these patients -7.0 ± 0.8 mmol/l (twofolds). 8.3 % received inpatient treatment for acute pancreatitis. Improvement of the pancreas compared with the changes to cholecystectomy was at 8.3% (normalization of blood glucose, improve ultrasound signs). The deterioration of the liver—25%: increase in ALT, AST, cholesterol + ultrasonic signs (increased density of the liver, the appearance of diffuse steatosis, periportal fibrosis, the appearance of hemangiomas of the liver). 2% had an improvement in laboratory parameters of liver in combination with ultrasound signs, 18.8 %—the deterioration of laboratory tests of the liver. According to the EGD with inspection of large duodenal papilla in 54.1% was identified duodenal bile reflux, 10.4 %—prefatorial diverticulum, 4.2 %—aterial diverticulum, erosive gastritis—in 6.3 %, 2 %—reflux esophagitis, 93.8 % have been diagnosed surface gastritis. According to the fractional duodenal intubation in all patients there is a violation of formation and excretion of bile, bacteria in the bile. Conclusion: As a result of cholecystectomy patients get rid of the affected organ, but they get a new problems related to the removal of the gall bladder (deterioration of the pancreas, liver, duodenal reflux, duodenal diverticula, violation of formation and excretion of bile and hepatic function).

Absno: 498 Topic: 5 Cholelithiasis and Biliary Tract Disease Late results of emergency cholecystectomy E. I. Mitusheva, A. R. Badretdinova, R. G. Saifutdinov, R. S. Shaimardanov Kazan State Medical Academy, Kazan, Russia Introduction: Investigate the state of hepatopancreatobiliary system in patients undergoing emergency cholecystectomy in the long term is important today. Materials and methods: The medical records of patients undergoing emergency laparoscopic cholecystectomy in 2006–2010 for acute cholecystitis were analysed. Of the 350 analyzed medical records 47 patients agreed and came to the survey—a complete blood count, blood chemistry (ALT, AST, bilirubin, total protein, cholesterol, glucose), EGD, with spot inspection large duodenal papilla, ultrasound of the liver, pancreas, fractional duodenal intubation. If the value of venous blood glucose more than 6.1 mmol/l patient retakes analysis. Characteristics of the examined 47 patients: mean age of 57.7 ± 8.84 years, men—6 women—41 people, 12.5 % had performed laparotomy cholecystectomy, 87.5 %—laparoscopic. Cholecystitis abscess was diagnosed in 11 people (23 %), gangrenous—in 1 (2 %), the remaining 35 people (73 %)—an acute calculous cholecystitis. Complicated acute calculous cholecystitis was diagnosed in 29:23 %—complicated with perivascular infiltrates, 2 %—obstructive abscess, 2 %—local serous peritonitis due to perforation of the modified gangrenous gallbladder wall, 2 %— empyema of the gallbladder. Results: A survey of 47 people 21.3% had no complaints, the remaining 78.7 % had a different complaint: bitter taste in the mouth (2.1%), intermittent loose stools (27.7 %), flatulence (25.5 %), abdominal pain (31.7 %), belching (10.3 %), vomiting bile (4 %), pain in the right upper quadrant (14.3%), heartburn (8.5 %), nausea (12.8 %), constipation (6.4 %), vomiting bile (4.2 %), xerostomia (8.5%), weight loss (6.4 %), weakness (5.8 %). The majority of patients (45.8 %) showed deterioration of pancreatic function— increase in venous blood glucose more than 6.1 mmol/l (doubly confirmed) and ultrasound signs of deterioration of the pancreas (increased size, increased density, fuzzy and rough outlines,

Absno: 499 Risk factors for bile duct stones after living donor liver transplantation T. Senoo1, T. Ichikawa1, K. Nakao1, A. Soyama2, M. Takastuki2, S. Eguchi2 1 Department of Gastroenterology and Hepatology, Nagasaki University, Nagasaki, Japan, 2Department of Surgery, Nagasaki University, Nagasaki, Japan

Backgrounds and aims: In Japan, living donor liver transplantation (LDLT) is commonly performed due to the lack of the deceased donor organ donation. Bile duct stone (BDS) is one of the complications after liver transplantation, often leading to severe cholangitis. However, the analytical studies of BDS in post liver transplantation, especially in LDLT patients, have been rarely reported. The aim of this study was to clarify the relevance and risk factors of bile duct stone in the patients after LDLT. Methods: We extracted 100 adult ([17 years) patients from 165 patients who underwent LDLT at Nagasaki University Hospital from August 2000 to May 2012. Pediatric transplants cases and death in early post-operative periods were excluded. We retrospectively reviewed their records, and analyzed their clinical characters and risk factors of BDS formation. Results: The median observation period was 49.5 (5–143) months. Ten cases (10.0 %) developed BDS (including 2 intrahepatic bile duct stone cases). The median follow-up period to BDS diagnosis was 45.5 (5–84) months from the time of LDLT. Twenty two cases (22.0 %) had bile duct stricture, and six of which accompanied with BDS. Between BDS and without BDS groups, significant difference was not seen in age, BMI, MELD score, serum total cholesterol, serum total triglyceride, and serum total bilirubin. With univariate analysis, male, right lobe graft, bile duct stricture, bile duct stenting were the factors that significantly correlated to BDS formation. These factors were also analyzed with multivariate analysis. Notably, right lobe graft

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S26 (odds ratio 10.05, p = 0.0428) was significant risk factor for BDS formation. Conclusion: In the present study, right lobe graft was significant risk factor of BDS formation after LDLT. More careful observation and monitoring are required in the cases with high risk factors.

Hepatol Int (2014) 8:S1–S405 Disclosure of Interest: None declared. Keywords: Emergency cholecystectomy, Pancreatitis, Duodenal diverticulum

Duodenal

reflux,

Topic: 5 Cholelithiasis and Biliary Tract Disease Topic: 5 Cholelithiasis and Biliary Tract Disease Absno: 508 Absno: 501 Long-term results of elective cholecystectomy A. R. Badretdinova, E. I. Mitusheva, R. G. Saifutdinov, R. S. Shaimardanov Kazan State Medical Academy, Kazan, Russia; e-mail: [email protected] Objective: To investigate the state of hepatopancreatobiliary system in patients undergoing elective cholecystectomy in the long term is important in gastroenterology today. Materials and methods: The medical records of patients undergoing elective laparoscopic cholecystectomy in 2006–2010 with a diagnosis of cholelithiasis cholecystolithiasis were analysed. Of the 250 analyzed medical records 47 patients agreed and came to the survey—a complete blood count, blood chemistry (ALT, AST, bilirubin, total protein, cholesterol, glucose), EGD with spot inspection large duodenal papilla, ultrasound of the liver, pancreas, fractional duodenal intubation. If the value of venous blood glucose more than 6.1 mmol/l patients retake analysis. Characteristics of the examined 47 patients: mean age 58.6 ± 6.9 years; males—3 people (6.4 %), women—44 people (93.6 %); during surgery in 8.5 % of patients had complications: perivascular infiltration (4.3 %), edema of the gall bladder (2.1 %), disabled gallbladder hydrops of the gallbladder (2.1 %). Results: A retrospective analysis of the results showed that 10 people (21.2 %) had no complaints, the remaining 37 people (78.7 %) reported: weakness (6.4 %), weight loss (6.4 %), dry mouth (6.4 %), bitter taste in the mouth (17 %), heartburn (12.7 %), nausea (6.4 %), belching (4.2 %), vomiting bile (2.1 %), pain in the right upper quadrant (10.3 %), abdominal (17 %) and abdominal pain (28.4 %), intermittent loose stools (19.1 %), constipation (8.5 %). 22 patients (46.8 %) showed the deterioration of pancreatic function—improving venous blood glucose more than 6.1 mmol/l (doubly confirmed) and ultrasonic deterioration characteristics of the pancreas (increasing size, increasing density, and fuzzy rough contours inhomogeneous structure of pancreatic calcifications in the pancreas). Average rates of glucose venous blood in these patients -6.92 ± 0.7 mmol/l. 6.4 % of patients hospitalized for acute pancreatitis in the surgical hospital. Improving pancreatic functions, compared with the data prior to cholecystectomy was 2.1 % (normalization of blood glucose, improving the ultrasonic characteristics). The deterioration of liver function after cholecystectomy was found in 25.5 %. It is manifested in the growth of blood levels of ALT, AST, cholesterol and ultrasound signs of deterioration (increase in density of the liver, the appearance of diffuse steatosis and hemangioma). 10.6 % had an improvement in laboratory parameters of liver in combination with ultrasound signs. According to the EGD detected in 68 % of the surface gastritis, at 10.4 %—erosive gastritis. At 46.8 % was identified duodenal bile reflux, 4.3 %—prefatorial diverticulum, at 2.1 %— a polyp of the esophagus, at 2.1 %—a polyp of the stomach. According to the fractional duodenal intubation in all patients there is a violation of formation and excretion of bile, bacteria in the bile. Conclusions: Cholecystectomy, relieving patients of cholecystolithiasis, leading to deterioration of the pancreas and liver, duodenal reflux, violation of formation and excretion of bile.

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Aberrant expression of MECA-79, a family of sialomucins known as peripheral node addressins, in biliary epithelium of PBC H. Baba1, K. Tsuneyama1, J. Imura1 1

Department of Diagnostic Pathology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan Introduction: MECA-79 is a carbohydrate epitope that is found on a family of sialomucins known as peripheral node addressins, or PNAds, that serve as ligands for CD62L. Expressed primarily on PNAds that are present in both inflamed tissues and on high endothelial venules (HEVs) in lymphoid tissues, the MECA-79 epitope binds to CD62L and, via this binding, induces leukocyte homing and lymphocyte rolling and tethering. The initiation of homing and rolling is critical for the localization of lymphocytes to peripheral lymph nodes, an event that is necessary for the cellular response to inflammation. In this study, we examined its expression in inflamed portal area of primary biliary cirrhosis (PBC) to assess the link between MECA-79 and PBC. Materials and methods: Liver specimens of 21 PBC cases, 13 chronic viral hepatitis-C (CVH) cases, and 5 normal cases were examined. We performed immunohistochemistry for meca-79 on these cases, and assessed all portal areas. Results: MECA-79 was not expressed in normal liver, whereas, in PBC, it was expressed in 74 % of portal area. MECA-79 expressed mainly in biliary epithelium. The expression was significant in damaged bile ducts compared with intact bile ducts (95 vs 19 %). Although MECA-79 was expressed in 15 % of biliary epithelium of CVH, there was no significant difference in the expression between damaged bile ducts and intact bile ducts (18 vs 9 %). The results are showed in Graph 1. Conclusion: High expression of MECA-79 in damaged bile ducts was specific for PBC, and may be related with the pathogenesis of PBC.

Graph 1 The expression of MECA-79 in bile ducts


S27 involvement. Long-term maintenance with azathioprine monotherapy appears safe and well-tolerated in Hong Kong Chinese.

Topic: 5 Cholelithiasis and Biliary Tract Disease Absno: 510 Sustained remission with long term immunosuppressive therapy in autoimmune pancreatitis and immunoglobulin G4-related cholangitis in Hong Kong Chinese 1

2

2

2

Topic: 5 Cholelithiasis and Biliary Tract Disease Absno: 632

2

T. L. Ng , W. C. Lao , C. M. Leung , T. W. Li , W. H. Li , L. F. Tai2, T. L. Lee2, W. L. Tang3 1

Department of Medicine and Rehabilitation, Tung Wah Eastern Hospital, Hong Kong, 2Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong, 3Department of Pathology, Pamela Youde Nethersole Eastern Hospital, Hong Kong Background and aim: Autoimmune pancreatitis (AIP) type 1 and Immunoglobulin (Ig) G4-associated cholangitis are part of the systemic fibro-inflammatory disease which is characterised by a dense lymphoplasmacytic infiltrate of IgG4-positive cells in the pancreas and biliary tree respectively. Immunosuppression with corticosteroids is the first line of treatment. However, relapses are common after corticosteroid discontinuation. Reports on the use of azathioprine as maintenance therapy in Chinese are lacking. The aim of the study is to evaluate the use of immuno-modulating agents in the treatment of IgG4-related disease with pancreatic and biliary tract involvement in Hong Kong Chinese. Methods: All patients diagnosed with IgG4-related disease between April 2008 and April 2013 in a regional hospital in Hong Kong were retrospectively reviewed. All patients were histologically proven to have IgG4 related disease from biopsies or surgical specimens. All were documented an elevated serum IgG4 level. Only those with pancreatic and/or biliary involvement were reviewed. The demographic, clinical, biochemical and radiological profiles, treatment and outcomes were evaluated. Results: Fifteen patients were identified. Seven patients were excluded in the study because of non-pancreatic, non-biliary tract involvement. The mean age at diagnosis was 60 (range 46–80 years). Male to female ratio was 7:1. Median follow-up was 46 months (range 6–54 months). Of the 8 patients reviewed, one had isolated AIP, four had IgG4-related cholangitis, and three had both AIP and biliary tract involvements. Except for the one with isolated AIP, who presented with a pancreatic mass on imaging, all others were presented with obstructive jaundice. Five (62.5 %) were operated on; two were endoscopically stented. One failed endoscopic retrograde cholangiopancreatography and was performed percutaneous transhepatic biliary drainage. Seven (87.5 %) were treated with prednisolone after intervention, except for the one with isolated AIP who had distal pancreatectomy done. One died during corticosteroid course due to infective complications. No disease relapse was noted in the AIP patient over a follow-up of 4 years. Of the 6 patients who were treated with corticosteroids, five (83 %) achieved remission. One patient failed to wean corticosteroids while on tapering course. All 5 patients had relapse after a median of 6 months when prednisolone was stopped (range 1–16 months). Relapses were re-treated with prednisolone therapy and azathioprine was then added. One was kept on maintenance low dose prednisolone only due to underlying myelodysplastic syndrome. Three patients (60 %) had sustained remission while on azathioprine alone over a mean follow-up of 48 months. Of the two patients who had biochemical relapse while on azathioprine monotherapy, one was switched to mycophenolate mofetil. In addition, both were maintained on low dose prednisolone with sustained clinical remission. Conclusion: Immunosuppressive therapy is effective in inducing remission in IgG4-related pancreatitis and cholangitis. Relapse is common after steroid cessation especially in those with biliary tract

Pancreatic and lung metastases from breast cancer: a very rare case A. F. Syam, M. Abdulah, D. Makmun, M. Simadibrata, A. A. Rani Division of Gastroenterology, Department of Internal Medicine, University of Indonesia, Cipto Mangunkusumo Hospital-JakartaIndonesia Introduction: Most of the pancreatic cancer is primary and only a few pancreatic cancers metastatic from other cancers. The Lung cancer is the most common of pancreatic metastases. Only few cases are metastatic from breast cancer. We reported pancreatic metastasis from breast cancer is a very rare case. Case report: A 43 years old female patient came to the hospital due to obstructive jaundice. She also suffered from breast tumor. Her sister also suffered from breast cancer 8 years ago. From physical examination, we found jaundice and breast tumor. Histopathology findings from breast tumor biopsy got mucinous adenocarcinoma. Abdominal examination found liver enlargement without splenomegaly. From chest X-rays, we found multiple coin lesions, conclude as lung cancer metastatic. From abdominal ultrasound and Abdominal CT scan revealed dilation of right and left hepatic duct, dilation of common bile duct. From pancreatic evaluation found a mass in the head of pancreas. ERCP proved the CT scan result. We put plastic stent into the CBD. Total and direct bilirubin was decreased after 3 weeks stenting from 21.7 to be 2.7 mg/dl. She was treated with adjuvant chemotherapy using fluorouracil, doxorubicin, cyclophosphamide protocol (FAC). The patient was in a good clinical condition after chemotherapy Fig. 1.

Fig. 1 X-ray after CBD stent placement

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S28 Conclusion: Pancreatic metastasis must be suspected for any pancreatic lesion in a breast cancer patient. Adjuvant chemotherapy may be effective to treat Pancreatic metastasis breast cancer. Reference 1. Bonapasta SA, Gregori M, Lanza R, Sangiorgi E, Menghi H, Scarpini M. Metastases to the pancreas from breast cancer: difficulties in diagnosis and controversies in treatment. Breast Care 2010;5:170–173

Hepatol Int (2014) 8:S1–S405 Hodgkin disease is seen in 10 % of patients with biopsies and 60 %of patients with autopsies. The reason for jaundice is usually extrahepatic biliary obstruction in Non-Hodgkin Lymphoma while it is the tumoral infiltration causing the jaundice in Hodgkin disease. Tumoral infiltration can manifest itself as a mass lesion or in an infiltrative style. We presented this case to emphasize that physical examination is essential before referring any patient for ERCP and classification of jaundice as flavin, rubin, verdin and melas which is thought to be too old and historical for nowadays is still valuable in practicing the art of medicine.

Topic: 5 Cholelithiasis and Biliary Tract Disease Topic: 5 Cholelithiasis and Biliary Tract Disease Absno: 663 Absno: 832 From the door of ERCP room to the hematology clinic: a case report Salih Boga, Ali Riza Koksal, Mehmet Bayram, Meltem Ergun, Huseyin Alkim, Canan Alkim Sisli Hamidiye Etfal Education and Research Hospital, Gastroenterology and Hepatology Department, Is Introduction: Jaundice is an expected finding in advanced stages of Hodgkin disease and reported to be 13–33 % in different series. But it is rarely initial manifestation of the disease. Here, we are reporting a case referred to our clinic from another center with a preliminary diagnosis of obstructive jaundice and cholangitis, and finally diagnosed as Hodgkin Disease with lymph node biopsy. Case: Fifty two years old female patient was admitted to a hospital different from ours with the complaints of jaundice, fever, weight loss and fatigue for 1 month. Direct hyperbilirubinemia was detected and patient was referred to our clinic with an appointment for ERCP with the prediagnosis of obstructive jaundice and cholangitis. While patient was examined in the endoscopy unit, her skin color was seen in a lemon yellow color (flavin jaundice) and obstructive jaundice was thought without any imaging procedure performed. Also her liver enzymes were less than two-fold of the upper normal limit, and she had severe anemia (Hb: 6.2 g/dl). The ERCP was cancelled and patient was hospitalized. In the physical examination her general situation was moderate and prominent lemon yellow jaundice was observed at the mucous membranes and skin. The liver was palpable 3 cm. below the right costal arch (hepatomegaly) and percussion of Traube’s space was dull in tone (splenomegaly). There were widespread and tender lymphadenopathies reaching 2–3 cm. in diameter in the neck region. Laboratory findings were as follows: WBC: 4600/mm3, Platelets: 224.000/mm3; ESR: 115 mm/h; total protein: 4.5 g/dl, albumin: 1.6 g/dl, viral hepatitis markers were negative. Hepatomegaly and splenomegaly were reported in abdominal ultrasonography and there was no gall stone in the gall bladder detected by ultrasonography There were widespread lymphadenopathies in the neck, mediastinum and abdomen and the appearance of spleen seemed compatible with lymphoproliferaltive disease involvement in the tomography scans. The pathological examination of the excisional lymph node biopsy from the neck revealed Hodgkin Disease. The patient was directed to Hematology clinic for chemotherapy treatment. Conclusion: Jaundice can be seen in a variety of diseases ranging from enzyme deficiencies to malignancies. Liver involvement in

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Comparing liquid based cytology(Cellprep) methods with conventional smear methods for ERCP guided brushing cytology of bile duct Myeong Ho Yeon1, Hee Seung Lee1, Jong Soon Jang1, Seungho Lee1, Hee Bok Chae1, Seon Mee Park1, Sei Jin Youn1, Joung-Ho Han1, Ho chang LEE2 1

Department of Internal Medicine, 2Department of Pathology, School of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Korea

Background/aims: ERCP guided brushing cytology has been used worldwide to diagnose bile duct cancer. Bile duct brushings have been recognized as a technique of moderate sensitivity and high specificity in identifying carcinoma of the biliary regions. In the 1990s, Liquid-based cytology (LBC) was developed as an alternative to conventional smear (CS). Recent studies suggests the Liquid-based cytology (ThinPrep) method can improve diagnostic sensitivity and accuracy than conventional smear methods in bile duct brushings. However, there is no a study comparing Cellprep methods with CS in bile duct cancer. Therefore, The aim of this study was to compare the morphologic features and diagnostic efficacy of LBC with those of CS for ERCP brushing cytology. Methods: This is the prospective study. This study was done with total 32 pts who were suspected bile duct cancer. Bile duct diagnosis was used by ERCP guided brushing cytology. Brushing cytology was done more than two. The final diagnosis is done by biopsy, cellblock, and clinical follow up. Results: There were performed 34 brushing cytology in our institution from 32 patients(among them, two patients, it was performed twice). The cytologic diagnoses for both CP and CS were categorized into five main groups: inadequate, ` negative, ´ atypical, ˆ suspicious for malignancy, and ˜ malignant. 1 cases (2.9 %) of CS preparations were inadequate, but 4 cases (11.8 %) CP preparations were inadequate. In CP and CS, the negative : 20.6 and 11.8 %, atypical cell : 11.8 and 14.7 %, suspicious : 5.9 and 11.8 %, and malignant : 50 and 55.8 %. accuracy : 58.8 and 73.5 %. The sensitivity was 57.6 % for CP and 72.7 % for CS. The specificity and positive predictive value was 100 % for both methods. Conclusion: Cellprep methods (Liquid-based cytology) revealed lower sensitivity and accuracy than conventional smear methods. Thus, Cellprep (liquid based cytology) methods can not be replaced by conventional smear methods.


Topic: 6 Drug Induced Liver Disease (DILD) Absno: 193 Risk of oral anti-fungal agent-induced liver injury in Taiwanese Wei-Yu Kao1, Chien-Wei Su2, Yi-Shin Huang2, Wen-Hung Chung3, Chun-Chao Chang1, Jaw-Ching Wu4 1

Division of Gastroenterology, Department of Medicine, Taipei Medical University Hospital, Taiwan, 2Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, 3Department of Dermatology, Chang-Gung Memorial Hospital, Taipei, Taiwan, 4Department of Medical Research and Education, Taipei Veterans General Hospital, Taipei, Taiwan Aim: Oral anti-fungal agent-induced liver injury is a common safety concern that may lead to patients’ hesitation in treating fungal infections such as onychomycosis. This study evaluated risk of druginduced liver injury (DILI) caused by oral anti-fungal agents in Taiwanese populations. Methods: A population-based study was conducted by analyzing Taiwan National Health Insurance Database who used oral anti-fungal agents from 2002 to 2008. A comparison control group was randomly extracted from the remainder of the original cohort. Results: Of the 90,847 oral anti-fungal agents users, 52 patients had DILI. Twenty-eight DILI cases used ketoconazole, 12 fluconazole, 8 griseofulvin, 3 itraconazole, and 2 terbinafine. The incidence rates (IR) of DILI per 10,000 persons were 31.6, 4.9, 4.3, 3.6 and 1.6 for fluconazole, ketoconazole, griseofulvin, itraconazole, and terbinafine, respectively. Longer exposure duration increased risk of DILI, with IR for exposure duration C60 defined daily dose (DDD) of 170.9, 62.5, and 36.1 per 10,000 persons for ketoconazole, itraconazole, and terbinafine, respectively. Patients taking anti-fungal agents had higher incidences of developing DILI compared to those in the control group after adjusting for age, gender, and co-morbidities (relative risk: 2.38; P\0.001). All of the 6 patients with fatal DILI used fluconazole. Old age and fluconazole increased the risk of oral anti-fungal induced fatal DILI. Conclusions: Oral anti-fungal agents are associated with low incidence of acute liver injury, but which may be fatal, especially for the elderly. Longer treatment duration may increase the risk of antifungal agent-induced liver injury, especially ketoconazole.

S29 Results and discussion: Significantly higher frequency of background of liver disease was observed in the first group (38 and 18 % accordingly). The frequency of a history of miscarriage was not significantly different (50 and 58 %). In addition, these groups had higher rates of present pregnancy after ovulation induction and in vitro fertilization protocols (61.5 and 32 % accordingly). We found a direct relationship between severity of hypertransaminasemia and significant hormonal stress as during the stage of planning pregnancy—ovulation induction and in vitro fertilization (IVF) protocols, as well as during the management of pregnant women. Thus 69 % of women in the first group and 42 % of women in the second group were prescribed more than 3 hormonal medicines for prolongation of pregnancy (estrogens, progestagens). The treatment of cytolytic syndrome were included maximal cancellation of hepatotoxical drugs, use of phosphatidylcholine, S-adenosilmetionin and antioxidants (88.5 and 79 % of pregnant women accordingly to these groups). Dynamics of indicators activity ALT and AST accordingly: 1 group 169.1 ± 23.2 vs 75.4 ± 8.6 U/L; 70.1 ± 5.3 vs 42.3 ± 3.4 U/L; 2 group 65.4 ± 2.6 vs 44.8 ± 5.7 U/L; 39.4 ± 2.4 vs 25.3 ± 2.3 U/L. Adverse pregnancy outcomes were recorded in 3 times more in the first group: 15.3 and 5.2 % of cases accordingly. Conclusions: We revealed a direct relationship between the number of hormonal drugs prescribed in ovulation induction and in vitro fertilization protocols with increased transaminase activity and the frequency of adverse pregnancy outcomes. Further research of the causes of increased levels of transaminases and influence of hepatotoxic drugs in pregnant women with high-risk of obstetrician at the stage of pregnancy and pregravidal preparation is needed.

Topic: 6 Drug Induced Liver Disease (DILD) Absno: 311 Liver injury is common among chronic ketamine abusers—a study of 297 subjects Grace Lai-Hung Wong1,2, Yuk-Him Tam3,4, Chi-Fai Ng4,5, Anthony Wing-Hung Chan6, Henry Lik-Yuen Chan1,2, Vincent Wai-Sun Wong1,2 Institute of Digestive Disease, 2Department of Medicine and Therapeutics, 3Division of Paediatric Surgery & Paediatric Urology, Department of Surgery, 4Youth Urological Treatment Centre, Department of Surgery, 5Division of Urology, Department of Surgery, 6 Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong 1

Topic: 6 Drug Induced Liver Disease (DILD) Absno: 309 The influence of high level of aminotransferase on pregnancy and delivery L. K. Palgova1, M. A. Tarasova2, I. V. Borisova2 1

North-Western State Medical University named after I.I. Mechnikov, D. O. Ott Research Institute of Obstetrics and Gynecology

2

Objective: To study the reasons of hypertransaminasemia in pregnant women at term of up to 20 weeks of pregnancy the effect of hypertransaminasemia on pregnancy and its outcomes. Materials and methods: 45 pregnant women were included in this study, who had the increase of transaminases in the period up to 20 weeks of pregnancy. (Group 1–26 women with increased transaminases more 3 normal levels, Group 2–19 women with increased transaminase lower 3 normal levels. The average age of the women 33.6 ± 1.1 and 31.7 ± 1.0 years accordingly.

Introduction: Evolving evidence shows ketamine abuse leads to liver injury. We aimed to investigate the prevalence and risk factors of abnormal liver biochemistry among ketamine abusers, and to describe the histopathological and radiological features of a subgroup with significant liver injury. Materials and methods: This was a cross-sectional survey of 297 consecutive chronic ketamine abusers presenting with urinary tract dysfunction. All subjects received a full medical history and blood tests were performed. Comprehensive liver assessment including liver biopsy, transient elastography and magnetic resonance cholangiopancreatography (MRCP) were arranged in a subgroup of patients with raised serum alkaline phosphatase and/or alanine aminotransferase [2 times of upper limit of normal. Results: Their mean age was 25 ± 4 years, and 157 patients (53 %) were females; 190 (64 %) were current abusers while the remaining 107 patients were ex-abusers. The prevalence of abnormal liver biochemistry was 42.4 %; all was cholestatic type. Female gender, high serum

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S30 C-reactive protein level and current ketamine abuse were independent risk factors of ketamine-induced abnormal liver biochemistry. Bile duct injury was uniformly observed in all 7 patients who underwent liver biopsy. Two patients had bridging fibrosis despite their young age. Prominent or dilated common bile duct without obstruction or extrinsic compression was observed in 3 of 6 patients who underwent MRCP examination. Conclusion: Abnormal liver biochemistry among ketamine abusers is considerably more common than previously thought. Ketamine abuse may lead to common bile duct dilatation, microscopic bile duct injury, and even significant liver fibrosis. Sustained abstinence protects ex-abusers from liver injury.

Hepatol Int (2014) 8:S1–S405 2. Fu D, Wakabayashi Y, Ido Y, Lippincott-Schwartz J, Arias IM. Regulation of bile canalicular network formation and maintenance by AMP-activated protein kinase and LKB1. J Cell Sci 2010;123(19):3294–3302

Topic: 6 Drug Induced Liver Disease (DILD) Absno: 727 The patients with multiple episodes of herb-induced liver injury have high depression tendency

Topic: 6 Drug Induced Liver Disease (DILD)

J. I. Suh

Absno: 616

Department of Internal Medicine, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeonju, Korea

Activation of AMPK prevents paracetamol-mediated depolarization and hepatocellular damage in collagen sandwich culture of hepatocytes

Introduction: Because herbal or folk remedies are so easy to access, the occurrence of herb-induced liver injury (HILI) is high in Korea. The patients who have been experienced with HILI are often rehospitalized, but there are no studies have been conducted on the depression in same patients with recurrent HILI. The purpose of this study was to evaluate the depression tendency in patients with multiple episodes of HILI. Materials and methods: Total 47 patients who have visited the Dongguk University Gyeongju Hospital from May 1, 2010 to December 31, 2012 were prospectively enrolled. The subjects were divided into three groups: healthy controls (group 1, n = 23), the patients with first attack of HILI (group 2, n = 12), and the patients with multiple episodes of HILI (group 3, n = 12). HILI was defined as the acute livery injury caused by herbal preparations, having the score of 4 or higher on the Roussel Uclaf casuality assessment method (RUCAM) scale. The clinical characteristics, Hospital AnxietyDepression Scale (HADS) and Beck Depression Inventory (BDI) of the groups were compared and analyzed. Results: The mean age was 51.1 ± 9.6 in group 1, 52.5 ± 13.2 in group 2, and 54.2 ± 12.4 in group 3. The number of male and female in each groups was 9 and 14 in group 1, 9 and 3 in group 2, and 2 and 10 in group 3. The mean RUCAM score was 7.5 ± 1.4 and 6.7 ± 1.8 in group 2 and 3, respectively. In group 3, the number of cases with two, three and four episodes of HILI was 8, 3, and 1, respectively. The depression subscale of HADS scores were higher in group 3 (10.0 ± 4.1) compared with group 1 (5.0 ± 3.6) and group 2 (6.8 ± 2.8) (p \ 0.01 vs group 1, p \ 0.05 vs group 2). The BDI scores were higher in group 3 (18.0 ± 12.2) compared with group 1 (6.6 ± 6.7) and group 2 (9.8 ± 7.1) (p \ 0.01 vs group 1, p \ 0.05 vs group 2). Conclusions: These results show that the patients with multiple episodes of HILI have high depression tendency. Therefore, it seems to be important to manage with psychological aspects for the patients with multiple episodes of HILI.

Ghada Haydar and Dong Fu Faculty of Pharmacy, the University of Sydney, NSW 2006, Australia Introduction: Drug induced liver injury (DILI) is responsible for 50 % of all acute liver failures. DILI is also the most frequently cited reason for abandoning compounds during development or withdrawing them from the market. Paracetamol is amongst the lead compounds cited in DILI. Hepatocyte polarization is essential for the liver to function in detoxification, drug metabolism and excretion. Loss of hepatocyte polarization results in accumulation of bile acids or exogenous substances (e.g. drugs) and cell damage. Our previous study reveals that AMP-activated kinase (AMPK) plays an important role in hepatocyte polarization (1, 2). The current study investigates whether paracetamol causes depolarization through inactivation of AMPK and if activation of AMPK prevents the effects of paracetamol on polarization as well as hepatocellular damage. Results: Immunofluorescence of tight junctional marker, occludin, and apical marker, ABCB1, was performed in collagen sandwich culture of rat hepatocytes to study the polarization. Confocal microscopy images showed that paracetamol (10 mM, 24 h) depolarized hepatocyte and caused internalization of ABCB1 and occludin. Quantitative measurement showed that paracetamol treatment resulted in a significant decrease in canalicular length per cell. Western blot of total and phosphorylated AMPK revealed that paracetamol inactivated AMPK, suggesting paracetamol depolarizes hepatocytes via the AMPK pathway. AMPK activator, AICAR (200 micro M, 24 h), prevented paracetamol-mediated depolarization, confirming the role of AMPK in polarization. In addition, paracetamol alone depleted cellular ATP, and decreased mitochondrial potential and cell viability while a combination of paracetamol and AICAR elevated ATP levels back to normal and restored mitochondrial potential and cell viability. Conclusions: Paracetamol inactivates AMPK and consequently depolarizes and damages hepatocytes. Activation of AMPK restores the polarization, cellular ATP, mitochondrial potential and viability after treatment of paracetamol, suggesting AMPK as a novel target in treatment of DILI. References 1. Fu D, Wakabayashi Y, Lippincott-Schwartz J, Arias IM. Bile acid stimulates hepatocytes canalicular network formation through a cAMP-Epac-MEK-LKB1-AMPK pathway. Proc Natl Acad Sci USA 2011;108(4):1403–1408

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Topic: 6 Drug Induced Liver Disease (DILD) Absno: 748 Regorafenib diminishes rat sinusoidal obstruction syndrome by inhibition of ERK phosphorylation/MMP-9 activation M. Okuno, E. Hatano, K. Nakamura, Y. Kasai, T. Nishio, S. Seo, K. Taura, S. Uemoto

Hepatol Int (2014) 8:S1–S405 Department of Surgery, Graduate School of Medicine Kyoto University, Kyoto, Japan Background and aims: Sinusoidal obstruction syndrome (SOS) is a drug-induced liver injury that occurs with oxaliplatin treatment and is associated with postoperative morbidity after hepatectomy. The aim of this study is to examine the impact of regorafenib, the first smallmolecule kinase inhibitor showing efficacy in metastatic colorectal cancer, on SOS in a rat model. Methods: SOS was induced in rats using Monocrotaline (MCT). To evaluate the efficacy of regorafenib on SOS, the rats were divided in 2 groups, one treated with regorafenib (6 mg/kg) and one with vehicle by gavage, at 12 and 36 h before MCT administration. Histopathological examination and serum biochemistry were performed at 48 h after MCT administration. Morphological changes of hepatic sinusoids were evaluated by immunohistochemistry and electron microscopy. We also performed 30 % hepatectomy in MCT-treated rats to examine whether regorafenib preserved remnant liver function. Results: In the vehicle group, the rats had the features of SOS with severe sinusoidal hemorrhage, sinusoidal dilatation, coagulative necrosis of hepatocytes and endothelial damage of the central vein, whereas the severity of these changes was significantly suppressed and total SOS scores were significantly decreased in the regorafenib group. In serum biochemistry, AST and ALT were significantly reduced in the regorafenib group compared with those in the vehicle group. Immunohistochemistry and electron microscopy showed a protective effect of regorafenib on sinusoidal endothelial cells. Survival rate at 7 days after surgery was significantly improved in the regorafenib group over the vehicle group (26.7 vs. 6.7 %, p \ 0.05). Regorafenib also diminished the activity of matrix metalloproteinase9 (MMP-9) through blocking the phosphorylation of ERK protein. Conclusions: Regorafenib had a beneficial effect to MCT-induced SOS by attenuating ERK phosphorylation/MMP-9 activation, suggesting that regorafenib would be a favorable agent to use in combination with oxaliplatin-based chemotherapy.

S31 (normal values, respectively, 0.3–1.2, 0–0.2), other biochemical and hemogram examinations were normal and the HBsAg, anti-HCV, anti- HbcIgM: were negative. In re-evaluation of the medical history, it was found that the patient had influenza-like symptoms for five days. The other atypical acute viral hepatitis serology was found to be normal. Furthermore, the serological markers for autoimmune hepatitis and primary biliary cirrhosis were negative. Bilirubin level has decreased in follow-up period and patient was discharged. 8 months later, the patient admitted to our clinic again with the same clinical chart. The examinations were repeated but there was no result, therefore, a liver biopsy was planned to the patient. When questioned again, the patient revealed that she had been taking an oral contraceptive (containing estrogen and progesterone) drug for 20 days due to menstural irregularity. It was found that the complaints in her previous admittance started after taking the same drug. Thus, it was thought that it might have been toxic hepatitis. Due to patient’s unwillingness, the liver biopsy was not performed. In the follow-up, patient’s bilirubin level has became to normal levels in 1 month and the patient was recommended not to take oral contraceptive drugs again. Conclusion: In the patients with cholestatic or acute hepatitis manifestations, especially with normal radiological findings, drug history must be evaluated insistently and oral contraceptives should be keep in mind especially in women.

Topic: 6 Drug Induced Liver Disease (DILD) Absno: 906 Clinicopathological spectrum of drug induced liver injury: a comparison between anti-tubercular versus other drugs N. Kumar1, C. Bihari2, A. Bhadoria3, K. N. Chandan1, S. K. Sarin1 1

Topic: 6 Drug Induced Liver Disease (DILD) Absno: 827 Recurrent cholestatic hepatitis due to oral contraceptives K. Gisi1, B. Kantarceken1, A. Cetinkaya1, H. Demir2 1

Department of Gastroenterology, School of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey, 2 Department of Internal Medicine, School of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey Introduction: Drug related cholestasis occurs as a result of gall secretion by hepatocytes. Many drugs have been reported to cause cholestasis. Oral contraceptives create cholestatic hepatitis in less than 1 %. However, recurrent cholestatic hepatitis is seen less often. With this case study, we aimed to present the case of recurrent cholestatic hepatitis due to use of oral contraceptives. Case: A 25 years old female patient was admitted to our clinic with icterus and itching mainly for request of ERCP from another hospital. Direct Bilirubin was high and she has gallbladder stones and slightly wide choledoc on ultrasonographic examination. Extrahepatic bile ducts were normal in ERCP. Continued raise of bilirubin levels have observed after ERCP. In physical examination there was only widespread icterus. In the laboratory tests; AST:48 U/L (high), ALT: Normal, Alkaline phosphatase: 218 U/L (high), GGT: Normal LDH: 326 U/L total bilirubin: 20.49 mg/dl, direct bilirubin: 16 mg/dL

Department of Hepatology, 2Department of Pathology, 3Department of Epidemiology and Statistics, ILBS, New Delhi

Objective: To analyze the clinical and histological features of the drug-induced liver injury (DILI), in order to gain insights into factors responsible for DILI and its varied clinical manifestation. Methods: Retrospective analysis of patients presenting as drug induced liver injury (DILI) during 2009 to august 2013 was done. Seventy one patients (male = 39, female = 32) were diagnosed as DILI based on clinical and/or histopathological findings. Patients were divided into ATT induced or non ATT induced DILI. Clinical and laboratory data were collected and used to classify the cases as hepatocellular injury, cholestatic, or mixed hepatocellular-cholestatic types. Liver biopsy and histopathological data was available in 30 patients. Results: ATT induced liver injury accounted for 49 % of the cases of DILI. Among the patients with non ATT induced DILI, ingestion of indigenous medications was responsible for 29 % of the DILI cases. Antibiotics, NSAID’s and hormonal therapy were the other major culprits, each accounting for 4 % of DILI cases. ATT induced DILI was more common among females (n = 23, 65 %) whereas non ATT DILI was more common in males (n = 27, 75 %). 30 patients (42 %) had underlying liver disease which was undiagnosed at the time of initiation of the offending drug. Patient with ATT induced DILI had a lower total bilirubin at presentation as compared to patients with non ATT induced DILI (8.6 vs 17.4 mg/dl, p = 0.001). Patient with ATT induced DILI had higher mortality (n = 7) as compared to non ATT induced DILI. Non ATT DILI group had features of autoimmunity with 8 patients (22 %) being ANA positive and a higher mean IgG

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S32 level (20.6 g). In patients with available liver biopsy the predominant histological presentation was as acute hepatitis with cholestasis (n = 10, 33 %, three them had autoimmune like hepatitis), acute hepatitis without cholestasis (n = 6, 20 %, two had autoimmune like hepatitis), bland cholestasis (n = 8, 27 %) steatohepatitis (n = 4), Veno-occlusive disease (n = 1), and granulomatous pathology (n = 1). Increased fibrosis and chronicity was seen in 12 cases, (8 portal/periportal fibrosis, 2 bridging fibrosis and 2 cirrhosis). Bile duct Injury (n = 3) and significant parenchymal necrosis (zonal necrosis, bridging necrosis) was seen in (n = 9) cases. All ATT induced DILI biopsy showed cholestatic hepatitis with significant parenchymal necrosis (n = 4). Conclusion: This is the largest cohort of DILI implicating indigenous medication as a major culprit of DILI. There is need for new prognostic models and rationalization of ATT. The presence of autoimmune features in non ATT DILI group could support the possible role of steroids as a therapeutic option. General awareness and avoidance of misuse of indigenous medications and over the counter drugs are required to reduce the incidence of this potentially preventable illness.

Topic: 7 Hepatitis B—Basic Science Absno: 11 Hepatitis B surface antigen (HBsAg) levels during the natural history of chronic hepatitis B (CHB): a Chinese perspective study Linyan Zeng, Jiangshan Lian, Jianyang Chen, Hongyu Jia, Yimin Zhang, Dairong Xiang, Liang Yu, Jianhua Hu, Yingfeng Lu, Ling Zheng, Lanjuan Li, YiDa Yang State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China Linyan Zeng and Jiangshan Lian contributed equally to this work. Background and aims: Hepatitis B surface antigen (HBsAg) is known as an early marker of infection with the hepatitis B virus (HBV), and qualitative HBsAg assays is used as a screening tool for several decades. Now the quantitative assessment of HBsAg in serum is more and more attention. This study aimed to determine baseline HBsAg during the different phases of chronic hepatitis B (CHB) in China. Methods: 623 HBV-infected patients without antiviral therapy before were analyzed in a cross-sectional study. And patients were classified into five phases including immune-tolerant (IT, n = 108), immuneclearance (IC, n = 161), HBeAg negative hepatitis (ENH, n = 149), low-replicative (LR, n = 135), and liver cirrhosis (LC, n = 70). HBsAg was quantified (Abbott ARCHITECT- assay) and correlated with HBV-DNA, and serum ALT/AST in each phase of CHB was also performed. Results: Median HBsAg titres were different between each phase of CHB (p \ 0.001): IT (4.85 log10 IU/ml), IC (4.36 log10 IU/ml), ENH (2.95 log10 IU/ml), LR (3.18 log10 IU/ml) and LC (2.69 log10 IU/ml). HBsAg titres were highest in the IT phase, and lowest in the LC phase. Serum HBsAg titers showed most strong correlated with HBV viral load in the IC phase (r = 0.683, p \ 0.001). No correlation between the serum HBsAg level and ALT/AST was observed. Conclusions: This study shows mean HBsAg baseline levels differ significantly during the five phases of CHB. These findings provide further implications for the natural history of HBV-infection, and baseline HBsAg quantification may be used as a good marker for

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Hepatol Int (2014) 8:S1–S405 predicting treatment effect of immune-modulator therapy or oral nucleos(t)ide analogue therapy. Keywords: HBsAg quantification, Chronic hepatitis B, Natural history, Perspective

Topic: 7 Hepatitis B—Basic Science Absno: 28 Comparative immune modulatory capacities of HBsAg, HBcAg, and HBsAg/HBcAg and their utility for development of therapeutic vaccines S. M. Akbar1, S. Chen2, M. Al-Mahtab3, Y. Hiasa2 1

Department of Medical Sciences, Toshiba General Hospital, Tokyo, Japan, 2Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan, 3Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Introduction: Vaccine therapy with HBV-related antigens appears to have therapeutic efficacy in chronic hepatitis B (CHB). However, the nature of antigens has not been properly elucidated and thus effective therapeutic vaccines are yet to be developed for CHB patients. In this study, we compared the immunogenicity of 3 vaccine preparations to develop insights about possible candidate of therapeutic vaccines for HBV infections. Materials and methods: Three HBV-related antigens, HBsAg, HBcAg, and a combined form of HBsAg and HBcAg (HBsAg/ HBcAg) were cultured with peripheral blood mononuclear cells and dendritic cells (DC) from 10 patients with CHB. Also, HBsAg, HBcAg and HBsAg/HBcAg were administered to 10 HBV transgenic mice (HBVTM) expressing HBV DNA and HBeAg for 5 times at an interval of 2 weeks. The levels HBsAg and anti-HBs were measured in the sera. The extents of proliferation of antigen-specific T lymphocytes were evaluated by cell proliferation assays. The levels of cytokines (IL-2, IFN-gamma and IL-12) were measured in culture supernatants. Ethical permission was obtained for both human and animal studies. Results: In vitro study using T lymphocytes from CHB patients showed that HBsAg and HBcAg induced HBsAg and HBcAg-specific proliferation of T lymphocytes from CHB patients, respectively. However, the levels of proliferation by HBcAg were significantly higher than those of HBsAg (p \ 0.05). HBsAg/HBcAg vaccine caused both HBsAg and HBcAg-specific T lymphocyte proliferation of CHB patients. Immunization with HBsAg caused negativity HBsAg and anti-HBs positivity in 50–60 % HBV TM. HBsAg-specific T cell proliferation was detected in 80 % HBV TM. On the other hand, immunization with HBcAg induced HBcAg- and HBsAg-specific T cell proliferation, HBsAg negativity and anti-HBs production in all HBV TM. Finally, HBsAg/HBcAg immunization resulted in negativity of HBsAg, production of anti-HBs and proliferation of HBsAg and HBcAg-specific T cell in all HBV TM. In addition, significantly higher levels of T cell proliferation and cytokine production were documented by DC from HBcAg- and HBsAg/HBcAgimmunized HBV TM compared to those with HBsAg-immunized HBV TM (p \ 0.05). Conclusions: This is the first study that compared the immunogenicity of three types of antigens for vaccine candidate in vitro and in vivo in same run. This study showed the inherent limitations of HBsAg-based vaccine as therapeutic vaccine as this was unable to induce HBcAg-specific immunity in vitro and vivo. Considerable optimisms have been shown about immune modulatory capacity of

Hepatol Int (2014) 8:S1–S405 HBsAg/HBcAg-based vaccine therapy for HBV-infected subjects. HBcAg should be an integral part of a therapeutic vaccine for CHB.

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Topic: 7 Hepatitis B—Basic Science Absno: 183

Topic: 7 Hepatitis B—Basic Science

Differential serum microRNA profiles in good responders of chronic hepatitis B pre- and post-lamivudine/adefovir dipivoxil combination therapy

Absno: 37 K. H. Xiang, R. Hao, Y. Q. Peng, Y. Li, L. Yan, H. Zhuang, T. Li Large-fragment deletions of hepatitis B virus core gene lead to over-expression of polymerase resulting in enhanced tumorigenicity in hepatoma cells

Department of Microbiology, School of Basic Medical Sciences, Peking University Health Science Center, 38 Xueyuan Road, Haidian District, Beijing 100191, P. R. China

Ya-Hui Huang1,2, Ying-Hsin Tseng1,2, George Hung3, Tse-Ching Chen4, Wei-Chen Lee5, Chau-Ting Yeh1,2

Introduction: MicroRNAs (miRNAs) have been suggested to play potential roles in the natural history of hepatitis B virus (HBV) infection. This study aimed to investigate if there was any miRNA profile changes associated with the good response to the lamivudine (LAM)/adefovir dipivoxil (ADV) therapy in chronic hepatitis B (CHB) patients. Materials and methods: Three hepatitis e antigen (HBeAg) positive CHB male patients (22, 26 and 26 years of age, respectively) with genotype C infection were treated with LAM/ADV for 104 weeks (w), when the HBV DNA was undetectable (Roche COBAS TaqMan, Germany) and HBeAg seroconversion occurred (Abbott ARCHITECT i2000, USA). The baseline (BL) and 104w sera were analyzed by a real-time

1 Liver Research Center and Molecular Diagnosis Lab., Chang Gung Memorial Hospital, Taoyuan, Taiwan, 2Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan, 3Department of Chemical and Biological Engineering, Princeton Universtity, NJ, USA, 4Department of Pathology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, 5Chang Gung Transplantation Institute, Chang Gung Memorial Hospital, Taoyuan, Taiwan

Background/aims: Several different types of naturally occurring hepatitis B virus (HBV) core gene deletion variants were identified in special patient groups including renal transplant recipients, children, and HIV-infected patients. However, the prevalence and clinical roles of core gene deletions in the natural course of general chronic hepatitis B patients have never been carefully investigated. Methods: HBV core genes were sequenced in three gender- and agematched groups of patients diagnosed as chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC) (n = 33 for each group) respectively. The prevalence and prognostic value of a novel type of large-fragment core deletion mutants were examined in the liver tissues of 185 hepatoma patients receiving surgical removal of HCC. Cell-based and animal-based models were used to investigate the mechanisms associated with the increased tumorigenicity. Results: Novel large-fragment core gene deletions were found in the serum samples of 5/33 (15.2 %) HCC patients, but in none of the other two gender- and age-matched groups. The large-fragment core gene deletions brought the polymerase reading frames under the control of core gene promoter. This type of core deletion variants was detected in the liver tissues of 24/185 (13.0 %) HCC patients receiving surgical resection. Significant shorter recurrence-free survival was found in this group of patients (P \ 0.001). Characterization of a representative core deletion clone revealed increased polymerase expression in Huh7 cells. Enhanced cell proliferation and reduced TRAIL-induced apoptosis were found in Huh7 and HepG2 cells stably expressing the mutant (Huh7-pol and HepG2-pol). Increased tumorigenicity in nude mice was found in a xenograft model using Huh7-pol and HepG2-pol cells (P \ 0.01 for both). Because of the epsilon-binding ability of HBV polymerase, we hypothesize that the over-expressed polymerase could bind to cellular microRNAs. Screening of a large panel of microRNAs revealed physical association of the HBV polymerase with 3 selective microRNAs. Further study discovered a binding inhibition effect on a microRNA, leading to enhanced tumor growth. Conclusions: Novel large-fragment HBV core gene deletion variants were identified in patients with HCC and were associated with poor postoperative prognosis. Mechanistic investigation showed that the deletions resulted in polymerase overexpression, leading to binding inhibition of selected microRNAs. Functional suppression of one of the microRNAs was associated with enhanced tumor growth.

Table 1

Significantly different expressed 22 miRNAs in BL and 104w serum samples

MiRNAa

2-DCt (mean ± SD) BL

Ratio (BL/104w)

p valueb

Potential functions (www.ncbi.nlm.nih.gov/genbank)

104w

miR-30d

0.109 ± 0.008

0.019 ± 0.015

5.65

0.0249

Promoting tumor invasion in HCCc

miR-17

0.329 ± 0.124

0.036 ± 0.024

9.24

0.0115

Repression of colon cancer cells apoptosis

miR-331

0.032 ± 0.017

0.003 ± 0.003

11.47

0.0183

Decreased expression in prostate cancer tissue

miR-28-3p

0.002 ± 0.004

0.000 ± 0.000

14.66

0.0229

Down-regulated in colorectal cancer cells

miR-598

0.002 ± 0.000

0.000 ± 0.000

14.81

0.0031

Up-regulated in esophageal cancer

let-7c

0.008 ± 0.005

0.001 ± 0.000

14.86

0.0129

Inhibiting influenza virus

miR-340#

0.001 ± 0.000

0.000 ± 0.000

17.82

0.0350

Up-regulation in coronary artery disease

miR-338-5P

0.001 ± 0.002

0.000 ± 0.000

17.97

0.0412

Up-regulated in lung carcinoma tissues

miR-30b

0.411 ± 0.267

0.022 ± 0.056

18.62

0.0499

Up-regulated by respiratory syncytial virus

miR-422a

0.010 ± 0.003

0.001 ± 0.000

18.68

0.0040

Inhibit CYP7A1 expression in hepatocytes

miR-30c

1.340 ± 0.475

0.056 ± 0.113

23.93

0.0177

Up-regulated by respiratory syncytial virus

miR-574-3p

0.259 ± 0.337

0.009 ± 0.013

29.33

0.0147

Aberrant expression in gastric cancer

miR-192

0.163 ± 0.059

0.006 ± 0.002

29.48

0.0004

Down-regulated by HBx

miR-151-5P

0.002 ± 0.002

0.000 ± 0.000

35.83

0.0214

Up-regulated in HCCc

miR-375

0.020 ± 0.007

0.001 ± 0.000

37.01

0.0018

Down-regulation of YAP1 in thyroid carcinoma

miR-194

0.032 ± 0.018

0.001 ± 0.000

57.89

0.0109

Promoting angiogenesis in colon cancers

miR-125b

0.013 ± 0.027

0.000 ± 0.000

58.38

0.0214

Promoting apoptasis

miR-146b

0.822 ± 1.445

0.014 ± 0.028

58.42

0.0203

Prognostic implication for papillary thyroid carcinoma

miR-1290

141.742 ± 498.681

2.421 ± 4.598

58.55

0.0376

Impairs cytokinesis

miR-885-5p

2.080 ± 2.728

0.035 ± 0.119

59.37

0.0234


miR-193b

0.326 ± 0.768

0.004 ± 0.015

73.34

0.0241

Promoting natural killer cell cytotoxicity

miR-122

2.090 ± 1.436

0.022 ± 0.059

94.77

0.0091


CYP7A1, cholesterol 7 alpha-hydroxylase; HBx, hepatitis B x protein; YAP1, Yes-associated protein 1 a

Two clusters of miRNAs were shown in bold letters and bold letters with underlines, respectively

b

Quantitative values were compared using the T-test with p\0.05 considered as statistically significant

c

Up-regulated in HCC. The patients in this study were found to have a decreased level of these miRNAs by LAM/ ADV treatment

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S34 quantitative polymerase chain reaction (RT-qPCR) based on a Taqman human miRNA array with 384 wells on each plate (Life Science, China). MiRNA U6 was used as an internal control of the assay and the expression level of the miRNA was expressed as 2-DCt value (DCt = Cttest - CtU6). Results: Among 768 human mature and precursor miRNAs tested, a panel of 22 miRNAs exhibited significantly higher expression in BL samples than those in 104w-LAM/ADV treated samples (p \ 0.05) (Table 1). The results showed that a few miRNAs, e.g., miR-30d, miR151-5P and miR-885-5p, were down regulated along with the good response to the LAM/ADV treatment. Hierarchical clustering analysis showed that a small panel of miR-17, -30b, -30c, -122, -192, -194, -331, 375, -442a, -574-3p and let-7c were clustered together, while another panel of miR-146b, -193b, -885-5p, -1290 and -260 were clustered together, respectively. In addition, miR-135b, -181c, -365, -367 and -191# were found to express only in BL samples, while miR-539 only in 104w samples. The results suggested that a good response to LAM/ADV treatment might be associated with a host regulation of certain miRNA expressions in favor of preventing the disease progression to hepatocellular carcinoma (HCC) (Table 1), but the findings need to be verified in more patients.

Topic: 7 Hepatitis B—Basic Science Absno: 203 Combined effects of TGFB and TGFBR1 polymorphisms on susceptibility to HBV-related advanced liver disease in Indonesian Population I. Suriapranata1, G. E. P. Langi1, W. M. Sudania1, F. Sugiarto1, R. A. Gani2, I. Hasan2, A. Sanityoso2, U. Budihusodo2, L. A. Lesmana2, A. Sulaiman3, G. Mathew1 1 Mochtar Riady Institute for Nanotechnology, Universitas Pelita Harapan, Tangerang, Indonesia, 2Division of Hepatology, Ciptomangunkusumo Hospital, Jakarta, Indonesia, 3Klinik Hati Prof. Ali, Jakarta, Indonesia

Background: The transforming growth factor-beta (TGF-b) cytokine and its isoforms initiate a signaling cascade, which is linked to liver fibrosis, cirrhosis and HCC. Because of its role in these stages of disease progression, TGF-b appears to play a unique role in the molecular pathogenesis of HCC. In this study we investigate the association of polymorphisms in TGFb gene and its receptor TGFbRI and their association with advanced liver disease. Materials and methods: A total of 485 subjects comprising of 133 chronic HBV, 132 cirrhosis (HBV), 96 HCC (HBV) and 124 control subjects were included in the study. Polymorphisms in TGFb and TGFbRI were identified using PCR and direct sequencing method. Logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (CI) with adjustment for age and gender. Results: CT, TT genotypes of rs1800469 and rs4803457 in TGFB promoter region as well as GC genotype of rs118065340 in TGFB intron 5 are associated with susceptibility to Cirrhosis and HCC (P \ 0.05). In TGFBR-I gene, SNP rs10819636 GT and TT genotypes are associated with increased risk of HCC. Combined polymorphisms in TGFB and TGFBR-I show a synergistic effect on Cirrhosis risk, with an OR of 10.1 (P \ 0.001) in control, and an OR of 13.1 (P \ 0.003) in chronic HBV subjects, respectively. Combination of the four SNPs is associated with an increased risk of HCC (P \ 0.008). Conclusions: Combination of polymorphisms in TGFb and TGFbRI genes might be associated with increased risk of developing Cirrhosis and HCC in our study population. Keywords: Single Nucleotide Polymorphisms, Cirrhosis, HCC, TGFb, TGFbRI

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Topic: 7 Hepatitis B—Basic Science Absno: 302 Beta2-glycoprotein I and annexin II as hepatitis B virus entryassociated molecules Yaming Liu1, Xue Jing2, Pujun Gao1 1

Department of Hepatology, First Hospital of Jilin University, Changchun, China, 2Department of Gastroenterology, The Affiliated Hospital of Medical College, Qingdao University, Qingdao, China Introduction: Human beta2-glycoprotein I (beta2-GPI) binds to recombinant hepatitis B surface antigen (rHBsAg), and can specifically bind to annexin II which located on the cell membrane of human hepatoma SMMC-7721 cells. Viral envelope protein(s) are essential for mediating cellular entry. We aim to investigate whether beta2-GPI and annexin II mediate the binding ability of HBsAg to cell surfaces. Materials and methods: Non-permissive cells, including L02, HepG2, HepG2.2.15, and 293T cells, were incubated with dose of beta2-GPI, rHBsAg protein, or both. ELISA was used to test the binding ability of HBsAg to cell surfaces. Expressions of beta2-GPI and annexin II were analyzed by Western blot in L02, SMMC-7721, HepG2, HepG2.2.15, and 293T cells. Then, the locations of beta2GPI, annexin II, and HBsAg were determined by using indirect immunofluorescence in HepG2 and HepG2.2.15 cells. Results: Beta2-GPI enhanced the binding of rHBsAg to L02, HepG2, HepG2.2.15, and 293T cells, and the adhesion differences appeared in different cells. Beta2-GPI was higher expression in HepG2.2.15 cells than in L02, SMMC-7721, HepG2 cells and almost not in 293T cells. Annexin II expressed lower in HepG2.2.15 cells than in L02, HepG2, and SMMC7721 cells. In addition, beta2-GPI appeared to colocalize with annexin II in the cytosol of HepG2 and HepG2.2.15 cells. HBsAg colocalized with beta2-GPI and annexin II in the cytosol of HepG2.2.15 cells. Conclusions: Beta2-GPI enhances the binding capability of HBsAg to cell surfaces. The differences of adhesion ability might attribute to differential expressions of beta2-GPI and annexin II in different cells. Acknowledgments: This work was supported by the National Natural Science Foundation of China (No.30971353/H0316).

Topic: 7 Hepatitis B—Basic Science Absno: 305 Serum levels of interferon-gamma-inducible protein 10 (IP-10) in each phases of chronic hepatitis B and response to peginterferon therapy in HBeAg-positive and HBeAg-negative chronic hepatitis B Kittiyod Poovorawan, Chintana Chirathaworn, Pisit Tangkijvanich, Piyawat Komolmit, Yong Poovorawan Chulalongkorn University Introduction: Serum levels of interferon-gamma inducible protein 10 (IP-10) are a marker for immune activity and might associated with an increased probability of HBeAg loss after pegylated interferon (PegIFN) therapy. This study aimed to determine serum levels of IP10 in each phase of chronic hepatitis B and after starting treatment with PegIFN. Materials and methods: 235 chronic hepatitis B patients without previous treatment and 50 healthy control subjects were recruited. Demographic and clinical data of the patients were recorded. All

Hepatol Int (2014) 8:S1–S405 patients were classified into the following categories based on ALT, HBV VL, HBeAg status from the previous 6 months; immune tolerance (n = 49), immune clearance (n = 48), low replication (n = 86) and HBeAg negative hepatitis (n = 52). Of the 235 patients, 60 patients with high ALT (HBeAg positive (n = 30) and HBeAg negative (n = 30)) were treated with PegIFN for 48 weeks. Serum IP10 was measured at baseline, on-treatment week 12, 24, 48 and week 72 post-treatment in those 60 patients. Results: One hundred and forty-four males and 79 females, median age of 35 years chronic hepatitis B patients and 50 healthy controls were included. The mean level of serum IP-10 at baseline was

S35 Table 1 In HBeAg-positive patients, IP-10 level were higher in responders (achieved HBeAg seroconversion at week 72) compared with non-responders among HBeAg positive patients IP-10 level (pg/ml)

Responders (n = 14)

Non-responder (n = 15)

P value

At base line

394 ± 473

318 ± 318

0.61

Week 12

606 ± 342

503 ± 340

0.42

Week 24

579 ± 211

395 ± 210

0.03*

Week 48

428 ± 375

375 ± 246

0.53

Week 72

299 ± 214

214 ± 112

0.35

Plus–minus values are mean ± SD for all comparisons

240 ± 201, 357 ± 277, 238 ± 153, 288 ± 353 and 202.6 ± 75 pg/ ml in IT, IC, LR, ENH and control groups, respectively. At baseline, IP-10 level were significantly higher in IC compare with IT, LR and control group (Fig. 1). However, no statistical difference between mean serum IP-10 level in IC and ENH patients was observed. The dynamic change of post-PegIFN treatment serum IP-10 level was different between HBeAg positive and HBeAg negative patients. In HBeAg positive group, the serum IP-10 level was statistically increased in week 12 and 24 after treatment and then a gradual declining of serum IP-10 level was observed after week 24 (Fig. 2). On the other hand, the HBeAg negative group’s serum IP-10 level showed a non-statistical decline after PegIFN treatment. In HBeAgpositive patients, IP-10 level were higher in responders (achieved HBeAg seroconversion) compared with non-responders (Table 1). Conclusions: Baseline IP-10 was significantly higher during the IC phase of chronic hepatitis B. HBeAg-positive patients had higher serum IP-10 response at week 12 and 24 after PegIFN treatment. Fig. 1 Mean level of serum IP-10 in healthy control (n = 50) and each phase of chronic hepatitis B including immune tolerance (IT, n = 49), immune clearance (IC, n = 48), low replication(LR, n = 86) and HBeAg negative hepatitis (ENH, n = 52)

Topic: 7 Hepatitis B—Basic Science Absno: 364 Expression of chemokine receptors on Th17 cell in peripheral blood of chronic hepatitis B patients Haixia Sun, Yanqiong Liu, Xiaoan Yang, Xingfei Pan, Ka Zhang, Yeqiong Zhang, Gang Li, Qihuan Xu Department of Infectious Diseases, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China

Fig. 2 Mean level of serum IP-10 at baseline and after starting treatment week 12, 24, 48 and 72 in chronic hepatitis B HBeAgpositive patients

Objective: To investigate the expression of chemokine receptors CCR4, CCR6, CXCR3 on Th17 cell, and analyze the correlation between chemokine receptors and serum biochemical indices of liver function test and HBV DNA load in peripheral blood of CHB patients. Methods: 30 Chronic hepatitis B patients, which were assigned to CHB group, and 15 normal cases, which were assigned to control group, were enrolled in the study. CCR4, CCR6, CXCR3 expression levels on Th17 cell were assayed by flow cytometry. The correlation between chemokine receptors and ALT, TBIL, HBV DNA load was analyzed using Pearson’s correlation analysis, respectively. Results: CCR4, CCR6, CXCR3 expression levels on CD4+Th17 cell in CHB group were higher than that of control group. Moreover, the difference between them was statistically significant (P \ 0.05). CCR4, CCR6 expression levels on CD8 + Th17 cell in CHB group were higher than that of control group (P \ 0.05). Although CXCR3 expression level on CD8 + Th17 cell in CHB group was higher than that of control group, there was no statistical significance between

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S36 them (P [ 0.05). CCR4, CCR6 expression levels were positively correlated with serum ALT, HBV DNA load, respectively (P \ 0.05), but were not correlated with TBIL (P [ 0.05). Conclusion: Expression levels of chemokine receptor on Th17 cell were increased in CHB patients and were positively associated with degree of liver inflammation. We, therefore, believe that CCR4, CCR6 expression on Th17 cell might be involved in liver injury resulted from Th17 cell.

Topic: 7 Hepatitis B—Basic Science Absno: 377 Incomplete prophylactic effect of nucleot(s)ide analogues using in vitro hepatitis B virus infection model Tsunamasa Watanabe1, Susumu Hamada-Tsutsumi1, Shuko Murakami1, Etsuko Iio2, Kayoko Matsunami2, Sayuki Iijima1, Katsumi Omagari1, Noboru Shinkai2, Wataru Sugiura3,Yasuhito Tanaka1 1

Department of Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan, 2Department of Gastroenterology and Metabolism, Nagoya City University Hospital, Nagoya, Japan, 3Department of Infectious Diseases and Immunology Clinical Research Center, National Hospital Organization Nagoya Medical Center Introduction: We report a reliable in vitro HBV infection model using primary human hepatocytes (PHH) isolated from uPA/SCID mice with humanized livers (chimeric mice). Using the model, we investigated a prophylactic effect of nucleot(s)ide analogue (NA)based antiviral therapy on HBV infection. Materials and methods: PHH isolated from chimeric mice were plated on collagen-coated plate, and exposed to HBV sera as inocula. Levels of HBV-DNA and hepatitis B surface antigen (HBsAg) in the culture medium were measured using real-time quantitative PCR and ELISA, respectively. Lamivudine (LVD), tenofovir (TFV), and Hepatitis B immune globulin (HBIG) were used for investigating protection of HBV infection. Results: After HBV inoculation, continuous secretion of HBV-DNA and HBsAg were confirmed in supernatants of HBV-infected PHH cells (HBV-DNA around 1 9 106 copies/mL and HBsAg around 10 IU/mL). Although the inoculation of HBV with HBIG completely inhibited HBV infection, treatment of high concentrations of LVD or TFV during inoculation of HBV could not block HBV infection (n = 3). Conclusions: PHHs isolated from chimeric mice could be a valuable in vitro HBV infection model to examine the analysis of prophylactic effect for HBV infection. We concluded that infection of HBV in PHH was completely inhibited by HBIG, despite of a failure by NA treatment.

Topic: 7 Hepatitis B—Basic Science Absno: 392 Antigene and antisense peptide nuclear acids inhibit hepatitis B virus replication Xing-Liang Zhao1, Wen-Li Guan, Qin Wang, Lai Wei, Xiao-Ben Pan

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Hepatol Int (2014) 8:S1–S405 Peking University People’s Hospital, Peking University Hepatology Institute, Beijing Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, Beijing 100044, P. R. China Introduction: Hepatitis B virus (HBV) is a major human infectious pathogen, with over 300 million chronically infected individuals worldwide. It has been demonstrated that viral proteins HBsAg and HBeAg serve as the immune toleragen during the development and persistent of chronic hepatitis B. However, current therapeutics for chronic HBV infections such as interferon alpha and nucleoside analogs have shown only limited success to break through immune tolerance, which emphasizes the need on new strategies to eliminate the viral proteins. Materials and methods: We designed a series of antigene and antisense peptide nuclear acids (PNA), which targeted the co-terminals of viral RNAs at location of nt1815-1831. The PNAs were linked with cell penetrating peptides, including nuclear location signal (NLS), Tat, R9 or r9. These PNAs were evaluated for their antiviral activity by HBV-DNA integrated cell line HepG2.215 or HepG2 cell transiently transfected with HBV DNA. Results: Our results showed that the antisense PNAs modified with R9, Tat or r9, but not NLS, markedly reduced viral proteins in supernatant of HepG2.2.15 cells after 5 days treatment. The values of EC50 were ranged between 2-5uM. Only r9-linked antigene PNA showed a moderate inhibition on viral proteins in HepG2.2.15 cells. However, the inhibition was enhanced by 3–5 folds in the HepG2 or Huh7 cells transiently transfected with pUC18-HBV1.2, suggesting that the antigene PNA was more sensitive to episome DNA than chromosome DNA. The RT-PCR analysis showed antigene PNAs reduced viral proteins by inhibiting RNA transcription but antisense PNAs targeted at step of post-transcription. In conclusion, our results implied that antigene and antisene PNA might be a feasible strategy to reduce viral proteins. Currently these PNAs are testing in the cccDNA-enriched cell lines and HBV DNA transgenic mice.

Topic: 7 Hepatitis B—Basic Science Absno: 459 Analysis of HBV mutations on epitopes of cytotoxic T lymphocytes in HBV-infected patients with different clinical presentations Zhihui Xu, Yan Liu, Yihui Rong, Xiaodong Li, Liming Liu, Saojie Xin, Dongping Xu Beijing 302 Hospital Introduction: The interplay between HBV and host immunity plays a key role for clinical outcome of HBV infection. The study aimed to investigate clinical relevance of HBV mutations on epitopes of cytoxic T lymphocytes (CTL) and its impact on CTL response. Materials and methods: Sequence analysis of complete HBV genomes was performed for 516 HBV-infected patients with different clinical presentations. Among them, 188 patients who were positive for HLA-A2 with infection of genotype C HBV were further studied, including 51 with acute hepatitis B (AHB), 86 with chronic hepatitis B (CHB), and 51 with acute-on-chronic liver failure (ACLF). The mutations at 31 known HLA-A2-resticted epitopes were analyzed. Biding affinity of epitopic peptides were estimated by BIMAS and measured by T2 cell binding assay. S-gene vaccines containing wildtype or mutant env183–191 epitope-encoding sequence were constructed and inoculated into HLA-A2/HBV transgene mice. The

Hepatol Int (2014) 8:S1–S405 epitope-specific CD8 T cells were detected by pentamers with either wild-type or mutant epitopic peptide. Results: The incidences of 12 HLA-A2-resticted epitopic mutations were significantly different among ACLF, CHB and AHB patients. BIMAS scores significantly reduced for 10 mutant epitopes and increased for 2 mutant epitopes compared to the wild-type. The affinity trends obtained from T2 cell binding assay and from BIMAS analysis were consistent for all mutant epitopes except env201–210. env183–191 (FLLTRILTI) had three mutational patterns, i.e., FLLTKILTI (K), FSLTRILTI (S), and FSLTKILTI (SK). The K, S, and SK mutation incidences were 11.8, 0, and 0 % in AHB patients; 1.2, 16.3, 0 % in CHB patients; and 15.7, 11.8, 9.8 % in ACLF patients. T2 cell binding assay showed that the K, S, and SK mutants had 52.2, 3.5, and 1.8 % of the binding affinity of the wild-type, respectively. K-mutant-immunized mice had moderate cross CTL response to wild-type epitope, but not to S mutant. Similarly, S-mutant-immunized mice also had moderate cross CTL response to wild-type epitope, but not to K mutant. SKmutant-immunized mice had weak CTL response to S mutant and the wild-type, but not to K mutant. The wild-type-immunized mice could induce week CTL response in the mice inoculated by K and S mutant vaccines. Conclusion: HBV CTL-epitopic mutation might be a factor influencing disease progression of HBV infection. Some epitopic mutations altered binding affinity to the specific CTL in vitro. env183–191 mutations were verified decreasing the binding ability of the epitope to CTL both in vitro and in vivo.

Topic: 7 Hepatitis B—Basic Science Absno: 467 Tracing the history of hepatitis B genotype I in Mengla, China Tao Shen, Xinmin Yan, Jinping Zhang, Li Li, Jinli Wang Institute of Basic and Clinical Medicine, Center of Clinical Molecular Biology, Provincial Key Laboratory for Birth Defects and Genetic Diseases, The First People’s Hospital of Yunnan Province, Affiliated Hospital of Kumning Science and Technology University, Kunming, Yunnan 650032, China Fundings: This work was supported by National Natural Science Foundation of China (No. 81160352), in part by the Health Bureau of Yunnan province (D-201203), in part by the Science and Technology Department of Yunnan province (2013HB084). Indroduction: There was no data about the origin of Hepatitis B virus (HBV) genotype I in Mengla, China. Methods: 24 S/Pol coding regions (nt148-902) of HBV/I from China were available for evolutionary analysis (four sequences obtained from this study, twenty sequences obtained from the GenBank). Bayesian estimating evolutionary rate and dating the origin of HBV/I were performed. Results: Under the strict clock model, the estimated evolutionary rates for HBV/I was 5.22 9 10-4 substitution/site/year. However, when added the geographic origin, the mean substitution rates was accelerated to 7.92 9 10-2 substitution/site/year. Estimated time to most recent ancestor of genotype I was around 63 and 5 years ago in China and Mengla, respectively. The original virus liked to be introduced to Mengla on one occasion. The phylogeographic tree was showed in the Fig. 1. Conclusion: Multi-factors like time-scale and spatial locations should be integrated to provide a better interpretation of HBV/I evolutionary history.

S37

Fig. 1 .

Reference 1. Zhou Y, Holmes EC. Bayesian estimates of the evolutionary rate and age of hepatitis B virus. J Mol Evol 2007;65(2):159–165

Topic: 7 Hepatitis B—Basic Science Absno: 479 Role of viral factors and oxidative stress in HBV related disease pathogenesis-A tribal dominant northeast Indian population based study Anjan Kumar Saikia1,2, Moumita Bose1, Manab Deka3, N. N. Barman4, Sujoy Bose1, R. S. Thangskhiew5, Talar Motu6 1

Department of Biotechnology, Gauhati University, Guwahati, Assam, India, 2Central Hospital, NF Railway, Guwahati, Assam, 3 Department of Biological Sciences, Gauhati University, Guwahati, Assam, 4Gauhati Medical College, Guwahati, Assam, 5Super Car Hospital & Research Centre, Shillong, Meghalaya, 6Ramakrishna Mission Hospital, Itanagar, Arunachal Pradesh Scanty data is available on factors associated with HBV-infection pathogenesis in Northeast India(NEI); which has an ethnically distinct tribal population predomi-nantly. Aim: Study the role of higher HBV viral load, genotype, HBeAg status; and oxidative stress in susceptibility and severity of HBV related liver disease. Methods: Study cohorts included 144-AVH patients who cleared the virus within 6months of follow up, 172-patients who developed chronic CHBV infection, and 61-cirrhosis cases, and controls(n = 100). HBV genotyping was studied by multiplex PCR method; viral load was studied by ultrasensitive hybrid capture assay. Estimation of nitrite using Griess reagent. Cellular oxidative stress was measured in plasma by ELIZA using 8-hydroxy-2-deoxy Guanosine EIA kit (Cayman). Results: Genotype D(62.30 %) was the most prevalent genotype in all the cohorts, but high distribution of genotype C in CHBV(20.93 %) and cirrhosis cases(13.98 %) was alarming. The viral load was significantly higher in cases that developed CHBV compared to cases that cleared the virus within 6months; and also in CHBV cases (10177062.8 ± 12704–2810.4 IU/ml) compared to cirrhosis (2237940.3 ± 3419279.842 IU/ml). HBeAg positivity was associated with development and severity of HBV related liver disease. High viral load was significantly associated with e antigen positive status (p \ 0.001) in both the chronic HBV and cirrhosis groups. Significant increase in

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S38 plasma nitrite levels were found in chronic HBV cases compared to controls (p = 0.002) and AVH cases (p = 0.042). 8-OH-dG levels were higher in CHBV (416.33 ± 158.86)pg/ml and cirrhosis (388.26 ± 198.22)pg/ml cases compared to AVH (319.46 ± 206.75) pg/ml and controls (327.625 ± 194.82). Conclusion: Higher oxidative stress definitely plays an associative role along with viral factors in the pathogenesis of HBV related liver disease susceptibility and severity.

Topic: 7 Hepatitis B—Basic Science Absno: 520 Investigation of the relationship between neutrophil to lymphocyte ratio (NLR) and fibrosis level in chronic HBV patients ¨ lçay1, Ergenekon Karago¨z1, Muammer Kara2, Alpaslan Asım U Tanog˘lu2, Levent Go¨renek1, Hakan Erdem1, Vedat Turhan1, ¨ ncu¨l1 Ali Acar1, Oral O 1 GATA Haydarpasa Training Hospital Department of Infectious Diseases and Clinical Microbiology, 2GATA Haydarpasa Training Hospital Department of Gastroenterology

Introduction: The neutrophil to lymphocyte ratio (NLR), which is an inflammation index, has been suggested to predict prognosis of various inflammatory and neoplastic diseases. It is also considered as a prognostic predictor of hepatocellular carcinoma (HCC). However, there are only a few studies examining the relationship between NLR and liver fibrosis score in HBV infected cases in literature. In this study, we aimed to investigate the association between neutrophil to lymphocyte ratio (NLR) and fibrosis level. Material and method: This is a retrospective case–control study evaluating chronic HBV-infected cases. The study included 118 naı¨ve chronic hepatitis B cases followed-up in GATA Haydarpasa Training Hospital. Previously treated patients by antiviral therapy and patients with anti-Delta positive were excluded from the study. Patients were divided into two groups with fibrosis scores of 0–2 and 3–6 (according to ISHAC score) and we investigated whether NLR has a relationship with the severity of liver fibrosis score or not. Result: Of the 118 cases, 104 (88.1 %) were male, 14 (11.9 %) were female. Fibrosis scores of 29 cases (24.5 %) were C3 while 89 cases had fibrosis scores\3 (75.5%).There was not a significant correlation existed between fibrosis score and NLR. NLR level was 1.87 ± 0.93 in patients with fibrosis score 0-2. This was 1.64 ± 0.62 in patients with fibrosis score 3-6 (p = 0,136). Although N/L ratio is a novel non-invasive, inexpensive test and can be used to predict prognosis of various inflammatory and neoplastic diseases, it does not appear to be a useful predictor of severity of liver fibrosis in our limited chronic Hepatitis B patients. Keywords: Chronic Hepatitis B, Liver fibrosis

Topic: 7 Hepatitis B—Basic Science Absno: 525 Antiviral activity of chemical compound isolated from Artemisia morrisonensis against hepatitis B virus in vitro Tsurng-Juhn Huang1, Shu-Heng Liu1, Yu-Cheng Kuo2,3, Chia-Wen Chen4,5, Shen-Chieh Chou1

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Graduate Institute of Ecology and Evolutionary Biology, China Medical University, Taichung, Taiwan, 2Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan, 3 Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan, 4Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan, 5School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan The compound p-hydroxyacetophenone (PHAP) isolated from Artemisia morrisonensis was found to have potential anti-HBV effects in HepG2 2.2.15 cells. We clarified its antiviral mode further and HBVtransfected Huh7 cells were used as the platform. During viral gene expression, treatment with PHAP had no apparent effects on the viral precore/pregenomic RNA. However, the 2.4-kb preS RNA of viral surface gene increased significantly relative to the 2.1-kb S RNA with PHAP. Promoter activity analysis demonstrated that PHAP had a potent effect on augmenting the viral preS promoter activity. The subsequent increase in the large surface protein and induce endoplasmic reticular (ER) stress has been reported previously. Interestingly, PHAP specifically reduced ER stress related GRP78 RNA/protein levels, but not those of GRP94, in treated Huh7 cells while PHAP also led to the significant intracellular accumulation of virus. Moreover, treatment with the ER chaperone inducer thapsigargin relieved the inhibitory effect of PHAP based on the supernatant HBV DNA levels of HBVexpressed cells. In conclusion, this study suggests that the mechanism of HBV inhibition by PHAP might involve the regulation of viral surface gene expression and block virion secretion by interference with the ER stress signaling pathway. Keywords: Artemisia morrisonensis, Chaperone, ER stress, GRP78, hepatitis B virus, HepG2 2.2.15 cell, Huh7 cell, p-hydroxyacetophenone

Topic: 7 Hepatitis B—Basic Science Absno: 602 Study on the role and mechanism of myeloid-derived suppressor cells in peripheral blood in patients with chronic hepatitis B Li-rong Lu1, Jing Liu1, De-chang Li2, Chao-shuang Lin1, Zhi-liang Gao1 1

Department of Infectious Diseases, Third Affiliated Hospital, Sun Yat-Sen University; Key Laboratory of Tropical Disease Control (Sun Yat-Sen University), Ministry of Education; Guang Dong Provincial Key Laboratory; Guangzhou, China, 2Department of Infectious Diseases, The Second People’s Hospital of North Guangdong, Shaoguan, Guangdong, China Introduction: HBV-mediated T-cell dysfunction has been reported to be associated with the establishment of HBV persistent infection. However, the mechanism is yet to be defined. Myeloid-derived suppressor cells (MDSCs) play a pivotal role in suppressing T-cell responses, but their role in chronic hepatitis B (CHB) infection in humans is yet to be known. Materials and methods: A total of 45 CHB patients, including 23 mild-to-moderate CHB patients and 22 severe CHB patients were enrolled.Meanwhile,15 healthy people were enrolled as controls. The peripheral blood was collected and the frequency of MDSCs and Tregs were analyzed using flow cytometry. Results: We observed a dramatic elevation of MDSCs (LIN1-HLADR-CD11b+CD33+ cells) in the peripheral blood of CHB subjects (M = 0.414 %) compared with healthy controls (M = 0.226 %),and

Hepatol Int (2014) 8:S1–S405 the differences between them were significant (P = 0.0189);The frequency of MDSCs was increased in CHB patients with low-level ALT or AST(ALT B 5ULN, AST B 3UNL); the frequency of MDSCs in CHB patients was negatively correlated with the level of ALT and AST (P \ 0.01), but no correlated with HBV viral load (P [ 0.05); the frequency of MDSCs in CHB patients was positively correlated with Tregs (r = 0.345, P = 0.02). Conclusions: The accumulation of MDSCs during the early phage of infecting may facilitate and maintain HBV persistent infection; immunosuppressive functions of MDSCs may be related with the development of regulatory T cells (Tregs) in CHB.

S39 over (OR 0.3, 95 % CI 0.1–0.6, p \ 0.001), family history of liver disease (OR 3.0, 95 % CI 1.7–5.2, p \ 0.0001) and being fisherman (OR 0.3, 95 % CI 0.1–0.6, p \ 0.01) while anti-HCV positivity was related to age of 50 or over (OR 9.2, 95 % CI 1.6–175.7, p \ 0.005) and being worker (OR 8.9, 95 % CI 2.3–36.5, p \ 0.005). Conclusion: In Vietnam, HBV and HCV infections are still highly endemic. The most predominant HBV genotype is genotype B, followed by genotype C. HBV acquisition in early childhood is essential whilst horizontal route in adulthood also plays a considerable role in HBV transmission. Keywords: Hepatitis B virus, Hepatitis C virus, Sero-epidemiological study, Vietnam, General population

Topic: 7 Hepatitis B—Basic Science Topic: 7 Hepatitis B—Basic Science Absno: 606 Absno: 623 The sero-epidemiological study on the prevalence of hepatitis B and C virus infections among the general population In Vietnam S. H. Do1,2, H. Yamada, M. Fujimoto1, T. Sato1, T. Kaishima1, T. Matsuoka1, T. Fujii1, M. Ohisa1, Y. Go1, J. Matsuo1, K. Katayama1, N. V. Nguyen2, J. Tanaka1 1

Department of Epidemiology, Infectious Disease Control and Prevention, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan, 2Department of Health of Binh Thuan Province, Binh Thuan, Vietnam Introduction: In Vietnam, liver cancer, which is predominantly attributed to hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, has been the most frequent cause of cancer death. For planning preventive strategies against HBV and HCV infections, we performed a sero-epidemiological study on prevalence and risk factors of HBV and HCV infections among general population in Vietnam. Subsequently, confirmation survey was conducted for clarifying acute and persistent HBV infection as well as estimating the incidence of HBV infection. Methods: Our cross-sectional study among adults living in Binh Thuan Province consisted of questionnaire survey on some demographic characteristics and risk factors, and serologic testing for determining HBV and HCV infections. Sample size was calculated based on the anticipated rate of hepatitis B surface antigen (HBsAg) of 20.0 %, confidence level of 95.0 % and precision of 5.0 %. Subjects were randomly sampled using multistage method. Additionally, about 6 months later, initial subjects were partly included and tested again for HBV markers in confirmation survey for differentiating acute and persistent HBV infection among HBsAg-positive individuals and detecting incident HBsAg-positive cases among susceptible persons. This study was approved by the Ethics Committee of Hiroshima University and that of Department of Health of Binh Thuan Province. Informed consents were obtained from all participants. Results: Totally 509 participants, including 230 males (45.2 %) and 279 females (54.8 %), were enrolled in our study. Age distribution ranged from 20 to 81 years old. Prevalence of HBsAg, HBsAb and HBcAb were 15.3 % (95 % CI 12.2–18.5 %), 60.3 % (95 % CI 56.0–64.6 %) and 71.7 % (95 % CI 67.8–75.6 %), respectively. Of 77 HBV DNA-positive sera, 58 (75.3 %) were classified as genotype B, 9 (11.7 %) as genotype C, 4 (5.2 %) as genotype D and 6 (7.8 %) as unidentifiable. Confirmation survey in 152 initial subjects found that 96.7 % of HBsAg-positive individuals were persistently infected and HBsAg-positivity incidence was 0 (95 % CI 0–29.5 per 100 personyears). Prevalence of anti-HCV and HCV RNA were 3.4 % (95 % CI 1.7–4.9 %) and 1.8 % (95 % CI 0.6–2.9 %), respectively. Multivariate analysis indentified that HBsAg positivity was associated to age of 50 or

Seven of eight children with perinatal transmission from an HBeAg-positive mother: a case report C. Ayaz1, M. K. Celen1, Y. Celik2 1 Department of Infection Diseases, Medical Faculty, Dicle University, Diyabakir, Turkey, 2Department of Biostatistics, Medical Faculty, Dicle University, Diyabakir, Turkey

Introduction: Transmission of an HBeAg-positive from mother to her infant may occur in utero, at the time of birth, or after birth. The rate of infection can be as high as 90 %. There seems to be a direct correlation between maternal HBV DNA levels and the likelihood of transmission. In mothers with highly replicating HBV the risk of transmission may be up to 85 or 90 %, and it continuously decreases with lower HBV DNA levels. Materials and methods: Mother was 43, her youngest child was 4 and her oldest child was 14 years old when they applied to the policlinic of infection diseases. They were four daughters and four sons. HBsAg with ELISA test and HBVDNA were determined by PCR method. Results: The mother was HBsAg-positive and HBV DNA levels [8 log10 IU/mL. HBsAg-positive was found in seven of eight children. One of them was not carrier. The mother gave birth to seven children in house without the control of doctor. The youngest four-year-old boy was born in hospital, under the medical control of the doctor. The hepatitis B immunoglobulin for passive immunization had been given him and active immunization had been given at three time points (10 lg at day 0, month 1, and month 6). It is possible to reduce the risk of perinatal transmission in several ways. The first step is the identification of persons at risk. Testing for HBsAg should be performed in all women at the first prenatal visit and repeated later in pregnancy if appropriate (CDC 2011). Newborns born to HBV-positive mothers can be effectively protected by passive-active immunization ([90 % protection rate).

Topic: 7 Hepatitis B—Basic Science Absno: 649 The study on the correlation between hepatic histo-pathology and pattern of intrahepatic HBcAg distribution at different phases of chronic HBV infection Q. He1, S. L. Ai1, Q. Y. Tang1, F. J. Ao1, Z. Y. Li1, B. Bai1, X. J. Liao1

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S40 1

Shenzhen The Third People’s Hospital, Shenzhen 518112, China

Introduction: There are different guidelines on how to divide the natural history of chronic HBV infection into stages and describe the characteristics of each stage.1 Although the Chinese guidelines were published in 2011,2 little research were focus on studying the correlation between hepatic histopathology and the pattern of intrahepatic HBcAg distribution at different phases of chronic HBV infection in Chinese patients. Methods: Patients with confirmed chronic HBV infection were included in this study. Referring to Guidelines for Chronic Hepatitis B in China (version 2010),2 participants were classified into four phases of infection, detailed as immune tolerant phase, immune clearance phase, immune control phase and reactivation phase. Liver biopsy specimens were obtained and read by 2 pathologists separately. Hepatic inflammation and fibrosis stages were evaluated. Assayed by immunohistochemistry staining, the patterns of HBcAg distribution were defined as four types: 1, HBcAg-negative type; 2, nucleic type, when HBcAg was detectable in nucleus from C95 % hepatocytes; 3, cytoplasmic type, HBcAg was detectable in cytoplasm from C95 % hepatocytes; 4, mixed type, HBcAg was detectable both in nucleus and cytoplasm from C5 % hepatocytes. The correlation between hepatic histo-pathological stage and pattern of HBcAg distribution were analyzed and statistical significance were determined when P B 0.05. Results: A total of 637 patients were recruited in this study, 501 male and 136 female. There are 101 patients at immune tolerant phase, 248 at immune clearance phase, 119 at low or non-replicative phase and 169 at reactivation phas, respectively. During immune clearance phase and reactivation phase, intra-hepatic inflammation was more active with signs of faster advancing fibrosis. The main patterns of HBcAg distribution in the liver were nucleic distribution type plus mixed distribution type (89.1 %), cytoplasmic distribution type plus mixed distribution type (74.6 %), HBcAg-negative type (89.1 %) and cytoplasmic distribution type plus HBcAg-negative type (73.4) in the four phase of infection, separately. Significant differences were found in hepatic inflammation stage, fibrosis stage as well as pattern of HBcAg distribution among four infection phases (all P \ 0.0001). References 1. McMahon BJ. The natural history of chronic hepatitis B virus infection. Semin Liver Dis 2004;24:17–21 2. Chinese Society of Hepatology and Chinese Society of Infectious Diseases, Chinese Medical Association. The guideline of prevention and treatment for chronic hepatitis B (2010 version) [J]. Zhongguo Bingdubing Zazhi 2011;1(1):9–23 (in Chinese)


Hepatol Int (2014) 8:S1–S405 Introduction: Genotype F of the hepatitis B virus (HBV) has a particularly severe phenotype. In an Alaska Native (AN) population, the median age at diagnosis of hepatocellular carcinoma (HCC) was younger than that of any other viral genotype but with no difference in the frequency of basal core promoter (BCP) A1762T/G1764A and pre-core G1896A mutations between HCC patients and controls. In this study, we examined the specific mutations of genotype F associated with HCC retrospectively, and examined mutation effects on HBV replication using an in vitro replication model. Materials and methods: In an age, gender-matched case-control study, we sampled 20 HCC patients (mean age 29.5 ± 19.0 years, M/F: 14/6) and 20 patients with chronic hepatitis B inactive disease (mean age 30.0 ± 16.7 years, M/F: 13/7) for a mean period of 13 years retrospectively. We determined HBV complete or partial sequences of serial samples from these patients and compared the nucleotide substitutions. HBV-DNA, HBeAg and anti-HBe were determined. Additionally, several 1.24-fold replication clones with the specific mutations (A1762T/G1764A, G1896A, T1938C, A2051C) were constructed and the replication efficacy was compared by real-time PCR and Southern blotting. Results: Phylogenetic analyses revealed that the isolated strains were all genotype F1b. The comparison of serial sequences from patients with HCC at baseline showed a higher prevalence of wild strain (17/ 20, 85 %, p \ 0.0001), and during the follow-up showed a higher accumulation of BCP mutation: A1762T/G1764A (16/20, 80 %, p \ 0.001) and core mutations: T1938C, A2051C (12/20, 60 %, p \ 0.001, 5/20, 25 %, p \ 0.05, respectively). Interestingly, A1762T/G1764A (10/20, 50 %), T1938C (7/20, 35 %), and A2051C (2/20, 10 %) mutations occurred 4–7 years prior to HCC diagnosis. The comparison of follow-up with baseline showed lower HBeAgpositivity (4/20) and HBV-DNA (median range 3.2 log10 copies/ mL) in HCC patients (p \ 0.01, p \ 0.0001, respectively). In contrast, inactive carriers at baseline have the appearance of A1762T/G1764A (9/20, 45 %), G1896A (4/20, 20 %), T1938C (4/20, 20 %), A2051C (4/20, 20 %) that is sustained. The comparison of follow-up from baseline showed lower HBeAg-positive prevalence (4/20) and HBVDNA (median range 4.4 log10 copies/ mL) in inactive carriers (p \ 0.05, p = 0.053, respectively). In vitro studies indicated intracellular replication efficiency of 1.24-fold HBV genome transfected into HuH-7 cells increased in the presence of BCP/PC/2051 (A1762T/ G1764A, G1896A, A2051C) and BCP/PC/1938/2051 (A1762T/ G1764A, G1896A, T1938C, A2051C) (p \ 0.01, p \ 0.05, respectively), and extracellular replication efficiency increased in the presence of BCP/PC/2051 (p \ 0.05). Conclusions: This study may support the idea of not only the existence of specific viral mutations but also the pattern of occurance may be reflected within persons that carry a higher risk of hepatocellular carcinoma. In genotype F1b among Alaska Native persons, the novel core mutation A2051C of genotype F may be responsible for higher viral replication efficacy. 1762T/G1764A, 1938C, A2051C mutations in BCP/Core region of patients 4–7 years prior to HCC correlated with the increased risk of HCC.

Absno: 656 Hepatocellular carcinoma associated with hepatitis B virus genotype F in Alaska: a retrospective case–control study Sanae Hayashi1, Anis Khan1, Brenna C. Simons2, Carol L. Jones2, Chriss Homan2, Brian J. McMahon2, Shuko Murakami1, Sayuki Lijima1, Tsunamasa Watanabe1, Yasuhito Tanaka1 1

Department of Virology & Liver unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan, 2Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, AK USA

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Topic: 7 Hepatitis B—Basic Science Absno: 668 Prevalence of anti-HBc total positivity in an impoverished urban community in Dhaka, Bangladesh D. K. Ghosh1, C. K. Ghosh2, S. K. Saha3, M. Nath1, A. H. M. Rowshon1, P. K. Roy2


Shaheed Suhrawardy Medical College, 2Bangabandhu Sheikh Mujib Medical University, 3National Center For Control Of Rheumatic Fever & Heart Disease, Bangladesh Introduction: The infection with the Hepatitis B virus (HBV) is a global health problem. Hepatitis B virus (HBV) infections are rapidly spreading in developing countries due to the lack of health education, poverty, illiteracy and Hepatitis B vaccination. So, a population-based serological survey was done to determine the prevalence of the Hepatitis B core antibody total(IgM + IgG) in an impoverished Urban Community in Dhaka city, Bangladesh. Material and method: This study was conducted in the department of gastroenterology, Shaheed Suhrawardy Medical College, Dhaka from January 2013 to June 2013. 384 healthy individuals,18–60 years old were selected from the urban slum by systematic sampling and blood tested for anti-HBc. Anti-HBc estimations were carried out by VITROS Immuno diagnostic assay. Ethical permission was taken from the institutional review board. Result: Among the 384 individuals, 183 (47.6 %) individuals were positive for the core antibody of hepatitis B virus (anti-HBc). 24.2 % of male and 23.4 % female were positive for anti-HBc. There was a significantly increasing prevalence of the core antibody among young adults and middle age individuals (28.7 %). Major risk factors for exposure to Hepatitis B appeared to be ear–nose–body piercing, Circumcision by Hajam (untrained non-medical person), unsafe blood transfusion and unsterile dental intervention. High prevalence of hepatitis B Core antibody (47.6 %) indicates that the members of this urban community are highly exposed to hepatitis B virus. The findings also highlight the need for prevention and control of HBV infection in Bangladesh by implementing universal hepatitis B vaccination and creating public awareness.

S41 Patients and methods: 27 Patients were included into the study. Median age of the patients was 43.51 ± 11.69. 15 patients were female, 12 patients were male gender. During the liver biopsy, two samples were obtained. Grade and stage scores were compared between the samples. Fibrosis staging and grading were assessed according to the Ishak scoring system. Results: Numbers of portal tract and biopsy size were equal in two samples. There was a significant difference between the samples in terms of histological activity index (p value 0.05). However, the difference to distinguish the mild and moderate stages was not enough. On the other hand, we have not found significant difference in fibrosis staging in two samples. Discussion: Although patient numbers were not much, in this study it has been shown, taken in the proper size of a liver biopsy is sufficient to predict treatment decisions. However, further studies are needed to show association sampling variability in patients with Hepatitis B. References 1. Rousselet MC, Michalak S, Dupre F, et al. Sources of variability in histological scoring of chronic viral hepatitis. Hepatology 2005;41:257–264 2. Bedossa P, Dargere D, Paradis V. Sampling variability of liver fibrosis in chronic hepatitis C. Hepatology 2003;38:1449–1457 3. Ratziu V, Charlotte F, Heurtier A, Gombert S, Giral P, Bruckert E, Grimaldi A, Capron F, Poynard T; LIDO Study Group. Sampling variability of liver biopsy in nonalcoholic fatty liver disease. Gastroenterology 2005;128(7):1898–1906

Topic: 7 Hepatitis B—Basic Science Topic: 7 Hepatitis B—Basic Science Absno: 739 Sampling variability of inflammatory activity and fibrosis in patients with hepatitis B Fuat Ekiz1, Ilhami Yuksel2, Baris Yilmaz3, Akif Altinbas4, Bora Aktas5, Murat Deveci6, Omer Basar7, Sahin Coban8, Osman Yuksel7 1

Hatay Antakya State Hospital, Department of Gastroenterology, Yildirim Beyazit University, School of Medicine, Department of Gastroenterology, 3Osmaniye State Hospital, Department of Gastroenterology, 4Ankara Numune Educational and Research Hospital, Department of Gastroenterology, 5Kecioren and Research Hospital, Department of Gastroenterology, 6Yozgat State Hospital, Department of Gastroenterology, 7Hacettepe University, School of Medicine, Department of Gastroenterology, 8Diskapi Yildirim Beyazit Educational and Research Hospital, Department of Gastroenterology

2

Background and aim: Liver biopsy is the gold standard for assessment of fibrosis in patients with Hepatitis B. However it has some disadvantages, including interobserver and intraobserver variability in biopsy interpretation and specimen variation. Standard biopsy specimen represents only about 0.0002 % of the whole liver. It has been shown that, two biopsy sample have significant influence in the diagnostic performance of interpretation in patients with Hepatitis C or non-alcoholic steatohepatitis. So far, we aimed to assess two sample of liver biopsy on the staging and grading of Hepatitis B.

Absno: 742 The immunoregulatory role of circulating iNKT cells by influencing Th1/Th2 bias and PD-1 expression during chronic HBV infection Man Li1, Xue-Hua Sun2, Zhen-Hua Zhou1, Xin Zhang1, Yue-Qiu Gao2 1

Laboratory of cellular immunity, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China, 2Department of Hepatopathy, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai,China Introduction: The protective role of Invariant Natural Killer T cells (iNKTs) against hepatitis B virus (HBV) remains controversial. We sought to clarify the role of peripheral iNKTs during chronic HBV infection. Methods: 109 Chronic HBV-infected patients and 29 healthy controls were enrolled. 21 patients were treated with entecavir (0.5 mg/d) for 6 months. The frequency of peripheral iNTKs and IFN-c, IL-4 levels were examined by flow cytometry, and the association between kinetic variation of iNTKs and Th1/Th2 bias was investigated. Programmed death-1 (PD-1) expression on peripheral iNKTs and its relationship with serum HBsAg and viral load were examined. Results: Circulating IFN-c-producing iNKTs gradually increased during chronic infection. Viral load was reversely correlated to the frequency of iNKTs. The correlation between the serum alanine transaminase levels and the percentage of IL-4-producing iNKTs was positive. The cytokine pattern of iNKTs was closely correlated with the Th1/Th2 bias, whereas antivirus drug effectively resumed the percentage of IFN-c-secreting iNKTs. Finally, a kinetic modulation of

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S42 PD-1 on iNKTs during chronic infection was revealed, and the upregulation of PD-1 inhibited HBV clearance. Conclusions: Circulating iNKTs exhibited a function skewing during chronic HBV infection, and play an immunoregulatory role by influencing Th1/Th2 bias and PD-1 expression.

Topic: 7 Hepatitis B—Basic Science Absno: 749 GWAS identifies novel susceptibility loci on chr4q28.1 for prognosis of hepatitis B virus related hepatocellular carcinoma Jung Woo Shin1, Neung Hwa Park1, Seok Won Jung1, Bo Ryung Park1, Chang Jae Kim1, Jong-Eun Lee2, Eun-Soon Shin2, Jeong A Kim2, Young-Hwa Chung3 1

Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Korea, 2DNA Link, Inc., Seoul, Korea, 3Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea Chronic hepatitis B virus (HBV) infection is one of the established etiologic agents of hepatocelluar carcinoma (HCC) worldwide, which is also an important contributing factor to majority of HCC cases in Korea. Despite extensive studies, little is known about genetic host factors that influence the outcome of HBV related HCC. To identify susceptibility variants for outcomes of HCC, we conducted a genomewide association study (GWAS) using the Axiom Genome-Wide ASI 1 Array on a cohort of patients that included 264 HCC patients (females 48, males 216) with surgical resection and 132 HBV carriers. Multivariate logistics and Cox regression models were used to control for the confounding effects of HCC risk, recurrence, and overall survival. Two hundred six SNPs showed significant associations at P \ 1 9 10-4 for development of HCC; 87 SNPs showed significant associations at P \ 1 9 10-4 for postoperative recurrence. In addition, 310 SNPs showed significant associations at P \ 1 9 10-4 for overall survival (OS). In particular, Cox regression survival analysis showed relation between rs10018662 or rs10470922 and OS (p = 7.26E-11, HR [hazard ratio] 33.040, CI [95 % confidence interval] 11.536–94.624 or p = 1.97E-10, HR 33.847, CI 11.441–100.138: additive model). Two SNPs are located on chr4q28.1 and the distance of two SNPs is 4,059 bp. Further replication studies of HCC are needed to confirm our promising susceptibility loci.

Topic: 7 Hepatitis B—Basic Science Absno: 750 NOTCH1 gene variants are associated with postoperative recurrence in patients with hepatitis B virus-associated hepatocellular carcinoma by Comprehensive Mutation Analysis Jung Woo Shin1, Neung Hwa Park1, Seok Won Jung1, Bo Ryung Park1, Chang Jae Kim1, Jong-Eun Lee2, Eun-Soon Shin2, Jeong A Kim2, Young-Hwa Chung3 1

Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Korea, 2DNA Link, Inc., Seoul, Korea, 3Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea

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Hepatol Int (2014) 8:S1–S405 Background and aims: Based on the current knowledge of cancer molecular pathogenesis, polymorphic variations are considered to be important for hepatocellular carcinoma (HCC) development. Serial Sanger sequencing of suspected HCC genes, while the current molecular diagnostic method of choice, can be slow and expensive. A comprehensive panel test for simultaneous screening of mutations in all known HCC-associated genes would be a more effective diagnostic strategy. Methods: Using a highly multiplexed PCR-based target enrichment method in conjunction with next-generation sequencing (NGS), we performed mutation detection in 10 hepatitis B virus (HBV)-associated HCC cases and validated in 285 HCC patients by Sanger sequencing. Results: Variants (rs3812603 and rs9411206) of NOTCH1 gene were significantly associated with the postoperative recurrence of 10 HBVassociated HCC patients by NGS, which were validated in 285 independent HBV-associated HCC cases. Three variants were located in close. In addition, NOTCH1 rs9411206 was significantly associated with distant metastasis of HCC. Conclusions: The novel NOTCH1 gene variants are associated with a significantly decreased risk of postoperative recurrence of HBVassociated HCC. Although the variant accounts for a small fraction of all HCCs, this finding has implications for postoperative recurrence risk assessment and may provide new mechanistic insights into HCC.

Topic: 7 Hepatitis B—Basic Science Absno: 753 Hepatoprotective effect of Xue-Fu-Zhu-Yu Decoction on carbon tetrachloride-induced liver fibrosis in rats Yue-Qiu Gao1,2, Xue-Hua Sun2, Man LI1, Xiao-Jun Zhu2, Zhen-Hua Zhou1, Xin Zhang1 1

Laboratory of Cellular Immunity, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China, 2Department of Hepatopathy, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China Background: The pathogenesis of liver fibrosis (LF) is blood stasis in liver tissue according to the theory of traditional Chinese medicine. The Xue-Fu-Zhu-Yu Decoction (XFZYD), a classic decoction in traditional Chinese medicine (TCM), is widely used to relieve the symptoms of blood stasis by promoting blood circulation.This study aimed to investigate the hepatoprotective effect of XFZYD on carbon tetrachloride (CCl4)-induced LF in rats and the underlying mechanisms which have not been explored yet. Methods: LF was established by subcutaneous administration of 3 ml/kg CCl4 (60 %, V/V) twice a week for continuously 7 weeks. To evaluate the effects of XFZYD (200, 400, 800 mg/kg) on LF, liver function, histological study and liver fibrosis evaluation were performed. Liver function was assessed by serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin (Alb) and total protein (TP). The biomarkers such as hydroxyproline (Hyp), hyaluronic acid (HA), type III precollagen (PCIII) and laminin (LN) were examined for the evaluation of LF. Histopathologic changes were observed after H&E and Sirius red staining. The contents of TGF-b1 were detected by ELISA. The levels of a-SMA, TbRI and TbRII were detected by western blot and RT-PCR. Results: XFZYD could significantly inhibit the body weight loss and the liver index increase in rats which induced by CCl4. XFZYD also improved the liver function as indicated by decreasing serum enzymatic activities of ALT, AST, TP and Alb (P \ 0.05). Histological

Hepatol Int (2014) 8:S1–S405 results indicated that XFZYD alleviated liver damage and reduced the formation of fibrous septa. Moreover, XFZYD dramatically decreased liver Hyp, HA, LN and PCIII (P \ 0.05). Research on mechanism revealed that the hepatoprotective effect of XFZYD may related to the concentration reduction of liver malondialdehyde (MDA), activities increase of liver superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px), expression inhibition of a-SMA, TGF-b1, TbRI and TbRII (P \ 0.05). Conclusions: XFZYD can inhibit CCl4-induced liver fibrosis, which probably ascribed to its radical scavenging action, antioxidant activity and modulation of TGF-b signaling pathway.

Topic: 7 Hepatitis B—Basic Science Absno: 772 RIPK2 could play an important role in controlling HBV replication Shuang Wu, Tatsuo Kanda, Shingo Nakamoto, Xia Jiang, Masato Nakamura, Tatsuo Miyamura, Fumio Imazeki, Osamu Yokosuka Department of Gastroenterology and Nephrology, Chiba University, Graduate School of Medicine, Chiba, Japan Background/aims: The disease progression of hepatitis B involves both innate and adaptive immunities to some extents. Innate immunity including toll-like receptors (TLRs), cytokine, and interferon signaling plays an important role. Receptor-interacting serine/threonine protein kinase 2 (RIPK2) is important, which are involved in both innate and adaptive immunities. Recent report showed that RIPK2-knock-out mice are susceptible to severe influenza infection. In the present study, we examined the roles of RIPK2 in hepatitis B virus (HBV) replication in hepatitis B pathogenesis. Methods: We examined whether HBV enhanced NF-kB activation in hepatocytes using reporter assay or immunoblot. We examined whether exogenous IFN-alpha and/or TNF had any effects on RIPK2 expression and HBV replication by real-time RT PCR. We also determined the interaction of HBV with RIPK2 using immunoblot, co-immunoprecipitation and confocal microscopic study. Results: HBV enhanced NF-kB activation, which is important for the endogenous cytokine production in hepatocytes. We observed that exogenous IFN-alpha and/or TNF enhanced RIPK2 expression and that IFN-alpha and/or TNF inhibited HBV replication at the same time. We observed the interaction between HBV and RIPK2. Conclusions: In the line with previous studies, HBV enhanced NF-kB activation. RIPK2 could be involved in HBV replication and one of the target candidates of hepatitis B.

Topic: 7 Hepatitis B—Basic Science Absno: 799 Polymorphisms of TLR-IFN pathway genes and the risk for persistently chronic hepatitis B virus infection in Chinese Han population Dengming He1,2, Shiqi Tao1, Maoshi Li1, Shimin Guo1, Junqiu Wu1, Zhaoxia Tan1, Yuming Wang1 1

Institute of Infectious Disease, Southwest Hospital, Third Military Medical University, Chongqing, China, 2Liver Disease Diagnoses and

S43 Treatment Center of Chinese PLA, The 88th Hospital of Chinese PLA, Tai’an, China Introduction: The differences of the innate immunity and adaptive immunity determined by genetic play a crucial role in the clinical outcome of chronic hepatitis B virus (HBV) infection. TLR-IFN pathway plays a key role in control of HBV. Although the association between HLA-DQ and HLA-DP gene polymorphisms and persistently chronic HBV infection was found by genome-wide association studies, there is no further explanation of the mechanism. We aimed to observe the association between TLR-IFN pathway gene polymorphisms and the risk of persistently chronic HBV infection by case-control genetic association studies. Materials and methods: Chinese Han population 1464 (male 929, female 535), include chronic HBV infection 1191 cases (35 ± 11 years) and HBV clearance 273 cases (42 ± 12 years), were involved. TLR-IFN pathway gene polymorphisms, included TLR3 rs3775296, TLR5 rs5744174, TLR9 rs352140, MYD88 rs7744, IRAK1 rs1059702, CXCL10 rs4256246, IFNG rs2069705, IL10 rs1800872, IL12A rs568408, IL1B rs16944, IL28B rs12979860, IL29 rs30461, IL6 rs1800796, EBI3 rs4905, IL12B rs3212227, IL15 rs105196133, MX1 rs469390 were selected as target genes and polymorphic loci. HLA-DQ rs7453920 was as a control polymorphism. iMLDR was used for polymorphism genotyping. SNPStars was used for statistical analysis. Results: Significant differences in the distribution of rs7453920 (p \ 0.0001, OR = 0.58), rs352140 (p = 0.0075, OR = 0.70), rs4256246 (p = 0.023, OR = 1.37), rs1800872 (p = 0.022, OR = 0.73), rs3212227 (p = 0.021, OR = 1.39), rs16944 (p = 0.022, OR = 0.69), and rs467960 (p = 0.012, OR = 0.66) were observed. HLA-DQ rs7453920, IL10 rs1800872 and MX1 rs467960 were highly linkage, and GTC haplotype (4 %) with high-risk of chronic HBV infection (p = 0.0074, OR = 0.51). TLR9 rs352140 was associated with chronic HBV infection independent of other loci. Conclusion: In Chinese Han population, TLR-IFN pathway gene polymorphisms are associated with the susceptibility of chronic HBV infection, especially identification stage and effects stage. Linking with immune effect may be the main method to influence the susceptibility of chronic HBV infection for HLA polymorphism.

Topic: 7 Hepatitis B—Basic Science Absno: 822 Problems of patients with viral hepatitis about infectivity of the infection Aliye Soylu1, Deniz Duman2, Filiz Akyuz3, Melih Ozel4, Serdal Cakmak1, Osman Cavit Ozdogan2 1 Gastroenterology, Bakirkoy Training&Research Hospital, Istanbul, Turkey, 2Gastroenterology, Marmara Medical Faculty, University of Istanbul, Turkey, 3Gastroenterology, Istanbul Medical Faculty, University of Istanbul, Turkey, 4Gastroenterology, Anatolian Health Hospital, Istanbul, Turkey

Aim: To detect shortfalls and mistakes in patient information about hepatitis B/C, to detect inconveniences of patients in family and society, to establish their expectations, and finally, to satisfy successful follow up and therapy. Method: We prepared questionnaire for patients with chronic hepatitis B/C with the assistance of psychiatrists. The questionnaire consisted of 36 questions about the prevalance of hepatitis B/C in family members, knowlegde about infectivity of their infection, effects of infection on familial and social relationship, to whom they

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S44 want to inform about their illnesses, emotions about their illnesses, adequacy in knowledge of herbal medicine, and expectations from physicians. The study included 134 patients with hepatitis B/C in 3 centers. Results: Of the 134 patients, 105 had chronic hepatitis B and 29 had chronic hepatitis C, 53.7 % were male (n = 72), with a mean age of 46.8 (median 19–82) years. Screening for hepatitis B/C had been performed in 73.4 % of the patients relatives, while 25 % of them were unaware of the necessity of screening. Seropositivity for hepatitis B was 16.2 % in parents, 5.7 % in spouses, 9.6 % in children, and 33.3 % in siblings. Seropositivity for hepatitis C was 3.5 % in parents and 7 % in children. According to patients, possible mode of transmission of their infection was sharing paraphernalia in 80.6 %, sharing dishes, spoons, etc in 4.5 %, household contact in 5.2 %, and social kissing in 14.2 %. Thirteen per cent of the patients had not informed their family members about their infection. In patients who informed family members about their infection, 63 % of them had behaved supportive and 47 % of them had behaved discriminatory to the patients. When they learned that they had hepatitis B/C, 28.5 % of the patients were afraid and 53.7 % of them worried. Thirty three per cent of the patients had reported that their sexual relationship had become depressed and 6.4 % had met with a refusal from their sexual partners. With respect to herbal medicine, 6.2 % were aware of its deleterious effects and 28 % thought that it was beneficial. Thirty per cent of the patients reported that physicians should give clear information about the infection, 28 % reported that information should be given in school ages, 27 % reported that information about the infectivity of the infection was inadequate, and 26 % reported that population must be informed about the importance of vaccination. Conclusion: Spread in family members is an important problem in hepatitis B. Spouses of patients with hepatitis C did not have hepatitis C and prevalance of hepatitis C was very low in children of mothers with hepatitis C. Patients and their relatives were unaware of mode of transmission of hepatitis B/C. Discrimination may be a predictor of inadequate information about hepatitis B/C. Social, sexual and business lives of patients with hepatitis B/C is affected by the disease. Patients should be informed about herbal medicine. Patients and society shoul be informed about hepatitis B/C and its infectivity, and importance of vaccination.


Fig. 1 Th22 cells preferentially increased in peripheral blood of ACLF patients.(A) Representative dotplots of IFN-c, IL-17 and IL-22 coexpression in peripheral CD4? T cells of HCs, CHB and ACLF patients. The values in the upper right corner indicate the percentage of each double-positive CD4? T cell subset.(B) Representative dotplots of Th22 cells(CD4?IL-22?IFN-c-IL-17-) in peripheral boood of HCs, CHB and ACLF patients. CD4?IFN-c- cells were gated in lymphocytes firstly, in which we then analysed the IL-22?IL17- cell subset, that is Th22 cels(CD4?IL-22?IFN-c-IL-17-). The values in the upper left corner indicate the percentage of Th22 cells. (C,D,E,F) Pooled data indicated the percentages of Th1, Th17, CD4?IL-22? cells and Th22 cells in HC, CHB and ACLF groups. The bars represent means and standard deviations. *P\0.05, **P\0.01 and *** P\0.001.

Topic: 7 Hepatitis B—Basic Science Absno: 860 T-helper(Th) 22 cells and IL-22 play an important role in progression of disease of chronic hepatitis B Ruidong Mo1, Xiaogang Xiang1, Peng Wang1,Rongtao Lai1, Qing Xie1 1

Department of Infectious Diseases, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China Introduction: IL-22 and Th22 cells have protctive role and immume immunomodulatory properties in the liver and other tissues [1, 2]. Therefore,it could have some functions in progression of disease of chronic hepatitis B(CHB). Materials and methods: We mesured frequency of Th1(CD4+IFNc+), Th17(CD4+IL-17+) and Th22(CD4+IL-22 IFN-c-IL-17-) in peripheral blood of CHB, HBV associated acue-on-chronic liver failure (ACLF) patients and healthy controls (HCs) by flow cytometry. In addition, plasma levels of IL-6, IFN-c, IL-17 and IL-22 were also measured by enzyme-linked immunosorbent Assay (ELISA).

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Fig. 2 The level of plasma Th22-associated cytokines is increased in CHB and ACLF patients. ELISA were performed to quantify plasma IL-6, IFN-c, IL-17 and IL-22 in HCs, CHB and ACLF patients. The bars represent means and standard deviations. *P\0.05, **P\0.01 and ***P\0.001.

Hepatol Int (2014) 8:S1–S405 Results: The Th1 frequencies of CHB and ACLF groups were significantly decreased compared with HC groups (all p \ 0.05). And we found significantly increased percentage Th22 cells in CHB patients compared with HCs, p \ 0.05. In addition,the frequencies of Th17 cells and Th22 cells in ACLF patients was significant increased compared with CHB patients and HCs (all p \ 0.05). And the plasma levels of IL-6, IL-17 and IL-22 in ACLF patients were also significant increased compared with healthy controls (all p \ 0.05). In addition, IL-6 and IL-22 concentration in plasma of ACLF patients was notably higher compared with concentrations in CHB patients (all p \ 0.05) (Fig. 2). Conclusion: Th22 cells and IL-22 probably play a role in chronic hepatitis B active phase and disease progression. So it is of great importance to investigate how Th22 cells and IL-22 impact disease activation and progression, and in further to determine whether Th22 cells and IL-22 could impact the prognosis of the disease. References 1. Zenewicz LA, Yancopoulos GD, Valenzuela DM, Murphy AJ, Karow M, Flavell RA. Interleukin-22 but not interleukin-17 provides protection to hepatocytes during acute liver inflammation. Immunity 2007;27:647–659 2. Zhang Y, Cobleigh MA, Lian JQ, Huang CX, Booth CJ, Bai XF, Robek MD. A proinflammatory role for interleukin-22 in the immune response to hepatitis B virus. Gastroenterology 2011;141:1897–1906

S45 5.6 9 10-3 substitutions/site, p = 0.6), in HBV genes and nonoverlapping regions. However, 18 of 20 patients showed phylogenetic trees of full-length sequences from baseline and during reactivation clustering separately suggesting a clear viral evolution during reactivation. Evolutionary rates were different in HBV regions (p = 0.008) and the precore/core non-overlapping region had the highest rates 2.6 9 10-4 substitutions/site/month (median). Conclusions: HBV evolves during reactivation in HBeAg negative chronic hepatitis patients and the precore/core non-overlapping region evolves the fastest towards the reactivation. Acknowledgment: This study was supported by NMRC Grant R-172-000-255-213. Reference 1. Lim SG, Cheng Y, Guindon S, Seet BL, Lee LY, Hu P, Wasser S, Peter FJ, Tan T, Goode M, Rodrigo AG. Viral quasi-species evolution during hepatitis Be antigen seroconversion. Gastroenterology. 2007;133(3):951–958

Topic: 7 Hepatitis B—Basic Science Absno: 878 Effect of entecavir treatment on regulatory T cells in chronic hepatitis B patients: a longitudinal analysis

Topic: 7 Hepatitis B—Basic Science Absno: 867 HBV quasispecies viral evolution during HBV reactivation in HBeAg negative patients Y. Cheng1, H. H. Chong1, J. L. Wang1, B. L. Seet1 , S. G. Lim1,2 1

Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 2Department of Gastroenterology and Hepatology, National University Health System, Singapore Introduction: We have demonstrated that the evolution of viral quasispecies may play important role during HBeAg seroconversion in chronic hepatitis B infection (1). However, the viral evolutionary pattern in HBV reactivation is unclear. This study aimed to evaluate viral quasispecies evolutionary patterns during HBV reactivation. Materials and methods: Twenty HBeAg negative patients with HBV reactivation were included. Full-length HBV DNA was amplified by PCR for 2 time-point sera per patient (before and during HBV reactivation), followed by cloning and sequencing. Twenty clones per sample were sequenced. Sequences were aligned using ClustalX2.0. Genotyping was determined by comparing full-length HBV sequences of patients to those with known genotypes in NCBI GenBank. Phylogenetic trees of HBV full-length, different genes or regions were constructed using Pebble 1.0 following maximum likelihood estimates of pairwise distances under a GTR+I+G model testing viral diversity and evolution. Results: Fourteen of 20 patients were with genotype B and 6 with genotype C. The viral diversity of HBV DNA was similar before and during reactivation in full-length (median 6.3 9 10-3 and

W. Kang1,2, J. Y. Park1, Y. J. Choi2, J. Lee2, S. U. Kim1, D. Y. Kim1, E.-C. Shin2, S. H. Ahn1 1

Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea, 2Laboratory of Immunology and Infectious Diseases, Graduate School of Medical Sci. & Eng., KAIST, Daejeon, Korea Regulatory T (Treg) cells play a major role in the impaired immune responses during chronic hepatitis B virus (HBV) infection; however, it is still not clear to what extent viral load reduction by entecavir treatment affect Treg cell population in chronic hepatitis B (CHB) patients. This study aimed to evaluate the longitudinal changes of Treg cell subpopulation during entecavir treatment in CHB patients. Twenty-seven (13 HBeAgnegative and 14 HBeAg-positive) patients with CHB were treated with entecavir and were followed for 12 months. Peripheral blood mononuclear cells (PBMCs) were collected at baseline and during entecavir treatment (0, 1, 3, 6, 9 and 12 months after treatment). HBV-specific T cell responses were quantitatively assessed by ex vivo interferon-gamma ELISpot assays employing pooled overlapping peptides corresponding to HBV proteins; the kinetics of immune cells were analyzed using multicolour flow cytometry; and serum HBV DNA level was measured by real-time quantitative PCR. Serum HBV DNA level significantly declined after 1 month of entecavir treatment. Concomitantly, Treg cell subpopulation significantly decreased at 1 month after entecavir treatment (P \ 0.01), especially in HBeAg-negative CHB patients. However, CD4+ T cell subpopulation and HBV-specific T cell responses were not affected by viral load reduction during entecavir treatment. Entecavir-induced viral load reduction leads to concomitant decline of circulating Treg cells at 1 month of treatment. Immunotherapy at 1 month after entecavir treatment may contribute to effective clearance of HBV.

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M. Crane1,2, S. Tennakoon1,2, B. Sebolao1,2, D. Iser1,2,3, S. R. Lewin1,2

Absno: 892

1

Association of Tim-3 polymorphisms with chronic hepatitis B virus infection: susceptibility, spontaneous seroclearance and hepatocarcinogenesis Liao Jingyu, ZhangQi, LiaoYun, Wang LanLan Department of Laboratory Medicine, West China Hospital of Sichuan University Introduction: T-cell immunoglobulin and mucin domain-containing molecule 3 (Tim-3) plays an important role in regulating T cells in chronic hepatitis B (CHB) and hepatocellular carcinoma (HCC). In this study, we hypothesized that polymorphisms of Tim-3 were associated with HBV susceptibility, HBsAg spontaneous seroclearance and HCC occurrence. Materials and methods: A total of 800 patients were involved in this study with 200 subjects in every group, including chronic hepatitis B group, spontaneous seroclearance group, HBV-associated HCC group and healthy controls. Three single-nucleotide polymorphisms (SNPs) of Tim-3, rs246871, rs25855 and rs31223 were genotyped to analyze the association of Tim-3 genetic variants with HBV susceptibility, HBsAg seroclearance and hepatocarcinogenesis. Result: It was found the minor allele ‘‘C’’ of rs31223 to be associated with HBsAg seroclearance (P = 0.033; OR 1.359; 95 % confidence interval [CI], 1.026–1.801) and genotype ‘‘CC’’ of rs246871 to be associated with HCC occurrence (recessive model: P = 0.007; OR 2.781; 95 % CI 1.329–5.820; additive model: P = 0.010; OR 2.696; 95 % CI 1.267–5.738). In addition, haplotypic analysis of the 3 polymorphisms also showed the haplotype block CGC* and TGC* were significantly associated with HBsAg seroclearance (CGC*: P = 0.040; OR 1.997; 95 % CI 1.022–3.902; TGC*: P = 0.043, OR 1.358; 95 % CI 1.010–1.826) while haplotype block CAT*, CGT*, TAC* and TGT* were significantly associated with HCC occurrence (CAT*: P \ 0.001; OR 0.107; 95 % CI 0.028–0.412; CGT*: P = 0.002; OR 1.825; 95% CI 1.248–2.669; TAC*: P = 0.013, OR 0.368; 95 % CI 0.162–0.836; TGT*: P = 0.003; OR 0.508; 95 % CI 0.321–0.805). Besides, haplotype block CAT* and CGT* were found to be associated with chronic hepatic B(CAT*: P \ 0.001; OR 2139.7; 95 % CI, 132.85–34463.64; CGT*: P = 0.006, OR 0.584; 95 % CI 0.398–0.857). Conclusion: Genetic variants of Tim-3 had an important impact on patients infected with HBV. With specific Tim-3 polymorphisms, patients could be potential candidates of CHB, HCC or spontaneous seroclearance. References 1. Sabatos CA, et al. Interaction of Tim-3 and Tim-3 ligand regulates T helper type 1 responses and induction of peripheral tolerance. Nat Immunol 2003;4(11):1102–1110 2. Ngiow SF, et al. Anti-TIM3 antibody promotes T cell IFNgamma-mediated antitumor immunity and suppresses established tumors. Cancer Res 2011;71(10):3540–3551

Topic: 7 Hepatitis B—Basic Science Absno: 919 IFN and bacterial TLR ligands act synergistically to increase production of CXCL10 from hepatocytes

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Department of Infectious Diseases, Alfred Hospital, Monash University, Melbourne, Australia, 2Centre for Biomedical Research, Burnet Institute, Melbourne, Australia, 3Department of Gastroenterology, St Vincent’s Hospital, Melbourne, Australia Background: Patients with HIV-HBV co-infection have accelerated progression of HBV-related liver disease although the mechanism for this remains unclear. HIV significantly depletes CD4 T-cells in the gut leading to increased microbial translocation (MT) which may contribute to chronic immune activation (IA) and disease progression. We hypothesised that in HIV-HBV co-infection, the effects of MT and IA on hepatocytes leads to enhanced production of CXCL-10 and accelerated progression of liver disease. Methods: Human hepatoma cell lines, Huh7 and HepG2, were treated with IFNy, IFNa, TNFa, IL-10 and IL-6 alone or in combination with a TLR4/2 ligand (e.coli 0111:B4, Invivogen) for 24 h and levels of CXCL-10 in the supernatant measured by ELISA. CXCL-10 mRNA expression levels were determined by qPCR using the comparative ct method. HIV-HBV co-infected patients (n = 14) naı¨ve to anti-retroviral therapy were biopsied and hepatocyte apoptosis determined by TUNEL staining. CXCL-10 (Milliplex, Millipore), sCD14 (ELISA, RnD Systems) and lipopolysaccharide (LPS, limulus amebocyte lysate assay, Lonza) were measured in patient plasma from matched samples. Results: A combination of TLR2/4 and IFNa or IFNy was found to increase CXCL-10 production three-fold (n = 3) or two-fold (n = 26) respectively compared to either IFN alone. The synergistic effect of IFNy and e.coli 0111:B4 were further confirmed by rt-PCR for CXCL10 mRNA and in a second hepatocyte cell line (HepG2, n = 3). We observed no significant correlations between hepatocyte apoptosis and circulating levels of LPS or CXCL10. Further studies will determine the mechanism of IFN and TLR synergism in inducing CXCL-10 production by hepatocytes and determine the relationship between intrahepatic CXCL-10 and e.coli and hepatocyte apoptosis in vivo. Conclusion: We have demonstrated that hepatocytes upregulate the expression of the pro-inflammatory chemokine CXCL-10 in response to IFN and bacterial TLR2/4 ligation. Increased intrahepatic CXCL-10 and induction of hepatocyte apoptosis may be one potential mechanism contributing to liver disease progression in HIV-HBV co-infection.

Topic: 8 Hepatitis B - Clinical Absno: 14 Tenofovir use in chronic hepatitis B infection women during pregnancy: auckland experience J. Huang1, E. Gane1, A. Upton2, L. Wilkinson3, E. Parry3 New Zealand Liver Transplant Unit, 2Labtests Auckland, New Zealand, 3Auckland District Health Board Women’s Health, New Zealand 1

Introduction: Tenofovir (TDF) is funded (i) from early pregnancy to treat active chronic hepatitis B (CHB) (HBV DNA [ 4 Log IU/mL and ALT [ ULN), and (ii) in third trimester to prevent vertical transmission in immunotolerant CHB (HBV DNA[7 log IU/mL and persistently normal ALT). Method: Retrospective audit reporting experience of tenofovir use during pregnancy and post-partum follow-up of mothers and babies. Results: 66 women received TDF during pregnancy, median age 30 years. 38 were Asian; 24 Pacific Islanders and 4 were Maori. (i) TDF was started during first trimester (median 10 weeks) in 17 women

Hepatol Int (2014) 8:S1–S405 with active CHB, of whom 12 were switched from entecavir or lamivudine (median viral load\1.2 log IU/mL) and 5 were started de novo for pregnancy-related hepatitis flare (median 7.5 log). 5 were HBeAg-positive, of whom one achieved seroconversion. All women were switched to entecavir after breastfeeding. (ii) TDF was started during third trimester (median 32 weeks) in 49 women to prevent vertical transmission. All were HBeAg-positive with baseline HBV DNA [7 log IU/mL which dropped to median 4.5 log at delivery. TDF was discontinued 8 weeks post-partum. 2 patients developed post-partum ALT flare ([3 xULN). Follow-up HBV serology in 15 babies confirmed protective hepatitis B immunity. Conclusion: TDF is safe and effective therapy for both active CHB and for prevention of vertical transmission of HBV. When TDF is administered to prevent vertical transmission, postpartum follow-up should include close monitoring of mothers for post-TDF flares and testing of neonates to confirm immunity.

Topic: 8 Hepatitis B - Clinical Absno: 16 Monitoring of hepatitis B virus (HBV) DNA prevents Hepatitis due to HBV reactivation in malignant lymphoma or multiple myeloma Takeshi Matsui1,2, Jong-Hon Kang1, Kazumasa Nagai1, Hajime Yamazaki1, Kunihiko Tsuji1, Seisho Andoh3, Sachiko Andoh3, Hajime Sakai3, Masayo Maemori3, Hiroyuki Maguchi1, Yasuhito Tanaka2 1 Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan, 2Department of Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan, 3 Department of Hematology, Teine-Keijinkai Hospital, Sapporo, Japan

Background/aims: Despite increasing reports of hepatitis B virus (HBV) reactivation in hematological malignancies, its incidence and risk factors are still obscure. The incidence of HBV reactivation during chemotherapy is higher in Japan than Europe or the United States, because more than 20 percent of people have a history of HBV infection. The aim of this study is to clarify the incidence and risk factors of HBV reactivation and to confirm the usefulness of HBV DNA monitoring monthly, in hepatitis B surface antigen (HBsAg) undetectable patients with malignant lymphoma or multiple myeloma, during or after chemotherapy. Methods: A total of 152 HBsAg undetectable patients undergoing chemotherapy for malignant lymphoma or multiple myeloma were enrolled in this study. Anti-hepatitis B surface (anti-HBs) and antihepatitis B core (anti-HBc) were checked before treatment, and HBV DNA in sera was quantified monthly during and after chemotherapy. Results: Out of 152 patients, 53 (34.6 %) had anti-HBs, 79 (51.9 %) had anti-HBc and 49 (32.2 %) had both. Among the 79 anti-HBc positive patients, five patients (5/79, 6.3 %) showed HBV reactivation during 21.9 median follow-up months. In all five patients with HBV reactivation, peripheral lymphocyte counts and immunoglobulin G before chemotherapy tended to be lower than those without HBV reactivation (p = 0.053/0.020), and minimum peripheral lymphocyte counts during chemotherapy was lower (p = 0.003). HBV reactivation occurred during and after chemotherapy containing rituximab for B cell non-Hodgkin lymphoma. Five patients, who showed HBV reactivation, did not develop de novo hepatitis due to HBV reactivation and were able to undergo chemotherapy against malignant lymphoma as scheduled. Conclusions: In HBsAg undetectable patients undergoing chemotherapy for malignant lymphoma or multiple myeloma, low peripheral

S47 lymphocyte counts and immunoglobulin G before chemotherapy and low minimum peripheral lymphocyte counts during chemotherapy might be risk factors. Monitoring of HBV DNA in sera is useful for the early diagnosis of HBV reactivation and prevention hepatitis due to HBV reactivation.

Topic: 8 Hepatitis B - Clinical Absno: 30 The risk factor of HCC development following HBeAg serovconversion in chronic hepatitis B patients Sung Kwan Bae, Yuki Kugiyama, Shigemune Bekki, Satoru Hashimoto, Masafumi Otani, Akira Saeki, Shinya Nagaoka, Atsumasa Komori, Seigo Abiru, Hiroshi Yatsuhashi Clinical Research Center, National Hospital Organization (NHO) Nagasaki Medical Center, 2-1001-1 Kubara Omura, Nagasaki 856-8562, Japan Background & aim: Our aim was to clarify predictive factors for HCC (Hepatocellular carcinoma) development after HBeAg (Hepatitis B e Antigen) seroconversion in CHB (chronic hepatitis B) patients. Methods: From 1991 to 2005, a total of 231 HBeAg-positive CHB patients were recruited for the study. Of the 231 patients, 100 underwent spontaneous HBeAg seroconversion. All the patients were HBV genotype C. After HBeAg seroconversion, the patients were followed up for the occurrence of HCC. Between HCC group and non HCC group, we compared the following factors at the time of HBeAg seroconversion; age, gender, the levels of ALT, platelets, albumin, alpha-fetoprotein (AFP), cirrhosis, HBVDNA, and mutations in the precore (G1896A) /core promoter (A1762T/ G1764A) domain. In addition, HBeAg reversion, and HBeAg-negative hepatitis were also included in the analysis. Results: HCC occurred in 9 (9 %) patients during a median follow-up of 8.2 years. In univariate analysis, factors predictive of HCC after HBeAg seroconversion were: age (p = 0.008), platelets (9103/mm3) (p = 0.003), and cirrhosis (p = 0.001) at the time of HBeAg seroconversion. Cox regression analysis showed that only platelets (\130 9 103/mm3) was an independent factor for the occurrence of HCC after HBeAg seroconversion [odds ratio 8.450 (95 % confidence interval 1.424–50.138), p = 0.019]. Cumulative rates of HCC occurrence at 5, 10, 15 years were 4.3, 9.8, 18.9 %, respectively. Cumulative HCC incidences of the 75 patients with platelets ([130 9 103/mm3) were 0, 0, 8.3 % at 5, 10, 15 years, respectively. Those of the 25 patients with platelets (\130 9 103/mm3) were 16.3, 37.2, 49.8 % at 5, 10, 15 years, respectively, and significantly higher than the patients with platelets ([130 9 103/mm3) (p \ 0.001). Conclusion: Platelets (\130 9 103/mm3) at the time of HBeAg seroconversion is the risk factors for the development of HCC after HBeAg seroconversion in CHB patients.

Topic: 8 Hepatitis B - Clinical Absno: 48 ‘Real life’ experience from Bangladesh on safety and efficacy of telbivudine in treatment naı¨ve and tenofovir-experienced patients with hepatitis B related chronic liver diseases with compromised renal function

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S48 M. Al-Mahtab1, S. M. F. Akbar2, H. Uddin3, S. Rahman1


Topic: 8 Hepatitis B - Clinical

1

Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, 2Department of Medical Sciences, Toshiba General Hospital, Tokyo, Japan, 3 Clinical Research Organization Ltd., Dhaka, Bangladesh Introduction: Tenofovir is used widely in patients with chronic hepatitis B virus (HBV)-related chronic liver diseases (CLD) in Bangladesh due to local generics and low-resistance profile. However nephrotoxicity remains an important concern. On the other hand, telbivudine is an effective anti-viral drug that is safe in patients with renal functional impairment. Telbivudine is also safe in hepatic decompensation/failure and pregnancy. Present study is real life scenario, where tenofovir-induced HBV-related CLD with compromised renal functions were switched over to Telbivudine. Also, treatment naı¨ve HBV-related CLD patients with compromised renal functions were also treated by Telbivudine. Taken together, the final aim of the study was to assess the utility of telbivudine in both treatment-naı¨ve and treatment-resistant patients with compromised renal functions. Materials and methods: Study had two arms. In the first arm, 9 patients with HBV-decompensated cirrhosis with impaired renal functions were recruited (age 19–47 years; 5 males and 4 females; 1 pregnant). Two of them had acute on chronic liver failure and acute insult being HBV flair in both patients. All were treatment naı¨ve. None had HCC. Renal function was compromised in all [creatinine clearance rate (CCR) 65–80 ml/min] patients (normal range 95–160 ml/min). All 9 patients had detectable HBV DNA (1.6 9 104–1.3 9 106 copies/ml); 6 HBeAg-negative and 3 HBeAg-positive. The levels of ALT were 23–96 IU/L (upper limit of normal range of ALT being 42 IU/L). All patients were treated with telbivudine (600 mg, orally, daily). In the second arm, 19 patients (age 19–65 years; 5 females and 14 males. 16 with chronic hepatitis B and 3 with HBV-related liver cirrhosis) were recruited. None had hepatic decompensation. All had detectable HBV DNA (2.0 9 106–1.7 9 1012 copies/ml). Eight were HBeAg negative and 11 were HBeAg-positive. The levels of serum ALT varied from 45–473 U/L. All had history of tenofovir (300 mg) intake for 6–18 months prior to enrolment to this study and all had compromised renal functions. CCR varied from 80–90 ml/min. Pregnancy was managed with help from Obstetricians. CCR and ALT were monitored at one month and then once in every 3 months. HBeAg and HBV DNA checked at 6 monthly intervals. Results: Normalization of renal function seen in all except 2 patients in each group with borderline impairment. No ALT flare noted in any patient. Five of 28 patients showed HBeAg seroconversion and all but 4 had undetectable HBV DNA during last follow up at the end of therapy. No significant adverse events were observed. Pregnancy was successfully terminated in one pregnant patient at term-end by caesarian section. Patients with acute on chronic liver failure also improved by this therapy. Conclusion: Although tenofovir has shown much enthusiasm about treatment of chronic hepatitis B, tenofovir-induced nephrotoxicity remains a major concern in clinical practice, especially in patients with CLD with compromised liver functions including patients with hepatic decompensation. Present study demonstrates the safety of telbivudine in HBV-induced CLD patients and CLD patients with compromised renal functions. Anti-viral efficacy of telbivudine also became evident from this study. Further study with larger sample size and longer durations are warranted.

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Absno: 54 Entecavir versus tenofovir: four years real life experience of a tertiary care hospital Rahmet Gu¨ner, Zeliha Kocak Tufan, Tu¨mer Gu¨ven, Gu¨l Ruhsar Yılmaz, Fatma Eser, Mehmet A. Tasyaran Infectious Diseases & Clinical Microbiology Department, Yildirim Beyazit University, Ankara Ataturk Training & Research Hospital, Ankara, Turkey Introduction: We aimed to compare the demographic characteristics and therapy response of our chronic hepatitis B patients, who are under entecavir (ETV) or tenofovir (TDF) therapy in long term duration. Materials and methods: Chronic hepatitis B patients whoever treated with ETV or TDF from 2008 to 2013 September in our department were included into the study. Patient files and hospital database were used to find variables. Results: Totally 95 patients included. All the patients were HBsAg and antiHBcIgG positive, antiHDV, antiHCV and antiHIV negative. Thirty six (78 %) of patients in ETV arm and 26 (57 %) of patients in TDF arm had biopsy before treatment. Demographic characteristics of the patients were given in Table 1.

Table 1 Entecavir vs tenofovir in chronic hepatitis B patients Characteristics

Entecavir n = 49

Tenofovir n = 46

P

Age, median (min–max) years

41 (18–69)

40 (20–83)

ns

Gender, M/F

32/17

35/11

ns

Therapy duration, median (min– max) months

36 (12–60)

36 (12–48)

ns

Naive patients, % (n/total n)

63 (31/49)

30 (14/46)

0.001

HBeAg positivity % (n/total n)

47 (23/49)

33 (15/49)

ns

HAI

8

7

ns

Fibrosis

2

2

ns

2.1 9 107

1.27 9 105

0.001

Liver biopsy findings (median)

Treatment outcome Median HBV DNA before treatment, copy/mL (IQR)

(23.4 9 107) (553 9 105)

HBV DNA negativity, % (n/total n) 1st year

63 (31/49)

72 (33/46)

ns

2nd year

71 (30/42)

89 (33/37)

0.05

3rd year

83 (30/36)

86 (24/28)

ns

92 (12/13)

95(18/19)

ns

HBeAg loss or seroconversion, % (n/total n)

4th year

13 (3/23)

13 (2/15)

ns

HBsAg seroconversion, % (n/total n)

0

0

na

ns not significant, na not applicable


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Conclusion: Demographic characteristics were similar between two treatment arms. Although the treatment naı¨ve patients were significantly less in TDF arm and median HBV DNA before treatment level was higher in ETV arm, DNA negativity and HBeAg loss rates were similar. HBsAg seroconversion was not seen in any patient in both arms.



R. Guner1, I. Koksal2, K. Hızel3, T. Yamazhan4, D. Inan5, E. Tutuncu6, O. Kandemir 7, N. Baykam8

Absno: 55 Immune effects of inflammatory cytokine in hepatitis progression in patients infected with hepatitis B virus Be Cai1, J. L. Zhang1, Y. Liao1, J. Chen1, J. T. Tang1, Y. Li1, L. L. Wang1 1

Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China, email: [email protected]

Introduction: Cytokines play the important immune effects in hepatitis patients, especially anti-viral cytokine such as IL-17 and IFN-c, inflammatory cytokines such as IL-1b, IL-6 and IL-8, as well as antiinflammatory cytokine IL-10. Here we detected serum inflammatory and anti-inflammatory cytokines expression in patients infected with hepatitis B virus in different disease progress to explore the roles of diverse cytokines in hepatitis B progress and outcome. Materials and methods: 173 patients with liver diseases derived from hepatitis B virus infection in our hospital, including 81 patients with chronic hepatitis B (CHB), 50 patients with cirrhosis and 42 patients with liver cancer (LC), were enrolled, as well as 70 patients with spontaneous clearance of HBV (SC). 29 healthy volunteers (HC) were recruited as controls. Serum cytokines including IL-1b, IL-6, IL8, IL-17, IFN-c and IL-10 were detected by Bio-Plex suspension array system. Results: (1) anti-viral cytokines expression in patients with hepatitis B: Serum IL-17 and IFN-c levels in SC patients were the highest among all subjects (P \ 0.05), and those in cirrhosis patients were the lowest (P \ 0.05). IL-17 level in HC, CHB and LC gradually decreased. However IFN-c level in CHB was higher than that in HC (P \ 0.05). (2) inflammatory cytokines expression in hepatitis B patients: serum IL-1b, IL-6 and IL-8 levels all were the lowest in cirrhosis patients and all of them increased to the highest in CHB patients (P \ 0.05). Compared with HC, IL-1b level slightly decreased in SC and LC patients; IL-6 level slightly increased in SC and LC patients; but IL-8 level in SC and LC was similar to HC. (3) Anti-inflammatory cytokine IL-10 expression in hepatitis B patients: among all subjects IL-10 level in SC was the lowest and that in CHB was the highest (P \ 0.05). IL-10 level gradually increased in cirrhosis, HC and LC. (4) multivariate logistic regression showed IL-17 and IFN-c were the important factors to influence the outcome of patients with infected with hepatitis B virus. With IL-17 level increasing patients infected with hepatitis B virus could decrease the risk to develop CHB. Conclusions: Increased IL-17 and decreased IL-10 could contribute to the hepatitis B virus clearance. Increased inflammatory cytokine IL-1b, IL-6 and IL-8 induced inflammatory injury in CHB and low levels of anti-viral and inflammatory cytokines were the characteristics of cirrhosis. Keywords: Fcytokines; Hepatitis B; Cirrhosis; Liver cancer

Absno: 57 Efficacy and safety of entecavir treatment in chronic hepatitis B: multicenter, real life and long term data from Turkey

1

Clinics of Infectious Diseases and Clinical Microbiology, Yildirim Beyazit University, Faculty of Medicine, 2Clinics of Infectious Diseases and Clinical Microbiology, Karadeniz Technical University, Faculty of Medicine, 3Clinics of Infectious Diseases and Clinical Microbiology, Gazi University, Faculty of Medicine, 4Clinics of Infectious Diseases and Clinical Microbiology, Ege University, Faculty of Medicine, 5Clinics of Infectious Diseases and Clinical Microbiology, Akdeniz University, Faculty of Medicine, 6Clinics of Infectious Diseases and Clinical Microbiology, Diskapi Yildirim Beyazit Education and Research Hospital, 7Clinics of Infectious Diseases and Clinical Microbiology, Mersin University, Faculty of Medicine, 8Clinics of Infectious Diseases and Clinical Microbiology, Ankara Numune Education and Research Hospital

Background and aims: The aim of this study was to determine the efficacy and safety of long term entecavir monotherapy in chronic hepatitis B (CHB) patients. Methods: We performed a retrospective, multicenter, observational study. Baseline demographic characteristics, serologic, virologic, biochemical and clinical outcomes were recorded at yearly intervals, ranging from one year to four years. Patients with decompensated liver disease, cirrhosis, hepatocellular carcinoma, pregnant or in lactation, and co-infected with hepatitis C, D or human immunodeficiency virus were excluded. Results: In this study, 337 CHB patients from eight centers receiving entecavir therapy were included. 78.9 % of patients were naive, 69.7 % were male, and average age was 41 ± 12 years. Prior to treatment, the patients’ mean ALT and HBV DNA levels were 98 U/L and 7.2 log10 copies/mL, respectively. Of the 134 patients (39.8 %) were HBeAg positive. Liver biopsy was performed in 229 (68 %) patients. Mean histopathologic activity index and fibrosis scores were found to be 8 and 2.6, respectively. At the end of the 1st, 2nd, 3rd and 4th years of therapy, HBV DNAB300 copies/mL was 79.7, 89.6, 92.6, and 94 %; ALT normalization was 73.5, 80.3, 84.2, and 76.4 %; HBeAg loss/seroconversion was 16.4, 30.9, 44.5 and 59.5 % respectively. HBsAg loss and HBsAg seroconversion were detected in 7 and 1 patients, respectively. No adverse effects were determined. In the Cox proportional hazards model, undetectable HBV DNA at the 12th month was an independent factor for maintained viral suppression at the 48th month (p \ 0.001). Baseline serum ALT, HBV DNA levels, and HBeAg positivity were not associated with maintained virological suppression. Conclusion: Entecavir monotherapy was well tolerated and resulted in a significant HBV DNA suppression and ALT normalization in clinical practice. Patients may also achieve HBeAg and even HBsAg seroconversion with long term therapy.

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Topic: 8 Hepatitis B - Clinical Absno: 59 HBsAg level and MELD score predict prognosis to therapy for patients with HBeAg-negative acute-on-chronic liver failure: entecavir versus lamivudine Jing Lai, Ka Zhang, Shao-quan Zhang, Sun Hai-xia Department of Infectious Diseases, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China Background and aim: The predictability of hepatitis B surface antigen (HBsAg) level and the model for end-stage liver disease (MELD) score during HBV-related acute-on-chronic liver failure (ACLF) treatment has been scarcely investigated. The aim of this study was to investigate HBsAg level combined with MELD score for predicting prognosis to antiviral therapy in HBeAg-negative ACLF and the versus of entecavir and lamivudine. Methods: 127 nucleoside-naı¨ve patients with HBeAg-negative ACLF were treated with either 0.5 mg of entecavir or 100 mg of lamivudine daily. Virological, biochemical characteristics and MELD scores were matched at baseline between the two therapies and monitored before death (patients died within 3 months) or after a 3-month antiviral therapy. Dynamic of these items and 3-month mortality were compared. Results: There were 66 patients treated with entecavir and 61 ones treated with lamivudine. No significant difference was found in posttreatment levels of HBsAg, HBV DNA, biochemical items, MELD scores and 3-month mortality between the two drugs (all P[0.05). In entecavir group, post-treatment HBsAg level and MELD scores of survivors were 7634 ± 2618 COI and 17.66 ± 6.11 but that of deaths were 4021 ± 1893 COI and 34.23 ± 8.41 respectively. In lamivudine group, that of survivors were 6497 ± 2011 COI and 18.22 ± 7.30 but that of deaths were 3263 ± 3264 COI and 33.41± 8.41 respectively. Regardless entecavir or lamivudine, post-treatment level of HBsAg in survivors was significant higher than that of deaths meanwhile posttreatment MELD scores of the former were significant lower than that of the latter (all P \ 0.05). In entecavir group, 3-month mortalities of the patients with pretreatment HBsAg above 4000 COI and the ones below to it were 34.8 % (16/46) and 65.0 % (13/20). In lamivudine group, the mortalities were 33.3 % (11/33) and 64.3 % (18/28) in sequence. The mortality of the former was significantly lower than that of the latter. Conclusions: In HBeAg-negative ACLF, the short-term efficacy of entecavir versus lamivudine was similar. HBsAg level and early decrease in MELD scores significantly affected 3-month outcome of the two therapies.

Topic: 8 Hepatitis B - Clinical Absno: 63 Serum hepatitis B surface antigen monitoring in entecavir treated hepatitis B e antigen negative acute-on-chronic liver failure Jing Lai, Shao-quan Zhang, Ka Zhang, Yu-sheng Jie Department of Infectious Diseases, The Third Affiliated Hospital,Sun Yat-Sen University, Guangzhou 510630, China Background and aim: The role of hepatitis B surface antigen (HBsAg) measurement in entecavir treatment in hepatitis B related

123

Hepatol Int (2014) 8:S1–S405 acute-on-chronic liver failure (ACLF) remains unclear. The aim of this study is to retrospectively investigate the dynamics and clinical significances of serum HBsAg level in hepatitis B e antigen (HBeAg) negative ACLF patients treated with short-term entecavir. Methods: Clinic data of 66 nucleoside-naı¨ve HBeAg-negative patients with ACLF treated with 0.5 mg of entecavir daily were collected from January 2011 to December 2012. Serum HBsAg levels were measured using electrochemical immunoassay (The Elecsys 2010, Roch diagnostics, Mannheim Germany) at baseline, before death (patients died within 3 months), 3 months (patients survived over 3 months) during treatment. The levels of HBsAg and 3-month survival rate were analyzed. Results: Thirty-six patients survived over 3 months and 30 patients died within 3 months after entecavir treatment, whose pretreatment HBsAg levels were 6659 ± 3282 COI and 5537 ± 3542 COI respectively meanwhile the post-treatment HBsAg levels were 7634 ± 2618 COI and 4017 ± 1897 COI in sequence. HBsAg levels of survival group were higher than that of dead group, regardless pre- or post-treatment. Furthermore, there were 46 patients with pretreatment HBsAg levels above 4000 COI and 20 patients below to it. The pretreatment HBsAg levels of the former were significantly higher than that of the latter (7882 ± 2306 COI vs 1978 ± 1044 COI, t = 13.17, P \ 0.001). And the 3-month survival rate of the former was also significantly higher than that of the latter (65.2 % (30/46) vs 35.0% (7/20), v2 = 5.167, P = 0.023). Conclusions: Changes in HBsAg level could be a useful parameter for assessing the short-term outcome of entecavir treatment in HBeAg-negative ACLF. Patient with higher pretreatment HBsAg level and maintaining during therapy has batter prognosis.

Topic: 8 Hepatitis B - Clinical Absno: 64 Immunological response of telbivudine treatment in drug-naı¨ve patients with HBeAg-positive chronic hepatitis B Tianjun Jiang, Zhen Li, Li Zhao, Liangliang Guo Treatment and Research Center for Communicable Diseases, Beijing 302 Hospital, 100039, China, email: [email protected] Background/aim: Antiviral drugs are the only treatment option for chronic hepatitis B infection (CHB). Nucleotide analogues induce potent suppression of HBV replication, but weak immunological control. This study evaluated the changes of immunological function with telbivudine (LdT) in drug-naı¨ve CHB patients. Method: We enrolled 50 HBeAg-positive CHB patients. Patients excluded: concurrent infection with HCV, HDV, HIV, HAV, HEV, coexisting alcoholic liver disease, coexisting liver cirrhosis, prior to treatment with anti-HBV interferon or nucleoside analogues. Primary measures: serological responses; changes of immune cells and cytokines. Secondary measures: virological and biochemical responses (Table 1). Results: Changes in immune cells: IFNr+Th1 cells were significantly increased at weeks 4 and 12 (P \ 0.05), then decreased at week 24. IL17+Th17 cells increased significantly at week 4, 12 and 24 (P \ 0.05), and decreased at week 52. Foxp+Treg cells showed a temporary decline at week 24, however no significant change at other time points. Changes in cytokines: IFNc did not change during treatment. IL17 was markedly elevated at week 4 and 12 (P \ 0.05) and returned to baseline levels by week 24. IL10 decreased over time and was significantly reduced vs. baseline by week 24 (P \ 0.05). Conclusion: During early LdT-treatment week 4 to 24, Th1, Th17 were significantly elevated. Other major immune cells and related


S51

Table 1 Summary of virologic, biochemical and serological efficacy parameters Parameters/time in weeks

Baseline N = 50

HBV DNA, log10 (IU/mL)

7.22

% Undetectable HBV DNA

12 W N = 50

24 W N = 48

52 W N = 46

3.15*

2.17*

2.00*

28 %

64.6 %

76.1 % 24.32*

ALT (U/L)

161.52

59.55*

33.67*

AST (U/L)

120.49

56.08*

31.43*

23.63*

HBeAg

498.76

410.53

112.56*

86.77*

HBsAg

4505.76

4130.87

4023.85

3932.51

* P \ 0.05

cytokines also changed. It is our hope that a better understanding of these early dynamic observations will help better predict those patients who benefit from the prescribed antiviral treatment regimen and help identify those patients requiring a change.

with pre-existing renal disease, these positive results were noted in patients without pre-existing hypertension or diabetes. Conclusion: In our small cohort of patients, TDF for treatment of chronic hepatitis B (up to 54 months) was not associated with clinically significant renal toxicity. Hypophosphatemia, proteinuria and glycosuria occurred, but did not herald the development of renal dysfunction during follow up. References 1. Nelson M, Katlama C, Montaner J et al. The safety of tenofovir disoproxil fumarate for the treatment of HIV infection in adults: the first 4 years. AIDS 2007;21:1273–1281

Topic: 8 Hepatitis B - Clinical Absno: 72 Sexual transmission of hepatitis b in married spouses


B. Bozca1, A. Kandemir2

Absno: 69

1 Department of ˙Infectious Diseases, Afyonkarahisar State Hospital, Turkey, 2Department of Gastroenterology, Afyonkarahisar State Hospital, Turkey

Management of chronic hepatitis B with tenofovir disoproxil fumarate is not associated with significant renal toxicity 1

1

1

1

2

S. Rao , N. Kontorinis , L. Tarquinio , J. Kong , M. Thomas , W. Cheng1 Department of 1Gastroenterology & Hepatology and 2Nephrology, Royal Perth hospital, Perth WA Background: Tenofovir (TDF) is an oral nucleotide analogue approved for use in chronic hepatitis B. TDF used in the management of HIV has been shown to be associated with reversible renal toxicity, leading to proximal tubular dysfunction, Fanconi syndrome and acute kidney injury. The incidence of renal toxicity in chronic hepatitis B has not been adequately studied. Aims: To evaluate the incidence and severity of renal impairment with TDF in chronic hepatitis B. Methods: Retrospective descriptive analysis of patients with chronic hepatitis B treated with TDF at our institution. Data collected by review of medical records—demographics, viral markers, biochemical investigations and urinalysis. Results: 103 patients (72.8 % male) from April 2009 to June 2013 were included. The mean age was 49.5 years (20 to 79 years). 29.5 % had cirrhosis or advanced fibrosis as indicated by liver biopsy showing F3 or F4 on Metavir score,[4 on Knodell score or Hepascore[0.80. 43.1 % were HBeAg positive. Hypertension noted in 5 patients and diabetes mellitus in 4. Baseline eGFR was [60 ml/min/1.73 m2 (Modification of Diet in Renal Disease formula) in 99 % of the patients. One patient had pre existing renal disease (IgA nephropathy), with a baseline eGFR of 55 ml/min/1.73 m2. Renal function was assessed 3–6 monthly during treatment. No significant derangement (20 % drop from baseline eGFR) was noted in any patient during therapy with TDF, mean duration of treatment being 29.2 months (4.2 to 54.2 months). Hypophosphatemia (\0.80 mmol/L) was noted in 17.2 % of the patients, 5 months to 2 years into treatment and was not associated with renal impairment. Urinalysis was performed in 33.3 % of the patients and 5.8 % of these patients were noted to have trace of glucose and 17.6 % had trace of protein (in the absence of infection) and these did not correlate or predict renal dysfunction. Apart from the one patient

The aim of the study: We aimed to determine the hepatitis B virus (HBV) serologic profiles of the spouses of patients with chronic hepatitis B, as a risk group. Methods: We studied 397 married patients having chronic B hepatitis fallowed up between 2009 december and 2013 august. We determined HBsAG and HBeAG levels and the treatment history of the spouses of patients using enzyme-linked immuno sorbent assay (ELISA) Results: The mean duration of marriage was 22.4 years (range 1–60 years). Both spouses Hepatitis B seropositivity rate was 11.6 % (46 of 397) (transmission-positive group). Treatment history for hepatitis B with antiviral or interferon as a risk factor was 17.4 % (8 of 46) for transmission-positive group and 15.4 % (54 of 351) for transmission-negative group. The diffirence was not significant (p 0.725). When we looked at rates of HBeAG positivity as a risk factor for transmission in seropositive and seronegative groups, it was 2.8 and 2.2 % respectively. The difference was statiscally not significant (p 0.830). Conclusions: Sexual contact is a weak risk factor for transmission of hepatitis B. Also, HBeAG positivity and history of treatment is not effective in transmission.

Topic: 8 Hepatitis B - Clinical Absno: 73 Imbalance of Th17/Treg and CTL/Ts in different stages of patients with hepatitis B infection Jie Chen1, Lanlan Wang1,Yang Fu1, Yi Li1, Bei Cai1, Limei Luo1, Yun Liao1 1

Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu 610041, P. R. China

123

S52


Objective: Chronic hepatitis B (CHB) affects 400 million people and is the most common cause of liver cirrhosis (LC) and hepatocellular carcinoma (HCC) worldwide. Cellular immune regulation plays an important role in determining the infection outcome. Different subsets of T cells were studied to explore their association with progress of HBV infection and to find key signal pathway in the cellular immune. Methods: 94 patients of HBV infection were categorized into three groups: 31 LC caused by CHB, 30 HCC caused by CHB, and 33 CHB. Patients who were positive for anti-HCV or anti-HIV or alcohol abuse ones were excluded. Th17, Th1, CD4+CD25+FOXP3+ Treg, CD8+CD28+CTL, CD8+CD28-Ts were analyzed by flowcytometer. Results: CHB patients who progress to LC or HCC showed a significant higher level of Th17 and Treg, but low CTL, while there was no significant difference of others between LC, HCC and CHB. Th17 was significantly associated with liver function tests while Treg was significantly associated with HBV-DNA. Conclusion: Increased Th17 mediated inflammation injury of liver and Treg induce tolerance, which resulted in the replication of virus. The balance of Th17 and Treg play an important role in the progress of HBV infection, disequilibrating of T subsets may be one of the reason why the host immune get out of balance and hepatic inflammation progress to cirrhosis and carcinoma

.

Table 1 HBsAg level at different time points for predicting response to Peginterferon a-2b in Chinese HBeAg positive CHB patients Predictors

AUC

Cut-off

Youden index

Se

Sp

PPV

NPV

Baseline 0.6626 23799.89 0.3052 HBsAg(IU/ml)

0.7647 0.5405 0.2766 0.9091

Week 12 0.6919 9894.92 HBsAg(IU/ml)

0.3687

0.8824 0.4863 0.2857 0.9467

Week 24 0.7103 4099.99 HBsAg(IU/ml)

0.3882

0.8235 0.5646 0.3043 0.9326

Change of HBsAg(week 12 to screen, log IU/ml)

0.6080 -0.5170

0.2575

0.5588 0.6986 0.3016 0.8718

Change of HBsAg(week 24 to screen, log IU/ml)

0.6349 -0.3715

0.2431

0.7941 0.4490 0.2500 0.9041

Materials and methods: Sustained response was defined as HBeAg seroconversion and HBV DNA \ 2,000 IU/ml 24 weeks after treatment. HBsAg levels were analyzed retrospectively from stored samples at baseline, week 12 and week 24 using the Abbott Architect assay. Receiver operating characteristic curves and area under curves were used to assess predictive values of variables. The optimal cutoff values of the predictors were determined and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each predictor. Results: Stored samples of 182 Chinese patients were available for analysis. 34 patients were in response group and 148 patients in nonresponse group. AUC and best cut-ff value of HBsAg levels at different time points were listed in the Table 1. Week 24 HBsAg provide the best prediction of sustained off-treatment response. At week 24, the best HBsAg cut-off of 4,100 IU/ml had PPV and NPV of 30.34 and 93.26 %. No patient with HBsAg[20,000 IU/ml at week 24 achieved response.

Topic: 8 Hepatitis B - Clinical Topic: 8 Hepatitis B - Clinical

Absno: 78

Absno: 76

Efficacy of 5-year telbivudine versus entecavir for HBeAg-positive chronic hepatitis B

Use of HBsAg level for prediction of sustained response for Chinese HBeAg positive chronic hepatitis B patients taken 48 weeks peginterferon a-2b therapy S. Yang1, H. C. Xing1, Q. X. Wang2, A. Fernando Bognar3, D. Z. Xu1, J. Cheng1, on behalf of P05170 study group 1

Center of Hepatology, Beijing Ditan Hospital, Capital Medical University, Beijing, China, 2MSD China, 3MSD Hong Kong Introduction: Use of HBsAg level for predicting response to PEGIFN a-2b in Chinese chronic hepatitis B (CHB) patients has seldom been reported. Previously we conducted a trial to evaluate PEG-IFN a-2b efficacy in Chinese HBeAg positive CHB patients, in which 220 patients were enrolled to take Peginterferon a-2b 1.5 lg/kg/week for 48 weeks. The aim of this study was to evaluate HBsAg level at treatment week 12 and week 24 for predicting sustained response to 48 weeks Peginterferon a-2b therepy in Chinese HBeAg positive patients.

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Ying Ye Department of Infectious Disease, The First Affiliated Hospital of Anhui Medical University, China, email: [email protected] Background/aim: Maximal suppression of virus replication is associated with delayed disease progression. HBeAg seroconversion is an important indication for drug withdrawal. Ideal therapy should deliver rapid suppression of virus replication and HBeAg seroconversion. The aim was to evaluate the efficacy of telbivudine (LdT) or entecavir (ETV) treatment for 5 years in HBeAg-positive chronic hepatitis B (CHB) patients. Methods: We enrolled 70 patients, including 35 patients treated in phase IV ETV clinical trials (080) in 2007, 35 patients treated in LdT clinical trials in 2007. Adefovir (ADV) was added if HBV-DNA [1000 copies/mL. Mean age years was 35.4/32.4 for ETV/LdT, male 28/27, HBeAg+ 35/35, mean HBV-DNA levels at baseline, 8.56 9 107 ± 2.34 9 108/5.63 9 107 ± 1.09 9 108 copies/mL mean ALT


S53

Table 1 Clinical Results % Virologic

% Biochemical

ETV LdT ETV

LdT

% HBeAg loss

% HBeAg seroconversion

ETV LdT ETV

LdT

3 months

57

74*

51

60

0

6

0

6 months

69

94*

71

94*

6

23*

3

0 3

1 year 2 years

80 97

94 89

83 97

97 94

9 17

34* 43*

9 3

17 28*

3 years

91

94

94

100

40

51

9

43*

4 years

91

97

97

97

40

57

11

45*

5 years

100

100

100

100

40

69*

26

51*

* P \ 0.05

levels at baseline, 194.54 ± 145.88/ 230.00 ± 145.47 (U/L). The primary efficacy included: rates of HBV-DNA undetectable, ALT normalization, HBeAg seroconversion and HBeAg loss. Secondary efficacy: To observe the rate of virological breakthrough and safety of 5-year telbivudine and entecavir treatment. Creatine phosphokinase and creatinine clearance were measured. Results: ADV was added to ETV-based regimen in 5 patients with HBV-DNA[104 copies/mL (2000 IU/mL) and to LdT-based regimen in 3 patients with HBV-DNA [1000 copies/mL. Side effects were manageable, 5 cumulative cases of CK elevation with LdT and 1 with ETV (Table 1). Conclusions: In our 5-year study, LdT yielded superior HBeAg seroconversion rates to ETV. During treatment, regular monitoring should be performed to determine whether drug resistance and elevated creatine phosphokinase occur. If above-mentioned symptoms occur, immediate treatment modification should be instituted.

Topic: 8 Hepatitis B - Clinical Absno: 86 Comparison of the efficacy and safety of tenofovir monotherapy versus tenofovir plus other nucleoside-analogues in nucleoside analogues experienced patients with chronic hepatitis B patients HUANG Ming-xing1,2, SHI Hong1, LI Xing-hua1, WU Yuan-kai1, CHONG Yu-tian1 Department of Infectious Diseases, the Third 1/ Fifth 2 Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China Objective: To compare the clinical efficacy and safety of tenofovir disoproxil fumarate (TDF) monotherapy with TDF plus other nucleoside-analogues (NAs) for NA experienced patients with chronic hepatitis B patients (CHB). Methods: A total of 62 patients with prior NAs experienced patients received TDF (300 mg/day) monotherapy (Group A, n = 38) or TDF plus other prior NAs (Group B, n = 24) for more than 48 weeks. Quantitative HBV-DNA (q HBV-DNA), the rate of undetectable HBV-DNA and the median time of HBV-DNA negative conversion were determined at week 0, 4, 12, 24, 36, 48. Serum ALT normalization rate,HBeAg seroconversion rate, viral breakthrough(VBT), the rates of viral response (VR) and the incidences of adverse events of TDF were determined at the end of follow-up.

Results: The baseline of qHBV DNA Group A and B were 5.61 ± 1.43 and 5.28 ± 1.51 log10 IU/ml respectively (P = 0.391) . qHBV-DNA did not differ significantly at weeks 4, 12, 24, 36, 48, (3.47 ± 1.43 vs. 3.87 ± 1.57 log10 IU/ml, P = 0.319; 2.96 ± 1.51 vs. 2.46 ± 0.83 log10 IU/ml, P = 0.100; 1.83 ± 0.40 vs.1.98 ± 0.65 log10 IU/ml, P = 0.311; 1.84 ± 0.48 vs. 1.73 ± 0.13 log10 IU/ml, P = 0.291; 1.78 ± 0.28 vs.1.85 ± 0.57 log10 IU/ml, P = 0.663). The rate of undetectable HBV DNA did not differ significantly at week 4, 12, 24, 36, 48 (28.9 vs. 16.7 %, P = 0.271; 50 vs.41.6 %, P = 0.522; 89.4 vs. 83.3 %, P = 0.700; 91.3 vs.92.8 %, P = 0.503; 90.4 vs. 100.0 %, P = 0.100). There was no difference in serum ALT normalization rate in Group A and B at week 48 (P = 0.613), neither in the rates of VR, HBeAg seroconversion,VBT in Group A and B (all P [ 0.05). The incidences of adverse events in Group A and B were both 0 % during in the follow up. Conclusion: There is no difference in the TDF monotherapy and TDF plus other NAs in the suppression of HBV-DNA replication and ALT normalization rate, neither of the incidence of adverse events in NAexperienced chronic hepatitis B patients.

Topic: 8 Hepatitis B - Clinical Absno: 87 48-week efficacy of tenofovir monotherapy for nucleosideanalogues experienced chronic hepatitis B patients HUANG Ming-xing1,2, SHI Hong1, LI Xing-hua1, WU Yuan-kai1, CHONG Yu-tian1 Department of Infectious Diseases, the Third 1/ Fifth 2 Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China Objective: To evaluate the clinical efficacy and safety of tenofovir disoproxil fumarate (TDF) for nucleoside-analogues (NA) experienced chronic hepatitis B patients (CHB). Methods: A total of 30 patients with NA-experienced CHB received TDF monotherapy in our follow-up clinic were retrospectively investigated for 48 weeks. Quantitative HBV-DNA (q HBV-DNA), the rate of undetectable HBV-DNA and the median time of HBVDNA negative conversion were determined at week 0, 4, 12, 24, 36, 48. Serum ALT normalization rate,HBeAg seroconversion rate,viral breakthrough (VBT), the rates of viral response (VR) and the incidences of adverse events of TDF were determined at the end of follow-up. Results: qHBV-DNA differ significantly between baseline and weeks 4, 12, 24, 36,48 espectively (all P \ 0.001), but did not differ significantly among weeks 24, 36, 48 (all P [ 0.05), as well as HBV DNA reduction (HBVDNA r) and HBV DNA cumulative reduction (HBV DNA cr). The biggest HBV DNAr was at weeks 4 (2.11 ± 0.38 log10 IU/ml), while HBV DNA cr was at weeks 24 (3.79 ± 0.37 log10 IU/ml). The rate of undetectable HBV DNA differ significantly between weeks 4 and 24, 36, 48(P \ 0.001, P = 0.007, P = 0.001). The cumulative rate of undetectable HBV DNA was 96.7 % at week 48. The median time of HBV-DNA negative conversion was 10.4 (3.43–34.0) weeks. Serum ALT normalization rate increased from 40 % at week 4 to 100 % at week 48 .The rates of VR, HBeAg seroconversion and VBT were 88.9, 6.67 and 0 % respectively. Creatine kinase (CK) in 9.18 % were more than two times upper limit normal (2 ULN) and did not differ significantly between before and after treatment. (All P [ 0.05). Serum creatinine was no more than 1 ULN in any patient. Conclusion: TDF monotherapy have a fast suppression of HBV-DNA replication and high ALT normalization rate, as well as

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low incidence of adverse events in NA-experienced chronic hepatitis B patients.

Topic: 8 Hepatitis B - Clinical Absno: 96


Assessment of the antiviral effect of entecavir on high viral load in type B chronic liver disease

Absno: 89 Efficacy of entecavir among chronic hepatitis B patients previously treated with peginterferon alpha 2a: new option of sequential therapy in a developing country Mobin Khan, Mohammad Golam Azam The Liver centre, Dhaka, Bangladesh and BIRDEM General Hospital, Shahbagh, Dhaka, email: [email protected] Background: Chronic hepatitis B (CHB) is a global problem which is not uncommon in Bangladesh. Considering the deadly consequences of long term infection and its correlation with persistent high viral load, clearance of cccDNA is the ultimate goal. Interferons have immunomodulatory and antiviral effect but side effects are common and costly for a developing country like Bangladesh. Aims and objectives: Sequential therapy with peginterferon alpha 2a for a shorter duration of 24 weeks irrespective of HBeAg status followed by entecavir therapy may minimize the cost and side effects with better efficacy. Materials and methods: A total of 35 patients (male 27, HBeAg positive 10 cases), age mean ± SD was 33 ± 11 years, baseline ALT mean ± SD was 68 ± 35 IU/L and baseline log HBVDNA mean±SD was 6.1 ± 1.7 copies/ml. Peginterferon alpha 2a was given for 24 weeks 180 microgram s/c weekly followed by entacavir for 18 months at 0.5 mg orally daily. Efficacy was assessed 6 monthly with serum ALT and HBV DNA load. Results: Figure 1 shows that although HBVDNA viral load reduced but did not come to undetectable level by PCR method at 6 month of peginterferon therapy. Further treatment with entecavir significantly reduced HBV DNA load and maintained below the detection limit. Serum ALT level was also reduced and sustained in the similar manner. Conclusion: Sequential therapy with peginterferon alpha 2a for a shorter duration of 24 weeks followed by entecavir therapy showed better efficacy in this pilot study.

Peginterferon alpha

7 6

Itaru ozeki, Tomoaki Nakajima, Shuhei Hige, Yoshiyasu Karino, Joji Toyota Sapporo kosei General Hospital Objectives: We calculated the HBV DNA virological response (VR) rate to Entecavir (ETV) therapy in CHB patients with baseline DNA high viral load and assessed poor antiviral responders. Subjects and methods: Of 250 patients who were initially started on ETV therapy after introduction of the TaqMan-PCR assay and were followed thereafter for at least 1 year, the VR rate was compared between a group of 49 patients with a baseline HBV DNA C8 log copies/mL (high viral load group; HVL group) and a group of 241 patients with a baseline DNA\8 log. For the HVL group, the VR rates at 2 and 3 years after the start of ETV therapy were then calculated by patient stratification according to whether the patients were DNA-positive or -negative at 1 year of ETV therapy. The frequency and characteristics of non-responders and patients with virological breakthrough (VBT) were also assessed. A non-responder was defined as a patient showing a DNA C5 log at 1 year of ETV therapy, VBT was defined as a consistent increase in DNA by C1 log above the nadir while on treatment, and VR as a DNA \2.1 log. Results: (1) The VR rates (%) at 1, 2, and 3 years after the start of ETV therapy were 51, 71, and 83, respectively, for the HVL group, clearly being lower than the 90, 96, and 94, respectively, for the\8 log group. (2) There were 25 DNA-negative patients and 24 positive patients at 1 year of ETV therapy in the HVL group, and the VR rates (%) at 2 and 3 years of ETV therapy were 47 and 69, respectively, for the DNA-positive subgroup, being lower than the 94 and 100, respectively, for the DNA-negative subgroup. (3) There were 3 non-responders to ETV and 3 patients with VBT. All 6 patients were HBeAg (+) and had genotype C with HVL. Of the 3 non-responders, 2 received tenofovir (TDF) and 1 adefovir concomitantly with ETV. The only 2 patients receiving TDF were both HBV DNAnegative at the last follow-up. No resistance to ETV emerged in any of these 3 non-responders. None of the 3 VBT cases had attained DNA negative conversion by 1 year after the start of ETV therapy, and the times of the occurrence of VBT and the ETV resistance in these 3 cases were 13 months (rtS202G), 52 months (rtT184A, rtS202G), and 45 months (under identification). The DNA loads were negative receiving TDF patient. Conclusion: In the HVL group, the VR rate was low at 1 year of ETV therapy and there were 3 non-responders. Three patients experienced a VBT among those who had been positive for DNA at 1 year of ETV therapy in the HVL group.

5

Mean log HBV DNA 4 copies/ml

Entecavir


3 2

Absno: 97

1

Hepatitis B transmission after blood transfusion despite nucleic acid testing in NZ

0 N=

35 0

34 6

27 12

Follow up months

23 18

16 24

C. B. Cederwall1, E. J. Gane1, R. Harry1, R. Nagappan2, K. Croxson2 1

Fig. 1 Serum HBV DNA load during treatment

123

New Zealand Liver Transplant Unit, Auckland Hospital, Department of Microbiology and Virology, Auckland Hospital

2


S55

Nucleic acid testing (NAT) has been shown to increase the detection of blood-bourne viruses infections (BBVI) HIV, HCV and HBV in blood and organ donors, through identification of recent infection prior to development of specific antibodies (eclipse phase). However, this technology is expensive and has little incremental yield over current serological testing in countries with low prevalence of BBVI. Although New Zealand has HBV prevalence, a reliable marker of acute infection during the window phase already exists - anti-HBcore. Anti-HBcore testing of blood donors is not routinely performed in New Zealand for blood screening. We present a 65 year old man who acquired HBV infection through blood transfused from an HBsAg negative, anti-HBcore positive donor. The recipient had intestinal diffuse B cell lymphoma treated with rituximab based chemotherapy and achieved remission. Eighteen months after transfusion, he presented with hepatic decompensation and was diagnosed with cirrhosis presumed due to alcohol. Although persistently HBsAg negative, he was noted to be anti-HBcore+ (negative in 2010). Serum HBV DNA levels were found to be high. Sequencing of recipient virus demonstrated L110IL mutation in the HBV ‘‘S’’ gene. This represents the first case of HBV transmission following blood transfusion in New Zealand since the introduction of NAT testing. Consideration should be given to universal anti-HBcore testing for blood donors.

10

8

HBeAg 6 Mean log HBV DNA copies/ml

positive negative

4

2

0 -2 N=

452 970

168 394

0

6

80 219

41 110

14 65

13 27

12 18 24 Follow up months

5

30

8

2

36

10

42

Fig. 1 Serum HBV DNA load during treatment

160 140

HBeAg

120

Mean S. ALT IU/L


Negative 80 60

Efficacy and safety of prolonged 3-year entecavir treatment in patients with chronic hepatitis B in Bangladesh: a ‘real life’ experience

40 20 0

Mohammad Golam Azam1,2, Mobin Khan2 1

Positive

100

N=

2

Background: Persistent HBV DNA suppression is associated with the less chance of liver cirrhosis and hepatocellular carcinoma in chronic hepatitis B patients. However, prolonged treatment with neucleos(t)ids leads to the development of drug-resistance by time. Aims: To investigate the long-term efficacy and safety of entecavir in chronic hepatitis B patients in Bangladesh. Methods: A total of 1417 chronic hepatitis B, e-antigen positive (Group A, n = 451) and e-antigen negative (Group B, 966), treatment naı¨ve cases were enrolled. Age mean ± SD was 33 ± 11 years. The study was carried out during the period of 2009–2012 at the Liver centre, Dhaka, Bangladesh. Entecavir was given 0.5 orally mg/day. Virological and biochemical responses were assessed 6 monthly. During follow up at 6, 12, 18, 24, 30, 36 and 42 months 562, 299, 151, 79, 40, 13 and 12 cases were evaluated. Results: Baseline mean ± SD of HBV DNA was 7.9 ± 2.0 versus 5.2 ± 1.5 log copies/ml (p = 0.002) and mean ± SEM of serum ALT was 125 ± 13.0 versus 79.6 ± 5.6 IU/L (p = 0.003) in group A and B respectively. Mean HBV DNA levels significantly reduced in first 6 months treatment and came below 2.0 log copies/ml which was sustained over the period of 3 years’ time (Fig. 1). Mean serum ALT levels which was gradually declining (Fig. 2). HBeAg seroconversion rate was satisfactorily increased over time. Conclusion: Three years of entecavir treatment yielded high rates of viral suppression and ALT normalization with a favorable safety profile. Rate of HBeAg seroconversion was achieved satisfactorily with prolonged entecavir therapy.

431 937 163 384

0

BIRDEM General Hospital, Dhaka, Bangladesh, The Liver Centre, Dhaka, Bangladesh, email: [email protected]

6

77 216

41 107

14 63

12 18 24 Follow up months

13 27

30

4

8

36

1

9

42

Fig. 2 Serum ALT level during treatment

Topic: 8 Hepatitis B - Clinical Absno: 106 Efficacy of telbivudine among chronic hepatitis B patients previously treated with peginterferon alpha 2a for a short period Mohammad Golam Azam1,2, Mobin Khan2 1 BIRDEM General Hospital, Dhaka, Bangladesh, 2The Liver Centre, Dhaka, Bangladesh, email: [email protected]

Background: Carrier rate of HBsAg is 4–7 % in Bangladesh. Long term chronic hepatitis B (CHB) can lead to cirrhosis of liver, hepatocellular carcinoma and liver failure. It is now established that HBVDNA load is directly correlated with these end stage liver diseases. Interferons have immunomodulatory and antiviral effects but side effects are common and costly for a developing country like Bangladesh. Aims and objectives: This study was aimed to explore whether sequential therapy with peginterferon alpha 2a for a shorter duration of 24 weeks irrespective of HBeAg status followed by telbivudine therapy could minimize the cost and side effects with better efficacy.

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S56


10

10

Peginterferon alpha 2a

8

HBeAg

8 Mean log HBV DNA copies/ml

6

positive negative

6

Telbivudine

Mean Log HBV DNA 4 Copies/ml

4

2

2

0

0 N=

44 0

40 37 6 12 Follow up months

34 18

29 24

-2 N=

Fig. 1 Serum HBV DNA load during treatment Materials and methods: A total of 44 patients (male 31, HBeAg positive 14 cases), age mean ± SD was 36 ± 14 years, baseline ALT mean ± SD was 88 ± 39 IU/L and baseline log HBVDNA mean ± SD was 6.5 ± 1.3 copies/ml. Peginterferon alpha 2a was given for 24 weeks 180 microgram s/c weekly followed by telbivudine for 18 months at 600 mg orally daily. Efficacy was assessed 6 monthly with serum ALT level and HBV DNA load. Results: Although HBVDNA viral load reduced after 24 weeks of peginterferon alpha 2a therapy but did not come to undetectable level by PCR method. Further treatment with telbivudine significantly reduced HBV DNA load and maintained below the detection limit (Fig. 1). Serum ALT level was also reduced and sustained in the similar manner. Conclusion: In this pilot study, better efficacy was obtained with sequential therapy with peginterferon alpha 2a for a shorter duration of 24 weeks followed by telbivudine.

18 46

18 39

16 41

18 42

12 36

10 29

7 25

0

6

12

18

24

30

36

4

17

48

Follow up months

Fig. 1 HBV DNA during treatment

400 350

HBeAg

300

Positive Negative

250 Mean S. ALT IU/L

200 150 100 50 0

Topic: 8 Hepatitis B - Clinical Absno: 107 Tenofovir ameliorates viral rebound in chronic hepatitis B patients previously treated with telbivudine: a single centre experience Mobin Khan1, Mohammad Golam Azam1,2 The Liver Centre, Dhaka, Bangladesh, 2BIRDEM General Hospital, Dhaka, Bangladesh, email: [email protected] 1

Background: Tenofovir, a newer antiviral agents showed better efficacy in chronic hepatitis B (CHB) patients in many clinical trials. Telbivudine has several limitations especially in the development of drug-resistance by time. Aims: The present study was aimed to assess the antiviral efficacy and safety of tenofovir switch in CHB patients who exhibited persistent viraemia under telbivudine therapy. Methods: This study was done at the liver centre, Dhaka, Bangladesh during the period of 2008–2012. A total of 64 CHB patients (both HBeAg-positive and HBeAg-negative) with viraemia [HBV DNA [3 log(10) copies/ml] under telbivudine treatment for 24 months were switched to continue tenofovir 300 mg/day for another 24 months. Endpoint of treatment was the reduction in serum HBV DNA levels and further improvement in ALT level. Results: The mean reduction in serum HBV DNA levels although significant in both HBeAg-positive and HBeAg-negative groups in initial period. But at after 2 years of treatment it was start rising.

123

-50 -100 N = 17 46 17 36 16 41 17 42 11 35 10 28 7 25 4 17 0 6 12 18 24 30 36 48 Follow up months

Fig. 2 HBV DNA during treatment

Similar pattern was also observed for serum ALT. When the patients were switched to tenofovir therapy, both serum HBV DNA and ALT levels were improving in a sustained manner (Fig. 1, 2). Conclusions: In this pilot study, it was observed that switching to tenofovir improves virological outcomes in CHB patients with persistent viral replication under telbivudine treatment.

Topic: 8 Hepatitis B - Clinical Absno: 108 Sequential therapy with telbivudine followed by IFNa-1b in chronic hepatitis B patients after complete response to telbivudine Juan Kang, Dazhi Zhang, Zhi Zhou, Peng Hu, Wei Zhang Department of Infectious Disease the Second Affiliated Hospital of Chongqing Medical University, China, email: [email protected]


S57

Table 1 The cumulative off-treatment relapse rate was no different between the 2 groups Groups

3

6

12

18

24

30

36

Cumulative relapse frequencies

IFN sequence 0/10a 1/10a 2/9a 0/6a 0/4a 0/3a 0/1a 3 LdT mono

1/10a 1/9a

1/8a 0/7a 0/7a 0/7a 1/2a 4

a

Relapse cases at this time point/total follow-up cases at this time point

Background/aims: HBeAg seroconversion is a basic goal for antihepatitis B virus (HBV) therapy. Prolonging the treatment of nucleos(t)ide analogues (NAs) can help achieve sustained off-therapy virological and biochemical responses. The aims was to compare the sustained off-therapy response and relapse of telbivudine (LdT) monotherapy (A) and LdT followed by IFNa-1b (B). To explore the predictive value of HBsAg levels for sustained off-therapy response. Method: 20 HBeAg-positive CHB patients with a complete response to LdT were enrolled into our study. Baseline characteristics were as follows: (A/B) Mean age 34.4/31.9, weight 54.3/53.8, TBIL lmol/L 27.9/20.9, ALT U/L 244.2/163.7 and HBV-DNA 6.9/5.5. Following complete response with LdT therapy, patients received 48 weeks of consolidation therapy with either 48 weeks of LdT (N = 10) or 24 weeks of LdT followed by IFN for 24 weeks, (N = 10). Results: Sustained off-treatment response rate of patients with decline of HBsAg C1000 IU/mL at 24 weeks was significantly higher than that of patients with decline of HBsAg \1000 IU/mL at 24 weeks (91.0 vs. 33.3 %),P \ 0.05. HBsAg level of 200 IU/mL at the end of therapy could be regarded as predictive value for relapse after drug withdrawal (P \ 0.05) (Table 1). Conclusions: HBeAg-positive CHB patients can achieve sustained response of extended periods with 1 year’s LdT consolidation therapy after complete response to LdT. LdT followed by IFNa-1b cannot reduce the relapse frequency after discontinuation.

Fig. 1 Changes of eGFR during long-term NUC therapy

entecavir (ETV) 0.5 mg/days and 36 untreated. We measured the following every 3 months: serum creatinine, liver function, HBVDNA, HBV-M levels. For patients who were treated with LdT, serum creatine kinase (CK) levels were also measured. eGFR was calculated from serum creatine levels based on the Cockcroft–Gault formula and MDRD formula. Results: Prolonged LdT results in improved eGFR, while adefovir therapy is associated with a decrease in eGFR, lamivudine and entecavir showed no effects over a 3-year period (Fig. 1). These effects were particularly noticeable in patients with mildly impaired eGFR at baseline. Age, eGFR at baseline and use of LdT were dependent factors predicting an increase ineGFR of more than 20 %. Conclusions: These beneficial results observed with LdT are particularly relevant to patients requiring prolonged treatment with NUCs, particularly those at risk for worsening renal function.


Absno: 118

Evaluation of HBV DNA decay kinetics in patients containing both rtM204V/I mutant and wild-type HBV subpopulations during tenofovir DF (TDF) monotherapy or combination therapy with emtricitabine (FTC/TDF)

Impact of nucleos(t)ide analogues on estimated glomerular filtration rate in the treatment of chronic hepatitis B

E. J. Gane1, Y. Liu2, K. M. Kitrinos2, P. Dinh2, J. F. Flaherty2, E. S. Svarovskaia2, M. D. Miller2, and S. Fung3

Xun Qi1,2, Jinyu Wang1, Richeng Mao1, Jiming Zhang1

2


1 Department Of Infectious Diseases, Huashan Hospital Affiliated to Fudan University, Shanghai, China, 2Department Of Liver Diseases, Shanghai Public Health Clinical Centre Affiliated to Fudan University, China

Background/aim: Prolonged treatment with oral nucleosi(t)de analogues (NUCs) is recommended for selected patients with chronic hepatitis B virus (CHB) infection. One area of concern with prolonged treatment in aging patients is worsening renal function. Adefovir (ADV) is dose limited by tubular toxicity, tenofovir (TDF) has been associated with increase in creatinine and anecdotal reports of kidney failure in HIV patients. Our study was designed to observe eGFR changes with long-term NUC therapy. Methods: We enrolled 275 CHB patients at the Huashan Hospital from January 2009 to December 2012 into the study. 50 patients received lamivudine (LAM) 100 mg/days, 60 patients ADV 10 mg/ days, 68 patients telbivudine (LdT) 600 mg/days, 61 patients

1

New Zealand Liver Transplant Unit, Auckland, New Zealand, Gilead Sciences, Inc., Foster City, CA, USA, 3Toronto General Hospital, Toronto, ON, Canada Objective: To compare the viral load decay kinetics of mutant versus wild-type (WT) virus in chronic hepatitis B infected patients harboring rtM204V and/or rtM204I prior to treatment with TDF or FTC/ TDF therapy. Methods: Baseline samples were quantified for rtM204V/I subpopulations from all patients (n = 280) in Study GS-US-174-0121, a study that evaluated TDF versus FTC/TDF in patients harboring LAM-R at screening. Allele-specific PCR assays (AS-PCR) were designed to detect rtM204V or rtM204I mutant and rtM204M WT subpopulations in serum samples with HBV DNA C1,000 copies/mL, with an assay sensitivity of 0.5 % of the total population. Seventeen patients (TDF, n = 8; FTC/TDF, n = 9) with a mixture of WT and rtM204V/I subpopulations at baseline were evaluated for the percentage of rtM204V/I subpopulations at all study visits until HBV DNA was \1,000 copies/mL. Differences in HBV DNA decline rates

123

S58 and the percentage of rtM204V/I subpopulations on treatment were evaluated using the Wilcoxon Rank Sum and signed rank tests. Results: The rtM204V or rtM204I mutation was detected in 272/280 (97.1 %) baseline samples with a range of 0.7 to [95 %. Overall, 205/272 patients (75.4 %) had [95 % rtM204V or rtM204I at baseline. The majority of patients (227/272, 83.5 %) had either rtM204V or rtM204I at baseline, while a minority of patients (45/272, 16.5%) had a mixture of rtM204V/I. For the 17 patients evaluated on treatment, the median change in HBV DNA through week 12 for the WT and rtM204V/I mutant subpopulation was similar, -2.65 and -3.34 log10 copies/mL respectively, as determined by AS-PCR quantification of each population (p = 0.161). Additionally, there was no significant difference in HBV DNA decline for either the WT or rtM204V/I mutant viruses through week 12 (p = 1.000 and 0.401 respectively) when comparing TDF to FTC/TDF treatment. Overall, there was a significant decrease in the relative amount of rtM204V/I mutant virus at the last on treatment visit compared to baseline (p = 0.002); the decrease in the relative proportion of rtM204V/I during treatment was not significantly different when comparing TDF and FTC/TDF treatment (p = 0.885). Conclusions: Among patients with mixtures of WT and LAM-R HBV at baseline, the rtM204V/I mutant showed similar HBV DNA decline kinetics to WT virus during treatment with either TDF or FTC/TDF. A significant decline in rtM204V/I subpopulations was observed in patients on TDF monotherapy or FTC/TDF combination therapy. These results demonstrate that TDF is equally active against both WT and LAM-R HBV.

Topic: 8 Hepatitis B - Clinical Absno: 121 Impact of genetic variability in the PreS1/S2 and hepatitis B surface antigen (HBsAg) regions of the hepatitis B virus (HBV) on quantitative HBsAg levels A. J. Thompson1, K. M. Kitrinos2, H. L. Y. Chan3, E. J. Gane4, S. Fung5, P. Dinh2, L. Lin2, A. Corsa2, M. D. Miller2, G. M. Subramanian2, and M. Buti6 1 Gastroenterology, St Vincent’s Hospital, Melbourne, Fitzroy, VIC, Australia, 2Gilead Sciences, Inc., Foster City, CA, USA, 3Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong S.A.R., Hong Kong, 4New Zealand Liver Transplant Unit, Auckland, New Zealand, 5Toronto General Hospital, Toronto, Ontario, Canada, 6Liver Center, Hospital Vall d’Hebron, Barcelona, Spain

Objective: It has been reported that predominantly genotype D, chronic hepatitis B (CHB) patients with preS1/S2 and HBsAg genetic variability have lower plasma HBsAg levels with no impact on HBV DNA levels [1]. We evaluated preS1/S2 and HBsAg genetic variability in CHB patients across multiple genotypes. Methods: Sixty-one patients with HBV DNA [1 9 108 cp/mL (1.7 9 107 IU/mL) and HBsAg \10,000 IU/mL were selected (low HBsAg group) for comparison with a matched patient set with HBsAg [10,000 IU/mL (high HBsAg group). The 2 cohorts were matched based on HBV DNA, ALT levels, genotype, and HBeAg status. PreS1/S2 and HBsAg population sequencing was conducted and sequences were evaluated for insertions, deletions, and start codon mutations in preS1/S2, premature stop codons in preS1/S2 and HBsAg, and HBsAg a-determinant mutation(s). Comparisons were conducted using Fisher’s exact test with the Hochberg’s procedure to control for multiple testing.

123

Hepatol Int (2014) 8:S1–S405 Table 1 Summary of sequence variability analyses Low HBsAg (N = 61) (%) PreS1/S2

HBsAg

a

High HBsAg (N = 61) (%)

Adjusted p-valuea

Insertion or deletion

31.1

11.5

0.070

Premature stop codon

0

0

NA

Start codon mutation

14.8

11.5

1.000

a-Determinant mutation(s)

41

39.3

1.000

Premature stop codon

16.4

11.5

1.000

Adjusted by Hochberg’s procedure

Results: The median HBV DNA was 8.53 log10 cp/mL, 75 % of patients had ALT C29 ULN, 58 % were HBeAg-, and genotype C (33 %) and D (43 %) were most common. Median HBsAg was significantly different between low and high groups (4,465 vs. 19,965 IU/mL, p = \0.0001). There was no significant difference between groups in the percentage of patients with preS1/S2 start codon mutations, HBsAg premature stop codons, or HBsAg a-determinant mutations (Table 1). No patient had preS1/S2 premature stop codons. There was a trend for a higher percentage of low HBsAg patients with preS1/S2 insertions or deletions compared to high HBsAg patients. A sub-analysis of genotype D patients (n = 52) found no difference between the low and high HBsAg groups for any variable assessed, with no trend for the percentage of patients with pre S1/S2 insertions and deletions (p = 0.722). Conclusions: HBsAg genetic variability does not appear to correlate with HBsAg levels in patients with HBV DNA [1 9 108 cp/mL. In patients with low HBsAg and high HBV DNA across genotypes, there is a trend for a higher percentage of pre S1/S2 insertions or deletions. References 1. Pollicino P, Amaddeo G, Restuccia A, Raffa G, Alibrandi A, Cutroneo G, Favaloro A, Maimone S, Squadrito G, Raimondo G. Impact of hepatitis B virus (HBV) preS/S genomic variability on HBV surface antigen and HBV DNA serum levels. Hepatology 2012;56:434–443

Topic: 8 Hepatitis B - Clinical Absno: 130 Chronic hepatitis B virus infection in children and adolescents: a single center study for 30 years A. Inui1, H. Komatsu2, T. Tsunoda1, K. Iwasawa1, M. Kawamoto1, T. Sogo1, T. Fujisawa1 1

Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan, 2Department of Pediatrics, Sakura Medical Center, Toho University School of Medicine, Chiba, Japan Background & aims: Despite an HB vaccination, chronic infection with hepatitis B virus (HBV) affects 350 million persons worldwide. Inactive chronic infection (ICI) extends to prevent HBV infected children from developing cirrhosis and HCC. Asian children with chronic HBV infection have one of the highest of these risks in the world. The aim of this study is to evaluate the natural history of chronic HBV infection and the factors affecting e-seroconversion to ICI state in Asian children and adolescents.

Hepatol Int (2014) 8:S1–S405 Patients and methods: Patients aged \ 20 years who were positive for hepatitis B surface antigen (HBsAg) for at least 6 months were identified retrospectively between 1980 and 2012. Patients with chronic hepatitis B (CHB) were typically evaluated every 6–12 months including serum levels of ALT, HBe Ag, anti-HBe, anti-HBs and HBV DNA. ICI was defined as loss of HBeAg, ALT\40 IU/ml, and HBV DNA\6 log copies/ml. Treatments are immunomodulating therapy including interferon, HB vaccine therapy and short-term prednisolone therapy, and nucleotide analogs, and combination therapies with the above therapies. Results: 90 % (186/205) of patients are Japanese. Of the 205 cases of chronic HBV infection identified, eight patients have been already HBe Ag(-) inactive carriers. 85 % (158/185) are genotype C. 78 % (159/ 205) are mother-to-infant transmission. Of 185 cases of genotyping identified, the number of patients with genotype C who were infected from their mothers was significantly larger than those with other genotypes (133/158 vs. 11/27. p \ 0.001). Total e-seroconversion rate (state from HBeAg(+) to ICI) was 45 % (86/192) over 0.5–35 years of follow-up, and this was not affected by gender and genotypes. In mother-to-infant transmission, e-seroconversion rate is higher in treated group than untreated group (50 vs. 35.7 %, p = 0.057). In flare-up of hepatitis cases (ALT[500 IU/ml), the rate of achievement to ICI state was significantly higher than those in non-flare-up of hepatitis cases (27/32 vs. 66/114, p = 0.002), which was not affected by treatment. Conclusions: Flare-up of hepatitis could lead ICI in Asian young patients with chronic hepatitis B. Immunomodulating therapy might be considered to prevent children and adolescents with chronic hepatitis B infection from cirrhosis and HCC.

Topic: 8 Hepatitis B - Clinical Absno: 134 Do long-term additional lamivudine and entecavir therapy enhance durability of antiviral treatment induced HBeAg loss/ seroconversion? Young Il Park, Soo Hyung Ryu, Seong Yeon Jeoung, Hye Jin Jung, Min Jung Kwon, Won Jae Yoon, Jin Nam Kim, You Sun Kim, Jeong Seop Moon Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea Background and aims: Lamivudine and entecavir induce significant virological and biochemical responses; however, post-treatment relapses are frequent, even in patients with hepatitis B e antigen (HBeAg) loss or seroconversion. In this study, we intended to investigate whether long-term additional administration of lamivudine and entecavir might enhance the durability of HBeAg loss/ seroconversion, therefore, to find information for when to stop of antiviral therapy. Patients and methods: We retrospectively analyzed clinical and laboratory data of 37 patients who exhibited HBeAg loss/seroconversion by lamivudine 100 mg once daily therapy and stopped the therapy after additional treatment, from January 2003 to August 2013. 20 patients who exhibited HBeAg loss/seroconversion during 0.5 mg once daily entecavir therapy and stopped the therapy after additional treatment were also investigated in the same manner, from March 2008 to August 2013. Post-treatment relapse was defined as the reappearance of serum HBV DNA, and/or HBeAg in two consecutive tests. In lamivudine group, we divided it into 3 subgroups according to the duration of additional lamivudine therapy after HBeAg loss/ seroconversion (12 months, 24 months, and more than 30 months).

S59

Fig. 1 Cumulative relapse rates according to the duration of additional lamivudine (a) and entecavir (b) therapy We made comparison of post-treatment cumulative relapse rates at 1, 3, and 5 years for each subgroup. In entecavir group, we compared post-treatment relapse rates between the shorter additional therapy subgroup (\12 months) and the longer subgroup ([12 months). We also made comparison of post-treatment relapse rates at 6, 12, and 18 months for each subgroup. Results: In lamivudine group, each number of patients in 12 months (range 10–16 months), 24 months (range 20–27 months), and more than 30 months (range 28–90 months) subgroups were 7 (18.9 %), 14 (37.8 %), and 16 (43.2 %). In entecavir group, each number of patients in shorter (range 4–10 months) and longer subgroups (range 14–35 months) were 7 (35 %) and 13 (75 %). Post-treatment relapse rates of lamivudine were as follows: the overall cumulative relapse rates of 12 months subgroup at 1, 3, and 5 years were 14.3, 54.3, and 54.3 %, respectively. These rates in 24 months subgroup at 1, 3, and 5 years were 7.1, 15.6, and 45.7 %, respectively. The rates in more than 30 months subgroup at 1, 3, and 5 years were 12.5, 23.4, and 50.8 %, respectively. We could not find any association between the duration of additional lamivudine therapy and post-treatment relapse (p = 0.756; Fig. 1a). Post-treatment relapse rates of entecavir were as follows: the overall cumulative relapse rates of shorter treatment subgroup at 6, 12, and 18 months were 14.3, 31.4, and 54.3 %. These rates in longer treatment subgroup at 6, 12, and 18 months were 23.1, 40.2, and 52.1 %. There was no association between the duration of additional entecavir administration and post-treatment relapse (p = 0.879; Fig. 1b). Conclusions: Long-term additional administration of lamivudine for more than 2 years might lower relapse rates in the earlier periods of follow-up compared to those in the 1 year treatment group, however, did not have the advantage in post-treatment relapse in the later periods of follow-up. In addition, about 1–2 years additional therapy of entecavir might not be helpful in reducing post-treatment relapse.

Topic: 8 Hepatitis B - Clinical Absno: 137 Reactivation of hepatitis B virus in HBsAg-negative patients with hepatocellular carcinoma undergoing anti-cancer therapy Young Woon Kim, Sung Won Lee, Jung Hyun Kwon, Chan Ran You, Si Hyun Bae, Jong Young Choi, Seung Kew Yoon, Kyu Won Chung, Jeong Won Jang Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea Background: Resolved or occult hepatitis B virus (HBV) infection have been associated with HBV reactivation in HBsAg-negative

123

S60 patients, particularly in settings of rituximab-containing chemotherapy or hematopoietic stem cell transplantation. HBV reactivation in HBsAg-negative patients with hepatocellular carcinoma (HCC) has not been reported explicitly. This study aimed to determine the incidence and risk factors of HBV reactivation during therapy in HBsAg-negative HCC patients. Methods: Between 2007 and 2012, HBsAg-negative patients with HCC were consecutively recruited for the study. Anti-cancer therapies for HCC were divided into three treatments according to intensity: transarterial mono-therapy (doxorubicin; n = 78), combination-ECF chemotherapy (epirubicin-cisplatin-5-FU; n = 17), or combined chemo-radiotherapy (ECF+RT; n = 14). With serial monitoring of HBV DNA and serologic markers, patients with HCC were observed for HBV reactivation (defined as reappearance of HBV DNA or sero-reversion of HBsAg) in comparison with controls consisting of those with HBsAg-negative cirrhosis (n = 16) and HBsAg loss (n = 46). Results: During the study, HBV reactivation occurred in 11 (10.1 %) and 1 (1.6 %) patients in the treated and control groups, respectively. The estimated probabilities of reactivation at 1 and 2 years were 7.7 and 15.9 % in patients with HCC, while the corresponding probabilities were 0 and 2.0 % in the control group (P = 0.006). Overall, four (36.4 %) and one (9.1 %) of them experienced hepatitis and hepatic decompensation due to HBV reactivation during therapy, respectively. Among the 12 reactivated patients, 8 (66.7 %) had confirmed evidence of prior chronic hepatitis B (CHB) or occult infection. Anti-cancer therapy was significantly correlated with a higher incidence of HBV reactivation, with increasing risk of reactivation with intensive treatment (P = 0.005). On multivariate analysis, treatment intensity and a prior history of CHB (HBsAg seroclearance) or occult HBV infection remained independently predictive of HBV reactivation. Conclusions: Anti-cancer treatment can reactivate HBV in HBsAgnegative patients, with a dose-risk relationship between treatment intensity and reactivation. HBsAg-negative patients with HCC, especially those with prior HBsAg loss or occult HBV infection undergoing intensive treatment, should be closely monitored, with an alternative approach of antiviral prophylaxis against HBV reactivation.

Hepatol Int (2014) 8:S1–S405 Table 1 Efficacy at week 104 HBVDNA \500 copies/ml

ALT normalization rate

HbeAg loss rate

HbeAg seroconversion rate

Total virological breakthrough rate at 104 week

Rate of new onset virological breakthrough after 52 week

LDT (84 cases)

79 (94)

80 (95.23)

40 (47.62)

38 (45.24)

7 (8.33)

3 (3.57)

ETV (80 cases)

77 (96.25)

78 (97.5)

22 (27.5)

18 (22.5)

1 (1.25)

1 (1.25)

X2

0.428

0.595

7.054

9.421

4.431

0.928

P

[0.05

[0.05

\0.01

\0.01

\0.05

[0.05

Results: Predictors for HBeAg seroconversion were baseline characteristics and on-treatment responses. HBeAg decline by [1 log at week 12 was the best predictor of HBeAg seroconversion at week 104 for both telbivudine and entecavir-treated CHB patients (Table 1). Decline in HBsAg levels was no statistically significant in these two groups at 104 week.Adverse effects were mild. 5 (5.95 %) LdTtreated patients had grade 3/4 CK elevation. 1 (1.25%) ETV-treated patient had grade 3/4 CK elevation. For all patients, the grade 3/4 CK elevation was transient and reversible, no therapy was stopped, and no dose adjustment was instituted. The results are illustrated in Table 1. Conclusions: Both LdT and ETV achieve potent suppression of virus replication. However, LdT-treatment provides higher HBeAg loss and HBeAg seroconversion rates than ETV. At 104 weeks, the new-onset resistance rate induced by telbivudine was comparable to that of entecavir.

Topic: 8 Hepatitis B - Clinical Absno: 142 Risk of hepatocellular carcinoma in patients with chronic hepatitis B treated with entecavir or lamivudine Young-Suk Lim1, Seungbong Han1, Nae-Yun Heo2, Ju Hyun Shim1, Han Chu Lee1, Dong Jin Suh1 1

Topic: 8 Hepatitis B - Clinical Absno: 139 Predictors of HBeAg-seroconversion in HBeAg-positive chronic hepatitis B patients treated with telbivudine and entecavir Xiaoping Chen, Jing Huang, Xuefu Chen Department of Infectious disease, Guangdong General Hospital, China Background/aim: 3.5 % of HBeAg-positive chronic hepatitis B (CHB) patients develop liver cirrhosis per year, while those in HBeAg loss and HBeAg seroconversion only 1.5 and 0.9 % do each year, respectively. Our study evaluates the efficacy of telbivudine (LdT) and entecavir (ETV) treatment in HBeAg-positive CHB patients and assesses predictors of HBeAg seroconversion. Methods: We enrolled180treatment-naı¨ve, CHB patients into our 2-year study. Patientswere randomized 1:1 to receive either LdT or ETV. Patients were aged 16 to 65 years, HBV-DNA[105 copies/mL, 2 ULN B ALT B10 ULN. Efficacy parameters were assessed every 12 weeks until week 104. If virological rebound and HBV-DNA [103 copies/mL occurred at week 52 Adefovir (ADV) 10 mg qd was added to therapy.

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Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, 2Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea Introduction: It remains unclear whether entecavir, a potent antiviral agent for hepatitis B virus, further reduces the risk of hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients than a less potent drug, lamivudine. Patients and methods: In this historical cohort study, a total of 5,374 consecutive patients with CHB who commenced treatment with either entecavir (n = 2,000) or lamivudine (n = 3,374) from November 1999 and December 2011 were evaluated. Patients were excluded if they died or transplanted within 6 months or developed HCC within 1 year of treatment. The patients were followed-up for up to 6 years. Results: Complete follow-up data were available in 99.8 % of the entire cohort. The cumulative rates of genotypic drug-resistance mutants were 1.5 and 50.8 % in the entecavir and lamivudine groups, respectively (P \0.001). During follow-up period for up to 6 years, a total of 525 patients (9.8 %) developed HCC. In multivariable analyses, entecavir was associated with a similar incidence of HCC compared with lamivudine (hazard ratio [HR], 1.00; 95 % confidence interval [CI], 0.81–1.23; P = 0.99). In the 1,792 overall propensitymatched pairs, entecavir was again associated with a similar HCC incidence (HR, 1.12; 95 % CI, 0.90–1.39; P = 0.30). The risk of HCC was also similar in 860 matched pairs of cirrhosis subcohort


S61


100 90 Virological response(%)

(HR 1.04; 95 % CI 0.81–1.34; P = 0.75) and 878 matched pairs of non-cirrhosis subcohort (HR 1.19; 95 % CI 0.68–2.09; P = 0.55). Conclusions: Treatment with entecavir did not further reduce the risk of HCC than starting treatment with lamivudine in overall, cirrhosis, and non-cirrhosis cohorts of patients with CHB. Keywords: Comparative Effectiveness, Entecavir, Hepatocellular carcinoma, Lamivudine

80 70 60 50 40 30 20 10 0

Absno: 148 Tenofovir versus entecavir for the treatment of chronic hepatitis B

1.year

2.year

3.year

4.year

5.year

Entecavir

21.80

47.80

65.20

56.50

73.90

Tenofovir

31.3

68.8

81.3

87.5

75

Fig. 2 Cumulative rates of virologic suppression in patients receiving tenofovir and entecavir

Orhan Yildiz, Bilgehan Aygen, Selma Gokahmetoglu, Haydar Urun, Zeynep Ture Organisation: Department of Infectious Diseases, Medical School of Erciyes University, Kayseri, Turkey

Serum HBV DNA (log copies/mL)

Summary/Description: Introduction: Tenofovir (TDF) and entecavir (ETV) are potent nucleos(t)ide analogues recommended as firstline monotherapies for chronic hepatitis B (CHB). The aim of this study was to compare the effect of TNF versus ETV for HBeAgpositive or HBeAg-negative CHB patients. Materials and methods: We determined the cumulative biochemical. serologic and virologic outcomes of 39 Turkish CHB patients receiving TDF (n:16) or ETV (n:23) for 5 years. The liver biopsies of all patients were consistent with the diagnosis of CHB. Liver biochemistry, creatinine, alpha-fetoprotein, HBsAg, HBeAg and HBV DNA were analyzed at baseline,6 months and yearly from years 1 to 5. HBV DNA levels were determined by real-time PCR and HBsAg and HBeAg by chemiluminescence. Serum levels of ALT, alphafetoprotein and creatinine were measured by an auto:matic biochemical analyzer. We compared the decline in serum HBV DNA levels at the 1st, 2nd, 3rd, 4th and 5th years of treatment between two groups (Figure 1). Results: Thirty-nine patients [average age: 40 (20-69) year, 28 males (71.8%), 24 HBeAg positive (61.5%)] were enrolled in the study. Sixteen patients (41%) used TDF and 51 patients (59%) used entecavir. The HBeAg seroconversion rates were 70% and 45.5%, and the biochemical response rates were 72.7% and 54.5% in five year in the ETV and TDF groups, respectively. The rates of undetectable HBV

9

n=23

n=23 n=16

6

n=16 n=23

n=16

5

n=16 n=22

n=16

4

n=19

3 2 1 0

Absno: 153 A case considering utilization of potent antiviral agents in a HBV infected patient with high viral load

GATA Haydarpasa Training Hospital, Department of Infectious Diseases, Istanbul, Turkey

n=16

7


¨ lçay, Vedat Levent Go¨renek, Ergenekon Karago¨z, Asım U ¨ ncu¨l Turhan, Ali Acar, Hakan Erdem, Oral O

n=23

8

DNA, HBeAg seroconversion, and ALT normalization rates were similar in both groups. One patient achieved HBsAg seroconversion in TDF group. There were no significant differences in the virological response rates between TDF and ETV groups at the 1st, 2nd, 3rd, 4th and 5th years of treatment (Figure 2, p [ 0.05). Four patients had virological breakthroughs in ETV group, and were switched from ETV to TDF (one patient at year 4 and tree patients at year 5). No virological breakthrough were noted TDF group. Skin rashes and itching were observed in 2 (12.5%) patients treated with TDF. Only one patient developed renal impairment (creatinine clearance 50 mL/ min) after TDF and, dose was adjusted for renal failure (300 mg every 48 hours). No serious adverse effects were noted ETV group. Conclusions: Both TDF and ETV monotherapies were effective and safe in the treatment of CHB patients. Keywords: HBV, Chronic hepatitis B, Treatment, Tenofovir, Entecavir.

Entecavir

Baseline 8.70

1.year 6.6

2.year 6.7

3.year 5.3

4.year 4.5

5.year 2.8

Tenofovir

7.4

5.5

4.4

5.7

3.7

6.1

Fig. 1 The decreasing trend of HBV DNA over time in patients receiving tenofovir and entecavir

Introduction: Chronic HBV and HCV which are both major infections all of the world concerns, an average of about 7 % of the world’s population are infected with them.It is estimated that approximately 400 million people are infected with HBV worldwide. Chemotherapy induced reactivation can be revealed not only in chronic HBV patients or HBV carriers but also in patients who had latent infection. Case presentation: In this case, we present a 80-year-old follicular non-hodgin lymphoma patient whose liver enzymes increased after withdrawal of chemotherapy and afterwards HBV reactivation was occurred despite HBsAg of the patient was negative before chemotherapy.Laboratory study results were notable for Anti Hbc Ig M:positive, HBV DNA:148. 203.779 IU/ml positive. We evaluated the condition of the patient as acute hepatitis B caused by HBV reactivation due to immunosuppressive treatment. After following-up

123

S62 of our patient for 6 months, relapsed NHL was occurred and he was planned to be recieved chemotherapy again. For this reason,Lamivudine at a daily dose of 100 mg was initiated. Despite the decrease in HBV DNA level at the beginning of lamivudine treatment, virological breakthrough was occurred in the first year of this therapy and YMDD mutation was detected by molecular methods. Due to YMDD mutation,treatment of the patient was switched with Tenofovir which is a more potent agent than Lamivudine. After 1 year of following this treatment, HBV DNA level of the patient was decreased and liver enzymes were found to be normal. Conclusion: We want to emphasize that potent antiviral agents should be preferred to the agents with low genetic barrier for the patients with high HBV DNA load especially in immunosuppressive patients. In addition, every patient who are planned to be received immunosuppressive therapy should be screened for HBV infection. Tests should not only be limited to HBsAg, but also Anti HBc Ig G and Anti HBs should be included in screening plan.

Topic: 8 Hepatitis B - Clinical Absno: 154 Clinical usefulness of measuring PDW and MPV for predicting hepatic fibrosis in chronic HBV patients ¨ ncu¨l1, Alpaslan ¨ lçay1, Ergenekon Karago¨z1, Oral O Asım U Tanog˘lu, Muammer Kara, Tuba Mu¨ftuög˘lu, Vedat Turhan1, Ali Acar1, Hakan Erdem1, Levent Go¨renek1 1

GATA Haydarpasa Training Hospital, Department of Infectious Diseases, Istanbul, Turkey, 2GATA Haydarpasa Training Hospital, Department of Gastroenterology, Istanbul, Turkey, 3GATA Haydarpasa Training Hospital, Department of Biochemistry, Istanbul, Turkey Background and aim: Platelet distribution width (PDW) and mean platelet volume (MPV), which are largely overlooked, are routine tests being part of complete blood count. The present study was designed to investigate whether PDW and MPV are variables that determine the severity of fibrosis in HBV-infected patients. Method: This is a retrospective case–control study evaluating chronic HBV-infected cases. The study included 203 naı¨ve chronic hepatitis B cases followed-up due to diagnosis and treatment in GATA Haydarpasa Training Hospital. Patients were divided into two groups with fibrosis scores of 0–2 (Group 1) and 3–6 (Group 2) according to ISHAC score and compared whether MPV and PDW were independent variables while determining the severity of liver fibrosis score or not. Results: Of the 203 cases, 189 (93.1 %) were male, 14 (6.9 %) were female. The mean age of the patients was 30 (min: 20, max: 79). 81 of the cases (39.9 %) had HBeAg-positivity. Fibrosis scores of 34 cases (16.7 %) were C3 while 169 cases had fibrosis scores \ 3 (83.3 %). There was a significant difference between these two groups for MPV(Group 1 = 8.04, Group 2 = 8.94,p \ 0.05). But, we could not detect a significant difference for PDW (p = 0.234) between two groups, yet PDW to MPV ratio was significantly higher in the group of fibrosis score 0–2 (p \ 0.001). Conclusion: MPV values are significantly increased in HBV infected patients associated with its severity and can be defined as an independent predicting factor in hepatic fibrosis. It is reported that when there is an active inflammatory disease such as rheumatoid arthritis, inflammatory bowel diseases, platelet counts increase due to increased inflammatory cytokine activity and breakdown of these increased larger young platelets in inflammation area lowers MPV. When the severity of fibrosis increases, because of the damage of

123

Hepatol Int (2014) 8:S1–S405 liver, platelet counts decrease and we are of the opinion that increased MPV levels may be associated with this condition. Further studies are required for optimization of PDW and MPV ratio.

Topic: 8 Hepatitis B - Clinical Absno: 156 Renal dysfunction analysis in 298 patients with HBV-associated liver cirrhosis Fengxia Sun1, Lu Zuo1, Xianbo Wang1 1 TCM Department, Beijing Ditan Hospital Capital Medical University, Beijing, China

Introduction: This study aims to evaluate the renal function of patients with HBV-associated liver cirrhosis using estimated glomerular filtration rate (eGFR), for the purpose of accurately understanding the occurrence of renal dysfunction of these patients. To suggest the liver disease physicians pay more attentions to this problem. Materials and methods: 298 cases with HBV-associated liver cirrhosis (compensated or decompensated) were involved in this study. All these patients were hospitalized in Beijing Ditan Hospital from January 2011 to July 2012. Patients coexisting hypertension, diabetes mellitus, malignant tumor, acute bleeding and other serious diseases were excluded. We retrospectively investigated renal function of these patients. Efficacy measures included SCR and eGFR. eGFRs were calculated with MDRD equation Results: A total of 298 HBV-associated liver cirrhosis patients (male: N = 223; female: N = 75; age 21 to 77 years, average age, 48.56 ± 10.77 years) were included in the study. 41 patients had compensated cirrhosis, 257 with decompensated liver cirrhosis. Normal SCr values are 45–84 lmol/L in women, and 59–104 lmol/L in men. Rates of renal dysfunction in the 298 patients were 6.7 and 20.8 % based by SCr and MDRD equation, respectively (Table 1). There is no significant difference between different gender group (P [ 0.05). The eGFR of HBV-associated with liver cirrhosis patients was gradually decreased with age, 36.0 % of patients aged above 60 years. There is significant difference (P \ 0.05) in different age group (20–40 years, 5.7 %. 41–60 years, 22.5 %. [60 years, 36.0 %). The rate of renal dysfunction in patients with decompensated liver cirrhosis was slightly higher than those with compensated cirrhosis (21.8 vs. 14.6 %, P [ 0.05), without significant difference. Due to small sample size, further analysis needs to be done. The results are illustrated in Table 1. Conclusions: Although the mechanism of renal dysfunction of patients with HBV-associated liver cirrhosis remains uncertain, renal dysfunction is common in this population. Liver disease physicians should pay more attentions to this problem. eGFR should be evaluated carefully before treatment is determined. Table 1 Occurrence of renal dysfunction in HBV-associated liver cirrhosis Groups

N

Renal dysfunction (%)

SCr-based

298

20 (6.7)

Female (SCr [84 lmol/L)

75

4 (5.3)

Male (SCr [104 lmol/L)

223

16 (7.1)

eGFR-based

298

62 (20.8)

Compensated liver cirrhosis Decompensated liver cirrhosis

41

6 (14.6)

257

56 (21.8)


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Table 1 Baseline characteristics of patients receiving add on ADV to LdT

Absno: 161

Characteristics

Adefovir-rescue therapy did not increase the occurrence of hepatocellular carcinoma in patients with lamivudine-resistant chronic hepatitis B

Patients enrolled, n

37

31

Age, years

27 (16 50)

35 (16–42)

0.487

Sae Hwan Lee, Kanghyug Choi, Hong Soo Kim, Yun Nah Lee, Soung Won Jeong, Sang Gyune Kim, Jae Young Jang, Young Seok Kim, Boo Sung Kim

Male gender, n (%) Previous LdT therapy (months)

31 (83.8 %) 15 (9–36)

28 (90.3 %) 15 (9–32)

0.428 0.877

Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea Background/aim: The emergence of drug resistance mutation and suboptimal response were associated with poor clinical outcome. We aimed to compare the occurrence of hepatocellular carcinoma (HCC) between naı¨ve patients with entecavir (ETV) therapy and patients with adefovir (ADV) rescue therapy for lamivudine (LAM)-resistant chronic hepatitis B. Methods: Electronic medical records of 156 patients with LAMresistant chronic hepatitis B who treated with ADV and 186 naı¨vepatients who received ETV 0.5 mg were reviewed retrospectively. Study subjects were matched using estimated propensity score and 107 matched subjects in each group were analyzed, eventually. Baseline characteristics and clinical outcomes were compared in both group and cumulative occurrence of HCC was evaluated during antiviral therapy. The association between clinical variables and development of HCC were analyzed using Kaplan–Meyer curve and risk factor for HCC was evaluated with Cox-proportional hazard model. Results: Age, gender, underlying cirrhosis, Child-Pugh score, HBeAg, and HBV DNA level were not different in both groups, except treatment duration with ADV or ETV (mean 52.6 ± 17.5 vs. 46.7 ± 11.4, P = 0.004), statistically. Cumulative virological response were 16 and 42 % in patient with ADV rescue therapy and 68% and 85% in naı¨ve-patients received ETV at 1 and 3 years (P \ 0.001), respectively. HCC were diagnosed in 6 of 107 patients with LAM-resistance and 9 of 107 naı¨vepatients during follow-period. Cumulative occurrence of HCC in total 214 subjects was 2.3, 4.8, and 9.6 % at 1, 3, and 5 years, respectively. In multivariate analysis, age (P = 0.008) and underlying cirrhosis (P = 0.002) were independent risk factors for occurrence of HCC. Conclusions: Occurrence of HCC of ADV rescue therapy in patients with LAM-resistant chronic hepatitis B was not higher than that of naı¨ve patients with ETV therapy. Cirrhosis was a strong risk factor of development of HCC. Keywords: Lamivudine-resistance; Virological response; HCC occurrence


Virological breakthrough

resistance

P

HBeAg-positive, n (%)

37 (100 %)

31 (100 %)

N.A.

HBV DNA (log10copies/mL)

4.96 (3.44–8.52)

5.00 (3.84–7.57)

0.882

ALT (9 ULN)

1.28 1.40 (0.58–13.58) (0.63–9.20)

0.676

ALT abnormal, n (%)

29 (78.4 %)

25 (80.6 %)

0.817

Compensated cirrhosis, n (%)

5 (13.5 %)

6 (19.4 %)

0.515

response at 6 months, switch to a more potent drug or add-on a drug without cross-resistance. The aim of our study was to evaluate the safety and efficacy of add-on adefovir dipivoxil (ADV) to LdT in patients with virological breakthrough or genotypic resistance in a real world setting. Methods: 403 patients receiving LdT were included in this study. Patients had HBV DNA [4 log10 copies/mL, positive for HBsAg, HBeAg, anti-HBc, ALT [29 ULN. Patients were monitored every 3 months. Results: 68/403 patients experienced either virologic breakthrough or resistance to LdT therapy. 70.3 % (26/37) VB and 74.2 % (23/31) VR patients receiving add-on ADV to LdT achieved a virologic response. Biochemical response was 65.5 % for VB and 64 % for VR. HBeAg loss was achieved in 35 % of VB and 10 % of VR, HBeAg seroconversion in 11 % of VB and 3 % of VR, P = 0.014 and P = 0.232, respectively. We report CK elevations in 7 VB and 4 VR patients. Elevated CK levels returned to normal, and muscular soreness was relieved after discontinuation of LdT+ADV. Renal abnormalities were reported in 1 VB (elevated creatinine) and in 1 VR patient (elevated urea nitrogen). Elevated creatinine and urea nitrogen levels spontaneous remitted (Table 1). Conclusions: Add-on adefovir dipivoxil to telbivudine following the occurrence of virological breakthrough or genotypic resistance yields clinically meaningful results. In the real world setting this is a suitable treatment option.


Efficacy of add-on adefovir dipivoxil in chronic hepatitis B patients with virological breakthrough to telbivudine in the real-world setting

HBeAg status, race and DNA levels in women with chronic hepatitis B infection

Ye Zhang, Jian-Qi Lian, Chang-Xing Huang, Xue-Fan Bai

Tram Tran, Stuart Gordon, Scott Fung, Phillip Dinh, Leland J. Yee, Eduardo Bruno Martins, Maria Buti and Patrick Marcellin

Department of Infectious Diseases, Tangdu Hospital, Fourth Military Medical University, Xi’an, China Background/aim: Guidelines recommend that in chronic hepatitis B (CHB) patients with primary non-response at 3 months or suboptimal

Gilead Sciences, Inc Background: High mother-to-child-transmission of hepatitis B (HBV) has been associated with HBeAg positivity and high HBV

123

S64


DNA levels. The relationship of age, genotype and HBV DNA and HBeAg status has not been fully elucidated. Methods: Standard descriptive statistics and logistic regression were used to explore these relationships in subjects screened for tenofovir disoproxil fumarate (TDF) pivotal studies GS-US-174-0102/GS-US174-0103. Results: Data from 355 female subjects were available at screening. Average age was 41 years, median ALT = 69 U/L (range 8–806), average HBV-DNA = 7.0 log10 copies/mL (range 2.2–10.2), 44.4 % were HBeAg+, 40.0 % Asian and 49.6 % Caucasian. HBV genotypes (gt) were available for 167/355 subjects: 21 (12.6 %) A, 21 (12.6 %) B, 39 (23.4 %) C, 82 (49.1 %) D, 3 (1.8 %) E, and 1 (0.6 %) H. Women aged B35 were more likely to be HBeAg+ than HBeAg- (odds ratio (OR) = 4.2, 95 % confidence interval (CI) 2.7–6.6, p \ 0.001) and to have HBV DNA C9 log10 copies/mL than \9 log10 copies/mL (OR = 6.0, CI 3.1–11.8, p \ 0.001). Asian women were more likely to be HBeAg+ than HBeAg- (OR = 2.8, CI 1.8–4.4, p \ 0.001). Among women B35 years (N = 135), Asians are also more likely to be HBeAg+ than HBeAg- (OR = 3.9, CI 1.7–9.1, p = 0.001). Compared to genotype B/C, women with genotype A/D were more likely to be HBeAg negative (OR = 4.2, CI 2.1–8.2; p \ 0.001). No difference in ALT was observed.

56.1

53.6

NS

HBeAg scroconversion

32.9

30.4

NS

HBV DNA undetectable

95.1

67.9

\0.05

ALT normalization

95.1

85.1

NS

\0.0001


1.21 (0.75–1.95)

0.4449

HBV DNA

3.46

ALT B29 ULN vs. [29 ULN

P-value

(1.95–5.26)

Multivariate OR* (95% CI)

Positive vs. negative

PEG-IFN a, N = 56 (%)

0.0009

Characteristics

HBeAg

HBeAg loss

Telbivudine, N = 82 (%)

evaluate the efficacy of telbivudine (LdT) treatment for 52 weeks of HBeAg-positive chronic hepatitis B (CHB) patients compared to (IFN-a) historical control group. Methods: We enrolled patients with a diagnosis of HBeAg-positive CHB according to 2010 guidelines. ALT C2 ULN, HBV DNA C105 copies/mL, no prior anti-HBV therapy. 82 patients received LdT 600 mg qd, and 56 (IFN-a) 180 lg, qw were used as the control group. LdT/(IFN-a) mean age, years 29.85 ± 5.73/28.75 ± 5.78, Male (%) 85/83, HBV DNA, log copies/mL 6.62 ± 0.60/6.48 ± 0.60, ALT, IU/L 325.33 ± 121.96, 301.14 ± 104.14. Results: 2 (2.4%) patients with good compliance experienced virologic breakthrough. These 2 patients had baseline HBV DNA viral load 107 copies/mL and HBV DNA levels at week 24 C103 copies/ mL. During the treatment, 2 (2.4 %) of patients had transient elevation in serum creatine kinase (CK) levels, which gradually returned to normal, no muscle weakness and muscle pain were found (Table 1). Conclusions: Telbivudine treatment yields similar HBeAg loss and HBeAg seroconversion rates compared to PEG-IFN a-2a. Telbivudine’s good safety profile makes this therapy an attractive option for patients requiring prolonged treatment.

Logistic regression analysis of associations between age (B35 vs. [35) and characteristics among female subjects (forward selection with a = 0.10)

C9 log cp/mL vs \ 9 log cp/mL

Table 1 Week 52 results

(1.66–7.19)

p-value

3.21

Absno: 178 Conclusions: Women under 35 had a significantly higher likelihood of HBeAg-positivity and high viral load. Asian women and those with gt-B/C are also more likely to be HBeAg+ compared to non-Asians and those with gt-A/D, respectively. These results suggest higher risk of HBV perinatal transmission in these groups.

Factors related to reactivation of hepatitis B after discontinuing telbivudine therapy according to APASL guideline Hsien-Chung Yu1, Kung-Hung Lin1, Ping-I Hsu1, Kwok-Hung Lai1


Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan

Absno: 171

Introduction: In real-world practice, stopping nucleos(t)ide analogue treatments before hepatitis B surface antigen (HBsAg) loss is unavoidable in some countries due to limited resources. This study aims to investigate the factors linking to the reactivation of hepatitis B after cessation of telbivudine (LdT) therapy in chronic hepatitis B patients according to APASL criteria. Patients and methods: We conducted a prospective, observational study for LdT-treated patients who achieving APASL criteria and discontinuing LdT therapy. Patients were followed by liver function, HBV-DNA and quantitative HBsAg (qHBsAg) levels at month 1, 2, 3 and every 3 months thereafter. The definition of reactivation of hepatitis B was reappearance of HBV DNA [2000 IU/ml combined with ALT flare (for more than 2 times of upper limit of normal or increasing for more than 100 U/L). The statistical analyses were using the Cox regression and Kaplan Meier survival analysis.

Efficacy of 52-week telbivudine treatment in patients with HBeAg-positive chronic hepatitis B Jing Xu Department of Infectious Disease, Anhui Provincial Hospital, China, email: [email protected] Background/aim: Two groups of agents are used for the treatment of chronic hepatitis B (CHB): nucleoside/nucleotide analogues (NAs) and interferon-alpha (IFN-a). Interferon has simultaneous viral suppression and immunoregulatory effects and is widely used because of its relatively high HBeAg seroconversion rate, low relapse rate and fixed treatment period. However, interferon is not suitable for longterm use because of its many side effects. The aim of our study was to

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1

Hepatol Int (2014) 8:S1–S405 Results: Treatment duration and post-treatment follow-up in the 45 enrolled patients (10 HBeAg-positive and 35 HBeAg-negative; 91 % non-cirrhotic) were 29.6 ± 8.5 and 14.1 ± 8.5 months, respectively. In overall, 14 of 45 (31 %) of patients had reactivation of hepatitis B. Cumulative rates of reactivation were 18, 25, 36 and 49 % at 6, 12, 18 and 24 months, respectively. Univariate analysis revealed factors related to reactivation of hepatitis B were baseline qHBsAg levels and months to virological flare (HBV-DNA [2000 IU/mL) after cessation of LdT, and multivariate analysis revealed baseline qHBsAg level (HR 4.28, 95 % CI 1.06–17.33,p = 0.042) as sole factor in reactivation. The significant cut-off value of baseline qHBsAg was [5000 IU/ml (HR 9.90, 95 % CI 1.28–76.82,p = 0.028) by the analysis of Cox proportional hazard model after adjusting for the months to virological flare. The cumulative rates of reactivation were 34, 41, 58 and 72 % at 6, 12, 18 and 24 months in patients with baseline qHBsAg [5000 IU/mL, respectively. In contrast, for patients with baseline qHBsAg B5000 IU/mL, cumulative rates of reactivation were 0, 7, 7 and 7 % at 6, 12, 18 and 24 months (log-rank test,p = 0.002), respectively. Conclusion: Baseline qHBsAg level was sole factor related to reactivation. Cessation of telbivudine therapy according to APSAL criteria is safe for patients with baseline qHBsAg B5000 IU/mL. However, the criteria for cessation of LdT therapy in patients with baseline qHBsAg [5000 IU/mL needs further study.

Topic: 8 Hepatitis B - Clinical Absno: 179 Comparison of the efficacies and safety of combined therapy between telbivudine plus adefovir versus lamivudine plus adefovir in patients with hepatitis B virus Ming-Tsung Lin1, Yi-Hao Yen1, Kuo-Chin Chang1, Ming-Chao Tsai1, Po-Lin Tseng1, Cheng-Kung Wu1, Tsung-Hui Hu1 1 Division of Hepato-Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, No.123, Dapi Rd., Niaosong Dist., Kaohsiung City, Taiwan

Introduction: Several recent reports from the GLOBE study indicate that the estimated glomerular filtration rate (eGFR) in chronic hepatitis B (CHB) patients is increased with telbivudine (LdT) treatment compared to lamivudine over 2 years. However, there are no studies comparing the eGFR change in LdT plus Adefovir (ADV) versus lamivudine (LAM) plus ADV treated patients especially in lamivudine-resistant patients. The aim of this study was to evaluate eGFR changes with LdT plus ADV versus LAM plus ADV and the efficacies of combined therapy. Methods: From May 2003 to May 2013, this retrospective, single-center study enrolled 171 patients treated with LdT plus ADV and LAM plus ADV at the Chang Gung Memorial Hospital, Kaohsiung Medical Center for at least 1 year. In our study, 64 CHB patients received LdT plus ADV therapy (experimental group) and 113 received LAM plus ADV. eGFR was estimated by MDRD formula at baseline and at 48 weeks. Results: There was no significant difference in terms of baseline eGFR, HBeAg status and HBV-DNA levels between the two treatment groups. The mean eGFR change from baseline to 12 months increased 3.04 mL/min/1.73 m2 in LdT plus ADV group versus decreased 3.26 mL/min/1.73 m2 in LAM plus ADV group. In LAM plus ADV group 33.3 % (3/9) eGFR improved from \60 mL/min/ 1.73 m2 to 60–90 mL/min/1.73 m2, but 21.7 % (5/23) eGFR

S65 decreased from [90 mL/min/1.73 m2 to 60–90 mL/min/1.73 m2. In LdT plus ADV group, all but one patient maintained a stable eGFR. This one patient (1/18, 5.6 %) eGFR decreased from [90 mL/min/ 1.73 m2 to 60–90 mL/min/1.73 m2. Conclusion: In real-life clinical practice, telbivudine plus adefovir seems to provide better preservation of renal function than lamivudine plus adefovir therapy. Prospective studies should be conducted to test the best combination for our CHB patients at high risk for renal dysfunction.

Topic: 8 Hepatitis B - Clinical Absno: 181 Early viral suppression at 24 weeks is associated with treatment responses of 2-year telbivudine therapy Chih-Lin Lin1, Ming-Yao Chen2, Jia-Horng Kao3,4 1 Department of Gastroenterology, Renai branch, Taipei City Hospital, Taipei, Taiwan, 2Department of Gastroenterology, Shuang-Ho Hospital, Taipei Medical University, Taipei, Taiwan, 3Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, 4Graduate Institute of Clinical Medicine, Hepatitis Research Center, and Department of Medical Research, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan

Introduction: Published guidelines for the management of patients with chronic hepatitis B (CHB) suggest that rapid and prolonged suppression of serum HBV-DNA is associated with clinical improvement. This study is designed to assess the optimal use of telbivudine (LdT) in real life clinical setting in CHB patients with defined 24-week PCR negativity. Methods: This study uses an open-label, observational design. Patients with eligible baseline characteristics qualify for this study. All patients received LdT 600 mg/day continuously for 2 years.Serum levels of ALT, HBV-DNA, HBeAg, and anti-HBe status were evaluated at weeks 12, 24, 52, 76 and 104. Results: A total of 24 CHB patients, 12 HBeAg-positive and 12 HBeAg-negative, with compensated liver function were enrolled. Biochemical response rates were 79.16 % (19/24), 75 % (18/24) and 77.27 % (17/22) at months 6, 12, and 24 of treatment, respectively. Undetectable serum HBV-DNA level was achieved in 54.16 % (13/24), 70.83 % (17/24), and 72.73 % (16/22) of patients at 6,12, and 24 months, respectively. The cumulative rates of HBeAg seroconversion were 8.3 and 25 % at years 1 and 2, respectively. 4 HBeAg-positive patients (33.3 %) and 11 HBeAgnegative patients (91.7 %) reached undetectable HBV-DNA at week 24. HBeAg seroconversion increased further in HBeAgpositive patients with early viral suppression by week 24 (50 %). In addition, 81.82 % of HBeAg-negative patients with early viral suppression at week 24 achieved viral suppression at 24 months. The viral breakthrough rates at 1 year of telbivudine treatment were 16.7 and 8.3 % for HBeAg-positive and -negative patients, respectively. None of the patients with early viral suppression had virological breakthrough at 1 year. Conclusions: The efficacy of telbivudine treatment for HBeAgpositive and HBeAg-negative patients was satisfactory in the realworld clinical practice. Early viral suppression at 24 weeks of treatment is the most important factor associated with treatment responses and virological breakthrough during long-term telbivudine therapy.

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Hepatol Int (2014) 8:S1–S405 Table 1 Predictors of CKD-EPI eGFR decrease from baseline Standard error

-0.147

0.024

\0.001

5.992

0.759

\0.001

-0.156

0.770

0.840

Diabetes mellitus

0.678

0.737

0.358

Baseline CKD-EPI

0.743

0.023

\0.001

ADV plus LdT

0.557

0.133

\0.001

ADV plus LAM

0.148

0.038

\0.001

Age Telbivudine protects renal function in patients with chronic hepatitis B infection in conjunction with adefovir-based combination therapy treatment Minjong Lee1, Sohee Oh2, Hyung Joo Lee1, Tae-sung Yeum1, Jeong-hoon Lee1, Su Jong Yu1, Hwi Young Kim2, Byeong Gwan Kim2, Jung-hwan Yoon1, Kook Lae Lee2, Hyo-suk Lee1, Yoon Jun Kim1 1

Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea, 2 Department of Biostatistics, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea, 3 Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea, email: [email protected] Introduction: Previous studies have demonstrated that the treatment of chronic hepatitis B (CHB) infection with adefovir (ADV) can impair renal function. In contrast, treatment with telbivudine (LdT) improves renal function in CHB patients. The aim of this study was to evaluate the renoprotective effect of LdT in CHB patients receiving ADV-based combination therapy. Materials and methods: The effects of treatment with ADV+LdT on renal function were compared to those resulting from treatment with ADV+entecavir (ETV), ADV+lamivudine (LAM), ADV alone and ETV alone. The consecutive cohort analysis included 831 CHB patients who received ADV+LdT, ADV+LAM, ADV+ETV, ADV alone or ETV alone for 96 weeks. Alterations in estimated glomerular filtration rate (eGFR) were compared between the five groups using a linear mixed-effects model. HBV DNA levels were also compared between the five groups during the 96-week period. Results: Among the five treatment groups, significant improvements in eGFR were observed in the ADV+LdT and ADV+LAM groups

P valuea

Estimate

Absno: 182 Sex (female vs. male) Hypertension

ADV plus ETV

0.203

0.118

0.086

ADV alone

-0.046

0.045

0.309

ETV alone

-0.020

0.034

0.553

ADV adefovir, LdT telbivudine, LAM lamivudine, ETV entecavir a

Results from the linear mixed-effects model for repeated measures

over time (P \ 0.001 for each group compared to baseline eGFR). In patients with a baseline eGFR between 50–90 ml/min, the change in eGFR was the most significant in the ADV+LdT group (+0.641 ml/ min;P \ 0.001) as shown in Fig. 1. Age, gender, baseline eGFR and treatment option were significant predictive factors for eGFR changes as shown in Table 1. In conclusion, our results suggest that the combination therapy of LdT and ADV is significantly associated with renoprotective effects in CHB patients when compared with other ADV-based combination or single therapies. References 1. Wang Y, Thongsawat S, Gane EJ, et al. Efficacy and safety of continuous 4-year telbivudine treatment in patients with chronic hepatitis B. J Viral Hepat 2013;20(4):e37–46 2. Li X, Zhong C, Yang S, et al. [Influence of adefovir dipivoxil or telbivudine monotherapy on renal function of patients with chronic hepatitis B]. J South Med Univ 2012;32(6):826–9 3. Jinlin Hou jS, Qing Xie, Deming Tan, Qin Ning, Junqi Niu, Xuefan Bai. Virological breakthrough and genotypic resistance in a randomized, controlled study on telbivudine treatment applying ‘‘Roadmap concept’’ in CHB:W76 interim analysis of EFFORT study. EASL Poster Barcelona, Spain, 2012 4. Piratvisuth T, Komolmit P, Tanwandee T, et al. 52-week efficacy and safety of telbivudine with conditional tenofovir intensification at week 24 in HBeAg-positive chronic hepatitis B. PLoS One 2013;8(2):e54279 5. Amarapurkar DN, Patel N. Increased eGFR with telbivudine in combination therapy of chronic hepatitis B infection. Indian J Gastroenterol 2013

Topic: 8 Hepatitis B - Clinical Absno: 184 Seroprevalence of occult hepatitis B virus infection in hepatitis B virus surface antigen-negative patients with liver cirrhosis or hepatocellular carcinoma

Fig. 1 Changes in the renal function of the treatment groups were assessed over the course of 2 years in baseline eGFR between 50 and 90 ml/min

123

Sung Soo La, Ji Yun Jung, Hyung Joon Kim, Sun Young Cho, Young Kwang Choo, Suk Bae Kim, Il Han Song Division of Hepatology, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea


S67

Table 1 Clinical characteristics of the patients with occult HBV infection

Table 1 Results week 96

No.

Group

Pregnant CHB, N = 20 (%)

Non-pregnant CHB, N = 20 (%)

HBeAg seroconversion

35.7

38.5

Cumulative virologic response

85

79

Cumulative ALT normalization rate

85

89

Age/sex

HBsAg/ anti-HBs/anti-HBc

HBV DNA titer (copies/mL)

Liver disease

Child-Pugh classification

LC or HC patients 1.

54/M

-/+/+

\116

HCC, LC

A

2.

70/M

-/-/+

\116

HCC

A

3.

46/M

-/+/+

144

LC

A

Healthy subjects 4.

40/M

-/-/+

\116

No

–

5.

70/M

-/+/+

\116

No

–

Introduction: Occult hepatitis B virus (HBV) infection is defined as the presence of HBV DNA or genome in the liver tissue or the serum in subjects negative for hepatitis B surface antigen (HBsAg). The prevalence of occult HBV infection may be considered to depend on the virus endemicity, the assay sensitivity, and the population variability. This study was conducted to estimate the seroprevalence of occult HBV infection in HBsAg-negative patients with liver cirrhosis (LC) or hepatocellular carcinoma (HCC). Subjects and methods: Serum samples from 114 patients with HBsAg-negative LC or HCC were obtained. HBsAg, anti-HBs, and IgG anti-HBc were measured by radioimmunoassay and serum HBV DNA was determined by real-time polymerase chain reaction. The lowest detection limit of HBV DNA is 116 copies/mL. The seroprevalence of occult HBV infection in these patients was compared to that of 94 age- and sex-matched healthy subjects negative for HBsAg. Results: The seroprevalence of occult HBV infection was 2.6 % in HBsAg-negative patients with LC or HCC, while that of healthy subjects was 2.1 %. In all cases with occult HBV infection, hepatitis B viral loads were less than 116 copies/mL except one with 144 copies/mL and IgG anti-HBc indicating past exposure to HBV was positive regardless of the presence of anti-HBs. Occult HBV-infected patients with LC or HCC revealed Child-Pugh classification A. Table 1 showed clinical characteristics of the patients with occult HBV infection. Conclusions: The overall seroprevalence of occult HBV infection was 2.4 % in which viral load was extremely low. No difference of the seroprevalence of occult HBV infection was observed between LC or HCC patients and healthy subjects in endemic area for HBV.

P [ 0.05 between the two groups Method: We enrolled 20 therapy-naı¨ve pregnant (PW) and 20 nonpregnant (NPW) CHB patients into a prospective, single-center, nonrandomized clinical studyof LdT 600 mg/day treatment for 96 weeks. Mean age NPW/PW 28.65/27.78 years, ALT 275.24/344.52 (IU/L), HBV DNA 6.19/5.95 (log copies/mL), HBsAg3.27/4.33 (log IU/mL) and HBAg-positive 66.7/70 %. The endpoints were: HBV DNA undetectable (\500 copies/mL), HBeAg seroconversion, HBsAg quantitation, safety, virological breakthrough (HBV DNA increased by[1 log) and resistance. Results: We report 2 cases of virologic breakthrough (rtM204I mutation) with LdT in NPW. Mild elevation of CK occurred in 1/20 PW (325 U/L), and 2/19 NPW (273 U/L and 412 U/L). CK levels did not continue to rise during continuous LdT treatment. All pregnant women delivered their infants after a full-term pregnancy. Newborns were normal (Table 1). Conclusions: The safety and efficacy of telbivudine treatment in pregnant and non-pregnant CHB groups was similar. Therapyyielded good efficacy and was well tolerated with no safety concerns in the telbivudine-treated mothers or their infants. Based on our study, telbivudine appears to be a good option for the management of pregnant CHB patients.

Topic: 8 Hepatitis B - Clinical Absno: 194 Efficacy of adefovir-based combination therapy for patients with lamivudine- and entecavir-resistant chronic hepatitis B


Dong Hyeon Lee, Jeong-Hoon Lee, Yun Bin Lee, Su Jong Yu, Yoon Jun Kim, Jung-Hwan Yoon, Chung Yong Kim, Hyo-Suk Lee

Absno: 186

Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea

Efficacy of 2-year telbivudine treatment in pregnant women with chronic hepatitis B

Introduction: Treatment strategies for entecavir (ETV)-resistant chronic hepatitis B (CHB) patients are not yet well established. The aim of this study was to evaluate overall antiviral efficacy and to compare the efficacy of combination therapy with adefovir (ADV) plus nucleoside analogues (lamivudine [LAM], telbivudine [LdT], or ETV) in patients infected with LAM- and ETV-resistant HBV variants. Material and methods: Virologic, biochemical and serologic response during combination therapy with ADV plus nucleoside analogues were assessed. Propensity score analysis was used to select a matched group of patients for the comparison of rescue therapy regimens. Results: A total of 67 consecutive patients were analyzed. Complete virologic suppression was achieved in 27 patients. Overall cumulative incidence of complete virologic suppression at month

Minning Song Xiamen 174 Hospital, China: Xiamen University Affiliated Hospital successfully, email: [email protected] Background/aim: The prevalence of HBV infection among women of childbearingage in China may be as high as 10–20 %. Pregnant women who are HBV carriers are of particular concern, as vertical transmission from infected mother to newborn child remains the predominant mode of infection in China. We aim to evaluate the safety and efficacy of telbivudine (LdT) for the treatment of chronic hepatitis B (CHB) during pregnancy.

123

S68 24 was 47.4 %: 44.3 % in the LAM or LdT plus ADV group and 51.4 % in the ETV/ADV group. There was no significant difference between these two groups (P = 0.234). Cumulative incidences of complete virologic suppression were still comparable between the two groups selected and matched using the propensity score model (P = 0.419). Virologic breakthrough was observed in 9 patients and rtA181V substitution was newly detected in one patient. HBeAgnegativity and lower baseline HBV DNA level were associated with complete virologic suppression in univariate analysis. In multivariate analysis, lower baseline HBV DNA level remained an independent predictor. Conclusion: Combination therapy with ADV plus nucleoside analogues fails to show sufficient antiviral efficacy in CHB patients with resistance to both LAM and ETV. Further study is warranted to evaluate the efficacy of more potent tenofovir-based regimen in such patients.

Topic: 8 Hepatitis B - Clinical Absno: 200 Evaluation of HBV transmission and antiviral therapy among HBsAg-positive pregnant women Suda Tekin Koruk1, Ayse Batirel2, Sukran Kose3, Sila Cetin ¸ igdem Hatipoglu6, Akhan4, Bilgehan Aygen5, Necla Tulek6, C 6 5 Cemal Bulut , Orhan Yıldız , Cahide Sacligil7, Fatma Sirmatel8, Elif Altunok4. (On behalf of Society of Turkish Clinical Microbiology and Infectious Diseases Viral Hepatitis Working Group) 1

Harran University, Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology (IDCM), Sanliurfa, Turkey, 2 Kartal Dr. Lutfi Kirdar Training and Research Hospital, Department of IDCM, Istanbul, Turkey, 3Izmir Tepecik Training and Research Hospital, Department of IDCM, Izmir, Turkey, 4Kocaeli University Faculty of Medicine, Department of IDCM, Kocaeli, Turkey, 5Erciyes University, Faculty of Medicine, Department of Infectious Diseases, Kayseri, Turkey, 6Ankara Training and Research Hospital, Department of IDCM, Ankara, Turkey, 7Kartal Yavuz Selim Training and Research Hospital, Department of IDCM, Istanbul, Turkey, 8 Abant Izzet Baysal University, Faculty of Medicine, Department of IDCM, Bolu, Turkey Introduction: Chronic hepatitis B (CHB) remains an important health problem especially in infants born to hepatitis B surface antigen (HBsAg)—positive mothers, since, despite immunoprophylaxis, mother-to-child transmission of hepatitis B virus (HBV) still occurs in 8–30 % of mothers with high levels of viremia. The aim of the present study was to assess the potential risk of HBV vertical transmission among Turkish parturient women and to evaluate the efficacy and safety of antiviral agents. Materials and methods: Data were collected retrospectively from 114 HBV infected pregnant women and their infants in 8 health institutions from Turkey. Mothers with HIV co-infection or pregnancy complications were excluded. Baseline demographic data and characteristics (age, number of birth, HBeAg, and history of prior HBV therapy) of pregnant women were recorded. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and HBV–DNA levels were assessed before initiation of therapy. Infants were assessed for serum HBsAg and anti HBs at birth and 24–36 weeks of age. Results: The baseline characteristics of the women were; mean age, 28.3 ± 5.2 (range 17–42) years, mean number of children 0.7 ± 1.1

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Hepatol Int (2014) 8:S1–S405 Table 1 Characteristics of the mothers of infants with HBsAgpositivity Patient

Age

HBeAg

HBV DNA (copy/ml)

Therapy (gestational week)

1

24

Negative

25200

No

2

35

Positive

21500

No

3

28

Positive

152000000

Yes (28)

Antiviral agent

Tenofovir

(1–6), ALT; 57.4 ± 139.0 (8–1064) U/L, AST; 56.6 ± 150.0 (10–1199) U/L, HBV DNA; 8.3 9 107 ± 2.6 9 108 (0–1.5 9 109) copies/ml, HBeAg positivity; 33.3 % (n = 38). Family history of HBV infection was detected in 53.5 % (n = 61). In total, 60 (52.6 %) pregnant women received tenofovir (60.0 %), lamivudin (33.3 %) or telbivudin (3.5 %) therapy at the median gestational age of 22.2 ± 8.5 (1–36) weeks. All infants were vaccinated and hepatitis B immunoglobulins (HBIG) were administered, with 81 of them (71.1 %) available for follow-up. After completion of HBV vaccination course, 71 (87.7 %) infants had protective anti-HBs levels, 3 (3.7 %) were HBsAg-positive, and 7 (8.6 %) were HBsAg-negative with nonprotective anti-HBs levels. Five of the infants had low gestational birth weight but no other birth defects Table 1. Conclusion: According to our results, viral load may not be the only effecting factor for transmission of HBV to children of infected mothers. Beside this, antiviral therapy at third trimester of pregnancy seems to be safe. The pregnant women with high viral load should be followed-up closely during pregnancy. They have to begin to take tenofovir or telbivudine, which are category B drugs for pregnancy, at latest at the beginning of the third trimester, as we do not have any better option in this situation, so that they can reach delivery with negative HBV DNA levels. We need new treatment strategies, and close follow-up of mothers and children is another important issue. Keywords: Hepatitis B, Pregnancy, Perinatal transmission, Antiviral therapy

Topic: 8 Hepatitis B - Clinical Absno: 205 3-year telbivudine treatment in drug-naı¨ve patients with HBeAg-positive chronic hepatitis B Xingjian Jiang Hangzhou Xixi Hospital, Hangzhou Sixth People’s Hospital, China Background/aim: Achieving HBeAg seroconversion is a critical endpoint required to consider the potential for finite therapy with antiviral therapy. We aimed to evaluate the efficacy of telbivudine (LdT) treatment for 3 years in HBeAg-positive Chronic Hepatitis B (CHB) patients, naı¨ve to antiviral therapy. Methods: We enrolled 64 HBeAg-positive CHB patients naı¨ve to nucleoside analogues or interferon therapy from the Department of Liver Disease at Hangzhou Sixth People’s Hospital since December 2007. Patients were eligible if: serum HBV-DNA C105 copies/ mL and ALT C29 ULN. Patients received LdT 600 mg/day orally. We evaluated the 3-year cumulative rates of HBV-DNA undetectable, HBeAg seroconversion, ALT normalization, HBsAg seroconversion and drug resistance. For patientswith emergence of


S69

Table 1 Cumulative efficacy results, N = 64 Months

3

6

12

18

24

30

36

% HBV-DNA undetectable

73

84

95

92

92

95

97

% HBeAg seroconversion

17

22

28

33

41

47

48

% ALT normalization

56

73

94

98

98

98

98

8

9

17

17

22

22

23

% HBsAg Levels \1000 IU/mL

resistance, adefovir dipivoxil (ADV) was added to ongoing LdT therapy. Results: More than half the patients had a transient elevation of CK with highest level of 4439 U/L, but no obvious discomfort and myopathy, and telbivudine was continued under close observation. 13 patients experienced a virological breakthrough, and M204I mutation was detected by gene sequencing. ADV was added to ongoing LdT treatment for 6 months, and normalization of virological markers were observed (Table 1). Conclusions: LdT-treatment yields potent, rapid suppression of HBV-DNA replication and high HBeAg seroconversion rate and even HBsAg seroconversion in some patients. Optimized treatment is critical to improve the efficacy of nucleoside analogues and reduce drug resistance, allowing more patients to achieve the desired therapeutic goals. Taken together, these results suggest that LdT therapy offers the possibility for finite therapy in some patients.

Topic: 8 Hepatitis B - Clinical Absno: 207 Efficacy and safety of three different treatments in 183 patients with hepatitis B cirrhosis Haiying Sun, Shuqin Zhang, Ming Wang Hepatology Hospital of Jilin Province, Changchun, China, email: [email protected] Background/aims: Patients with chronic hepatitis B (CHB) can be successfully treated using nucleos(t)ide analogues (NAs), but drugresistant hepatitis B virus (HBV) mutants frequently arise, leading to treatment failure and progression to liver disease. Aim: To evaluate the efficacy and safety (in particular renal function) of telbivudinebased combination therapy versus monotherapies in patients with HBV-associated with liver cirrhosis. Method: 183 nucleotide analogue-naive patients with HBV-associated with liver cirrhosis from the Jilin Provincial Liver and Gallbladder Diseases Hospital between March 2007 and November 2009 were eligible to enter the study. Patients received one of three regimens, telbivudine (LdT)+adefovir (ADV) or monotherapy LdT or ADV. Results: Baseline characteristics were similar between the three equally divided groups. No drug resistance was observed in patients treated with LdT+ADV. 5 LdT monotherapy-treated and no ADV-treated patients developed resistance. At week 96, GFR scores improved from baseline in patients receiving ADV+LdT combination therapy 119.7 mL/min to 123.3 and LdT monotherapy 108.9 to 125.1, while a decrease is reported in patients receiving ADV monotherapy 121.2 to 99.8 mL/min. Elevation in serum creatinine was significantly more frequent with ADV-monotherapy than with ADV+LdT combination therapy. Side effects were manageable; CK elevations were more frequent with LdT-based therapies. Conclusions: LdT in combination with ADV yielded superior biochemical and histological results compared to the individual

monotherapies. These data suggest that in a population at high risk for poor outcomes, the combination of LdT+ADV is an attractive therapeutic option. Results at week 96 Group

HBVDNA undetectable


LdT+ADV

54/ 20/38 61(88.5 %) (52.63 %)

56/61 (92 %)

LdT*

43/61(70.5)

44/61 (72.1%)

14/32 (43.75 %)

ALT normalization

ADV**

27/61 (44.3)

8/35 (22.86)

37/61 (60.7)

v2 value, P value*

6.08, \0.05

0.54, [0.05

7.99, \0.01

6.83, \0.01

16.33, \0.01

v2 value, P value** 26.78, \0.01

Topic: 8 Hepatitis B - Clinical Absno: 208 Performance of a highly sensitive hepatitis B surface antigen assay among chronic hepatitis B patients after hepatitis B surface antigen seroclearance Wai-Kay Seto1, Yasuhito Tanaka2, Noboru Shinkai2, Danny Ka-Ho Wong1, James Fung1, Ching-Lung Lai1, Man-Fung Yuen1 1

Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, 2Department of Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan Background: Hepatitis B virus (HBV) persists at low replicative levels among chronic hepatitis B (CHB) patients after hepatitis B surface antigen (HBsAg) seroclearance. The performance of novel HBV serologic assays among this group of patients is undetermined. Methods: We used a highly-sensitive HBsAg (hs-HBsAg) assay employing a sem-iautomated immune complex transfer chemiluminescence enzyme technique (ICT-CLEIA, Sysmex, Kobe, Japan) for the detection of HBsAg. The lower limit of detection is 0.0005 IU/ mL, 100 times more sensitive than conventional HBsAg assays. We recruited CHB patients achieving HBsAg seroclearance with hsHBsAg measured at the time of HBsAg seroclearance and 6–12 months after HBsAg seroclearance as documented by Elecsys HBsAg II (Roche Diagnostics, Branchburg, NJ). Results: 75 patients (mean age 49.7 years, 76 % male, genotype B/C distribution 57.3/42.7 % respectively) were recruited, of which 25 (33.3 %) were on nucleoside analogue therapy (median duration of therapy 6.0 years). Six patient had detectable HBV DNA ([20 IU/ mL) at HBsAg seroclearance; there was no detectable HBV DNA in all patients 6–12 months after HBsAg seroclearance. 59 (78.7 %) and 45 (60.0 %) patients were hs-HBsAg positive at time of HBsAg seroclearance and 6–12 months after HBsAg seroclearance respectively (median detectable levels 0.042 and 0.013 IU/mL respectively). For all 150 measurements, a positive antibody to HBsAg (anti-HBs, [10 m IU/mL) was borderline associated with a negative hs-HBsAg (p = 0.052). Patients with positive anti-HBs, compared to patients with negative anti-HBs, had significantly lower median hs-HBsAg levels (0.002 and 0.010 IU/mL respectively, p = 0.019). Conclusion: Serum hs-HBsAg achieved high rates of detectability among CHB patients with HBsAg seroclearance. Anti-HBs positivity was associated with lower hs-HBsAg levels. Serum hs-HBsAg could

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S70 potentially assist the differentiation of occult hepatitis B patients from individuals with only past HBV exposure.

Topic: 8 Hepatitis B - Clinical Absno: 209 Low levels of IFN-c predicts high chance of HBe seroconversion in chronic hepatitis B Ziying Lei1, Zhishuo Mo1, Xudan Chen2, Huijuan Cao1, Shuru Chen1, Dongying Xie1, Zhiliang Gao1 1

Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China, 2Department of Liver Diseases, Guangzhou Eighth People’s Hospital, Guangzhou, China Introduction: The aim of this study was to assess the levels of IFN-c in hepatitis B e antigen(HBeAg)-positive chronic hepatitis B (CHB) before and after treatment with nucleoside/nucleotide analogue (NUC), and to evaluate their clinical significance. Methods: A total of 28 patients with HBeAg-positive CHB were studied, all the patients met the indications for antivirus treatment and treated with NUCs. Blood samples were collected at the baseline and 12, 24, 48 weeks after treatment. 8 healthy people were chosen as healthy control (HC). We employed Milliplex Map Kit to detect simultaneously IL-10, TNF-a and IFN-c levels in plasma. Results: The levels of IL-10, TNF-a and IFN-c in CHB patients at baseline were higher than that in HC. After treatment with NUCs for 12 weeks, the serum concentrations of IL-10 and TNF-a, except IFNc decreased compared with baseline (P \ 0.05). 7 out of 28 patients occurred seroconversion from HBeAg to anti-HBe antibodies after antivirus treatment for 48 weeks with NUCs. The levels of IFN-c were lower in the HBe seroconversion group compared with the nonseroconversion group at baseline (P = 0.008), 12 weeks (P \ 0.001) and 48 weeks (P = 0.007). While there were no difference in the levels of alanine aminotransferase (ALT), HBV DNA, IL-10 and TNF-a between two groups. Conclusions: Different serum levels of IFN-c between the HBe seroconversion group and non-seroconversion group revealed that serum IFN-c levels may affect the results of antivirus treatment with NUCs. To some extent, low level of IFN-c predicts high chances of HBe seroconversion in HBeAg-positive patients when treat with NUCs.

Hepatol Int (2014) 8:S1–S405 Background/aims: The combination therapy of peginterferon (PEG-IFN) and a potent antiviral drug might improve the response rate in patients with chronic hepatitis B. The aim of this study was to compare the efficacy of PEG-IFN plus entecavir and PEG-IFN alone in Thai patients with HBeAg-negative chronic hepatitis B. Methods: 106 treatment-naı¨ve patients with HBeAg-negative chronic hepatitis B were randomly assigned to either combination of PEGIFN alpha-2b (1.5 mg/kg weekly for 48 weeks) and entecavir (0.5 mg/ day for 48 weeks) (group 1) or PEG-IFN alpha-2b monotherapy (1.5 mg/kg weekly for 48 weeks) (group 2). Serum HBV DNA and HBsAg levels were quantified using commercially available assays (Roche Diagnostics). Virological response (VR) was defined as HBV DNA level \2,000 IU/mL at week 72. Results: There were 51 and 55 patients in groups 1 and 2, respectively. At baseline, no significant difference between groups 1 and 2 was observed with respect to sex, mean age (41.3 vs. 40.6 years), ALT level (58 vs. 60 IU/L), HBV DNA level (5.0 vs. 5.1 log10 IU/mL) and HBsAg level (3.3 vs. 3.4 log10 IU/mL). At week 48, the mean HBV DNA level in group 1 was significantly lower than that of group 2 (0.2 vs. 1.5 log10 IU/mL, respectively) (p \ 0.001). However, there was no difference in mean HBsAg level between both groups (2.5 vs. 2.4 log10 IU/mL, p = 0.532). At week 72, there was no significant difference between groups 1 and 2 with respect to mean HBV DNA level (2.9 vs. 3.4 log10 IU/ mL,p = 0.144) and HBsAg level (2.8 vs. 2.7 log10 IU/mL, p = 0.503). VR at week 72 was achieved in 29 (56.9 %) of group 1 and 27 (49.1 %) of group 2 (p = 0.443). HBsAg clearance was detected in 3 (5.9 %) and 5 (9.1 %) in groups 1 and 2, respectively (p = 0.717). Conclusions: PEG-IFN plus entecavir leaded to a higher rate of HBV DNA suppression than PEG-IFN monotherapy at the end of treatment. However, both treatment regimens were comparable on the basis of viral suppression, HBsAg reduction and HBsAg clearance at 24 week after therapy.

Topic: 8 Hepatitis B - Clinical Absno: 216 The change of IL-33 in patients with chronic hepatitis B after treatment with nucleoside-analogues


Ziying Lei1, Zhishuo Mo1, Shuru Chen1, Huijuan Cao1, Zhanyi Li1, Dongying Xie1, Zhiliang Gao1

Absno: 215

1 Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China

A randomized study comparing efficacy of peginterferon-alpha2b monotherapy versus combination with entecavir in HBeAgnegative chronic hepatitis B: analysis of week 72 Pisit Tangkijvanich1, Salyavit Chittmittraprap2, Kittiyod Poovorawan2, Yong Poovorawan3 1 Research Unit of Hepatitis and Liver Cancer, Department of Biochemistry, 2Department of Medicine, 3Center of Excellence in Clinical Virology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330 Thailand, email: [email protected]

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Introduction: Hepatitis B virus (HBV) related liver injury is dependent on the interaction between the virus, hepatocytes, and the host immune system, but the pathogenesis has not been fully understood. Interleukin-33(IL-33) is an alarmin of inflammation; previous studies have revealed that IL-33 drives antiviral CD8+ T Cells responses. This study mainly focuses on the changes of IL-33 in Patients with chronic hepatitis B (CHB) before and after antivirus treatment with nucleoside/nucleotide analogue (NUC). Methods: A total of 42 patients with CHB were studied, all the patients met the Indications for antivirus treatment and treated with NUCs. Blood samples were collected at the baseline and 12, 24, 48 weeks after treatment. 20 healthy people were chosen as

Hepatol Int (2014) 8:S1–S405 healthy control (HC). We employed Milliplex Map Kit to detect simultaneously IL-33, IL-10, TNF-a and IFN-c levels in plasma. Results: The levels of IL-33, IL-10, TNF-a and IFN-c in CHB patients at baseline were higher than that in HC. The level of IL-33 in CHB was correlated with IL-10 and TNF-a at baseline (r = 0.316,P = 0.041; r = 0.718, P = 0.002). After treatment with NUCs for 12 weeks, serum alanine aminotransferase (ALT) and HBV DNA were significantly lower than baseline (P \ 0.001), and the concentrations of all the serum cytokines detected (IL-33, IL10, TNF-a and IFN-c) were also decreased comparing with baseline (P \ 0.05). However, the cytokines rebounded follow-up, the serum levels of IFN-c and TNF-a at 48 weeks was higher than 12 weeks (P \ 0.05), the mean values of IL-33 at 48 weeks were also higher than 12 weeks, but with no statistically significance (P = 0.089). Conclusions: The cytokines (IL-33, TNF-a and IFN-c) in this study all dropped for a short time after antivirus treatment and rebounded follow-up, revealed IL-33 may participates in the pathogenic process of CHB. However, the precise mechanisms remain to be further investigated.

Topic: 8 Hepatitis B - Clinical Absno: 217 The relationships of HBV DNA loads and MELD scores during the procedure from acute attack to remission in chronic hepatitis B Ziying Lei1, Zhishuo Mo1, Jing Liu1, Shuru Chen1, Zhebin Wu1, Weimin Ke1, Dongying Xie1, Zhiliang Gao1 1 Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China

Introduction: In order to make clear the changes and differences of HBV DNA loads during the fastigium and remission in different degrees of acute attack of chronic hepatitis B. Methods: A total of 217 patients were studied: 107 patients with HBVrelated acute-on-chronic liver failure (ACLF, 96 males and 11 females, 39 ± 11 years) and 110 patients with chronic hepatitis B (CHB, 99 males and 12 females, 37 ± 10 years). ACLF was defined as acute deterioration of liver function in a patient with previously compensated chronic liver disease, and development of coagulopathy with prothrombin activity (PTA) lower than 40 %, jaundice with total bilirubin (TB) greater than 171 lmol/L. Observe and compare the model for end-stage liver disease (MELD) scores and HBV DNA loads in the fastigium and remission in the acute attack of liver disease in ACLF group and CHB group. Results: There were differences in MELD scores between the fastigium and remission in ACLF group (20.38 ± 5.31 vs. 13.82 ± 5.43, P \ 0.001) and CHB group (13.24 ± 3.71 vs. 7.27 ± 3.79,P \ 0.001). And the HBV DNA loads decrease from fastigium to remission in ACLF group (5.64 ± 1.63 vs. 3.73 ± 1.26 log10 IU/ml,P \ 0.001) and CHB group (6.08 ± 1.73 vs. 4.67 ± 1.76 log10 IU/ml,P\0.001). The change of HBV DNA loads was more notable in ACLF group than in CHB group (1.91 ± 1.55 vs. 1.41 ± 1.61 log10 IU/ml,P\0.05). Conclusion: Different degrees of acute attack of chronic hepatitis B, regardless of ACLF or CHB, along with the decline of MELD scores from the fastigium to remission of acute attack of liver disease, HBV DNA loads occurred spontaneous decrease. The decrease level of HBV DNA loads was more obvious in ACLF group than in CHB group, reveal more severe hepatic necrosis along with stronger immune clearance of HBV.

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Topic: 8 Hepatitis B - Clinical Absno: 218 Anti-fungal treatment in patients with acute-on-chronic liver failure of chronic hepatitis B Ziying Lei1, Zhishuo Mo1, Shuru Chen1, Shaoquan Zhang1, Xinhua Li1, Dongying Xie1, Zhiliang Gao1 1 Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China

Introduction: The progression of pulmonary fungal infection develops quickly, and it is an important cause of the death of Acuteon-chronic liver failure (ACLF) in chronic hepatitis B (CHB) patients. But no clinical data exist regarding the use of Fluconazole or Caspofungin in patients with severely impaired liver function. Our objective is to study the safety and efficacy of Fluconazole and Caspofungin in patients with ACLF. Methods: Consecutive pulmonary fungal infection patients with ACLF in chronic hepatitis B were recruited from 2010 to 2011. Pulmonary fungal infection was diagnosed by throat swab fungal culture and chest Computed Tomography. ACLF was diagnosed according to the diagnostic criteria recommended by the Asian Pacific Association for the Study of the Liver (APASL). All the patients were followed up until death or survival time was more than 3 months. Results: A total of 58 pulmonary fungal infection patients with ACLF in chronic hepatitis B were recruited for this study. 33 patients were treated with Fluconazole 0.2g (FLU) daily (FLU group); 19 patients received Caspofungin 35mg (CAS) daily (CAS group); 6 patients did not take any anti-fungal treatment (NON group). The NON group had a significantly high mortality, compared with the anti-fungal treatment group (FLU+CAS), (100 vs. 55.8 %, Chisquare = 4.398, P = 0.036), with the CAS group (100 vs. 36.8 %, Chi-square = 7.287, P = 0.0069), FLU group (100 vs. 66.7 %, Chisquare = 2.786, P = 0.0951). Compare with The CAS groups, FLU groups showed high accumulative mortality (66.7 vs. 36.8 %, Chisquare = 4.348, P = 0.0371). Survival analysis and Cox regression analysis show that anti-fungal treatments were significant improvement of clinical outcome (OR 8.491,P = 0.001), and Caspofungin is more effective than Fluconazole.

Topic: 8 Hepatitis B - Clinical Absno: 221 Tenofovir may not impair phosphate and calcium levels in chronic hepatitis b patients: a retrospective single center real life study Rahmet Guner, Zeliha Kocak Tufan, Tu¨mer Guven, Gul Ruhsar Yilmaz, Siran Keske, Dilem Erdogmus, Imran Hasanoglu, Mehmet A. Tasyaran Infectious Diseases & Clinical Microbiology Department, Yildirim Beyazit University, Ankara Ataturk Training & Research Hospital, Ankara, Turkey Introduction: Tenofovir use has been blamed for renal and bone toxicity resulting in hyphophosphatemia. We aimed to check the serum phosphate (PO4) levels of our hepatitis B patients who are under tenofovir therapy and wanted to investigate if there is a

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Table 1 Phosphate (PO4) and calcium (Ca) levels of hepatitis B patients during tenofovir treatment n

Mean ± SD Minimum Maximum

Minimum PO4 levels (mg/dL)a

57 2.7 ± 0.5

1.6

3.7

Maximum PO4 levels (mg/dL)a

57 3.6 ± 0.6

2.0

5.7

Topic: 8 Hepatitis B - Clinical Absno: 223 Impact of oral nucleos(t)ide analogues on renal function in chronic hepatitis B patients Jilian Fang, Qian Jin, Lai Wei, Hao Wang

PO4 levels at the beginning 38 3.2 ± 0.7 of the therapy (mg/dL)

2.0

4.7

Institute of Liver Diseases, Peking University People’s Hospital, Beijing, China

PO4 levels at the last visit (mg/dL)

53 3.1 ± 0.5

2.0

4.2

Min Ca level (mg/dL)a

58 9.0 ± 0.4

7.8

10.3

Max Ca level (mg/dL)a Ca level at the beginning of the therapy (mg/dL)

58 9.8 ± 0.4 36 9.3 ± 0.4

9.0 8.8

10.9 10.4

Ca level at the last visit (mg/dL)

53 9.5 ± 0.4

7.8

10.6

Background: The oral nucleos(t)ide analogues, such as lamivudine (LAM), adefovir dipivoxil (ADV), telbivudine (LDT), entecavir (ETV), tenofovir disoproxil fumarate (TDF), were metabolized by kidney. Now studies have shown that ADV induced potential nephrotoxicity that was characterized by proximal tubular epithelial cells dysfunction. Serum creatinine is not always sensitive for evaluation of renal damage, but estimated glomerular filtration rate (eGFR) has been widely considered as the best indicator to assess renal function in recent years. Objective: To evaluate the impact of oral nucleos(t)ide analogues, whether alone or in combination, on GFR in patients with chronic hepatitis B (CHB). Methods: A total of 161 outpatients with CHB or decompensated cirrhosis who visited Peking University People’s Hospital from Jan 2007 to Dec 2010 and received LAM (n = 18), LDT (n = 20), ETV(n = 40), ADV(n = 43), LAM+ADV (n = 24), LDT+ADV (n = 16) therapy were included in the study, their eGFRs were calculated using the Modification of Diet in Renal Disease (MDRD) formula. Results: The eGFR curve in patients treated with LAM was almost flat, which showed an increasing tendency in those with LDT, significant difference was found at 12,18 and 24 months of treatment (P \ 0.05). Patients receiving LAM+ADV had a flat eGFR curve, while those with LDT+ADV showed a eGFR curve with slightly positive slope, the eGFR curve was significantly different at 3,6,12, 18 and 24 months of treatment (P \ 0.05). The eGFR curves in both ETV group and ADV group increased first and then decreased, and the eGFR curve in ADV group declined earlier than that in the ETV group (30 vs. 36 months), and greater decrease in eGFR was also exhibited in ADV group. Conclusion: LDT may have a protective effect on the kidneys; however, long-term treatment with ADV and ETV may induce renal damage, which requires further research.

a

Minimum and maximum levels ever detected for each patient, either at the beginning or during the therapy period were noted and the mean levels were calculated

significant change in its levels or not during the therapy period. Beside PO4 we also measured the calcium (Ca) levels. Materials and methods: Chronic hepatitis B patients whoever treated with tenofovir from 2008 to 2013 September in our department were included into the study. Patient files and hospital database were used to find variables. Ca and PO4 levels which were measured during the therapy period were noted for each patient. Results: In sum 59 patients included: 42 male/17 female; mean age 47 years (21–85 years). Only 34 % of the patients were naı¨ve, remaining patients had a history of either interferon or other antiviral therapies before tenofovir medication. The mean tenofovir therapy duration was 35 months (6–68 months). The PO4 and Ca levels at the beginning of the therapy were available for 38 (64 %) and 36 (61 %) patients respectively. Results were depicted in Table 1. PO4 and Ca levels were checked 6 times in average for each patient (1–16 times for PO4 and 1–18 times for Ca). In according to our database hypocalcemia was not noted in any of the patients (0/36) while hypophosphotemia (\2.5 mg/dL) was present in 7.9 % (3/38) at the beginning of the therapy. Forty percent of patients have a PO4 level of below 3mg/dL at the beginning of the therapy. Seventeen (29.8 %) of the patients had experienced one or more time a PO4 level below 2.5 mg/dL during the therapy period, 94 % was mild hypophosphatemia (2–2.5 mg/ dL). The critical values for PO4 (below 1 mg/dL) and Ca (\6 and [13 mg/dL) were not seen in any of the patients. Hypocalcemia and hypophosphatemia were present in 3.8 % (2/53) and 5.7 % (3/ 53) of the patients at the last visit respectively. No correlation was found between the Ca and PO4 levels and age, gender or duration of the therapy. Conclusion: Although hypophosphatemia was defined as below 2.5 mg/dL, a normal adult is expected to have a PO4 level of 3-4.5 mg/dL and 40 % of our patients have already a PO4 level of below 3 mg/dL at the beginning of the therapy. Mild hypophosphatemia was observed during therapy period in our study population but didn’t persist. In conclusion tenofovir did not seem to alter the PO4 and Ca levels in a significant level in our study population on a real life setting.

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Topic: 8 Hepatitis B - Clinical Absno: 227 Predictors of changes of HBeAg and HBsAg levels and outcomes of HBeAg-positive chronic hepatitis B patients treated with telbivudine Yuehong Zhu Changshu No.2 People’s Hospital, Changshu, Jiangsu, China, email: [email protected] Background/aim: Serum hepatitis B surface antigen (HBsAg) loss is the preferred endpoint of HBV therapy and approximates clinical cure of the infection. HBsAg loss may serve as a main indicator for the short-term efficacy of antiviral drugs, but can it predict long-term efficacy. Our study evaluates the safety and efficacy of telbivudine (LdT) for treatment of HBeAg-positive CHB patients and the predictors of HBeAg and HBsAg change


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Tabe 1 Efficacy results,N = 48 Week 48

Week 96a

HBV DNA undetectable

87.5 %

91.3 %

ALT nomalization

87.5 %

91.3 %

HBeAg loss

31.1 %

39.1 %

HBeAg decline \1 log10 at 24 week

10.0 %

11.0 %

HBeAg decline C1 log10 at 24 week

46.5 %*

64.3 %*


20.1 %

34.8 %


0.0 %

11.0 %

HBeAg decline C1 log10 at 24 week

35.7 %*

57.1 %*

4358.1± 1545.33

3264.9 ± 709.56


5300.4 ± 6012.72

4469.9 ± 4345.73

HBeAg decline C1log10 at 24 week

2593.2 ± 1916.59*

2361.1 ± 1846.55*

HBsAg quantitation (9 ± s, IU/L)

a

5 of whom with HBV DNA rebound had HBV DNA undetectable after receiving combination therapy 1 withdrew due to NA drug switching * p \ 0.05 for HBeAg decline \1 log10 at 24 week vesrus C1 log10 at 24 week

Methods: We enrolled 48 CHB patients into a single center study with LdT 600 mg/daily for 96 weeks. Patients age (years) 16–58 (32.83 ± 11.53), (male/female) 32/16, mean ALT (U/L) 213.91 ± 146.43, mean HBV DNA (log10 copies/mL) 6.62 ± 1.30, mean HBeAg (s/co) 465.35 ± 505.16, mean HBsAg (log10 IU/L) 14858.00 ± 6068.37. Results: No obvious toxic and adverse effects were reported during the treatment (Table 1). Conclusions: Telbivudine delivers potent suppression of HBV replication and high HBeAg seroconversion. Patients with low baseline HBV DNA levels and profound decline in HBeAg levels C1 log10 at weeks 24 are more likely to achieve HBeAg loss and seroconversion rates at weeks 48 and 96. Gradual decline of HBsAg quantitation over time was also observed in HBeAg-positive CHB patients with telbivudine treatment. Patients with HBeAg decline C1 log10 at 24 week achieved lower HBsAg levels at week 48 and 96.

Institute for Infectious Diseases1, Department of Gynecology and Obstetrics2, Southwest Hospital, Third Military Medical University, Chongqing 400038, PR China, Institute for Infectious Diseases4,Changsha First Municipal Hospital3, Hunan 410005, PR China, The 309th Hospital of PLA, Beijing 100091, PR China4, email: [email protected], [email protected] Objectives: To evaluate the efficacy and safety of telbivudine in preventing mother-to-child transmission (MTCT) of hepatitis B virus (HBV) in HBeAg-positive pregnant women with high viral load. Methods: We investigated the effects of telbivudine in preventing MTCT of HBV in an open-label study since 2008. A total of 236 HBeAg-positive pregnant women with HBV DNA levels C106 IU/ mL received telbivudine 600 mg daily from 24 to 33 weeks of gestation, and 166 pregnant women with the same situation who were unwilling to take antiviral drugs were served as untreated controls. Each infant of both groups was vaccinated with recombinant HBV vaccine and injected with hepatitis B immune globulin (HBIG) according to standard routine methods. MTCT rate was determined by the results of HBsAg and HBV DNA of infants at week 26. Results: Baseline demographics and clinical characteristics of the mothers and the infants were comparable. The incidence of undetectable HBV DNA levels was significantly higher in infants born to telbivudine-treated mothers than in the controls (P = 5.62 9 10-11). The serum anti-HBs positive rate in infants delivered from telbivudine-treated mothers over 3 months was significantly higher than in the controls (P \ 0.001). As for the serum HBsAg positive rate in infants over 6 months, the difference was strikingly significant between the two groups (P \ 0.001). Telbivudine-treated mothers displayed a marked decline in HBV DNA levels from the beginning to the end of the treatment. Thirty (21.1 %) of 142 telbivudine-treated mothers had undetectable HBV DNA, as compared to 0% in the controls. No severe adverse events or complications were observed in telbivudine-treated mothers or infants. The rate of spontaneous delivery in untreated mothers and in telbivudine-treated mothers was similar (41.7 vs. 48.5 %, P = 0.186). Conclusion: Telbivudine was effective and well-tolerated in HBeAgpositive pregnant women and their infants, and it was associated with significant reduction of vertical transmission of HBV. Acknowledgments: The authors have no commercial associations and real conflict interest. This study is supported by NSFC of ChinaGrant Number: 30830090.

Topic: 8 Hepatitis B - Clinical Absno: 232 Long-term efficacy and safety of initial treatment of telbivudine alone or in combination with adefovir dipivoxil for HBeAgpositive chronic hepatitis B


Yunhua Liu, Li Liu, Dan Peng, Weikun Li, Yingrong Du, Ting Jia, Lixian Chang

Absno: 231

The Third People’s Hospital of Kunming, Kunming 650032, China, email: [email protected]

Effective prevention of perinatal transmission of hepatitis B virus infection using telbivudine in high viral load patients: a retrospective study

Objective: To retrospectively evaluate the long-term efficacy and safety of initial treatment of telbivudine (LDT) alone or in combination with adefovir dipivoxil (ADV) for HBeAg-positive patients with chronic hepatitis B (CHB). Methods: A total of 140 HBeAg-positive CHB patients were randomly to orally once daily LDT 600 mg alone or LDT 600 mg plus ADV 10 mg for 96 to 240 weeks. The efficacy, incidence of drug

Quan-Xin WU1, Xiao-Wen Sun1, Mei-Ming Pan3, Yun He4, Shun Tan1, Yi Zeng2, Li Li2, Guo-Hong Deng1, Hong-Fei Huang1, ZeHui Yan1, Deng-Ming He1, Yu-Ming Wang1, Jun-Nan Li2

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resistance and adverse reactions were observed, HBV markers (HBVM), HBV DNA quantification, liver and kidney function as well as creatine kinases (CK) levels were detected at week 12, 24, 48, 96, 144, 192 and 240. Results: Patients treated with LDT alone had rates of HBV DNA undetectable, HBeAg seroconversion and incidence of drug resistance similar to that in those treated with LDT plus ADV (P [ 0.05). Early, rapid and sustained HBV DNA undetectable rate was observed in both groups. 86.7 % of patients treated with LDT alone had HBV DNA decline by C2 log at week 12, the HBV DNA undetectable rates were 62.7, 76.0, 80.0 and 93.3 % at week 24, 48, 96 and 240, respectively, which was significantly different at week 24, 96 and 240 (P \ 0.05). 92.3 % of patients treated with LDT plus ADV had HBV DNA decline by C2 log at week 12. HBV DNA undetectable rates were 61.5, 81.5, 89.2 and 88.9 % at week 24, 48, 96 and 240, respectively, with significant difference (P \ 0.05). Among patients treated with LDT alone, 29.3, 42.7, 55.0, 55.8 and 63.3 % of patients had HBeAg seroconversion at week 48, 96, 144, 192 and 240, respectively. Among patients treated with LDT plus ADV, 30.8, 40.0, 43.3, 66.7 and 66.7 % of patients had HBeAg seroconversion at week 48, 96, 144, 192 and 240, respectively. Significant difference was not found in HBeAg seroconversion rate at week 24 and 48, but was observed in HBeAg seroconversion rate at week 24 and 96, 144, 192 and 240 in both groups. Drug resistance occurred in 4, 5.3, 10, 11.6 and 13.3 % of patients treated with LDT alone, which developed in 1.5, 3.1, 3.3, 8.3, 11.1 % of patients treated with LDT plus ADV at week 48, 96, 144, 192 and 240, respectively, without significant difference. Muscular soreness and elevated CK levels occurred in three patients, respectively, which were usually transient and disappeared or returned to normal levels after symptomatic treatment. Conclusion: LDT shows early, rapid, potent and sustained suppression of HBV replication, extended treatment of LDT is associated with higher rates of HBV DNA undetectable, HBeAg seroconversion and sustained response, particularly for at least 96 weeks of treatment, suggesting that administration of LDT for treatment of CHB should be at least 96 weeks. Initial treatment of LDT in combination with ADV results in higher HBV DNA undetectable rate at week 48 than LDT alone, but which does not reduce the incidence of drug resistance. Extended treatment had no effects on occurrence of drug resistance. Long-term initial therapy of LDT alone or in combination with ADV shows better efficacy and safety. Keywords: Chronic hepatitis B, Telbivudine, Initial treatment, Alone, Combination, Longterm,Efficacy, Safety

Table 1 Relationship between HBVDNA, ALT and liver histology HBeAg

HBVDNA r

Negative

Positive

p

ALT

0.204

Necroinflammation

0.135

0.079

Fibrosis score

0.063

0.411

ALT

0.007**

0.027

0.812

Necroinflammation

-0.032

0.778

Fibrosis score

-0.094

0.411

Spearman’s rho correlation test ** p \ 0.01

Materials and methods: The patients who had been HBsAg positive for at least the last six months and admitted to our clinic between January 2003 and April 2009 were included to this study. HBV DNA levels were detected by using real time PCR assays. The biopsy specimens were scored according to the Knodell histological activity index. Results: Of the 249 enrolled patients, 84 (33.7 %) were female and 170 (68.3 %) were HBeAg(-) whereas others were HBeAg(+). Mean (standard deviation—SD—) age of HBeAg(-) and HBeAg(+) patients was 37.9 (11.3) and 28.7 (9.3) years, respectively. HBeAg negativity was statistically significantly higher in males (p \ 0.05). Mean (SD) HBV DNA levels were 79.2 (455.7) and 239.9 (254.9) 9 106 copies/ml in HBeAg(-) and HBeAg(+) patients, respectively (p \ 0.01). In both groups, a signifıcant relationship was not found between HBV DNA levels and hepatic fibrosis and also necroinflamation (Table 1). There was no significant difference between ALT levels of both groups (p \ 0.05). There was a statistically signifıcant relation between HBV DNA and ALT levels in HBeAg(-) patients whereas not significant in HBeAg(+) patients (Table 1). Conclusion: There was no significant relationship between viral load, hepatic fibrosis and necroinflamation; and this shows the importance of the liver biopsy. In chronic hepatitis B patients, we should consider all the parameters to predict progression of disease.



Higher proportion of viral basal core promoter mutant increases the risk of liver cirrhosis in hepatitis B carriers

Absno: 233 Evaluation of the relationship between HBV DNA and liver histology in naive chronic hepatitis B patients

Tai-Chung Tseng1,7, Chun-Jen Liu2,3, Hung-Chih Yang2,6, TungHung Su2,3, Pei-Jer Chen2,3, Ding-Shinn Chen2,3,4,8, Jia-Horng Kao2,4,5 1

1

1

1

1

1

P. Elbir , N. Ozgunes , T. Z. Elbir , D. Yalcin , O. Aydın , P. Ergen1 1

Medeniyet University, Goztepe Educational Hospital, Department of Infectious Diseases ˙Istanbul Turkey

Introduction: Biochemical, serological, molecular methods and liver biopsy is widely used to determine the stage of chronic hepatitis B infection. ˙In this study, the relationship between HBV DNA histological activity, fıbrosis score, age, gender and ALT were examined by separating untreated chronic hepatitis B patients both HBeAgpositive and HBeAg-negative.

123

Division of Gastroenterology, Department of Internal Medicine, Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Taiwan, 2Division of Gastroenterology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, 3 Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan, 4Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan, 5Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan, 6Department of Microbiology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan, 7School of Medicine, Tzu Chi University, Hualien, Taiwan, 8 Genomics Research Center, Academia Sinica, Taipei, Taiwan

Hepatol Int (2014) 8:S1–S405 Background & aims: Precore stop codon (PC) variant (G1896) and basal core promoter (BCP) variant (A1762T/G1764A) of hepatitis B virus (HBV) are associated with risk of hepatocellular carcinoma in HBV carriers. However, little is known about their impact on the adverse outcomes of hepatitis B e antigen (HBeAg)-negative hepatitis and liver cirrhosis. Methods: A total of 251 spontaneous HBeAg seroconverters who had genotype B or C infection and received a long-term follow-up were enrolled. PC and BCP mutants were determined qualitatively and quantitatively to correlate with these adverse outcomes. The findings were validated by an independent case-control study, which included 184 patients with biopsy-proven liver fibrosis stages. Results: In the longitudinal cohort, we found that PC wild type and BCP mutant were associated with cirrhosis development, but not HBeAg-negative hepatitis. Further multivariate analysis showed only BCP mutant was the independent risk factor for cirrhosis development (adjusted hazard ratio 4.2, 95 % confidence interval 1.4–12.6). Using quantitative analysis of BCP mutant, a higher proportion of BCP mutant was associated with a higher risk of cirrhosis over time (P for trend \.001). If we chose 45 % of BCP mutant as the cutoff, the risk of cirrhosis was higher in patients with BCP mutant C45 % compared to \45 % in the longitudinal cohort and this finding was validated by the case–control study (odds ratio 2.8, 95 % 1.4–5.7). Conclusions: A higher proportion of BCP mutant increases the risk of liver cirrhosis development in HBV carriers with genotype B or C infection.

S75 Fatigue was comparable across all groups (24–44 %). Myalgia, arthralgia, chills, and pyrexia were less frequent with Lambda/RBV than with alfa/RBV (for CHC). Grade 3–4 laboratory abnormalities in hemoglobin, leukocytes, lymphocytes, platelets, and neutrophils were less frequent with Lambda-containing regimens than with alfa/RBV. Incidence of aminotransferase elevations was most frequent among CHB patients (who received Lambda monotherapy); among CHC patients, aminotransferase elevations were more frequent with Lambda/RBV/ASV than with Lambda/RBV, Lambda/RBV/DCV, or alfa/RBV. Details of hepatic safety will be presented.

Grade 3–4 laboratory abnormalities, emergent (%)

Lambda Lambda+ (CHB) RBV (N = 75) (CHC) (N = 131)

Lambda+ RBV+DCV (CHC) (N = 45)

Lambda+ alfa+RBV RBV+ASV (CHC) (CHC) (N = 174) (N = 38)

Hemoglobin

0

4.6

0

2.6

23.7

Neutrophils+bands (absolute)

1.3

0.8

0

0

22.0

Leukocytes

0

0.8

2.2

0

7.5

Lymphocytes (absolute)

1.3

0.8

6.7

0

14.5

0

Platelets

0

0

0

1.7

ALT

42.7

2.3

2.2

15.8

5.2

AST

34.7

2.3

6.7

26.3

5.8

2.7

5.4

4.4

10.5

2.9

Bilirubin, total

Topic: 8 Hepatitis B - Clinical Absno: 243 Safety profile of peginterferon lambda for treatment of chronic hepatitis B (CHB) or chronic hepatitis C (CHC): cross-study analysis of patients treated in three phase 2 studies A. J. Muir1, C. Jurkowski2, E. Cooney2, J. Hillson3, M. Lataillade2, V. Mas Casullo2, T. Gray3, D. Xu2, L. Yogendran2, S. Srinivasan2 1 Duke Clinical Research Institute, Duke University, Durham, NC, USA, 2Bristol-Myers Squibb Research and Development, Wallingford, CT, USA, 3Bristol-Myers Squibb/Zymogenetics, Seattle, WA, USA

Background: Peginterferon lambda-1a (Lambda) is a Type III interferon with limited extra-hepatic receptor distribution, which may result in fewer adverse events (AEs) than peginterferon alfa (alfa). Lambda 180 lg weekly demonstrated more rapid early viral suppression than alfa in patients with CHC and CHB. We present an integrated analysis of safety data for Lambda 180 lg weekly for 24–48 weeks in non-cirrhotics from all three Lambda phase 2 studies. Methods: Available on-treatment safety data from non-cirrhotic patients who received Lambda 180 lg monotherapy; Lambda 180 lg plus ribavirin (RBV); or Lambda 180 lg, RBV, and a direct-acting antiviral (asunaprevir [ASV] or daclatasvir [DCV]) were grouped by regimen and compared with alfa 180 lg /RBV. Patients in the Lambda monotherapy group had CHB; all others had CHC. Differences [2-fold between groups are considered clinically significant. Results: Analyses included 463 patients in 5 groups (Table). Overall, 59 % were male. Among CHB patients, mean age was 36 years, 89 % were Asian, and median baseline alanine aminotransferase (ALT) was 94 U/L. Among CHC patients, mean age across the 4 groups ranged from 46–48 years; 83 % were white, 6% black/African American; and median baseline ALT across the 4 groups ranged from 53–77 U/L.

Conclusions: Lambda 180 lg once weekly/RBV for CHC is associated with significantly fewer hematologic abnormalities but a numerically higher rate of total bilirubin elevations than alfa/RBV. Lambda is a better tolerated interferon than alfa with a differentiated safety profile.

Topic: 8 Hepatitis B - Clinical Absno: 245 Entecavir versus other standard-of-care treatments for up to 5 years in nucleos(t)ide-naı¨ve patients with CHB in a Chinese clinical practice setting J.-L. Hou1, M.-L. Cheng2, W. Zhao3, H. Tang4, L.-X. Zhang5, D.-Z. Xu6, D.-Y. Tian7, Q. Xie8, S.-M. Lin9, Z.-L. Gao10, M. Yu11, C. Llamoso11 1

Institute of Hepatology and Key Lab for Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China, 2 Department of Infectious Diseases, Affiliated Hospital of Guiyang Medical College, Guiyang, China, 3Nanjing Second Hospital Affiliated to Medical College, Southeast University, Jiangsu Province, China, 4Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China, 5Institute of Infectious Diseases, Viral Hepatitis Research Laboratory, 302 Hospital of PLA, Beijing, China, 6 Department of Infectious Diseases, Beijing Ditan Hospital, Beijing, China, 7Department of Infectious Diseases, Huazhong University of Sciences and Technology, Tongji Hospital, Tongji Medical College, Wuhan, China, 8Department of Infectious Diseases, Ruijin Hospital, Jiao Tong University School of Medicine, Shanghai, China, 9 Department of Infectious Diseases, X’ian, The First Affilliated

123

S76


Hospital of Medical College of Xi’an Jiantong University, Shaanxi Province, China, 10Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China, 11Research and Development, Bristol-Myers Squibb Company, Wallingford, CT, USA


Introduction: Chronic hepatitis B (CHB) is a significant public health issue and an important cause of liver-related mortality in China. This study presents the virologic efficacy and limited safety data for up to 240 weeks of entecavir (ETV) therapy or other standard-of-care (oSOC) anti-hepatitis B virus nucleos(t)ide analog (NUC) therapy (lamivudine [LVD], telbivudine [LdT], or adefovir [ADV]) in NUC-naı¨ve CHB subjects from a ‘real-world’ clinical practice setting in China. Methods: This prospective, randomized, observational cohort comprised a subgroup of NUC-naı¨ve, CHB patients enrolled in the REALM study at 50 sites in China. Patients were treated with ETV or oSOC, and assessed for virologic responses over 240 weeks. Patients with decompensated liver disease or HCV co-infection were excluded from the efficacy analysis, and missing values were handled using a non-completer=missing analysis. All patients were assessed for limited safety parameters. Results: Overall, 3526 patients were treated (ETVn = 1766; oSOC n = 1760); 82 patients had either decompensated cirrhosis or HCV co-infection and were excluded from the efficacy analysis. Baseline patient characteristics were balanced across treatment groups; approximately 80 % male, 100 % Asian, 64 % HBeAg(+), and mean HBV DNA &7 log10 IU/mL. In the ETV arm, 109 patients discontinued from the study compared with 175 in the oSOC arm (most common reasons: lost to follow-up [ETVn = 43, oSOC n = 65]; withdrawal of consent [ETV n = 32, oSOC n = 61]). The median time on original study therapy was 286.6 (range 1.3–337.1) weeks for ETV, 306.7 (range 12.1–325.9) weeks for LVD, 256.4 (range 147.4–274.1) weeks for LdT, and 283.6 (range 0.3–333.4) weeks for ADV. At week 240, 85 % of ETV-treated patients had HBV DNA \50 IU/mL compared with 67 % of the oSOC arm (LVD, LdT, or ADV; non-completer=missing analysis). Serious treatment-related adverse events were infrequent (\1 %) and comparable across treatment arms Table 1. Conclusions: In a real-world setting, NUC-naı¨ve Chinese CHB patients treated with ETV achieved higher rates of virologic response compared with patients receiving oSOC therapy over 5 years.

Are the elderly with chronic hepatitis B different from the young?

Table 1 HBV DNA \50 missing analysis)

IU/mL

through

ETV

week

240

(non-completer=

oSOC

Absno: 247

F. Tabak1, B. Mete2, B. Ceylan2, N. Ozgunes2, A. Gunduz2, H. Kumbasar Karaosmanoglu2, A. Cagatay2, K. Gokturk2, L. Erdem2, F. Kocak2, L. Gorenek2, T. Aslan2, O. Colak2, E. Senates2, R. Ozaras2 1

Department of Infectious Diseases and Clinical Microbiology, Cerrahpasa School of Medicine, Istanbul University, 2Realist Study Group, Istanbul, TURKEY Introduction: The course of HBV infection in the elderly can be different in different stages of the disease. The people described as the elderly ([65 years old) in Turkey constitute approximately 7 % of all the population. In this study, we aimed to investigate the elderly having diagnosed with chronic hepatitis B (CHB) in terms of their clinics, laboratory results and treatments. Materials and methods: We included 500 patients having diagnosed with CHB from The Realist Study Group composed of 11 centers (Department of Infectious Diseases and Gastroenterology) in Istanbul/ Turkey. They were all naive patients with a treatment indication. The patients were included in our study between the dates of November 2008 and May 2013. We monitored the patients included in the study through an Internet based data program prospectively. We compared the results of the elderly with those of the young. Results: Of the 500 patients included in our study, 13 (2.6 %) were the elderly (11 males). There were no differences between the groups in terms of their genders (p 0.240). When the young and the elderly were compared in terms of their biochemical parameters, the initial AST, ALT, Bilirubin and Alpha Fetoprotein levels were similar; whereas the albumin levels in the elderly (3.77 ± 0.17 g/dl) were lower than the young (4.20 ± 0.37 g/dl) (p 0.006). Initially, the number of cases having HBeAg negativity was 11 and no statistical difference was observed (p 0.742). We found advanced stage fibrosis (3–4 for knodell; 4–6 for Ishak) in 5 of 8 cases having liver biopsies among the elderly. The rate of advanced stage fibrosis was found to be higher in the elderly than that of the young (p 0.006). The initial HBV-DNA level was lower in the young (6.38 ± 1.64 log vs. 7.15 ± 1.15 log) (p:0.037). While Pegylated Interferon was not chosen for the elderly, it was used for the 15.4 % of the young. Of the thirteen patients, the treatment was initiated with Entecavir in 7 (53.8 %), Tenofovir in 4 (30. 8%), and Lamivudin in 2 (15.4 %) patients. All the anti-viral drugs were found to be effective in the elderly group. The incidence of the elderly within all the CHB group was found to be low (13/500; 2.6 %). When the elderly were compared with the young, we found the albumin levels to be lower, the fibrosis score more advanced, and the HBV-DNA levels higher.

Overall N = 1724

HBeAg(+) HBeAg(–) Overall N = 1114 N = 582 N = 1720

HBeAg(+) HBeAg(–) N = 1108 N = 571

Week 24

869/1672 (52)

429/1089 (39)

426/558 (76)

368/1658 (22)

119/1077 (11)

240/541 (44)

Week 48

1151/1672 (69)

626/1084 (58)

505/561 (90)

589/1635 (36)

247/1065 (23)

328/532 (62)

Week 96

1288/1623 (79)

765/1053 (73)

503/544 (92)

774/1567 (49)

393/1018 (39)

361/515 (70)

Absno: 251

Week 144

1327/1597 (83)

805/1033 (78)

502/538 (93)

849/1529 (56)

452/983 (46)

377/509 (74)

Histological outcomes of 2-year telbivudine treatment in patients with HBeAg-positive chronic hepatitis B

Week 192

1319/1544 (85)

807/999 (81)

490/520 (94)

902/1460 (62)

503/931 (54)

379/499 (76)

Week 240

1238/1457 (85)

764/936 (82)

458/500 (92)

899/1347 (67)

530/868 (61)

350/448 (78)

All data shown as n/N (%). Among those with known HBeAg status oSOC other standard of care, ETV entecavir

123


Qinglong Jin1, Yue Qi1, Xiaoyu Wen1, Meishan Jin2, Hongqing Yan1, Ruihong Wu1, Ge Yu1, Junqi Niu1 1 Department of hepatology, First hospital of Jilin University,Changchun,China, 2Department of Pathology, First hospital of Jilin University,Changchun,China

Hepatol Int (2014) 8:S1–S405 Background/aim: The goals of therapy focus necessarily on prevention of bad clinical outcomes, because clearance of hepatitis B virus (HBV) infection is rarely, if ever, achievable,. Ideally, therapies would be shown to prevent tangible clinical endpoints like development of cirrhosis, end-stage liver disease and hepatocellular carcinoma. Our aims were to evaluate the histological outcomes of 2-year telbivudine (LdT) treatment in patients with HBeAg-positive chronic hepatitis B and factors influencing responses. Methods: We enrolled 26 males, 3 females in our open-label LdT study. Baseline HBV-DNA distribution: 3 % 6 log, 34.5 % 7 log, 28 % 8 log and 34.5 % C9 log at baseline. Enrollment criteria: Eligible for nucleos(t)ide analogue therapy according to the criteria of the Guideline of Prevention and Treatment for Chronic Hepatitis B (2010 version). Exclusion criteria: Pregnancy, tumor, decompensated liver cirrhosis, prior immunosuppressive agents. Adefovir (ADV) was added-on if HBV-DNA declined by \2 log at week 24. If HBV-DNA declined by [2 log, telbivudine monotherapy was continued. Results: At the end of 2 years of LdT-treatment, 69% achieved undetectability, 28 % had HBV-DNA levels B3 log. 7 of 29 patients received ADV add-on at week 24. 24 patients (82.8 %) had improvement in liver inflammation and fibrosis. Inflammation improvment rate was 95 % (19/20) in patients who achieved complete virological response (CVR) with 2-years of LdT and 55.6 % (5/9) in those who achieved partial virological response, p = 0.022,with significant difference. While fibrosis improvement rate was 90 % (18/20) and 66.7 % (6/9) respectively but without significant difference. Significantly lower HBV-DNA levels were achieved in treated patients without hepatic steatosis than in those with hepatic steatosis, p = 0.0391. All patients incurred asymptomatic elevation of CK with highest CK levels of 111–3589 U/mL, which correlated with exercise. Conclusions: In our study, patients who achieved CVR with 2-years of LdT had significant improvement in liver inflammation. Virological response in LdT-treated patients is influenced by hepatic steatosis. Further studies should evaluate strategies to manage this clinical issue.


S77 Results: A hundred and five cases were included in the study. The mean duration of follow ups was 40.57 ± 17 months. Of the 105 patients, 93 were given monoterapy (tenofovir: 19, entecavir: 30, telbuvudin: 10, lamivudin: 27, adefovir: 7) and 12 were given combination therapy (tenofovir+lamivudin: 8, lamivudin+adefovir: 4). During the treatment period, adverse reactions were developed in five patients. Rush was appeared in one patient taking adefovir and vertigo in the other patient taking entecavir. These symptoms disappeared with symptomatic treatment and the drugs were not changed. Creatinin elevation was detected in three patients. One of them was on adefovir therapy. His creatinin level elevated to 1.48 mg/dl (normal: 0.6–1.3 mg/dl) at the end of the first year. Four weeks later creatinin level reached to 1.6 mg/dl (GFR:76.87 ml/min/1.73 m2) and adefovir was changed to entecavir. After this change, creatinin decreased to 1.2 mg/ dl. The other two patients were on tenofovir therapy when elevation of creatinin was noticed. One of these patient also had haemolytic anemia and fever concomitant with mild creatinin elevation (1.3 mg/dl). However, diagnostic investigations revealed that this clinical presentation was most probably due to viral respiratory system infection. In the follow ups, creatinin level decreased to normal level, haemolytic anemia improved spontaneously and antiviral therapy continued without any problem. The third patient has been taking tenofovir for nearly 2 years when creatinin elevation was detected (creatinin: 1.7 mg/dl, GFR: 50 ml/min/1.73 m2). At follow ups, creatinin level continued to increase and reached to 2 mg/dl (GFR: 42 ml/min/1.73 m2). Gross proteinuria (4486.20 mg/24 h) developed. Tenofovir was stopped and the other causes of renal impairment were investigated. Patient continued the therapy with entecavir and a dose reduction was done. Any other causes of renal impairment was found and renal dysfunction was attributed to tenofovir. Although tenofovir was discontinued, his renal impairment persisted. Despite nearly one year past form the discontinuation of tenofovir, his creatinin level is 1.65 mg/dl which is above the normal level. In the patients taking telbuvudin, creatinin kinase (CK) elevation was the major side effect. Of the 10 patients, three had CK elevations (216, 2355 and 2996 U/L) without myalgia. Fortunately, CK improved the normal levels (\190 U/L) spontaneously in all patients without any change in the therapy. Additionally, one patient had severe nausea, vomiting and myalgia during telbuvudin therapy. The treatment of this patient had to be switched. Any side effect was detected during lamivudin and entecavir treatment. Conclusion: Antiviral drugs were safe for the long term therapy of chronic hepatitis B. However, follow ups of the renal function tests should be done carefully, especially for potentially nefrotoxic NUCs like tenofovir and adefovir.

Safety of treatment with nucleoside/nucleotide analogues in chronic hepatitis B: evaluation of ten-year period H. Bodur1, E. Akinci1, B. U. Kayaaslan1, A. T. Bastug1, S. S. Eren1, P. Onguru1, A. But1, H. Arslaner1, M.A. Yetkin1, Emsal Aydin2


1

Department of Infectious Diseases and Clinical Microbiology, Ankara Numune Education And Research Hospital, Ankara, Turkey, 2 Department of Infectious Diseases and Clinical Microbiology, Kafkas University Medical Faculty, Kars, Turkey Introduction: Optimal duration of chronic hepatitis B (CHB) is not well defined to date and currently lifelong therapy is recommended for patients treated with nucleoside/nucleotide analogues (NUCs). Thus, safety of these drugs is important for maintenance of the therapy. Methods: Side effects of NUCs during 10-year period (2002–2013) were analysed. The records of the patients were examined retrospectively from individual patient-forms.

The factors effecting virological response at week 48 in chronic hepatitis B patients under the therapy with nucleoside/nucleotide analogues H. Bodur1, E. Akinci1, A. T. Bastug1, B. U. Kayaaslan1, S. S. Eren1, P. Onguru1, A. But1, H. Arslaner1, M. A. Yetkin1, Emsal Aydin2 1 Department of Infectious Diseases and Clinical Microbiology, Ankara Numune Education And Research Hospital, Ankara, Turkey, 2 Department of Infectious Diseases and Clinical Microbiology, Kafkas University Medical Faculty, Kars, Turkey

123

S78


Table 1 Comparison of the virological response at week-48 in the patients taking NUCs Characteristics

At week-48a

P value

Virological response (%)

No response (%)

Male

54 (69)

20 (74)

Female

24 (31)

7 (26)

Mean age (years)

38 ± 12

33 ± 9

0.029

Naive

37 (47)

11 (41)

0356

Therapy with potent antivirals

52 (67)

15 (56)

0.505

Mean HBV-DNA (copy/ml)

349 9 106 493 9 106 ± 158 9 106

±158 9 106

0.009

HBV-DNA [ 107 copy/ml

29 (37)

12 (44)

0.950

0.634

Mean ALT (IU/L)

103 ± 177

122 ± 210

0.300

ALT [ 29 ULN

26 (33)

12 (44)

0.389

HBeAg positives

24 (31)

16 (59)

0.464

Histological activity index (HAI)

7±3

6±3

0.547

Fibrosis score

2±1

2±1

0.300

Compliance to the therapy

71 (91)

9 (33)

\0.001

HAI and fibrosis score were not available for 54 patients. When HAI and fibrosis score were excluded from the variables, HBeAg positives and compliance to the therapy were significantly different in univariate analysis. However, in logistic regression analysis, the only independent predictor was compliance to the therapy again Data given as n (%) or mean±standart deviation where it is appropiate

Introduction: Optimal treatment of chronic hepatitis B (CHB) is not well defined to date. This paper presents the analysis of the factors effecting the virological response at week 48 in CHB patients under the therapy with nucleoside/nucleotide analogues (NUCs). Methods: CHB cases treated with NUCs were evaluated retrospectively from the individual patient records. The diagnosis of CHB was performed by positive HBs Ag for at least six months, intermittent/ persistent elevation of ALT, positive HBV-DNA ([104 copies/ml) by PCR and/or liver biopsy showing CHB. During the therapy, HBVDNA level was measured every three months and HBV-DNA \ 300 copies/ml at week 48 was accepted as virological response. Taking the drugs regularly without an interruption was defined as compliance to therapy. Results: Totally 105 patients were included in the study. Of these patients, 67 were treated with potent antivirals (tenofovir: 19, entecavir: 30, telbuvudin: 10, tenofovir+lamivudin: 8). The other 38 patients were given lamivudin (27), adefovir (7) or lamivudin+adefovir combination (4). At the 48-week of the therapy, virological response was achieved in 78 (74.28 %) patients. The characteristics of the patients were compared statistically according to the virological response and the results of univariate analysis were presented in Table 1. When logistic regression analysis was performed to find independent factors, only compliance to therapy was found an independent predictor for virological response at the end of 48 week (RR 20, % 95 CI 7–62, p \ 0.001). Conclusion: It seems that compliance to the therapy is the most significant factor effecting virological response in the first year of the treatment with NUCs.

123

Absno: 268 A comparative study of the antiviral efficacy and safety of entecavir versus placebo in HBeAg-positive pediatric subjects with chronic hepatitis B

Gender

a


D. Kelly1, M. M. Jonas2, K. Schwarz3, M-H. Chang4, D. Oraseanu5, E. Sokal6, N. Assy7, L. Reynolds8, A. Thiry8, P. Ackerman8 1 Birmingham Children’s Hospital, Birmingham, UK, 2Boston Children’s Hospital, Boston, MA, USA, 3Johns Hopkins Children’s Center, Baltimore, MD, USA, 4National Taiwan University Hospital, Taipei, Taiwan, 5Grigore Alexandrescu Hospital for Children, Bucharest, Romania, 6Cliniques Universitaires Saint-Luc, Bruxelles, Belgium, 7Ziv Medical Center, Safed, Israel, 8Bristol-Myers Squibb, Wallingford, CT, USA

Introduction: The aim of this study was to assess the safety and efficacy of entecavir (ETV) in children and adolescents with CHB. We present the results for the primary endpoint at week 48. Methods: In this ongoing, Phase 3, comparative, randomized, doubleblind, placebo-controlled, multicenter study, nucleos(t)ide-naı¨ve children and adolescents with CHB were randomized 2:1 to receive ETV or placebo for 96 weeks. The primary endpoint was the proportion of subjects in the primary cohort (first 123 treated subjects) with combined HBV DNA \50 IU/mL and HBeAg seroconversion at week 48 (non-completer = failure). Secondary endpoints included the proportion of subjects with HBV DNA \50 IU/mL, alanine transaminase (ALT) normalization (B1 9 upper limit of normal [ULN]), HBV DNA \limit of quantitation (LOQ; 29 IU/mL), and HBeAg seroconversion at week 48. Adverse events (AEs), serious AEs (SAEs), and height and weight for age percentiles were assessed through week 48. Results: A total of 228 subjects were enrolled; 180 subjects were randomized and treated with ETV (n = 120) or placebo (n = 60). Baseline characteristics are shown in Table 1. Efficacy was assessed for subjects in the primary cohort (ETV,n = 82; placebo, n = 41). A significantly higher proportion of ETV-treated subjects achieved the primary endpoint of combined HBV DNA \50 IU/mL and HBeAg seroconversion compared with those receiving placebo. The proportions of subjects who achieved key secondary endpoints of HBV DNA \50 IU/mL, ALT normalization, and HBV DNA \LOQ were also significantly higher in the ETV group. A higher proportion in the ETV group experienced HBeAg seroconversion, although this was not statistically significant. Few subjects in either group achieved HBsAg loss (2 % in each), and one ETV-treated subject achieved HBsAg seroconversion at week 48. Among all treated subjects, SAEs occurred in 11 subjects (ETV, n = 4; placebo, n = 7); none were considered related to study drug. Two subjects, both in the placebo group, discontinued study drug due to AEs. AEs occurred in 62 % of the ETV group and 72 % of the placebo group; the most common AEs were comparable between groups. No clinically significant differences in mean height or weight z-score change were observed between ETV and placebo through week 48. Conclusions: ETV demonstrated superior antiviral efficacy to placebo in pediatric subjects with CHB, with a safety and tolerability profile that was comparable to adult subjects. These results support the use of ETV as a therapeutic option in children and adolescents with CHB.


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Table 1 Baseline characteristics and Week 48 efficacy results Baseline characteristics

ETV (n = 120)

Placebo (n = 60)

treated patients, serum level of surface antigen (HBsAg) decreased by a median of 27 % at 12 weeks of therapy. The median level of HBs antigen decrease tended to be higher in IL28B TT: 7 % in IL28B TG/ GG and 27 % in TT. The incidence of HBsAg decrease by [50 % tended to be higher in IL28B TT: 0 and 30 % in IL28B TG/GG and TT genotype. However, these differences were not statistically significant. Conclusion: The IL28B had no impact on HBV mutation or response to NUC therapy. There may be a trend for favorable response to IFN in IL28B TT genotype in chronic hepatitis B. The impact of IL28B genotype on treatment response is much smaller in chronic hepatitis B compared to chronic hepatitis C.

Median age, years (range)

12 (2–17)

12 (2–17)

Male

78 (65.0)

31 (51.7)

Median HBV DNA, log10 IU/mL, (range)

8.3 (4.9–10.0)

8.0 (4.7–9.7)

Median ALT level, U/L (range)

91.5 (28.0–401.0)

72.5 (31.0–764.0)

Week 48 efficacy resultsa

ETV (n = 82)

Placebo (n = 41)

HBV DNA \50 IU/mL and HBeAg seroconversion

20 (24.4) [p = 0.0049]

1 (2.4)

HBV DNA \50 IU/mL

38 (46.3) [p \ 0.0001]

1 (2.4)

Absno: 278

ALT normalization

55 (67.1) [p \ 0.0001]

9 (22.0)

HBV DNA \LOQ

35 (42.7) [p \ 0.0001]

1 (2.4)

Predictive value of interferon-gamma inducible protein 10 kD for HBeAg clearance and HBsAg decline during pegylated interferon alpha therapy in chronic hepatitis B patients


20 (24.4) [p = 0.11] 5 (12.2)


All data are n (%) unless otherwise stated. a

Endpoints were tested sequentially

Topic: 8 Hepatitis B - Clinical Absno: 275 Evaluation of the impact of IL28B genotype on HBV mutations and on response to antiviral treatment in chronic hepatitis B R. Osaki1, M. Kurosaki1, N. Nakakuki1, H. Takada1, S. Matuda1, S. Kaneko1, M. Muraoka1, K. Yamashita1, N. Tamaki1, N. Hattori1, Y. Yasui1, S. Suzuki1, T. Hosokawa1, K. Ueda1, K. Tuchiya1, H. Nakanishi1, J. Itakura1, Y. Takahashi1, N. Izumi 1

Department of gastroenterology, Musashino Red Cross hospital, Tokyo, Japan Background and aim: Interleukin 28B (IL28B) genotype is a major determinant of virological response to interferon based therapy in chronic hepatitis C. Moreover, mutations in HCV core region and NS5A region are related to IL28B genotype. The present study aimed to evaluate the impact of IL28B genotype on HBV mutations and on the treatment outcome of chronic hepatitis B. Method: Patients treated by nucleot(s)ide analog (NUC) (n = 145) or by interferon (IFN) (n = 57) were studied. The genotype of IL28B (rs8099917) was determined. Result: The prevalence of IL28B TT and TG/GG allele was 86 and 14 %, respectively. Unlike in chronic hepatitis C, there was no relationship between IL28B genotype and baseline clinical factors such as cGTP, AFP, LDL-Cholesterol, ALT and platelet counts in chronic hepatitis B. The IL28B genotype was not related to baseline HBV DNA level or mutations in core promoter and pre-core gene. Patients with IL28B TG/GG genotype had numerically higher incidence of advanced fibrosis (F3-4) (TG/GG 48 % vs. TT 28 %, P = 0.08). In NUC treated patients, IL28B genotype did not impact time to ALT normalization or time to HBV DNA suppression below 4.0 log IU/ml. In Peg-IFN

Ya-dong Wang, Cai-yan Zhao, Chuan Shen, Wei Wang, Wei-yan Yu, Li Zhang Department of Infectious Diseases, the Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, HeBei, China, email: [email protected] Introduction: Chronic hepatitis B (CHB) is an immune-mediated infectious disease. However, no ideal immunological markers were identified for predicting disease progression and antiviral response to date. The predictive value of interferon-gamma inducible protein 10 kD (IP-10) to pegylated interferon-alpha (Peg IFN-alpha) antiHCV therapy were identified, but to anti-HBV is unconfirmed. Materials and methods: Fifteen asymptomatic chronic HBV carriers (AsC), 30 patients with CHB, and 15 patients with HBV-related acute-on-chronic liver failure (ACLF) were enrolled in this singlecenter, open-label, prospective, cohort study from January 2010 to December 2011. Intrahepatic IP-10 mRNA and protein expression, and serum IP-10 levels were detected by real-time polymerase chain reaction (PCR) analysis, immunohistochemistry (IHC) staining, and enzyme-linked immunosorbent assay (ELISA). Meanwhile, serum IP10 changes were followed at pre-, on- and post-treatment period for 60 CHB patients receiving Peg IFN-alpha therapy. The correlation between IP-10 with inflammation activity (IA) score, ALT level, HBV DNA load, and HBsAg quantification were evaluated by univariate and multivariate regression analysis. Results: The IP-10 expressions increased gradually from AsC, CHB to ACLF patients (all P\0.05). Serum IP-10 levels were positively correlated with hepatic IA score and ALT level, but negatively with HBV DNA load and HBsAg quantification (all P \ 0.05). The CHB patients achieved HBeAg clearance or HBsAg decline [1 log10 IU/ ml had a higher pre-treatment IP-10 levels and more obviously ontreatment reduction of IP-10 than those with HBeAg persistentpositive and HBsAg decline \1 log10 IU/ml (P \ 0.05). In multivariate logistic-regression analysis, serum IP-10 level was an independent predictor of HBeAg clearance and HBsAg decline. In conclusion: IP-10 expression distinctly varies at different clinical stages of HBV infection. Higher pre-treatment serum IP-10 expression and dynamic down-regulation might be associated with an increased probability of HBeAg clearance and HBsAg decline in CHB patients during Peg IFN-alpha therapy. Keywords: Interferon-inducible protein 10 kD (IP-10), Chronic hepatitisB, Antiviral immunity, Immune injury, Predictive value.

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Topic: 8 Hepatitis B - Clinical Absno: 279 Prevalence of hepatitis B virus seromarker in long-term methotrexate treated rheumatologic diseases patients at Siriraj Hospital, Thailand Charlie Laohapand, Tawesak Tanwandee, Emvalee Aromdee Faculty of Medicine, Siriraj Hospital, Mahidol University. Bangkok, Thailand Background & objective: Hepatitis B virus (HBV) infection is prevalence in Asia. Use of immunosuppressive or chemotherapeutic agents can reactivate hepatitis even those who have cleared the virus. Methotrexate (MTX) is a first-line treatment for many rheumatologic disorders, e.g. DMARDs in rheumatoid arthritis (RA). One of the common side effects of MTX is progressive liver fibrosis, whereas the effect on hepatitis B reactivation is unknown. This study is aimed to determine prevalence of HBV seromarker in the patients who have received long-term MTX and to see whether presence of those markers effect on hepatitis outcome. Method: This is a cross-sectional study at Rheumatology clinic, Siriraj Hospital, Bangkok, Thailand. We invited all patients aged over 15 years old, who was treated with MTX more than 24 weeks. History taking, review of MTX prescription and dose during last 52 weeks, liver function tests (LFT), HBV serology, HBV DNA viral load were performed. The patients were excluded if they had been treated with biological DMARDs, drugs active against HBV, co-infection with HCV, HIV and previous diagnosis of cirrhosis from any cause or hepatocellular carcinoma. Result: A total of 117 patients were enrolled (104 females, 13 males, mean age of 50.9 ± 13.5 years). Majority of patients were diagnosed with RA (68.4 %), while the rest included SLE (15.4 %), spondyloarthopathies (11.1 %) and others (5.1 %). About a quarter of them (32/117, 27.4 %) had no previous data for HBV

Table 1 Prevalence of hepatitis B virus seromarker in chronic MTXtreated patients (N = 117) Presence of HBV seromarker data before prescribing MTX Available

85 72.6 %

HBsAg negative HBsAg positive

84 98.8 % 1 1.2 %

Not available

32 27.4 %

HBV seromarker at date of research entry HBsAg status

Negative Positive

Anti-HBs status Anti-HBc status HBV viral load among HBsAg and/or Anti-HBc positive pts. (n = 40)

a

116 99.1 % 1

0.9 %

Negative

76 65.0 %

Positive

41 35.0 %

Negative

77 65.8 %

Positive

40 34.2 %

VL \20 IU/ ml

39 97.5 %

VL 21–2000 IU/ml

1a

2.5 %

HBsAg positive, Anti-HBc positive patient with HBV viral load 452 IU/ml

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seromarker at the time MTX was started. Among 85 patients who have baseline data, only 1 (1.2 %) HBsAg positive. Average duration of treatment was 9.8 years and average MTX dose prescribed was 569.6 ± 245.9 mg during last 52 weeks. Out of 117 patients, only 1 had clinically significant hepatitis (0.85 %) and 1 was HBsAg positive (0.85 %). Hepatitis B surface antibody (AntiHBs) was positive in 41/117 (35.0 %) and Anti-HBc positive 40/117 (34.2 %). 68 patients (58.1 %) were negative for all seromarker. Only 1 out of 40 patients (2.5 %) who have any HBV seromarkers positive had HBV DNA detectable. The results are illustrated in Table 1. Conclusion: Prevalence of HBV seromarker in rheumatic patients treated with MTX in Thailand are HBsAg positive 0.85 %, which is lower than general Thai population at these age. Prevalence of AntiHBs positive 35.0 % and Anti-HBc positive 34.2 %, while absence of all HBV seromarker was 58.1 %. One case was HBsAg positive since baseline evaluation. She did not receive any treatment for HBV due to low HBV DNA viral load and no evidence of advanced fibrosis. From our study, long-term MTX use did not associate with clinical hepatitis flare in patients who are HBV seropositive, inactive disease. Disclosure: This study is supported by Siriraj Routine to Research Management Fund.

Topic: 8 Hepatitis B - Clinical Absno: 286 Outcomes of patients with acute liver failure secondary to acute or acute on chronic hepatitis B infection in NZ A. Sekra1, E. Gane1, J. Judson2 1

New Zealand Liver Transplant Unit, Auckland City Hospital, NZ, Department of Critical Care Medicine, ACH, Auckland, NZ

2

Background: Hepatitis B virus (HBV) infection is the most common cause of acute liver failure (ALF) in NZ. Outcomes of these patients in a NZ population have not been reported. Aim: To report outcomes of patients with ALF secondary to HBV infection in a single transplant centre. Methods: A prospective database of patients with HBV-ALF was maintained. ALF from acute HBV infection was defined as rapid development (\4 weeks) of coagulopathy (INR [1.5), hyperbilirubinaemia, and encephalopathy in absence of prior liver disease. Acute on chronic liver failure (ACLF) was defined as same parameters in patients with chronic HBV. Results: 35 patients were identified, 49% male, median age 41 years, 46 % Polynesian, 31 % Caucasian and 23 % Asians. All commenced on antivirals, 23 transplanted, 9 recovered and 3 died. 13 had ACLF, none were Caucasian. Transmission was vertical in 11 and early horizontal in 2. All fulfilled King’s Criteria and were listed. One died whilst waiting and remaining 12 patients were transplanted. 22 had ALF from acute HBV infection, of which 45 % were Caucasian. Route of transmission was sexual in 13, human bite in 1 and unknown in 8. Nine recovered, 2 died and 11 were transplanted. Three patients died early post transplant and 20 remain alive without HBV infection, median 7 years post-transplant. Conclusion: In patients with HBV-related ALF who meet King’s Criteria, prognosis is poor without liver transplantation. Antivirals should be commenced immediately to rescue those patients with ACLF and also to prevent recurrent HBV infection after transplantation.


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Topic: 8 Hepatitis B - Clinical Absno: 287 Hepatitis B stages of desease in first visit in all different age groups at isra university hospital hyderabad M. A. Bawany1, M. S. Memon1, M. Zaki1, A. A. Khahro1 1

hepatitis inactive carries. HCV was found in the patients of this study very poor. The result is illustrated in Fig. 1. Reference(s) European Association for the Study of the Liver*. EASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infection. J Hepatol 2012:57:167–185


Department of Medicine, Isra University Hospital Hyderabad

Introduction: HBV (Hepatitis B virus) is DNA virus and belonged with the ‘‘Hepadnaviridae’’ family which infected the humans, causing a disease of strongly infecting liver cells. Just about two billion people in the world are exposed to HBV, even as 350 million from them are infected by chronic hepatitis B (CHB). Hepatitis B virus induced disease is the 10th cause of death worldwide with 500,000 to 1.2 million deaths per year due to, cirrhosis, chronic hepatitis, and hepatocellular carcinoma (HCC). HCC is the fifth most common cancer that is accountable for 300,000 to 500,000 deaths yearly. Material and methods: This observational and descriptive study was conducted at Isra University Hospital Hyderabad during the time of January 2010 to December 2012. In this study all patients’ presentation was noted on the Performa who first visited with HBV, all age groups were included in this study. Results: All patients of this study mostly infected with HBV were with young age group with the percentage of 32.25 % between the 26–35 year. Mostly patients was found in HBV phase of chronic

HBV DISEASE STAGES occult HBV chronic hypatitis immune reactive phase chronic hepatitis inactive carrier chronic hepatitis IT phase 13.2%

0.3%

12.9%

Absno: 294 HBsAg loss in HBeAg positive and HBeAg negative patients with chronic HBV treated with entecavir : a retrospective case series I. Tuzcuog˘lu1, M. Sungur2, K. Kurt3, T. Go¨kmen3, K. Acılar3 1

Merkez Efendi State Hospital Gastroenterology Department, Manisa, Turkey, 2Merkez Efendi State Hospital Infectious diseases Department, Manisa, Turkey, 3Merkez Efendi State Hospital Pathology Department, Manisa, Turkey We retrospectively investigated our patients who have been followed up in our gastroenterology and infectious diseases clinic between 2007 and 2013. All the patients were followed up at least 6 months before therapy to ensure that they had chronic hepatitis B. Every patient had liver biopsy procedure to assess the liver pathology. Of the patients who were started entecavir treatment 130 patients had enrolled for this retrospective assesment. All the patients had continous treatment (0.5 or 1 mg/day). Of these patients 21 were HBeAg positive (13 male, 8 female) and 109 HBeAg negative patients (84 males, 25 female) with chronic HBV infection, treatment initiated starting from 2007 till 2012. All the follow-ups for liver biochemistry were done every 3 months and HBV DNA was assessed every 6 months. HBsAg was controlled yearly. Total of 6 patients have had HBsAg loss (4.6 %) (2 patients of HBeAg+, and 4 patients HBeAg). Overall, the mean time to HBsAg loss was 3 years ± 4.5 months in HBeAg(+) patients and 3.5 years ± 7.5 months in HBe Ag(-) group. In this case series, HBsAg loss was observed both in HBeAg positive patients and in HBeAg negative patients. All of the patients with HBsAg loss received entecavir as 0.5 mg. Our results are consistent with the previous reports. Therefore, it may be suggested that treatment with entecavir could be associated to HBsAg loss in a period of time, in both HBeAg positive and HBeAg negative HBV patients.

3.4%

Topic: 8 Hepatitis B - Clinical Absno: 296 HBsAg loss in HBeAg positive and HBeAg negative patients with chronic HBV treated with tenofovir disoproxil : a retrospective case series

70.3%

Fig. 1 HBV disease stages

M. Sungur1, I. Tuzcuog˘lu2, K. Kurt3, T. Go¨kmen3, K. Acılar3 1 Merkez Efendi State Hospital Infectious Diseases Department, Manisa, Turkey, 2Merkez Efendi State Hospital Gastroenterology Department Manisa, Turkey, 3Merkez Efendi State Hospital Pathology Department, Manisa, Turkey

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S82 Tenofovir disoproxil has been licensed in Turkey since 2008. We retrospectively investigated our patients who have been followed up in our gastroenterology and infectious diseases clinic between August 2008 and August 2013. All the patients were followed up at least 6 months before therapy to ensure that they had chronic hepatitis B. Every patient had liver biopsy procedure to assess the liver pathology. Of the patients who were started tenofovir disoproxil fumarate treatment 148 patients had enrolled for this retrospective assesment. All the patients have had continous treatment. Of these patients 26 were HBeAg positive (18 male, 8 female) and 122 HBeAg negative patients (94 males, 28 female) with chronic HBV infection, treatment initiated starting from 2008 till 2012. All the follow-ups for liver biochemistry were done every 3 months and HBV DNA was assessed every 6 months. HBsAg was controlled yearly. Total of 7 patients (4.7 %) have had HBsAg loss (2 patients of HBeAg+, and 5 patients HBeAg-) Overall, the mean time to HBsAg loss was 3 years ± 6.5 months in HBeAg(+) patients and 3.5 years ± 4.5 months in HBe Ag(-) group. In this case series, HBsAg loss was observed both in HBeAg positive patients and in HBeAg negative patients. Our results are consistent with the previous reports. Therefore, it may be suggested that treatment with tenofovir could be associated to HBsAg loss in a period of time, in both HBeAg positive and HBeAg negative HBV patients.

Hepatol Int (2014) 8:S1–S405 0.81 ± 0.75, 0.83 ± 0.68, and 0.91 ± 1.48 log IU/mL for patients in group A, B, and C respectively, and the difference among groups were not significantly (P = 0.269). In this cohort, 62.5 % (10/16) in group A obtained undetectable HBV DNA; and subgroup analysis showed that the difference in serum qHBsAg between patients with detectable or undetectable HBV DNA were not significan (0.77 ± 0.32 vs. 0.75 ± 0.76 log IU/mL, P = 0.698). Conclusion: LAM or LdT add-on therapy could not induce more qHBsAg decline for patients with suboptimal response to ADV, even achieved undetectable HBV DNA. Acknowledgement: This work was supported by grants from the National Twelve-Five Project of China (2012ZX10002007-001-003 and 2013ZX10002001).

Topic: 8 Hepatitis B - Clinical Absno: 307 The association between serum hepatitis B surface antigen titer and liver fibrosis in chronic hepatitis B Ling-bo Liang1,2, Hong Tang1,2, En-Qiang Chen1,2, Xia Zhu1,2, Li-bo Yan1,2, Ling-yao Du1,2

Topic: 8 Hepatitis B - Clinical Absno: 301 Lamivudine or telbivudine add-on therapy could not induce more hepatitis B surface antigen decline in chronic hepatitis B patients with suboptimal response to adefovir dipivoxil En-Qiang Chen1,2, Hong Tang1,2, Lang Bai1,2, Tao Liang1,2, Ling-Yao Du1,2, Lan-Lan Chen1,2, Cui-Ping Liu1,2 1

Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China, 2Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China Aim: Nucleos(t)ides combination therapy effectively inhibit HBV DNA replication but on quantitative hepatitis B surface antigen (qHBsAg) titer is not yet clear. This study aimed to determine whether add-on of lamivudine (LAM) or telbivudine (LdT) to an ongoing adefovir dipivoxil (ADV) accelerates decline of qHBsAg in chronic hepatitis B patients with poor response to naı¨ve ADV monotherapy. Methods: In this study, the antiviral strategies were adjusted according to viral response at years 2 of ADV monotherapy. Patients with poor viral response to ADV and switching to add-on therapy were defined as group A; patients with poor viral response to ADV but no treatment adjustment were defined as group B; and patients with viral response to ADV and continuing ADV monotherapy were defined as group C. The dynamics of quantitative serum HBsAg were compared among groups. Results: A total of 51patients were included in this study, with 16 patients in group A, 10 patients in group B and 25 patients in group C. The demographic and clinical characteristics prior to naı¨ve ADV monotherapy were comparable between groups, and the absolute level of qHBsAg after 2 years of naı¨ve ADV monotherapy were also similar in group A (3.30 ± 0.47 log IU/mL), B (3.17 ± 0.34 log IU/ mL) and C (2.78 ± 1.40 log IU/mL) (P = 0.184). Two years after treatment adjustment, the declines of serum qHBsAg were

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1 Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China, 2Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, Sichuan Province, China, email: [email protected]

Background: There are few data on the relationship between serum HBsAg titer and liver fibrosis. The present study aims to explore the correlations between serum HBsAg titer and liver transient elastography as well as historical fibrosis score. Methods: There were 202 treatment naı¨ve chronic hepatitis B patients participated in the study. All patients accepted liver transient elastography and 119 of them accepted liver biopsy. Serum HBsAg level, serum HBV DNA level, HBV genotypes, liver stiffness measurement (LSM) value detected by transient elastography, histological fibrosis staging by METAVIR classification were detected. Results: Inverse correlations were found between log10 HBsAg and LSM value (r = -0.425, P \ 0.001) as well as fibrosis staging (r = -0.331, P \ 0.001) in HBeAg positive patients. No correlation was found between HBsAg and LSM value in HBeAg negative patients (r = -0.054, P = 0.719). HBeAg positive patients with fibrosis score \F2 (4.5 ± 0.7) had significantly higher log10 HBsAg than patients with fibrosis score C F2 (3.7 ± 1.2, P \ 0.001). The differences between HBsAg levels in patients with fibrosis scores \F2 and CF2 were not statistically significant in HBeAg negative patients (P = 0.243). HBsAg titer achieved an AUC of 0.716 (P = 0.003, 95 % CI 0.593–0.840) in predicting liver fibrosis score \F2, with a cut-off value of 10318 IU/ml, positive predictive value of 75.2 % and a negative predictive value of 73.3 %, respectively. Serum HBsAg titer [10318 IU/ml correlated with liver fibrosis score \F2 independently (P = 0.003, odds ratio 37.8, 95% CI 3.41–419.2). Conclusions: Inverse correlations were found between HBsAg titer and liver fibrosis in HBeAg positive phase. A high HBsAg titer could be supportive of mild or no liver fibrosis. Acknowledgement: This work was supported by grants from the National Twelve-Five Project of China (2012ZX10002007-001-003 and 2013ZX10002001).


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Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, Sichuan Province, China

Absno: 310

Aim: Long-term benefits are limited by the emergence of drugresistant virus. However, the effect of interferon alpha treatment on these drug-resistant viruses was unknown. This study was to examine the effect of polyinosinic-polytidylin acid (poly-IC) which was the interferon inducer inhibit different drug resistance HBV mutants in HBV transfected mice. Methods: The drug-resistant plasmids (lamivudine/telbivudine resistance (LAMr), adefovir dipivoxil resistance (ADVr) and entecavir resistance (ETVr) mutants were constructed by using the pHBV 4.1 (wild-type HBV) as a template. Wild-type or drug-resistant mutants HBV replication-competent mice were firstly established. Twenty-four hours later, mice were treated with poly-IC or phosphate-buffered saline (PBS) via intraperitoneal injection 3 times at 24 h intervals. The HBV DNA replication intermediates (RI) in the liver were analyzed. Result: Poly-IC inhibit HBV replication and increased the level of 2’,5’-oligoadenylate synthase (2OAS) mRNA transcripts which is a known maker of IFN-a/binduction. Between wild-type and the drugresistant mutants groups, the level of HBV DNA RI was significantly decreased in the most of mutants groups and similar in the rtM204V+L180M+V173L,rtA181T, rtA181V and rtA181V+N236T groups compared to the wild-type group. After poly-IC treatment, the decreasing of HBV RI was similar between the LAMr, ADVr and the wild-type groups; however, there were no obviously changes in the ETVr groups. Conclusion: The capacity of HBV replication and sensitive of interferon therapy was influenced by the position of mutations in the RT region. The interferon therapy may effective inhibit HBV replication in the patients with LAMr and ADVr mutation. The ETVr mutation showed resistant to the interferon therapy.

Digital gene expression profile of mouse liver with fulminant hepatic failure induced by lipopolysaccharide/d-galactosamine En-Qiang Chen1,2, Hong Tang1,2, Lang Bai1,2, Ling-Yao Du1,2, Lan-Lan Chen1,2 1 Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China, 2Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, Sichuan Province, China

Aim: The precise gene expression profile and their interactions association with FHF are yet to be further elucidated. This study aimed to reveal the digital gene expression profile (DGEP) of FHF mouse liver by high-throughput sequencing,and search for potential therapeutic targets to the prevention and treatment of FHF. Methods: Liver tissue samples were obtained 6 h after intraperitoneal injections of d-Galactosamine/lipopolysaccharide,and the Solexa/ Illumina RNA-seq and digital gene expression technology was employed to analyze the global gene expression profile in normal and FHF mouse liver by DGEP method. And real-time polymerase chain reaction, western blot, enzyme linked immunosorbent assay and immunohistochemical methods were used to analyze expression of candidate molecules expression in serum and liver tissues of FHF mouse model. Results: Totally 12727 genes were detected, and 3551 genes were significantly changed in FHF mouse liver. Biological process analysis showed that the DEGs in FHF mouse liver were mainly enriched in metabolic processes, biosynthetic process, response to stimulus and response to stress. Similarly, KEGG pathway analysis showed that metabolic pathways, apoptosis and chemokine signaling pathways were the major pathways altered in FHF mouse liver. Considering the important role of nuclear factor-kappa B (NF-jB) in metabolic regulation and delicate balance between cell survival and death, several DEGs involved in NF-jB pathway were selected for experimental validation. As compared to normal control, NF-jBp65 and its inhibitory protein IjBa were both significantly increased, and NF-jB targeted genes including tumor necrosis factor (TNFa), inducible nitric oxide synthase (iNOS), interleukin-1b, chemokines CCL3 and CCL4 were also increased in hepatic tissues of FHF. In addition, after NF-jB was successfully pre-blocked, there were significant alteration of hepatic pathological damage and mortality of FHF mouse model. Conclusion: Our findings provide the globe gene expression profile of FHF mouse liver, and demonstrates the possibility of NF-jB gene would be a potential therapeutic target for FHF.

Topic: 8 Hepatitis B - Clinical Absno: 312 The effect of poly-IC inhibit drug resistance HBV mutants replication in vivo Qiao-Ling Zhou1,2, Hong Tang1,2, Lan-Lan Chen1,2, En-Qiang Chen1,2, Cui-Ping Liu1,2 1

Center of Infectious Diseases, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China, 2Division of

Topic: 8 Hepatitis B - Clinical Absno: 314 Vitamin D deficiency predicts clinical events in patients with HBeAg-negative chronic hepatitis B Grace Lai-Hung Wong1,2, Henry Lik-Yuen Chan1,2, Chi-Hang Tse1,2, Hoi-Yun Chan1,2, Vincent Wai-Sun Wong1,2 1 Institute of Digestive Disease, 2Department of Medicine and Therapeutics, The Chinese University of Hong Kong

Introduction: We studied serum vitamin D3 [25(OH)D3] level could predict long-term clinical outcomes in patients with negative hepatitis B e antigen (HBeAg). Materials and methods: This was a prospective cohort study of 103 patients with HBeAg-negative chronic hepatitis B recruited since 1997. Serum 25(OH)D3 level was measured at baseline. Patients were prospectively followed up to monitor for clinical events namely hepatocellular carcinoma (HCC), hepatic events, and deaths. Results: Their mean age was 46 ± 12 years, and 70 patients (68 %) were males; baseline serum HBV DNA and 25(OH)D3 level was 4.17 ± 1.67 log10 IU/ml and 25.8 ± 9.2 ng/ml respectively. Twentyone patients developed clinical events at a median follow-up duration of 104 ± 26 months. Patients developed clinical events had lower baseline serum 25(OH)D3 level (22.6 ± 10.0 vs. 28.8 ± 8.7 ng/ml) compared those did not. Low baseline serum 25(OH)D3 and clinical events were two independent risk factors of clinical events. Whereas baseline serum 25(OH)D3 level did not correlate with any clinical and virological parameters. Patients with insufficient baseline serum

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Hepatol Int (2014) 8:S1–S405 Results: Table 1. Conclusions: Consistent with what is being reported by others, in our study, LdT was well tolerated during pregnancy. Furthermore, LdT yields potent antiviral and laboratory effects and most importantly did not exert harmful effects on the newborn baby.

Topic: 8 Hepatitis B - Clinical Absno: 324 Polyclonal B-cell activation in chronic hepatitis B induced by IL-21-producing circulating CXCR5+CD4+ T cells Juanjuan Zhao, Xiangsheng Xu, Zheng Zhang, Xinyue Chen, Fu-Sheng Wang Fig. 1 Kaplan–Meier analysis of cumulative incidence of a clinical events, b HCC, c hepatic events and d deaths in patients with or without vitamin D deficiency 25(OH)D3 level (\30 ng/ml) had significantly higher risk of any clinical events, HCC, hepatic events and deaths (Fig. 1a–d). Conclusion: Vitamin D deficiency is associated with poor clinical outcomes in patients with HBeAg-negative chronic hepatitis B.

Topic: 8 Hepatitis B - Clinical Absno: 315 Efficacy and safety of telbivudine among pregnant women with chronic hepatitis B: an observational case series Mohammad GolamAzam1 1

Dept. of Gastroenterology and Hepatology, BIRDEM General Hospital, Dhaka, Bangladesh, email: [email protected] Background/aim: The management of chronic hepatitis B (CHB) during pregnancy is a unique challenge. Reducing the hepatitis B virus (HBV) load in pregnant women can minimize the transmission rate to the newborn. The aim of our study was to evaluate the safety and efficacy of telbivudine (LdT) in this at risk patient population. Methods: A total of 14 pregnant women were observed during pregnancy and post delivery period after completing at least 1 year of treatment with LdT 600mg/day in a tertiary care liver clinic in Dhaka, Bangladesh during the period of 2009–2012. CHB patients with high HBV-DNA levels, HBeAg-positive or –negative and had ALT measures of any value were enrolled during the third trimester of pregnancy. Baseline characteristics were as follows: age years, mean ± SD = 28 ± 4; Serum ALT U/L, mean ± SD = 77 ± 21; HBeAg-positive (N = 5); HBV-DNA, log copies/mL= 9.7 ± 2.1 (mean ± SD). Table 1 Clinical outcomes Baseline, N = 14

At 6 months, At 12 months, N = 14 N = 14

Serum ALT, IU/L, (mean ± SD)

77 ± 21

56 ± 18

44 ± 15

HBV DNA, copies/mL (mean ± SD)

9.7 ± 2.1

2.7 ± 1.5

All are \300 copies

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Research Center for Biological Therapy, Beijing 302 Hospital, Beijing 100039, China Background: Autoimmune extrahepatic manifestations, though they occur less frequently than in HCV infection, may be observed in patients with chronic HBV infections. Follicular helper T cells (Tfh) play an important role in the pathogenesis of autoimmune diseases, however, it remains unknown whether Tfh cells contribute to the autoimmune tendency in CHB patients. Methods: The frequency, phenotype and function of peripheral B cell subsets and CXCR5+CD4+ T cells from CHB patients in different phases: immune tolerance (IT), HBeAg positive patients with chronic hepatitis B (CHB), responders with HBsAg seroconversion (RP), and healthy controls (HC) were comprehensively investigated. Results: The CHB patients displayed lower percentages of peripheral blood memory B cells versus other groups. An overall polyclonal activation of B cells, indicated by higher levels of activation markers and secretion of IgG and IgM, was observed in CHB patients. In addition, CXCR5+CD4+ T cells were also inceased in CHB patients, which was positively correlated with polyclonal activation of B cells. Of note, expression of activation markers and IgG/IgM secretion of B cells was induced by circulating CXCR5+ CD4+ T cells and B cell activation was abrogated by blockade of IL21 signal. Additionally, circulating CXCR5+CD4+ T cells shared similar phenotypic markers to Tfh cells compared with CXCR5CD4+ T cells. Notably, both polyclonal activation of B cells and increased CXCR5+CD4+ T cells were partially reversed in RP patients compared with CHB patients. Conclusions: Increased CXCR5+CD4+ T cells contributed to B cell hyperactivation in patients with chronic HBV infection.

Topic: 8 Hepatitis B - Clinical Absno: 326 The early renal injury in patients with chronic HBV infection and affecting factors Li Hai1, Han Tao2, Li Yan2, Chen Lin-yan1, Wang Yu-lin1, Zhu Li-min1 1

Department of Hepatopancreatobiliary and Splenic Medicine, Affiliated Hospital of Logistical College of Chinese People’s Armed Police Force, Tianjin 300162, China P.R., 2Tianjin Third Central Hospital, Jintang Road 83, Hedong District, Tianjin 300170, China P.R.

Hepatol Int (2014) 8:S1–S405 Background: Clinically, hepatitis B virus (HBV) infection is observed to be associated with nephropathy. Comorbidities or antiviral treatment might further increase renal risk, therefore regular monitoring of renal function is recommended. The well established formulae using serum creatinine for the calculation of glomerular filtration rate (eGFR) are validated only for patients with substantially impaired renal function and not for monitoring patients with normal renal function. There is limited data of early renal injury evaluated in patients with chronic hepatitis B virus infection. Methods: This was a multicentre retrospective observational study conducted in two hospitals located at Tianjin China, over a time period between April 2012 and June 2013. The study included 90 patients with chronic hepatitis B virus infection who never receive antiviral treatment. Based on the hepatitis status, they were divided into three groups named of chronic hepatitis, liver cirrhosis and hepatic carcinoma. Patients were assessed for early renal injury by urinary albumin, urine transferrin, urine IgG, and serum b2 microglobulin, and the informations of patients were also be collected for diagnosis, serum creatinine, eGFR and other laboratory datas. According to clinical characteristics the differences were compared among the three groups of various lab results of patients. Moreover, Logistical regression analysis was conducted to determine the association between early renal injury and the following variables: age, gender, comorbidities (diabetes and hypertension), and chronic disease stages. Results: Creatinine levels in all subjects were in normal range, but the abnormal rate of albumin, transferrin, IgG in urine, or serum b2 microglobulin is much higher than that of eGFR (72.2 vs. 12.7 %, v2 = 56.25, P = 0.000). The proportion of early renal injury is different in different status of chronic hepatitis B virus infection. Among those lab results, urinary transferrin levels in patients with chronic hepatitis, cirrhosis and liver cancer were 1.91 ± 1.06, 2.66 ± 3.01, 6.73 ± 8.32 mg/L (v2 = 7.671, P = 0.001) respectively; abnormal rate of urine IgG were 4/30 (13.3 %), 15/29 (51.7 %), 11/30 (36.7 %), F = 10.39, P = 0.006; and the abnormal cases of blood b2 microglobulin were 10/30 (33.3 %), 18/29 (62 %), 23/30 (76.7 %), F = 12.75, P = 0.00 in three groups respectively. By Logistical regression analysis, the patients’ age and disease status are independent risk factors accompany with early renal function abnormalities in patients with chronic HBV infection. Conclusions: There is very high proportion of early renal injury in patients with Hepatitis B virus infection rather than eGFR. Age and disease status are the main factors affecting such abnormalities. It is necessary to assesse early renal injury before the drug selection of antiviral treatment.

Topic: 8 Hepatitis B - Clinical Absno: 329 Peg-interferon alfa-2a improved the response of chronic hepatitis B patients resistant to nucleotide analogues Y. H. Liu, D. Pen, W. K. Li, Y. R. Du, L. X. Chang, T. Jia, L. Liu, H. M. Li Liver Unit 3, the Third People Hospital, Kunming, Yunnan,China Background and objectives: Long term treatment with nucleotide analogues may have resistance risk, which have an impact on efficacy and even lead to disease progression. The aim of this study is to investigate whether peg-interferon alfa-2a can improve the response of HBeAg(+) chronic hepatitis B (CHB) patients resistant to nucleotide analogues compared with that of nucleotide analogues continuous treatment.

S85 Methods: 25 HBeAg(+) CHB patients resistant to lamivudine, adefovir, entecavir or telbivudine were recruited in the outpatients department, which were changed to combination treatment with peg-interferon alfa2a and nucleotide analogues without cross resistance. Meanwhile, 31 HBeAg(+) CHB patients resistant to nucleotide analogues were also recruited in the same outpatients department, which were changed to nucleotide analogues without cross resistance as control group. Results: The baseline ALT and HBV DHA levels in peg-interferon alfa-2a combination group were higher than that of nucleotide analogues group (ALT: 131.8 vs. 61.7 U/L; HBV DNA: 6.2 vs. 5.1 log10 copies/ml), but age, gender and previous treatment duration of nucleotide analogues were comparable between the two groups (age: 25 vs. 31; M/F: 21/4 vs. 20/11; treatment duration: 2.4 vs. 2.5 years). At the end of the trial, all the patients in peg-interferon alfa-2a combination group stopped the therapy (mean therapy duration: 104 weeks, follow-up 115 weeks). The HBV-DNA negative rate (92 vs. 67.7 %, p = 0.0279), HBeAg serum conversion rate (48 vs. 12.9 %, p = 0.0039), HBsAg clear rate (16 vs. 0 %, p = 0.0344) and HBsAg serum conversion rate (16 vs. 0 %, p = 0.0344) in peg-interferon alfa2a combination group were significantly higher than that of nucleotide analogues continuous group. The rate of sustained HBeAg seroconversion post-treatment was 91.7 %. Conclusion: The combination of peg-interferon alfa-2a and nucleotide analogues without cross resistance is a effective option to improve the response of CHB patients with resistance and realize consistent response after termination.

Topic: 8 Hepatitis B - Clinical Absno: 331 Management of chronic hepatitis B cases with normal ALT and [2000 IU/mL HBV-DNA: when do we perform liver biopsy? H. Pullukçu1, T. Yamazhan1, B. Kurtaran2, A. S. Inal2, M. Tasbakan1, O. R. Sipahi1, S. Ulusoy1 1

Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Bornova, Izmir, Turkey, 2 Department of Infectious Diseases and Clinical Microbiology, Cukurova University Faculty of Medicine, Adana, Turkey Introduction: It is known that many HBsAg-positive/HBeAg-negative patients may show normal alanine aminotransferase (ALT) levels. However, two different scenarios exist: inactive HBV carriers and patients with chronic hepatitis B (CHB) with high HBV-DNA level ([2000 IU/mL). The CHB patients who have high HBV-DNA levels may have severe liver damage. The issue of liver biopsy in HBeAgnegative CHB with persistently normal ALT activity has always been a debate. It is widely accepted that liver biopsy is not required in such patients with HBV DNA \2000 IU/mL, while HBeAg-negative patients with HBV-DNA [2000 IU/mL appear to represent a controversial group. But there is no consensus about when the biopsy should be done. In this study we evaluated that management of these patients in whom liver biopsy was performed and revealed liver damage. Materials and methods: We retrospectively evaluated hospital records of 480 chronic HBV cases who were performed liver biopsy, between 2008 and October 2013 and retrieved demographic data (age and gender), HBV-DNA levels, HBeAg/antiHBe status, biopsy scores (Ishak) and therapy of cases who had normal ALT level (four times in a year in 3 month intervals) and HBV-DNA [2000 IU/mL. Results: A total of 98 cases (47 female, 51 male, aged 43.7 ± 9.83, min 18, max 69) who fulfilled the study inclusion criteria were included in the study. All cases but three were antiHBe positive. Mean HBV-DNA

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S86 level was 9769000 ± 42829100 IU/mL (min: 1834, max: 2970000000). Fibrosis scores were as follows: F0: 36 cases, F1: 38 cases, F2: 14 cases, F3: 5, F4: 3 cases, F5: 1case, F6: 1 case. Thirteen cases had hepatic activity index (HAI) score of C7. A total of 27 cases (27.5 %) were started antiviral therapy (5 PEG-interferon, 6 lamivudin, 9 telbivudin, 3 tenofovir, 9 entecavir, 1 case did not follow-up). When we evaluated only cases aged[40 (67 cases), nineteen patients (28.3 %) were started antiviral therapy whereas 23 of 85 cases (%27) aged [35 received antiviral therapy (p \0.05). Five of six cases whose liver biopsy were normal and were performed repeat biopsy three years later, were started antiviral. Of all patients who underwent biopsy (older than 35 years group and older than 40 years group), there is no statistical significant difference between men and women (p \0.05). Conclusion: These data suggest that performing liver biopsy in cases aged [35 and HBV-DNA[2000 IU/mL may be useful for evaluating HAI and fibrosis score and starting therapy in cases with high HAI and/ or fibrosis score.

Hepatol Int (2014) 8:S1–S405 four HCV RNA tests were positive. There was no hepatitis B and C co-infection. Seven (%4,3) had positive HEV serology among 163 patients who tested. Anti -rubella Ig G was positive 305 (%95) of 319 tested patients and anti-rubeola Ig G was detected at 25 (%83,4) of 30 patients who checked. Seventeen patients (%4,5) of 371 patients who looked for were anti-CMV Ig G positive. For VDRL, two of 104 patients were positive. Moreover, TP Ig G+M were asked to 56 patients and only one patient had positive result. Conclusion: People who planning pregnancy must be checked for viral hepatitis and TORCH infections in countries with moderate endemicity for hepatitis B like our country. Rational serology testing and multidisciplinary approach is necessary to interpret results right and to manage patients. Additionally, the country’s economy as well as public health.

Topic: 8 Hepatitis B - Clinical Topic: 8 Hepatitis B - Clinical Absno: 338 Absno: 335 Screening for hepatitis and viral infections in a significant risk group

Assessment of liver volume in patients with hepatitis B virusrelated liver cirrhosis during long-term oral nucleos(t)ide analogues therapy

M. Yamazhan1, S. Uysal2, M. Soylar3, A. Akdogan4, G. Sahin4, E. Tavmergen4, M. Tasbakan2, H. Pullukcu2

Chang Hun Lee, In Hee Kim, Jin Chang Moon, Seong Hun Kim, Sang Wook Kim, Seung Ok Lee,Soo Teik Lee, Dae Ghon Kim

1

Division of Gastroenterology, Department of Internal Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea

Tepecik Maternity and Research Hospital, Izmir, Turkey, Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Bornova, Izmir, Turkey, 3 Department of Clinical Microbiology, Ege University Faculty of Medicine, Bornova, Izmir, Turkey, 4Department of Obstetrics and Gynecology In Vitro Fertilization Unit, Ege University Faculty of Medicine, Bornova, Izmir, Turkey 2

Introduction: Each visit for outpatient clinics should be considered an opportunity to detect viral infections particularly in high risk populations. Serological tests for viral hepatitis and TORCH infections must be evaluated at people who planning pregnancy. According to the results, necessary managements can be planned. We aimed to screen viral hepatitis and TORCH infections at patients admitted to in vitro fertilization department of our hospital. Materials and methods: The patients admitted to In Vitro Fertilization Unit at Ege University Faculty of Medicine were searched retrospectively for serological tests for viral hepatitis, syphilis, rubella, rubeola and CMV between 01.01.2005 to 05.01.2013. Results: Mean age of patients included in the study is 39.50 (±9.6). Serological tests were asked for total 1664 patients. HAV, HBV, HCV serology asked 534, 1373, 1215 patients, respectively. In evaluating hepatitis A serology, anti-HAV IgG was positive in number of 468 (%87.6). Anti-HAV IgM serology asked also 461 of these patients unnecessarily. At patients who took Hepatitis B serology, HBsAg, anti-HBc, anti-HBs were positive number of 43 (%3, 1), 95 (%6.9), 289 (%21) respectively. Although, anti-HBe was positive at 29 (2.1 %) people, HBeAg was detected at none of patients. The rate of immune patients by past HBV infection was 4.7 % (64), moreover this rate was %5 (69) by vaccination. In 156 patients, only HBsAg and anti-HBs tests were looked for, so immunization by past hepatitis B infection or vaccination could not be decided. Forty-three (3.1 %) patients had positive serology for chronic hepatitis B or C infection among 1215 patients who tested. Twenty-four (1.9 %) patients were anti-HCV positive. Furthermore, two Western Blot and

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Background: Oral nucleos(t)ide analogues (NUCs) are known to suppress hepatitis B virus (HBV) replication effectively and reduce disease progression of liver cirrhosis. This study aimed to assess effect of long-term oral NUCs therapy on liver volume in patients with HBV-related liver cirrhosis. Material and method: We reviewed data from naı¨ve patients with HBV-related liver cirrhosis who started oral NUCs therapy from 2003 to 2007 in Chonbuk University Hospital. Two consecutive sets of abdominal CT scan at the time of treatment (±3 months) and 2 year follow-up (±6 months) were used. Liver volume was calculated by liver extraction measurement program Dr. Liver (version 04.2013, POSTECH Inc., Korea). And estimated standard liver volume (SLV) was also calculated. Results: Totally 55 patients (34 for male, 21 for female) were included. There was 114.3 ± 167.8 mL (12.9 ± 17.9 %) of increase in liver volume during two year of NUCs therapy (993.8 ± 242.8 mL at baseline vs. 1108.1 ± 263.3 mL at 2-year follow-up, p \ 0.001). The estimated SLV was 1436.0 ± 170.2 mL and measured liver volume was improved from 70.8 to 78.0 % of estimated SLV during the two year of treatment period. Liver volume increase was more significant in patients with decompensated cirrhosis (p \ 0.001) than those with compensated cirrhosis (p = 0.046). Significant factors for volume increases were as follows: CTP grade improvement, MELD score improvement [5 and no virological breakthrough during treatment period. In multiple linear regression analysis, delta albumin (y = 105.006x + 31.820, p = 0.002) and delta ALT level (y = 0.388x + 0.131, p = 0.005) showed significant correlation with increase in liver volume (R2 = 0.347). Conclusions: Long-term oral NUCs therapy in patients with HBVrelated liver cirrhosis significantly increased liver volume. Significant variables correlated with increase in liver volume were delta albumin and delta ALT level.


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Absno: 339

Absno: 343

Estimation of serum hepatitis B virus covalently closed circular DNA (HBV cccDNA) during treatment with potent antiviral agents

Improvement of hepatic fibrosis in a chronic hbv infected patient with juvenile rheumatoid arthritis: a case report ¨ lçay1, Hu¨srev Diktas¸ 2 Ergenekon Karago¨z1, Asım U

1

1

2

1

3

Y. K. Chawla , B. Singla , A. Chakraborti , A. Duseja , A. Das , R. K. Dhiman1 1

Department of Hepatology, Post Graduate Institute of Medical education & Research, Chandigarh, India, 2Department of Experimental Medicine & Biotechnology, Post Graduate Institute of Medical education & Research, Chandigarh, India, 3Department of Histopathology, Post Graduate Institute of Medical education & Research, Chandigarh, India Background & aim: Monitoring of HBV cccDNA levels can provide a direct indication of HBV activity in the liver of HBV infected patients. The main obstacle for serial monitoring of HBV cccDNA during treatment is the non availability of liver tissue samples. Earlier studies have shown the presence of HBV cccDNA in sera of HBV infected individuals. Hence, we attempted to determine the effect of newer potent antiviral agents (tenofovir & entecavir) in reducing this molecular form of HBV DNA in serum samples of chronic hepatitis B (CHB) patients. Materials & methods: Total 69 CHB patients were recruited for the present study from January 2009 to June 2011. Blood samples were obtained from all recruited subjects (30 tenofovir; 39 entecavir) before and during the treatment and 17 baseline synchronous liver biopsies were collected. Real time PCR was performed to determine the levels of total HBV DNA and cccDNA. Results: The baseline levels of total intrahepatic HBV DNA and intrahepatic HBV cccDNA ranged from 0.09–1508.92 copies/cell and 0.06–1.63 copies/cell, respectively. The range of serum cccDNA was 530–73500 copies/ml in HBeAg negative patients, while it was 4670–730000 copies/ml in HBeAg positive subjects. The rate of baseline serum HBV cccDNA detection was 84 and 45.5 % in HBeAg positive and negative patients, respectively. After 6 months of treatment, serum cccDNA was detectable in 2 HBeAg positive cases (1 entecavir; 1 tenofovir) and one HBeAg negative subject (entecavir), while the serum HBV DNA was detectable in 9 HBeAg positive patients (8 tenofovir; 1 entecavir) and 12 HBeAg negative patients (3 tenofovir; 9 entecavir). Only one patient showed the presence of serum cccDNA after 1 year treatment. There was approximate 4 log decrease in serum HBV DNA after 6 months of treatment with given antiviral drugs. A significant negative correlation (r = -0.706, p = 0.010) was observed between serum globulin levels and necroinflammatory score in HBeAg negative patients. Baseline serum cccDNA was found to correlate positively with baseline serum HBV DNA levels (r = 0.862, p \ 0.001) and intrahepatic total HBV DNA levels (r = 0.899, p \ 0.001) after combining all enrolled patients, while we observed significant association of serum cccDNA with intrahepatic cccDNA (0.899, p = 0.025) in HBeAg negative patients. Moreover, there was significant positive correlation between levels of intrahepatic total HBV DNA and intrahepatic cccDNA in all liver tissue samples (r = 0.578, p = 0.015). Conclusion: Serum cccDNA can be detected in presence of high serum HBV DNA and predominantly observed in HBeAg positive patients. It becomes undetectable in majority of patients after 6 months of antiviral treatment. Estimation of baseline serum cccDNA can avoid the need of baseline liver biopsy for measuring intrahepatic cccDNA.

1

GATA Haydarpas¸ a Training Hospital, Department of Infectious Diseases and Clinical Microbiology-Istanbul-TURKEY, 2Tatvan Military Hospital Bitlis-TURKEY Introduction: Hepatitis B virus (HBV) infection is the most common chronic viral infection which affects the liver around the world with over 350 million people . It is known to be the leading cause of cirrhosis and hepatocellular carcinoma. Reactivation of HBV replication in patients undergoing immunosuppressive therapy is a frequently reported complication of considerable clinical importance. These cases have been mostly reported from the fields of hematooncology and transplantation units, yet there have been also some cases reported in patients with rheumatical disease undergoing immunosuppressive therapy and from other fields such as hematology and endocrinology units as well. Treatment of all HBsAg positive patients should be started with prophylactic antiviral drugs before receiving immunosuppressive therapy including corticosteroids to avoid them from reactivation leading to serious complications such as liver failure and even death. We present a case of a 24-year old chronic HBV patient with JRA whose liver enzymes elevated while he was under immunosuppressive therapy. Case presentation: A 24 year old man visited infectious diseases outpatient clinic with complaints of weakness,fatigue and elevated liver enzymes. Poor oral intake was evident for one week. He was previously diagnosed with JRA at 2008. Until that time, he made regular visits to the outpatient physical medicine and rehabilitation department. Firstly, he was administrated corticosteroid (deflazocort 30 mg 1 9 1) treatment for 2 weeks and DMARD therapy(metotrexate 2.5 mg 1 9 4/weekly, leflunamide 100 mg/20 mg 1 9 1, respectively). After 4 weeks of DMARD therapy, his body temperature elevated to 38.5 C and uveitis attack was alsorevealed. Secondly, his treatment was altered with Adalimumab 40 mg (subcutaneously once to 2 weeks). After switching to antirheumatic drugs, his liver enzymes elevated 7 times to its upper limit. In his laboratory; ALT:280 U/L, AST:88 U/L HbsAg: positive, AntiHBcIgG: positive, HBV DNA: positive (8.000.000 IU/ml). His HbsAg carriage status was detected 4 years ago before receiving immunosuppressive treatment. Antiviral treatment didn’t started because HbsAg positivity was overlooked by the doctors of physical medicine and rehabilitation department (BUNU ÇIKARTABI˙LI˙RI˙ Z BELKI˙). After these laboratory results, liver biopsy was performed. In pathological examination; histology activity index (HAI) score was 7/18 and fibrosis score was found to be 3/6 according to ISHAC score. Entecavir 0.5 mg 1 9 1 therapy was initiated for the patient and follow-up visits at infectious disease and physical medicine and rehabilitation department were scheduled. After 3 years starting this therapy, his laboratory results were normal. Control liver biopsy was performed and histological improvement was observed (HAI:0/18, Fibrosis score:0/6) in the pathologI˙cal examination. Conclusion: Defining the HBsAg carriage and reactivation of chronic hepatitis b status before the immunosuppressive therapies is an important point which affected the state of theraphy. Moreover, utilization of entecavir in immunosuppresiive chronic HBV patients provides histological improvement and regression of fibrosis.

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Hepatol Int (2014) 8:S1–S405 Conclusion: This specific HB vaccination trial for children with prenatal HBV infection has the potential to alter the immune tolerance to HBV.

Topic: 8 Hepatitis B - Clinical Absno: 344 Hepatitis B (HB) vaccine therapy for children with prenatal HB virus infection Kentaro Iwasawa1, Ayano Inui1, Takeo Kondo1, Tomoyuki Tsunoda1, Manari Kawamoto1, Tsuyoshi Sogo1, Haruki Komatsu2, Tomoo Fujisawa1 1

Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Japan, 2Department of Pediatrics, Sakura Hospital, Toho University School of Medicine, Japan Background: Vaccination against hepatitis B virus (HBV) infection in infants born to hepatitis B surface antigen (HBsAg)-positive mothers by HB immunoglobulin (HBIG) and hepatitis B (HB) vaccine was launched in Japan in 1985. Infants testing positive for HBsAg at 1 month of age are usually excluded from the prevention program. In this study, long-term outcomes were evaluated in children with prenatal HBV infection who recived the HBIG and HB vaccine in Japan. Methods: Newborns of both HBsAg and HBeAg positive carrier mothers received HBIG within 48 h of birth and at 2 months of age. Subsequently, three doses of recombinant HB vaccine were administered at 2, 3, and 5 months of age. Outcomes were compared between the following two groups: infants who completed the vaccination program (n = 15), even if they were HBsAg positive at 1 month of age, and infants who did not (n = 51). Results: The patient characteristics are shown in the Table 1. Seroconversion from HBeAg to anti-HBe antibody (HBeAb) was observed in five children (33 %) who completed the vaccination program and in 13 children (25 %) who did not (p = 0.53). The mean age of e- seroconversion was 1.6 (0.9–2.5) years old in the accomplishment group, which was significantly younger than 6.0 (2–18) years old in the dropout group (p = 0.02). Seroconversion from HBsAg to HBsAb occurred in two children (13 %) in the accomplishment group

Table 1 . Accomplishment Dropout group (n = 15) group (n = 51)

Differences (P value)

No of male (%)

8 (53)

31 (61)

NS

Present age (median) year

1–16 (5.0)

1–25 (10.0)

P = 0.01

Follow-up period (median) yearr

1–16 (4.8)

0.5– 17 (6.9)

NS

No of seroconversion (n) 5

13

NS

Age of e-seroconversion (mean) year

0.9–2.5 (1.6)

2–18 (6.0)

P = 0.02

No of s-seroconversion (%)

2 (13)

0 (0)

P = 0.049

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Topic: 8 Hepatitis B - Clinical Absno: 349 Serum HBsAg concentration in chronic renal failure with hemodialysis and peritoneal dialysis Tsang-En Wang1,4, Yu-Wei Chen2, An-Mei Wang3, Ching-Wei Chang1, Ming-Che Wu3, Yu-Huei Chen3, Chien-Yuan Hung1, Jen-Ren Wu2, Shou-Chuan Shih1,4 1 Division of Gastroenterology, 2Division of Nephrology, 3Department of Internal Medicine and Department of Nuclear Medicine, 4Mackay Memorial Hospital, and Mackay Medicine Collage, Taipei, Taiwan

Introduction and aim: As we known, patients with chronic renal failure (CRF) and HBsAg carrier, their serum HBV-DNA level is lower than the general population, and the HBV DNA level is relatively stable. However, the serum level of HBsAg concentration in this population is not very clear. This study is tried to understand serum of HBsAg before and after dialysis, and the trend of serum HBsAg of patients who received regular hemodialysis (HD) or peritoneal dialysis (PD). Patients and methods: Patients who have chronic hepatitis B and CRF receiving long-term dialysis were tested HBsAg every year from 2010 to 2012. Test equipment and reagents used Abbott products. HBsAg after and before dialysis were checked and compared in some patients with hemodialysis (HD). Liver function, HBeAg and routine laboratory were recorded and analyzed. Results: 27 patients with HD and 22 patients with PD were enrolled, M: F = 15:12 (HD) and 9:13 (PD). 4 patients had positive HBeAg. The mean age of two groups were 58.4 and 52.4 years. Almost all patient had normal AST and ALT in this period. In HD group, serum HBsAg concentration difference is quite large, 0.4 to 3998 iu/ml range in HBeAg negative patients. Using the test value in 2010 as a basis, the average change of HBsAg level in 2011 and 2012 were 141.5 and 128.2 iu/ml in HBeAg negative patients, respectively. Three patients with HBeAg-positive had variable levels of HBsAg. One patient took Lamivudine more 3 years. Her HBsAg increased from 2903.5 to 10728.1 iu/ml due to drug resistance. One patient had decreased HBsAg from 89,616.8 to 1798.7 iu/ml. Another patient maintained HBsAg between 3000 to 3900 iu/ml in this period. The differences of HBsAg between pre-HD and post-HD were very small, the average of change was 83.4 iu/ml in the 15 patients. In PD group, two patients had very high HBsAg level. Excluding the two patients, the averages of HBsAg level were 1313.2 (2010), 1116.9 (2011) and 1198.8 (2012) iu/ml. The differences of HBsAg among the years were 366.9 iu/ml (n = 20, 2010 vs. 2011) and 384 iu/ml (n = 16, 2011 vs. 2012). The value of HBsAg concentration is seemingly stable in CRF patients. Conclusions: The first, regardless HD or PD, this study confirmed the dialysis does not affect the concentration of the blood of HBsAg. The molecular of HBsAg is small to moderate size and may not be easily dialysis. HBsAg presents a relatively stable situation in HBeAg-negative patients under observation 3 years. The secondary, patients with CRF may have lower immune response, which is consistent with normal liver

Hepatol Int (2014) 8:S1–S405 function. Third, in HBeAg positive patents with dialysis, HBsAg concentrations were variation because of the un-predictive viral activity.

Topic: 8 Hepatitis B - Clinical Absno: 350 Early entecavir treatment for chronic hepatitis B with severe acute exacerbation W. L. Tsai, H. H. Chan, K. H. Lai, J. S. Cheng, P. I. Hsu Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan Introduction: Severe acute exacerbation (SAE) of chronic hepatitis B virus (HBV) can lead to liver decompensation and death. Previous study found that lamivudine if started early enough may improve survival. Entecavir is more potent and induces less resistance than lamivudine in treating chronic HBV, but the effect of entecavir treatment in chronic HBV with SAE remained controversial. The aim of the study is to investigate the effect of early entecavir treatment for chronic HBV with SAE. Materials and methods: Consecutive patients of chronic HBV with SAE and a serum bilirubin level \20 mg/dl before antiviral treatment who received lamivudine or entecavir were enrolled. Short term (4 months) survival was evaluated. Results: One hundred and fourteen patients received lamivuidne and 53 patients received entecavir. Baseline characteristics were similar between the entecavir and lamivudine group except that the entecavir group had older age (P = 0.023) and lower ALT level (P = 0.029). Three (8.0 %) in the entecavir group and 9 (7.9 %) in the lamivudine group died (P = 1.000). If only patients who started antiviral treatment before serum bilirubin level rises to above 15 mg/dl were included, 3 (8.3 %) in the entecavir group and 3 (3.0%) in the lamivudine group died (P = 0.189). If only patients with a baseline HBV DNA greater than 105 copies/ml and bilirubin level is lower than 15 mg/dl were included, five out of 40 (12.5 %) patients in the ETV group died and 1 out of 59 (1.7 %) patients in the LAM group died. Multivariate analysis found ETV treatment was associated with overall mortality (P = 0.035). Conclusions: Early entecavir treatment in patients with high HBV viral load is associated with worse outcome than lamivudine in chronic HBV with severe acute exacerbation.


S89 treament at least one year in HBV patients for monitoring the treatment result and correlation between TE and APRI. Methods: Data were collected from 41 HBV patients with and by using before-and-after treatment method to assess the changes of the liver stiffness and APRI after one year of treatment. The patients were perfomed TE and APRI before and after one year of treatment. The patients were excluded if had infection of HCV or HIV, failure of the procedure, the worsening of hepatitis like acute excacerbation and HCC. Results: The median liver stiffness measured by TE was significanly decreased from 10.8 to 5.9 kPa after 1 year of antiviral treatment with p \ 0.001. The median value of APRI before treatment was 1.13 and decreased significantly after treatment to 0.43 and with p\0.001.The correlation between liver stiffness and APRI before treatment were moderate with r = 0.399 and after treatment the correlation were stronger with r = 0.731. Conclusion: The liver stiffness that measured with transient elastography and APRI significantly decrease after one year of antiviral treatment in chronic HBV patients. There was a moderate correlation between TE and APRI before treatment and strong correlation after one year of treatment. Keywords: Chronic Hepatitis B, Transient elastography, Aspartate aminotransferase to Platelet Ratio Index Reference 1. Enomoto M, Mori M, Ogawa T, Fujii H, Kobayashi S, Iwai S, et al. Usefulness of transient elastography for assessment of liver fibrosis in chronic hepatitis B: Regression of liver stiffness during entecavir therapy. Hepatol Res 2010;40:853–861

Topic: 8 Hepatitis B - Clinical Absno: 352 A new risk estimation scale of HCC development, named JABHCC score (Japanese risk estimations of HBV-related HCC), shows a good discrimination capability Tetsuya Hosaka1, Fumitaka Suzuki1, Masahiro Kobayashi1, Taito Fukushima1, Yusuke Kawamura1, Hitomi Sezaki1, Norio Akuta1, Yoshiyuki Suzuki1, Satoshi Saitoh1, Yasuji Arase1, Kenji Ikeda1, Mariko Kobayashi2, Hiromitsu Kumada1 1

Department of Hepatology, Toranomon Hospital, Tokyo, Japan, Research Institute for Hepatology, Toranomon Hospital, Tokyo, Japan

2

Absno: 351 The changes of liver stiffness with transient elastography and aspartate aminotransferase to platelet ratio index in chronic hepatitis B virus after one year of antiviral treatment Riki Tenggara1, Marcelus Simadibrata2, Juferdy Kurniawan3, C. Rinaldi Lesmana3, Andri Sanitiyoso S3, Irsan Hasan3, Rino A. Gani3 1

Internal Medicine Department Atma Jaya Medical School Catholic University of Atma Jaya Jakarta Indonesia, 2Gastroenterology Division of Internal Medicine Department University of Indonesia Jakarta, 3Hepatology Division of Internal Medicine Department University of Indonesia Jakarta Aim: This study was intended to know the changes of the liver stiffness by transient elastography (TE) and APRI before and after

Introduction: Chronic hepatitis B virus (HBV) infection leads to cirrhosis and hepatocellular carcinoma (HCC). However, the risk of HCC in each patient is non-uniform. The criteria for starting antiviral therapy are needed for preventing HCC development. Thus, we newly created an easy-to-calculate risk estimation scale of HCC in Japanese untreated chronic hepatitis B (CHB) patients. Patients & methods: Our hospital-based cohort (n = 1143) in which no patients received antiviral therapy was used to generate a risk scale of HCC development. Patients in this cohort began to be followed from 1973 to 1999 in Toranomon Hospital, Tokyo, Japan. We randomly dichotomized our cohort to two groups (2:1 ratio), and assigned 762 patients to the derivation set and 381 patients to the validation set. We generated a new risk scale of HCC development based on the results of Cox regression analysis. Results: During follow-ups of 10.6 years (median), 145 patients (12.7 %) had developed HCC (10.9/1,000 person-years) in entire cohort. Multivariate Cox model showed that predictive factors of

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S90 HCC development were age, gender, preexisting cirrhosis, ALT, albumin, platelet count, HBV genotype, HBeAg, and HBVDNA in the derivation cohort. Next, we generated the risk score for these risk factors using b regression coefficient in Cox proportional hazard model. Projected HCC risk score is sum total of each risk score (range 0–20). AUROC to predict HCC development at 5 years was 0.949 (95 % CI 0.922–0.975, P \ 0.001) in the derivation cohort, and 0.933 (0.900–0.965, P \ 0.001) in the validation cohort. AUROC to predict HCC development at 10 years was 0.937 (95 % CI 0.908–0.967, P \ 0.001) in the derivation cohort, and 0.920 (0.878–0.962, P \ 0.001) in the validation cohort. Projected HCC risk score was divided into four categories as following; 0–5 as low risk, 6–9 as medium risk, 10–14 as high risk, and 15–20 as very high risk. Cumulative HCC incidence rates at 10 years in the entire cohort were 0 % in low risk group, 5.9 % in medium risk group, 26.5 % in high risk group, and 72.9 % in very high risk group (P \ 0.001).

Topic: 8 Hepatitis B - Clinical Absno: 358 Why do patients with chronic hepatitis B use complementary and alternative medicine? Kyi Kyi Tha1, Chirk Jenn Ng2, Wen Ting Tong2, Syafiqah Abdul Kadar1, Wah Yun Low2, Rosmawati Mohamed2 1 Jeffrey Cheah School of Medicine & Health Sciences, Monash University Sunway Campus, Malaysia, 2Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Introduction: The use of complementary and alternative medicine (CAM) is common among patients with chronic hepatitis B (CHB) infection. However, the effectiveness of CAM in the treatment of CHB infection remains unknown and may have a negative health impact. This study aimed to explore patients’ reasons for using CAM and the findings will help the healthcare professionals (HCP) to understand patients’ help-seeking behavior and address their concerns. Methods: We used a qualitative methodology to capture patients’ views and experiences. The participants were CHB patients attending a tertiary hospital located in an urban area in Malaysia between the year 2012 and 2013. Four focus group discussions were conducted (n = 19) and trained facilitators organized the focus groups using a topic guide, which was developed based on literature review and expert opinions. The interviews were audio-recorded, transcribed verbatim, checked and analysed by researchers using a thematic approach. Results: The participants used a range of CAM including herbs, fish oil, acupuncture and spiritual healing to improve their general health and hepatitis B infection. The reasons for using CAM pertained to the effectiveness, safety and accessibility. The preference for CAM was related to the limitations of modern medicine; some patients were concerned about the side effects while others were uncomfortable with the lack of active treatment. CAM was felt to be ‘‘natural’’ and provided a way to maintain their energy and control the illness. The participants also felt that CAM worked faster and were more accessible than modern medicine. Some used CAM as a ‘‘last resort’’ if their CHB infection could not be treated with modern medicine. Conclusions: CAM was used due to the limitations of modern medicine in terms of safety, accessibility and availability of effective treatment. Despite the lack of evidence of CAM, patients would still use them. The HCP must address patients’ concerns and educate them on the potential harms of CAM.

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Topic: 8 Hepatitis B - Clinical Absno: 361 Clinical characteristics and host genotypes of patients with dual infection by hepatitis B and C viruses in china Hong Tang1,2, Li-Bo Yan1,2, Yuan-Ji Ma1,2, En-Qiang Chen1,2 1

Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu 610041, People’s Republic of China, 2Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu 610041, People’s Republic of China Background/aims: The purpose of this study was to compare the epidemiological, biochemical, virological characteristics and host genotypes of patients with chronic hepatitis B and C with those of patients suffering from chronic hepatitis C alone. Methods: We Screened 997 anti-HCV positive patients. Forty-three patients with chronic hepatitis C, who were anti-HCV positive and HBs antigen positive were enrolled in this study. They were compared to 43 age- and sex-matched patients with chronic hepatitis who were anti-HCV positive and HBs antigen negative. Result: The prevalence of patients with dual infection by hepatitis B and C viruses in anti-HCV positive patients was 4.31 % (43/997). Epidemiological, and biochemical parameters were not different between the two groups. Liver cirrhosis was more common in patients with HCV and HBV infection than it was in the controls infected with HCV only (16/43 vs. 3/43, P \ 0.05). The HCV RNA level and HCV genotypes did not differ between the two groups. The main genotypes of HCV in both groups was still 1b. The distribution of IL-28B genotypes rs12979860 has no difference between two groups(P = 0.559). Liver cirrhosis was more common in patients with CT or TT than in patients with CC in rs12979860 genotypes in dual infection patients (5/6 vs. 11/35, P = 0.039). Conclusions: Liver cirrhosis was more common in patients with dual HCV and HBV infection than in patients with HCV infection only, especially the dual infection patients with CT or TT at rs 12979860.

Topic: 8 Hepatitis B - Clinical Absno: 363 Short-term efficacy and security of telbivudine as a sequential therapy in the pegylated IFNa-2a treatment failure patients with HBeAg positive Haixia Sun, Ka Zhang, Sihong Cheng, Fengqin Zhu, Yeqiong Zhang, Gang Li, Qihuan Xu Department of Infectious Diseases, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China Objective: To investigate short-term efficacy and security of telbivudine as a sequential therapy in the HBeAg positive chronic hepatitis B (CHB) patients with pegylated IFNa-2a treatment failure. Methods: 27 CHB patients with HBeAg positive and HBV DNA detectable after a 48-week pegylated IFNa-2a therapy were enrolled into this study, and were assigned to group A,with telbivudine as a sequential therapy. 54 CHB patients with HBeAg positive were assigned to group B, with telbivudine as a naı¨ve treatment. To assessment the efficacy and security of telbivudine at week 48. Results: At week 12, the rates of aminotransferases normalization, HBeAg seroconversion and HBV DNA undetectable (\100 IU/ml)

Hepatol Int (2014) 8:S1–S405 among the two groups were 59.3, 14.8, 66.7 % versus 75.9, 5.6, 46.3 % respectively. And the levels of creatine kinase (CK) were 144.1± 62.5 U/L versus 109.9 ± 46.8 U/L (t = 1.956, P = 0.735). At week 24, the rates among the two groups were 92.6, 25.9, 70.3, versus 92.6, 7.4, 85.2 %, respectively. And the levels of CK were 177.8 ± 116.9 U/L versus 158.3 ± 193.4 U/L (t = 0.38, P = 0.855). At week 48, the rates among the two groups were 88.9, 29.6, 81.5 % versus 98.1, 28.0, 83.3 % respectively. And the levels of CK were 290.3 ± 255.3 versus 220.3 ± 232.6 U/L (t = 0.938, P = 0.659). All these were not statistically significant (P [ 0.05). But the rate of HBeAg seroconversion in group A is higher than that in group B. The virological breakthrough rate of group B at week 48 is 14.8 %, no virological breakthrough was observed in group A. During the treatment, 38.3 % of patients had CK elevation,but there was no case stopping treatment for severe adverse effect. Conclusion: CHB patients with HBeAg positive after a 48-week pegylated IFNa-2a treatment failure can also achieve the same efficacy and security as the naı¨ve treatment, after receiving telbivudine as a sequential therapy.

S91 ml. During follow up period, 12 patients had hepatitis B reactivation (ALT higher than 2 times of upper limit normal and HBV DNA more than 4 log copies/ml). No trend of relationship between hepatitis B reactivation and biologic immunosuppressive therapies or type of rheumatic disorder had been observed. 8 of 12 patients received NUCs treatment and all recovered, including one who developed liver failure. 4 patients did not receive NUC treatment but hepatitis B was not exacerbated. 8 patients received prophylactic NUCs and did not have hepatitis B reactivation. One patient died of hart failure during follow up period. Discussion: Hepatitis B reactivation is not uncommon in patients with co-morbidity of rheumatic disorder and chronic hepatitis B infection. Some cases can be serious. Risk factors of hepatitis B reactivation and its outcomes in this cases series are under evaluation. NUCs therapy can usually result in favorable outcomes for hepatitis B reactivation. In our cases series, some patients received prophylactic use of NUCs, however some patients with evidenced hepatitis B reactivation did not received NUC therapies. Well-design clinical studies are required to evaluate the role of prophylactic use of NUCs in patients with co-morbidity of rheumatic disorders and chronic HBV infection; And clinical use of NUCs in these patients require more consensus.

Topic: 8 Hepatitis B - Clinical Absno: 365 Outcomes of chronic hepatitis B virus infection in Chinese patients with rheumatic disorders H. Zhang1, Q. Luo1, Y. Yu1, Y. Ye2, G. Chen1 1

Department of Rheumatology, First People’s Hospital of Foshan, Foshan, Guangdong Province, PRC, 2Department of Infectious Disease, First People’s Hospital of Foshan, Foshan, Guangdong Province, PRC Background: Prevalence of hepatitis B virus (HBV) infection in general population in China is 7.18 % according to latest survey. Comorbidity of rheumatic disorders and chronic HBV infection is not uncommon. Nucleoside/nucleotide analogs (NUCs) have become standard of care for chronic hepatitis B patients, but the role of prophylactic use of NUCs in HBV infected patients with rheumatic disorders receiving immunosuppressive therapies has not been determined. Methods: This was a retrospective cohort study. All patients were from our hospital. Inclusion criteria: 1) had co-morbidity of rheumatic disorders and chronic HBV infection, 2) received immunosuppressive therapies and, 3) admitted to hospital at least two times in the period of Jan 2007 to Jun 2013. Medical charts were evaluated. Information about demography, types of rheumatic disorders, HBV serology and virology, name and doses of immunosuppressive therapies, NUC therapies, outcome of HBV infection and rheumatic disorder was retrieved and evaluated. Results: 37 patients were included in this study. Fourteen were male. Median age at fist admission was 42 years (11–73). Median follow up duration was 39 months (5–163). 15 patients had rheumatoid arthritis; other patients had such rheumatic disorders as systemic lupus erythematosus, Sjogren’s syndrome, Behcet’s disease, Ankylosing Spondylitis, etc. All patients received anti-rheumatic drugs such as Methotrexate and hydroxychloroquine, 30 patients simultaneously received corticosteroid and 5 received biologic immunosuppressive therapies (TNFa blocker). All patients’ rheumatic disease was under controlled after hospitalization. 30 patients were hepatitis B e antigen negative. HBV DNA level varied from less than 500 to 9 log copies/

Topic: 8 Hepatitis B - Clinical Absno: 371 Predictive factor of partial virologic response to entecavir in treatment-naı¨ve patients with chronic hepatitis B Byung Seok Kim, Dae Young Yun, Hyun Hee Kim, Jang Seok Oh, Hyun Sik Hwang, Hee Sang Jang, Han Na Choi, Ji Suk Kim, Chang Hyeong Lee Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea Introduction: Entecavir (ETV) has highly potent antiviral activity with a high genetic barrier to resistance, therefore it is recommended as a first-line therapy in treatment-naı¨ve patients with chronic hepatitis B (CHB). The optimal management of patients with partial virologic response (PVR) to ETV is currently not well defined. The aims of this study were to assess the predictive factor of PVR and efficacy of prolonged ETV monotherapy in CHB patients with a PVR to ETV therapy. Methods: A total of 292 treatment-naı¨ve CHB patients, who were treated with ETV 0.5 mg daily for at least 48 weeks, were enrolled in this study. PVR was defined as a decrease in serum HBV DNA of more than 2 log10 IU/mL but detectable HBV DNA by real-time PCR assay at week 48. All patients were monitored at baseline and every 3 months during ETV treatment. Results: The mean age was 48.9 years, and 168 patients (57.5 %) were men. 179 patients (61.3 %) were HBeAg-positive, and 102 patients (34.9 %) had cirrhosis. Forty-three of 268 patients (14.7 %) showed PVR to 48 weeks of ETV treatment, and twenty-six of these 43 patients were followed up for at least 96 weeks. Among them, 16 of 26 patients (61.5 %) achieved a complete virologic response (HBV DNA \20 IU/mL) during prolonged ETV monotherapy, and none of them developed genotypic resistance to ETV during follow-up. Multivariate analysis showed that high viral load (HBV DNA [7 log10 IU/mL) at baseline and detectable HBV DNA at week 24 were independently associated with a PVR during ETV therapy.

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S92 Conclusions: This study revealed that long-term ETV therapy may be effective for achieving viral suppression in treatment-naı¨ve CHB patients with a PVR to ETV. Also HBV DNA levels at baseline and week 24 after ETV treatment were predictor of PVR to ETV in treatment-naı¨ve patients with CHB.


Topic: 8 Hepatitis B - Clinical Absno: 374 The clinical features and disease spectrum of hospitalized patients with chronic HBV infection treated with antiviral therapy before admission

Topic: 8 Hepatitis B - Clinical Absno: 372 A study on the disease spectrum and epidemic features of hospitalized patients with chronic HBV infection Yu-Sheng Jie, Yuan-Kai Wu, Guo-Li Lin, Xiang-Yong Li, Xin-Hua Li,Yu-Tian Chong Department of infectious diseases, the third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China Introduction: Chronic HBV infection is a serious public health problem in china. And the spectrum of disease with chronic HBV infection is very complicated, which range from an inactive carrier state to progressive chronic hepatitis B (CHB) and HBV-related cirrhosis. The aim of this study was to investigate the disease spectrum and epidemic features of hospitalized patients with chronic HBV infection. Methods: We retrospectively studied the discharged diagnosis, epidemic features of patients with chronic HBV infection hospitalized in our hospital from 1 January 2011 to 31 December 2011. The discharged diagnosis included CHB, ACLF (acute-on-chronic liver failure) and HBV-related cirrhosis [1]. Results: A total of 1619 hospitalized patients with chronic HBV infection were enrolled in this study, male 87.3 % (1413/1619) and female 12.7 % (206/1619), HBeAg-positive 38.8 % (628/1619) and HBeAg-negative 61.2 % (991/1619). There was significant difference between male and female patients on mean age (43.5 ± 13.4 vs. 48.9 ± 15.6, p \ 0.05). 17.2 % (279/1619) of inpatients had received antiviral therapy more than 3 months before they were admitted to hospital, the others 82.8 % (1340/1619) hadn’t received antiviral therapy before. The constituent ratio of disease spectrum of all inpatients included CHB 38 % (1055/1619), ACLF 12 % (189/1619) and decompensated HBV-related cirrhosis 50 % (807/1619). There was significant difference on the constituent ratio of disease spectrum between inpatients with HBeAg-positive group and HBeAg-negative group (v2 = 151.0, p \ 0.05). The rate of diagnosis of CHB in HBeAg-positive group was higher than that in HBeAg-negative group(56.6 vs. 27.0 %, p \ 0.05), but the rate of diagnosis of HBV-related cirrhosis in HBeAg-positive group were lower than that in HBeAg-negative group (33.0 vs. 60.5 %, p \ 0.05). The rate of diagnosis of ACLF was no significant difference between these two groups (10.4 vs. 12.5 %, p [ 0.05). Conclusion: The majority of hospitalized patients with chronic HBV infection were diagnosed with HBeAg-negative cirrhosis, and the majority hadn’t had antiviral therapy experience before they were admitted to hospital.

Yu-Sheng Jie, Xiang-Yong Li, Ming-Xin Huang, Xin-Hua Li, Guo-Li Lin, Yu-Tian Chong Department of infectious diseases, the third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China Introduction: Earlier studies had shown that antiviral therapy was of good benefit to the patients with chronic HBV infection. But a lot of them were stll need to be admitted to hospital for treatment by many causes in real life. The aim of this study was to investigate the clinical features and disease spectrum of inpatients with chronic HBV infection who had received antiviral therapy before admission. Methods: We retrospectively studied the discharged diagnosis, clinical features of patients with chronic HBV infection hospitalized in our hospital from 1 January 2011 to 31 December 2011. The discharged diagnosis included CHB (chronic hepatitis B), ACLF (acuteon-chronic liver failure) and HBV-related cirrhosis [1]. Results: Of all 1619 hospitalized patients with chronic HBV infection in 2011, 279 (17.2 %) inpatients were enrolled in this study who had received antiviral therapy for more than 3 months before admission. Among 279 inpatients (male 253, female 26), 87 (31.2 %) were HBeAg-positive and 192 (68.8 %) were HBeAg-negative, and the mean age was 47.6 ± 12.2 years. The mean ALT (U/L), TBIL (lmol/ L) and level of HBV DNA (log IU/mL) was 201.0 ± 398.7, 97.9 ± 148.3 and 3.6 ± 2.2, respectively. The mean duration of antiviral therapy with nucleos(t)ide analogues before admission was 24.5 ± 18.3 months (range 4–132). The constituent ratio of disease spectrum of 279 inpatients included CHB 22.2 % (62/279), ACLF 3.6 % (10/ 279) and decompensated HBV-related cirrhosis 74.2 % (207/279). The major causes (65 %) of admission were abnormal ALT, upper gastrointestinal hemorrhage, ascites and jaundice. Conclusion: The majority of patients with chronic HBV infection who had received antiviral therapy were admitted to hospital bacause of the complications of decompensated cirrhosis. Reference 1. Chinese Society of Hepatology and Chinese Society of Infectious Diseases, Chinese Medical Association. The guideline of prevention and treatment for chronic hepatitis B (2010 version). Chin J Hepatol 2011;19:13–24

Topic: 8 Hepatitis B - Clinical Absno: 375 Disease spectrum difference in hospitalized patients with chronic HBV infection between treated and non-treated with antiviral therapy before admission

Reference 1. Chinese Society of Hepatology and Chinese Society of Infectious Diseases, Chinese Medical Association. The guideline of prevention and treatment for chronic hepatitis B (2010 version). Chin J Hepatol 2011;19:13–24

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Introduction: Chronic HBV infection is a very serious public health problem in china. And the spectrum of disease with chronic HBV infection is very complicated. The aim of this study was to investigate the difference in disease spectrum of hospitalized patients with chronic HBV infection between treated and non-treated with antiviral therapy before admission. Methods: We made a retrospective study on the discharged diagnosis and case history of inpatients with chronic HBV infection hospitalized in our hospital from 1 January 2011 to 31 December 2011. The discharged diagnosis include CHB, ACLF (acute-on-chronic liver failure) and HBV-related cirrhosis [1]. Results: Based on whether the inpatients had received antiviral therapy before admission or not, a total of 1619 inpatients with chronic HBV infection were divided into treated group (n = 279, male 90.7 and female 9.3 %) and non-treated group (n = 1340, male 86.6 and female 13.4 %). The mean age of treated group was higher than that of non-treated group (47.6 ± 12.2 vs. 43.5 ± 14.0, P \ 0.05). Not only the high-peak of ALT and TBIL but also the level of AFP and HBV DNA and the rate of HBeAg positive in treated group were lower than those in non-treated group, respectively (P \ 0.05). The mean duration of antiviral therapy with nucleos(t)ide analogues in treated group before admission was 24.5 ± 18.3 months (range 4–132). There was significant difference on the constituent ratio of disease spectrum between these two groups (P \ 0.05). The rates of diagnosis of CHB and ACLF in treated group were lower than that in non-treated group (22.2 vs. 41.9 %, P \ 0.05; 3.6 vs. 13.4 %, P \ 0.05, respectively), but the rate of diagnosis of HBV-related cirrhosis in treated group were higher than that in non-treated group (74.2 vs. 44.8 %, P \ 0.05). And all the HBV-related cirrhosis were in decompensated status. Conclusion: Antiviral therapy could reduce the rate of hospitalized patients with chronic active hepatitis B.

as HBV DNA \2000 copies/mL until June, 2008 and \20 IU/mL after July, 2008. Results: Two hundred and ten (68.2 %) patients had compensated cirrhosis and remaining (31.8 %) patients had decompensated cirrhosis. The serum PIIINP decreased from 10.73 to 9.78 lg/L after 1 year of ETV treatment (p = 0.004). VR was achieved in 77.1 and 69.4 % of patients, and alanine aminotransferase (ALT) normalization was observed in 67.6 and 77.6 % of patients with compensated and decompensated cirrhosis, respectively (p = 0.145 and p = 0.074). Hepatitis B e-antigen (HBeAg) loss was noted at 36.4 and 38.6 %, and HBeAg seroconversion was noted at 6.8 and 7.0 % of patients with compensated and decompensated cirrhosis, respectively (p = 0.786 and p = 1.000). Univariate analysis showed that high baseline ALT (p = 0.001), low baseline HBV DNA (p = 0.000), HBeAg negativity (p = 0.001), low serum PIIINP level after 12 months (p = 0.010) were predictive factors for achievement of VR. Multivariate analysis showed that high baseline ALT (p = 0.016), low HBV DNA level (p = 0.000), and low serum PIIINP level after 12 months (p = 0.020) were independent predictive factors for achievement of VR. Conclusions: Serum PIIINP level during ETV treatment is useful to predictive the treatment response in CHB patients with cirrhosis.

Reference

Guo-Rong Han1, Yuhong Dong2, Molla Uddin3, Katrina O’Connor2, Serguei Titaevski2, Charles Koehne3, Aldo Trylesinski2

1. Chinese Society of Hepatology and Chinese Society of Infectious Diseases, Chinese Medical Association. The guideline of prevention and treatment for chronic hepatitis B (2010 version). Chin J Hepatol 2011;19:13–24

Topic: 8 Hepatitis B - Clinical Absno: 376 Change in procollangen iii n-terminal peptide as a predictor of virological response in chronic hepaitits b patients with cirrhosis during entecavir therapy Soon Sun Kim, Seun Joo Ahn, Hyo Jung Cho, Jae Youn Cheong, Sung Won Cho Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea Background: The serum procollangen-III-N-terminal peptide (PIIINP) is assumed to be a useful marker for liver fibrosis. This study evaluated the change in the PIIINP, and identified the predictive factors for treatment response in chronic hepatitis B patients (CHB) with cirrhosis during entecavir (ETV) treatment. Methods: A total of 308 patients with clinically diagnosed cirrhosis were treated with ETV for C12 months. The serum PIIINP levels were measured at baseline and after 12 months of ETV treatment. Virological response (VR), biochemical response, and serological response were assessed after 12 months of treatment. VR was defined

Topic: 8 Hepatitis B - Clinical Absno: 378 Overview of Safety and Efficacy of Telbivudine Exposure in Pregnant Women with Hepatitis B Virus Infection

1

Department of Gynecology and Obstetrics, The Second Affiliated Hospital of the Southeast University, Nanjing, China, 2Novartis Pharma AG, Basel, Switzerland, 3Novartis Pharmaceuticals Corporation, New Jersey, USA Background: Nearly 50 % of chronic hepatitis B virus (HBV) infections are acquired from perinatal transmission (or mother-tochild transmission, MTCT). Immunoprophylaxis against HBV fails and MTCT occurs in 10–15 % of infants. Telbivudine (LDT) has been classified as pregnancy category B (FDA) and has been recommended by EASL and APASL guidelines for preventing HBV vertical transmission during pregnancy. The objective of the current study is to perform a systemic review to establish an evidence-based conclusion regarding safety and efficacy of LDT in HBV-infected pregnant women. Methods: A systemic review was performed to filter all pregnancy cases with LDT exposure from the following databases: literature (cut-off date: 10-Jan-2013), periodic safety update report (PSUR, a Novartis data collecting system used to report adverse events, cut-off date: 31-Aug-2013), and antiretroviral pregnancy registry (APR, cutoff date: 31-Jul-2013). Key search terms included, ‘telbivudine’, ‘pregnancy’ and ‘hepatitis B’. The overlapping cases were excluded through clarification with the respective authors. Outcomes were reported in terms of the following: prevalence rate of live births, prevalence rate of spontaneous births and perinatal and intrauterine HBV transmission. Results: After excluding the overlapping cases, a total of 1695 LDTtreated pregnancies (including 262 cases exposed to telbivudine during the first trimester) were pooled from the 3 databases. From the literature search, 16 of 26 publications were identified to have 1260 non-

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overlapping pregnancy cases. Of these pregnancy cases, 1196 infants were born (2 with and 1194 without congenital anomaly). 405 and 30 cases were identified from PSUR and APR, respectively. Birth outcomes were known in 207 / 405 (4 with and 203 without congenital abnormality) cases from PSUR and 23/30 (no birth defects) cases from APR. The total prevalence rate of live birth defects in LDT-treated pregnancies was 2.5/1000 compared to 3.4/1000 in the non-antiviral control in the same literature studies or to the overall population (14.54–60/1000). No target organ toxicity is observed. Perinatal and intrauterine HBV transmission rates with LDT was 4.2/1000 versus 103/1000 in non-antiviral control (P \ 0.0001) in the same literature studies. Prevalence rate of spontaneous abortion in LDT-treated pregnancies was 4.73/1000 versus 16/1000 in the overall population. Conclusions: Use of LDT during pregnancy has a favorable safety outcome for mothers and infants with no increase in live birth defects or spontaneous abortion. Also, LDT was shown to be effective in preventing MTCT of HBV infection without increasing the risk of birth defects in infants from LDT-exposed mothers.

long-term follow-up, one infant (0.5 %) was diagnosed with congenital megacolon at 1.5 years and underwent surgical treatment; one infant (0.5 %) had patent ductus arteriosus at 2 years without treatment. In the overall long-term follow up, congenital abnormality rate was 0.99 % (2/202). Serious adverse events (SAEs) requiring hospitalization occurred in 18 infants (8.91 %); of which 4 had inguinal hernia. Other SAEs includes pneumonia (8), tonsillitis (1), asthma (1), acute gastroenteritis (1), diarrhea (2) and herpetic angina (1). None of the 18 SAEs were related to LDT exposure during their mothers’ pregnancy period. Of 100 infants selected for DDST, 92 infants’ parents had agreed to test and the qualified rate of DDST was found to be 97.82 %, which was comparable to the rate of 92% in normal Chinese children. Conclusion: In highly viremic HBeAg positive mothers with CHB, LDT treatment at the 2nd or 3rd trimester of pregnancy safely blocks perinatal transmission of HBV. Infants born to telbivudine-treated mothers presented a normal growth and development during the longterm follow-up up to 4 years.



Absno: 381

Absno: 395

Long-term safety and efficacy outcomes in infants born to HBeAg positive chronic hepatitis B mothers treated with telbivudine during 2nd or 3rd trimester

Incidence and characteristics of HBV reactivation in hematological malignant patients in south Egypt Abeer Elkady1,2, Elsayed Mostafa Ali3, Yasuhito Tanaka1

1

1

1

2

Guo Rong Han , Hong Xiu Jiang , Cui-min Wang , Yi Ding , Xin Yue1, Gen-ju Wang1, Yong-Feng Yang3 1

Department of Gynecology and Obstetrics, The Second Affiliated Hospital of the Southeast University, Nanjing, China, 2Department of Gynecology and Obstetrics, School of Medicine, Southeast University, Nanjing, China, 3Department of Infectious Diseases, The Second Affiliated Hospital of the Southeast University, Nanjing, China Background: Standard immunoprophylaxis may not be effective in infants born to highly viremic mothers with HBeAg positive CHB and results in 10–30 % risk of HBV perinatal transmission (PT). Telbivudine (LDT) treatment has previously shown to reduce HBV PT and is safe in infants up to 1 year. However the long-term safety of infants born to LDT-treated pregnant women has not been reported. Methods: A total of 200 pregnant women treated with telbivudine at the 20–32 weeks of gestation period enrolled in this study (NCT00939068). The efficacy and safety of LDT from 202 infants, born to these pregnant women aged C1 during Feb 2008–Mar 2012 were collected. The HBV markers and HBV DNA of infants at 7 and 12 months were used to determine PT rates; and were followed-up at 1 year, 2 years, 3 years and 4 years of their age. The head circumference, height, weight, congenital abnormality rate and hospitalization rate in infants were evaluated at each age. 100 infants were randomly selected by the hospital and were tested with Denver Developmental Screening Test (DDST). Results: None of the 202 infants acquired HBV infection for up to 4 years follow-up. The blocking of HBV PT was 100 %. All infants had effective HBsAb and the serum levels (mean ± SD) by each age group were 552.12 ± 394.89, 340.30 ± 336.37, 390.86 ± 393.98, 184.12 ± 155 IU/L. Based on the WHO and the Chinese standard of children’s growth curve, there were no differences in mean values of the height, weight and head circumference in these 202 infants in all age groups born to LDT-treated mothers. No birth defects were observed in the total 202 babies. During the

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1 Department of Virology and Liver Unit, Nagoya City University, Nagoya, Japan, 2Department of Clinical and Chemical Pathology, Medical School of South Valley University, Qena, Egypt, 3 Department of Medical Oncology, Medical School of Sohag University, Sohag, Egypt

Aim: To investigate characteristics of hepatitis B virus (HBV) implicated in HBV reactivation in patients with hematological malignancies receiving immunosuppressive therapy. Methods: Serum samples were collected from 53 patients with hematological malignancies negative for hepatitis B surface antigen (HBsAg) before the start of and throughout the chemotherapy course. HBV reactivation was diagnosed when the HBsAg status changed from negative to positive after the initiation of chemotherapy and/or when HBV DNA was detected by real-time detection polymerase chain reaction (RTD-PCR). For detecting the serological markers of HBV infection, HBsAg as well as antibodies to the core antigen (antiHBc) and to the surface antigen (anti-HBs) were measured in the sera by CEIA. Nucleic acids were extracted from sera, and HBV DNA sequences spanning the S gene were amplified by RTD-PCR. The extracted DNA was further subjected to PCR to amplify the complete genome as well as the specific genomic sequences bearing the enhancer II/core promoter/pre-core/core regions [nt 1628–2364]. Amplicons were sequenced directly. Results: Thirty-five (66 %) of the 53 HBsAg-negative patients were found to be negative serologically for anti-HBc, and the remaining 18 (34 %) patients were positive for anti-HBc. Five of the 53 (9.4 %) patients with hematologic malignancies experienced HBV reactivation. Genotype D1 was detected in all five patients. Four types of mutant strains were detected in the S gene of HBV strains and were isolated from 3 patients with HBV reactivation: T/S120, L143, and I126. HBV DNA was detected in the pretreatment HBsAg-negative samples in one of the five patients with HBV reactivation. In this patient, sequences encompassing the HBV full genome obtained from sera before the start of chemotherapy and at the time of de novo HBV hepatitis were detected and it showed 100 % homology. Furthermore, in the phylogenetic tree,

Hepatol Int (2014) 8:S1–S405 the sequences were clustered together, thereby indicating that this patient developed reactivation from an occult HBV infection. Conclusion: Past infection with HBV is a risk factor for HBV reactivation in Egypt. Mandatory anti-HBc screening prior to chemotherapy in patients with hematological malignancies is recommended.

S95 spontaneous HBsAg clearence has occured, the cases should be closely monitorized for development of complications.



To evaluate the clinical classification of HBV-related acute on chronic liver failure

Absno: 397

Hong Shi, Yuankai Wu, Mingxing Huang, Yutian Chong, Guoli Lin

Evaluation of spontaneous HBsAg clearence in cases with inactive HBsAg positivity

Department of Infectious Diease, The Third Affiliated Hospital of Sun Yat-sen University,Guangzhou

Safak Kaya, Necla Tulek, Saygin Nayman Alpat, Mustafa Kemal Celen, Selma Tosun, Vesile Yazici, Ayse Batirel, Davut Ozdemir, Nazan Tuna, Yasemin Cag, Aziz Ogutlu, Recep Tekin, Fehmi Tabak Izmir Bozyaka Education and Research Hospital Aim: Although at a very low rate, inactive HBV carriers are known to have spontaneous HBsAg clearence. In this study, we aimed to determine the rates of spontaneous HBsAg clearence observed in inactive HBV carriers followed-up in various cities of our country, and to evaluate the relevant data. Methods: Data on subjects having HBsAg positivity for more than six months, those who received no medical treatment for this and had spontaneous HBsAg clearence, were recorded on an Excel form that was prepared by the Turkish Viral Hepatitis Society Study Group. Relations between HBsAg seroclearance and age, male gender, HBV DNA level, ALT level were investigated. Results: Total number of HBsAg positive cases followed-up in medical centers involved in this study was 5390. Mean duration of follow-up of cases was 6.17 ± 4.13 years (min: 1, max:19). During this period, the number of cases with spontaneous HBsAg clearence was 71 (1.3 %). Except in four cases, anti-HBcIgG positivity still continues in all cases. Anti-HBs developed in 29 cases (40.8 %), while it did not develop in 42 cases (59.2 %) out of a total of 71 cases. None of the patients had consumption of commercial herbal/vegetable product. The number of cases with HBsAg clearence increased significantly as the age of the patients increased. Anti-HBe positivity and HBV DNA level were found statistically significant for HBsAg seroclearance. HBsAg seroclearance was mostly seen in negative or continuosly low HBV DNA values and antiHBe positivity which were the main predictors of HBsAg seroclerance (p \ 0.001). Discussion and conclusion: Majority of cases who had chronic HBV infection after encountering HBV carry on their lives as inactive HBV carriers. Those cases may have spontaneous HBsAg clearence at a rate of 0.5–1.5 % per year. However, spontaneous HBsAg clearence should not be considered as a favorable outcome and those cases should be closely monitored for disease progression and development of hepatocellular cancer (HCC). HBV-DNA levels were negative in all cases with seroclearence. Cirrhosis or findings suspicious for HCC was not detected in any of the cases with HBsAg loss. Evaluation of the age groups of patients with spontaneous HBsAg clearence revealed that the number of cases with HBsAg clearence increased with aging in consistent with the literature. This result suggests that spontaneous HBsAg clearence can be expected in ongoing cases in older ages. Rate of spontaneous HBsAg clearence detected in this study was less than the rates in similar studies. Nevertheless, such a possibility should be kept in mind, particularly in cases with advanced age. Moreover, even if

Objective: To study the clinical feature for HBV-related acute on chronic liver failure (HBV-ACLF) patients with different degrees of liver disease,and to propose scientific and practical clinical classification. Methods: Based on the degree of chronic liver disease before the onset of liver failure, chronic hepatitis and liver cirrhosis were grouped. A total of 220 patients with HBV-ACLF, including 118 with chronic hepatitis and 102 with liver cirrhosis were enrolled. The diagnosis of ACLF was based on the Asian-Pacific Association for the Study of the Liver criteria. Laboratory indicators, the incidence of complications and prognosis were compared in the two groups. Results: Serum ALT and AST levels were significantly higher in patients with chronic hepatitis than liver cirrhosis group (p \ 0.001). ALB and CHE levels were lower in patients with liver cirrhosis than chronic hepatitis group (p \ 0.001). Ascites, spontaneous bacterial peritonitis, hepatic encephalopathy were more common in patients with liver cirrhosis than chronic hepatitis group (56.8 vs. 89.2 % p \ 0.001; 22.9 vs. 37.2 % p = 0.020; 38.9 vs. 52.9 % p = 0.038). 28-days mortality was higher in patients with chronic hepatitis than liver cirrhosis group, but clinical prognosis (the rate of improvement and cure) was better in patients with chronic hepatitis (v2 = 5.418, p = 0.020; v2 = 5.157, p = 0.023). Conclusions: There are different clinical feature and prognosis in the two groups. It is in favor of treatment implementation and prognosis evaluation according to this classification. Keywords: Liver failure, Acute on chronic, Hepatitis B, Clinicalclassification

Topic: 8 Hepatitis B - Clinical Absno: 399 Significant reduction in liver disease burden through the national hepatitis B immunization program: thirty-year experiences in Taiwan Chien-Jen Chen1,2, Chun-Ju Chiang3, Ya-Wen Yang3, San-Lin You3, Mei-Shu Lai1 1

Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan, 2Genomics Research Center, Academia Sinica, Taipei, Taiwan, 3Taiwan Cancer Registry, Taipei, Taiwan Background: Hepatitis B virus (HBV) infection causes infant fulminant hepatitis (IFH), and chronic HBV infection may progress to chronic liver diseases (CLD) and hepatocellular carcinoma (HCC).

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S96 This study aimed to assess the 30-year outcomes of the nation-wide hepatitis B immunization program for newborns in Taiwan. Methods: The mortality of IFH, CLD and HCC and the incidence of HCC were compared among birth cohorts born before and after the launch of the immunization program. The National Death Certificates Database (1977–2011) was used to derive the mortality rates of IFH (ICD-9 code 570), CLD (ICD-9 code 571) and HCC (ICD-9 code 1550 and 1552); and the National Cancer Registry Database (1977–2009) to derive the incidence rates of HCC (ICD-O-3 code C220). Sex-adjusted or age-sex-adjusted incidence and mortality rate ratios were calculated using Poisson regression models (SAS 9.2). Results: IFH mortality rates and sex-adjusted rate ratios declined significantly for infants born from 1977–1980 to 2009–2011. The sexadjusted IFH rate ratio declined to 0.88 (95 % CI 0.65–1.21), 0.46 (95 % CI 0.31–0.69), and 0.03 (95 % CI 0.01–0.24) in 1981–1984, 1985–1988, and 2009–2011, respectively, compared with1977–1980 as the referent (rate ratio 1.00). There was also a continuous decline in age-sex-adjusted rate ratios of CLD and HCC mortality and HCC incidence for birth cohorts born after implementation of the program. The age-sex-adjusted rate ratio in 2001–2004 was 0.11 (95 % CI 0.02–0.80) for CLD mortality, 0.08 (95 % CI 0.02–0.34) for HCC mortality, and 0.20 (95 % CI 0.06–0.65) for HCC incidence compared with 1977–1980. Conclusion: National program of hepatitis B immunization in infancy has significantly reduced the disease burden of IFH, CLD and HCC in Taiwan since its launch in 1984. The protective effect of the immunization may persist for 30 years.

Topic: 8 Hepatitis B - Clinical Absno: 409 The utility of quantitative HBeAg and HBsAg in the prediction of HBeAg seroconversion following pregnancy in HBV Vi Nguyen1, Kathy Jackson2, Astrid Greenup1, Anne Glass1, Scott Davison1, Stephen A Locarnini2, Miriam T Levy1,3 1

Department of Gastroenterology & Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia, 2Victorian Infectious Diseases Reference Laboratory, Melbourne, Victoria, Australia, 3University of New South Wales, New South Wales, Australia Background & aims: Antepartum antiviral therapy (AVT) is often administered to further prevent perinatal transmission of HBV. Postpartum flares often occur and may be associated with HBeAg seroconversion. It is uncertain whether quantitative HBeAg and HBsAg levels could help identify those women at high probability of HBeAg seroconversion post-partum. Methods: Pregnant women with HBeAg positive HBV and a high baseline viral load (Clog 7 IU/ml) were prospectively recruited through a tertiary centre in Sydney, Australia from November 2011 till 2013. Women were administered tenofovir from 32 weeks gestation and continued for 12 weeks post-partum. In this interim study, those women with quantitative HBsAg and HBeAg levels, virological, biochemical and clinical parameters collected at baseline, birth, 12 weeks and up to 48 weeks post delivery were included. Results: A total of 26 pregnancies were analysed. The majority of women were of Asian background with mean age of 30.2 ± 4.7 years and mean parity of 1.1 ± 1.5. Median baseline ALT was 27.5 U/L (16.5–41.8), viral load log 8.14 IU/ml (7.4–8.5), and follow-up was 44 (30–48) weeks post-partum. There were 3 cases of HBeAg seroconversion noted (11.5 %), all of which persisted to the end of the

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Hepatol Int (2014) 8:S1–S405 follow-up period and were associated with a durable decline in viral load (mean reduction of log 2.2 IU/ml). Women who seroconverted had lower mean baseline quantitative HBeAg levels in comparison to those who did not (906.5 ± 625.7 vs. 2640.9 ± 1002.2 S/CO, p = 0.03). In contrast, HBeAg seroconversion could not be predicted by quantitative HBsAg titres, nor any other clinical parameters, including viral load, genotype, or the occurrence of a post-partum flare. Conclusion: HBeAg seroconversion is uncommon following pregnancy, but when it occurs is often accompanied by a durable decline in viral load. HBeAg seroconversion may be predicted by lower baseline quantitative HBeAg levels, but is not related to quantitative HBsAg titres, nor any other clinical parameters.

Topic: 8 Hepatitis B - Clinical Absno: 411 Association of pre-S2 antigen level with surface antigen loss in chronic hepatitis B patients receiving nucleos(t)ide analogue S. J. Ahn, H. J. Kim, S. S. Kim, J. Y. Cheong, S. W. Cho Department of Gastroenterology, Ajou University School of Medicine, Suwon, South Korea Introduction: This study evaluated the change in serum pre-S2 antigen levels during nucleos(t)ide analog(NUC) therapy and the correlation with surface antigen(HBsAg) loss in patients with chronic hepatitis B. Patients and methods: Thirty chronic hepatitis B patients undergoing NUC therapy were included. Fifteen patients lost HBsAg during therapy and another fifteen patients had HBsAg throughout therapy. Among 30 patients, 22 were HBeAg(+) patients and 14 lost HBeAg during NUC therapy. Baseline and on-treatment pre-S2 antigen level and HBsAg were serially measured every year during the 5 years treatment duration, and HBV DNA were determined every 3–4 months. Pre-S2 antigen was measured using a quantitative ELISA kit. Results: Decreases in pre-S2 antigen titer were observed during the treatment period. In HBsAg-loss patients, the mean pre-S2 antigen level was 1507.6, 692.0, 100.2, and 94.5 ng/ml at baseline, 12, 24, 36 months, respectively. In HBsAg-persistent patient, the mean level of serum pre-S2 antigen showed decrease with 6024.8, 2605.7, 2493.3, and 2611 ng/ml at baseline, 12, 24, 36 moths of treatment, respectively. The level of pre-S2 antigen was significantly higher in HBsAg-persistent patients than in the HBsAg-loss patients (P \ 0.001). The baseline pre-S2 antigen titer showed a statistically significant positive correlation with baseline HBV-DNA levels in both of group. In univariate analyses, lower level of mean HBV-DNA at baseline and lower level of pre-S2 antigen were significant predictive factors for HBsAg loss during NUC treatment. Multivariate analysis revealed that pre-S2 antigen \2000 ng/ ml at baseline (P = 0.008, odds ratio 17, 95 % confidence interval 2.097–140.965) was an independent factor for HBsAg loss. A significant difference was noted between the HBeAg-persistant and HBeAg-loss groups in terms of pre-S2 antigen titer at 24 and 36 months treatment in HBeAg(+) patients . Multivariate analysis revealed that PreS2 levels \900 ng/ml at 24 months of treatment (P = 0.02, odds ratio 28, 95 % confidence interval 1.700–476.604) was factors associated with HBeAg loss in HBeAg(+) patients. Conclusions: On-treatment pre-S2 antigen level would be useful for predicting HBsAg loss and HBeAg loss during NUC therapy in patients with chronic hepatitis B.


S97

Topic: 8 Hepatitis B - Clinical Absno: 421 Long-term efficacy observation of three step treatment in patients with hepatitis B liver failure Shuqin Zhang, Haiying Sun,Ming Wang,Wenjing Zhao Hepatology Hospital of Jilin Province,Changchun,China, email: [email protected] Objectives: This research aims at analyzing long-term efficacy of three step treatment of comprehensive medical therapy, following artificial liver support therapy and subsequent autologous bone marrow stem cell transplantation therapy in patients with hepatitis B. Methods: 220 patients with HBV-associated with liver failure from Hepatology Hospital of Jilin Province between January 2010 and January 2012 were eligible to enter the study. All patients start from the treatment to accept the different type nuclear glucoside medicine for long-term treatment. 220 patients were randomly divided into three groups. Group A (74 patients) received comprehensive medical treatment for 8 weeks, following with artificial liver support therapy 3 or 4 times during this 8-week period, the survival of patients received further treatment of autologous bone marrow stem cell transplantation 2 or 3 times from week 12. Group B(73 patients) received comprehensive medical treatment for 8 weeks, following with artificial liver support therapy 3 or 4 times during this 8-week period. Group C (73 patients) received comprehensive medical treatment for 8 weeks only. All the patients were followed up 72 weeks. Comprehensive medical treatment Including the nutrition support treatment, the liver-protected treatment, the blood products treatment and so on.The mode of artificial liver support therapy was PDF (plasma exchange combined with continuours hemodiafiltration). Mortality, liver function Child-pugh classification, liver function reserve (ICGR 15 %), the overall rate of complication occurrence were observed at week 12 and week 84. Results: Baseline characteristics were similar between the three divided groups. Liver function Child classifications of all patients were grade C before treatment Results at week 12 Group (n = 220)

Mortality

Liver function reserve (ICGR 15 %)

The overall rate of complication

A, n = 74

6/74 (8.11%)

29.3 ± 17.1

13/74 (17.57 %)

B, n = 73

7/73 (9.59 %)

28.6 ± 14.7

11/73 (15.07 %)

C, n = 73

14/73 (19.18 %)a

39.1 ± 8.6a

21/73 (28.77 %)a

a

Group C contrasted to Group A and Group B, P \ 0.05

At week 12, there are 28 patients (37.84 %) whose Child-pugh grade improved from grade C to grade B and 19 patients (25.68 %) from grade C to grade A in group A; There are 25 patients (34.25 %) whose Child-pugh grade improved from grade C to grade B and 19 patients (26.03 %) from grade C to grade A in Group B (contrasting to group A, P [ 0.05); The corresponding rate in group C are 20.54 % (15/73) and 12.33 % (9/73) (contrasting to group A and group B, P \ 0.05)

After 12 weeks,53 patients in Group A accepted autologous bone marrow stem cell transplantation and accepted observation untill week 84.the other 15 patients were out of this study. At week 84, 9 patients in group B and 10 patients in group C can not be contected during the follow-up period At week 84, there are 49 patients(49/59, 83.05 %) in group A, 39 patients (39/64, 60.94 %) in group B and 29 patients(29/63, 46.03 %) in group C whose Child-pugh grade improved from grade C to grade A (group A contrasting to group B, P \ 0.05; group B contrasting to group C, P \ 0.05) Results at week 84 Group (n = 186)

A, n = 59

Mortality

7/59 (11.86 %)a

Liver function reserve(ICGR15 %)

the overall rate of complication

15.4 ± 5.2a

11/57 (19.29 %)a

B, n = 64

13/64 (20.31 %)

27.4 ± 10.3

18/64 (28.13 %)

C, n = 63

19/63 (30.16 %)

35.3 ± 9.9a

24/63 (38.10 %)

a

Group A contrasted to Group B and Group C, P\0.05

2 patients in group A, 3 patients in group B and 2 patients in group C developed HCC (P[0.05)

Conclusions: Through 84 weeks of follow-up,contrasting to comprehensive medical therapy and comprehensive medical therapy with artificial liver support therapy, three step treatment of comprehensive medical therapy, following artificial liver support therapy and Autologous bone marrow stem cell transplantation. Subsequent therapy can significantly improved liver function reserve and Childpugh classification, reduce the mortality rate and the complication formation rate in patients with hepatitis B liver failure.

Topic: 8 Hepatitis B - Clinical Absno: 423 The Utility of thrombopoietin in predicting liver fibrosis in chronic hepatitis B ¨ mer Bas¸ ar2, Akif Altınbas¸ 1, Fuat Yas¸ ar Tuna3, Barıs¸ Yılmaz1, O ¸ oban2, I˙lhami Yu¨ksel2, Osman Ekiz1, Bora Aktas¸ 1, S¸ ahin C Yu¨ksel2 1

Diskapi Yildirim Beyazit Educational and Research Hospital, Department of Gastroenterology, Ankara, Turkey, 2Hacettepe UniversitySchool of Medicine, Department of Gastroenterology, Ankara, Turkey, 3Akdeniz University, School of Medicine, Department of Gastroenterology, Antalya, Turkey, 4Diskapi Yildirim Beyazit Educational and Research Hospital, Department of Biochemistry Ankara, Turkey Backgrounds and aims: Many noninvasive serum markers have been studied to determine the liver fibrosis score (LFS). In this study, we aimed to investigate the association between thrombopoietin (TPO) levels and the stage of liver fibrosis in patients with chronic hepatitis B (CHB). Patients and methods: Seventy-seven patients (64 active and 13 inactive) with CHB were included in this cross-sectional study. Patients were divided into three groups: Group 1 was containing patients with no/mild fibrosis (F0, F1), Group 2 was patients with significant fibrosis (F2–F4) and Group 3 was inactive CHB carriers.

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S98


Computerized patient registry database was used for laboratory tests including HBV DNA, HBeAg, ALT, AST, total bilirubin, PLT, albumin, INR before the initiating of therapy. Liver biopsies were examined by the experienced pathologists of our hospital who were blinded to the data of the patients. Serum TPO levels were measured using commercial ELISA kit. Results: Serum TPO levels were significantly lower in patients with active CHB compared with the inactive carriers (528 vs. 687.1 p = 0.003). There was no statistically significant difference in TPO levels among the patients with and without significant fibrosis (568.9 vs. 459.8 p = 0.367). Correlation analysis consisting of ALT, AST, TPO, HBV-DNA level, platelet count, histological activity index (HAI) and liver fibrosis score was performed. TPO Table 1 Characteristics of the patients with CHB

was only weakly positively correlated with AST, ALT and HBVDNA levels (r = 0.269, p = 0.018; r = 0.341 p = 0.002; r = 0.308 p = 0.006; respectively) and no correlation in TPO with LFS and HAI˙ was found (r = 0.140 p = 0.270, r = 0.162 p = 0.201; respectively). TPO was not associated with significant fibrosis (p = 0.270) (Tables 1, 2). Conclusion: TPO levels are decreased in active CHB patients compared with inactive carriers but there is no correlation between TPO levels and the stage of fibrosis in active CHB. Keywords: Thrombopoietin, Chronic hepatitis B, Liver fibrosis


Group 1 and 2 (active) (n = 64)

Group 3 (inactive HBV carriers) (n = 13)

Age (years)

45.0 (13.0)

44.7 (9.5)

0.734

Sex (M/F)

33/31

7/6

0.562

Ismail Balik1, Selma Tosun2, Fehmi Tabak3, Nese Saltoglu3, Necati Ormeci4, Irfan Sencan5, Yunus Gurbuz6, Nefise Oztoprak7

Duration of the disease, mean, years (SD)

6.6 (5.5)

6.6 (6.4)

0.743

1

Bilirubin, mg/dl (SD)

0.9 (0.6)

0.7 (0.3)

0.178

Albumin, gr/dl (SD)

4.2 (0.3)

4.4 (0.3)

0.162

INR

0.99 (0.08)

1.0 (0.27)

AST, IU/ml (SD)

46.7 (42.8)

26.4 (22.9)

\0.001

ALT, IU/ml (SD)

62.7 (65.7)

33.5 (33.0)

0.007

Platelet count, /mm3, (SD)

195.000 (59.000)

220.000 (77.000)

0.301

HBV-DNA, IU/ml, (SD)

2.329.017 (5.729.725)

424 (550)

HBeAg negativity, n (%)

57 (89.1)

13 (100)

0.595

TPO, pg/ml (SD)

528.0 (±373.6)

687.1 (±478.6)

0.003

P value*

Investigation of viral hepatitis epidemiology by a touring/ travelling team [Turkish Viral Hepatitis Society Bus Project]

0.090

\0.001

Table 2 Characteristics of the patients with active CHB Group 1 (n = 24) F0–F1

Group 2 (n = 40) F2–F4

P value

Age (years)

40.2 (9.7)

47.9 (14.0)

0.142

Sex (M/F)

11/ 13

22/ 18

0.986

Duration of the disease, mean, years (SD)

5.8 (5.0)

7.1 (5.8)

0.280

Bilirubin, mg/dl (SD)

0.8 (0.5)

1.0 (0.6)

0.054

Albumin, gr/dl (SD)

4.2 (0.3)

4.2 (0.4)

0.895

AST, IU/ml (SD) ALT, IU/ml (SD)

33.2 (21.5) 43.5 (38.5)

54.9 (50.0) 74.3 (75.7)

0.013 0.029

INR

0.97 (0.07)

1.00 (0.08)

0.185

Platelet Count, / mm3, (SD)

209.000 (61.000)

186.000 (57.000)

0.028

2.931.757

0.003

HBV-DNA, IU/ml, (SD) 1.324.451 (3.804.374)

(6.595.720)

HBeAg negativity, n (%) 23 (95.8)

34 (85.0)

0.185

TPO, pg/ml (SD)

568.9 (433.7)

0.367

123

459.8 (235.7)

Ankara University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey, 2Izmir Bozyaka Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Izmir,Turkey, 3Istanbul University, Cerrahpasa Medical Faculty, Infectious Diseases, Istanbul, Turkey, 4Ankara University, Medical Faculty, Department of Gastroenterology, Ankara, Turkey, 5The Ministry of Health, Ankara, Turkey, 6Yildirim Beyazit University, Faculty of Medicine, Department of Infectious Diseases, Ankara, Turkey, 7Antalya Education and Research Hospital, Department of Infectious Disease, Antalya, Turkey Aim: In this study, basically we aimed to raise awareness of the people all over the country about viral hepatitis, to notify them about ways of transmission and means of prevention of this infection, and contribute to dissemination of adult vaccination. Methods: Within the scope of the activities regarding ‘‘Raising awareness of the society and determination of the alteration in viral hepatitis epidemiology’’ carried out by the ‘‘Turkish Viral Hepatitis Society’’ by permission of the Ministry of Health between 2009 and 2011; a large number of cities and towns all over the country were visited by a specially designed and equipped bus. This bus contained an education unit, a blood obtaining unit, test machines and a laboratory. During the course of those visits, the public was informed about viral hepatitis by means of specially-prepared brochures and presentations, blood samples were obtained from volunteers and were tested for HBsAg, anti-HBs ve anti-HCV. Initially, immunochromatographic screening tests called ‘‘cassette test (rapid test)’’ were performed. Positive serum samples were further tested by EIA device on the bus. Also anti-Delta antibodies were studied in sera of subjects with HBsAg positivity. At the end of the tests, after notification of people with negative hepatitis markers about hepatitis B vaccination, first dose of hepatitis B vaccine was administered to people who wanted to be vaccinated. Vaccines were obtained from the Ministry of Health, and health personnel of the City Health Directorate collaborated our team in Hepatitis B vaccination in each city visited. Results: During the study period, blood samples were obtained from a total of 41 041 people (mean age: 40.41 SD ± 14.26, range 1–103). HBsAg seropositivity was detected in 6 % (0–7.9 %); anti-HBs seropositivity in 16 % (10.6–51.9 %); anti-HCV seropositivity in 0.5 % (0.2–0.8 %). Mean countrywide Anti-HBs seropositivity was determined as 17.5 %. During the study period, 200 000 informative brochures were distributed, 37 341 people had blood tests. Conclusions: HBsAg seropositivity detected in the bus study was found to be higher than the rates obtained in the study carried out by primary

Hepatol Int (2014) 8:S1–S405 healthcare centers and family physicians all over the country. When the reason for this was searched; it was found out that, nearly half of the people who got on the bus for blood tests were the ones who had prior diagnosis of chronic hepatitis (B or C) and were under treatment for this, and they had come for confirmation of their blood tests. Therefore, the true results of the bus study may be considered to be nearly half of the obtained results and these seropositivity rates were relevant to the rates of field studies all over the country. However, obtained results have been suggestive about the occasion in different regions and, by means of the bus study, useful information was gathered about the regions where HBsAg and anti-HCV seropositivity were prominent. These data will be considered in further studies intending to decrease HBsAg positivity and will be quite useful in planning of related activities.

S99 seropositivity all over the country has decreased compared to previous years in our country. Besides, HBsAg seropositivity still continues to be a problem in HBV endemic regions such as East Anatolia, Southeast Anatolia and partially in Central Anatolia. As we could not test the subjects for anti-HBc in our study, we could not determine the cause of anti-HBs seropositivity, whether it developed due to previous infection naturally or as a result of vaccination. However, as the rates of adult HBV vaccination is quite low in our country, these subjects may be considered to gain natural immunity after previous infection. As the mean anti-HCV seropositivity of 0.5 %, which was obtained from a considerably high number of antiHCV tests, is relevant to the rates in normal population generally, no change was detected in this rate. Conclusion: While a decrease in HBsAg seropositivity was observed in recent years in our country, no prominent change occured in anti-HCV seropositivity; rates of adult HBV vaccination remained to be quite low.

Topic: 8 Hepatitis B - Clinical Absno: 439 Alteration in seroprevalence of hepatitis B virus (HBV) and hepatitit C virus (HCV) in Turkey Fehmi Tabak1, Selma Tosun2, Ismail Balik3, Nese Saltoglu1, Necati Ormeci4, Irfan Sencan5, Rahmet Guner6, Nefise Oztoprak7, Yunus Gurbuz6 1

Istanbul University, Cerrahpasa Medical Faculty, Infectious Diseases, Istanbul, Turkey, 2Izmir Bozyaka Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Izmir,Turkey, 3Ankara University, Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey, 4 Ankara University, Medical Faculty, Department of Gastroenterology, Ankara, Turkey, 5The Ministry of Health, Ankara, Turkey, 6Yildirim Beyazit University,Medical Faculty, Infectious Diseases and Clinical Microbiology, Ankara, Turkey, 7Antalya Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Antalya, Turkey Aim: In previous studies conducted in our country, HBsAg and antiHCV seropositivity have been found to be approximately 5 %, and between 0.5 and 1 %, respectively. In this study, we aimed to determine the up-to-date change in the epidemiology of HBV and HCV. Methods: This study includes the results of the researches carried out by the ‘‘Association for Fight against Viral Hepatitis (AFVH)’’ between 2008 and 2011 within the scope of activities regarding ‘‘Raising awareness of the society and determination of the alteration in viral hepatitis epidemiology’’, which were performed by permission of the Ministry of Health. It was conducted in family health and primary care centers all over the country; HBsAg, antiHBs and antiHCV were tested in sera obtained from volunteers; also a questionnaire form was completed for each volunteer. Results: During the study period, tests were done and questionnaire forms were completed for 43.431 people in 2008, 50.987 in 2009, 40.581 in 2010, and 22.054 in 2011. After the exclusion of data lacking information about age, gender and other sociodemographic variables in questionnaire forms, and dublication data (as some people had dublicated data); the data of the questionnaires and tests of a total of 150 298 people. At the end of the study, results of 150 298 people tested for HBsAg, 32 570 people tested for anti-HBs, and 150 216 people tested for anti-HCV were analyzed. HBsAg positivity was found to be 2.5 % (1.9–3 %), anti-HBs positivity 7.2 %(4.6–10), antiHCV positivity 0.5 % (0.4–0.7%). These results reveal that HBsAg

Topic: 8 Hepatitis B - Clinical Absno: 441 The short term therapeutic efficiency of telbivudine in chronic hepatitis B patients under the restriction of the National Drug Using Policy A. Ari1, S. C. Akhan2, N. A. Demir3, N. A. Turker4, B. Aygen5, A. A. Batirel6, N. Tulek7, M. Zencir1, A. Aynioglu2 1 Izmir Bozyaka Education and Research Hospital Infectious Disease and Clinical Microbiology Department, Izmir, Turkey, 2Infectious Disease and Clinical Microbiology Department, Kocaeli University Medicine Faculty, Kocaeli, Turkey, 3Infectious Disease and Clinical Microbiology Department, Konya Selçuk University Medicine Faculty. Konya, Turkey, 4Infectious Disease and Clinical Microbiology Department, Izmir Atatu¨rk Education and Research Hospital, Izmir, Turkey, 5Infectious Disease and Clinical Microbiology Department, Kayseri Erciyes University Medicine Faculty, Kayseri, Turkey, 6Infectious Disease and Clinical Microbiology Department,Istanbul Dr.Lutfi Kırdar Kartal Education and Research Hospital, ˙Istanbul, Turkey, 7Infection Diseases and Clinical Microbiology Department, Ankara Education and Research Hospital, Ankara, Turkey

Aim: To investigate the therapeutic efficiency of telbivudine in chronic hepatitis B patients (CHBP) under the restriction of the National Drug Using Policy retrospectively. Method: One hundred and nine patients from seven medical center that 102 antiHBe positive (%93.5) and 7 HBeAg positive (%6.5) were included. Patients were selected according Naitonal Drug Using Policy which was regulated by Social Security Institution with health application notification. According to this notification CHBP who has HBV DNA values below 2000000 IU/ml can only be used lamivudine or telbivudine as oral antiviral and if any detectable HBV DNA above 50 IU/ml at the end of 6 mounth, drug switch or adding are allowed. All of the patients’s initial HBV DNA level was below 2000000 IU/ ml (mean 242834.46 SD 399073.07). Results: At the end of 3 and 6 mounth of telbivudine therapy, HBV DNA below 50 IU/ml as therapeutic response were achived in 77 (% 73.3) of 105 patients and 105 (%92.6) of 109 patients respectively. Any advers event caused stopping therapy was not seen. Conclusion: Telbivudine has high therapeutic efficiency in chronic hepatitis B under the restriction of the National Drug Using Policy.

123

S100

Topic: 8 Hepatitis B - Clinical Absno: 444 Telbivudine in the treatment of chronic hepatitis B Iu. A. Lupasco, V.-T. A. Dumbrava, G. G. Harea Laboratory of Gastroenterology and Hepatology, Department of Internal Medicine N4, State University of Medicine and Pharmacy ‘‘N.Testemitsanu’’, Chisinau, Moldova Introduction: In the Republic of Moldova the death rate from the liver cirrhosis and chronic hepatitis (CH) takes first place worldwide, accounting for 81.6 (2012 year) per 100 thousand population. Among the etiologic factors the CH B (prevalence -588.82/ 100 thousand population) is still playing the important role. Objective: To study the effectiveness of antiviral therapy with telbivudine in patients with CH B depending on the activity of liver enzymes and the level of viremia. Materials and methods: 36 patients received antiviral therapy with telbivudine, men—26, women— 10. The average age was 36.03 ± 7.6. Patients were divided in 2 groups: group 1 (15) were patients with normal activity of transaminases and viremia before treatment—ADN HBV-8,876,076 ± 2,665,946 ui/ml, group 2 (21)—with transaminases [2N and ADN HBV-149,914,070 ± 72,106,944 ui/ml. Monitoring was carried out every 3, 6, 9 months. Results: After 12 months of treatment with telbivudine 600 mg/daily, in group 1 aviremia HBV was achieved in 14 patients (93.33 %), of which 5 are retained in treatment (35.71 %), 9 people (64.29 %) refused further treatment, 1 patient had relaps and therapy was discontinued . In group 1 aviremia HBV was achieved in four patients (19.05 %) in 9 viremia presented[log10 (indices compared with 3, 6, 9 months), they continue therapy. 8 patients failed to have positive dynamics, the treatment was discontinued. Conclusion: The antiviral therapy with telbivudine is more effective in patients with chronic hepatitis B with normal transaminases and viremia \8 million. References 1. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infection. J Hepatol 2012; 57:167–185 2. Chan HLY, Chen YC, Gane EJ, Sarin SK, Suh DJ, Piratvisuth T, et al. Randomised clinical trial: efficacy and safety of telbivudine and lamivudine in treatment—naiv patients with HBV-related decompensated cirrhosis. J Viral Hepat 2012. http://dx.doi.org/ 10.1111/j.1365-2893.2012.01600.x

Hepatol Int (2014) 8:S1–S405 are important in deciding on treatment. One of the most recently defined response markers to treatment is the idea of quantitative evaluation of HbeAg, and early virologic response (EVR, week 12). The aim of this study was to assess the effectiveness of potent oral antiviral drugs used in patients being treated for CHB infection and to determine the relationship between novel response indicators and virological response. Method: This study was performed between the 1st of April, 2007, and the 1st of April, 2013, at the Department of Infectious Diseases, Medical Faculty, Black Sea Technical University. The study was planned to assess the responses of patients being monitored with a diagnosis of CHB indicated for treatment and started on the potent oral antiviral therapy (entecavir or tenofovir). The relationship between novel response markers (early virological response (EVR) and HBeAg titer monitoring) and HBV DNA was investigated. The data obtained were transferred onto SPSS for analysis. Results: One hundred and eighty seven patients were included, 92 receiving entecavir and 95 receiving tenofovir. Virological response rates at the weeks 48 and 96 were 68.2 and 74.6 %, respectively, in those receiving entecavir and 70.6 and 76.9 % in the group receiving tenofovir (P [ 0.05). EVR was 92.6 % in patients receiving entecavir and 84.3 % in those receiving tenofovir. Response was obtained at the end of the week 48 in 73.8 % of the patients who developing EVR. A significant relation between the decrease in HBV DNA levels at the week 12 and the response at the week 48 (P = 0.02) was determined. The decrease in HBV DNA levels throughout the 48-week treatment in 80 HbeAg(+) positive patients was significantly correlated with a decrease in HbeAg titers (r = 0.41 P = 0.02). Discussion: Our results show that EVR, in other words at least a 2 log10 reduction in HBV-DNA at the week 12 of therapy, used as a response predictor in IFN-based therapies, can also be used as a response marker in oral potent antiviral agents. Additionally, the determination of a positive correlation between a decrease in HbeAg titers and a decrease in HBV-DNA levels in HbeAg(+) patients established that monitoring HbeAg titers can be used as a novel monitoring parameter.

Topic: 8 Hepatitis B - Clinical Absno: 447 A New Zealand community-based model for follow-up of people with chronic hepatitis B: does it make a difference? S. Hay; E. Gane, J. Fung, C. Moyes, J. Hornell Hepatitis Foundation of New Zealand

Treatment of Hepatoma Screened vs Non-screened tumours


80

% of patients treated

Absno: 445 Response rates to potent nucleos(t)id analogs accompanied by novel response predictors in the treatment of chronic hepatitis B Ilknur Yavuz1, Iftihar Koksal1, Gurdal Yilmaz1

60

79%

Screened

70

Non-screened

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Abstracts of the Urological Society of Australia and New Zealand, 67th Annual Scientific Meeting, Brisbane, Australia, 16-19 March 2014.

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Abstracts of the British Psychosocial Oncology Society, 2014 Annual Conference, 27 - 28 February 2014, Preston, UK.

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Abstracts from the USCAP 103rd Annual Meeting, March 1-7, 2014, San Diego, California.

RCGP Annual Conference.