Clinical significance of HBV core gene mutations during lamivudine therapy

Category 6: Viral hepatitis: clinical aspects 780) for compensated

cirrhosis308.8&145.2 (84-660) for decompensated cirrhosis, 238.4&125.3 (48-480) for HCC and 221.6&133.9 (17-550) for ALT normal CH. Analysis of CH patients revealed different durations of development of CH as 200.0&129.5 (11-504) months in stage 1 and 311.9&145.7 (48-780) in stage 4. The difference in duration of HCV infection between stage 1 and 4 was statistically different (p
I

512

PREDICTORS

OF HEPATIC STEATOSIS

IN LIVING LIVER

DONORS Z. Karasu’, Y. Tokat2, D. Nart3, A. Celebi’, C. Arikan4, M. Kilic2, U.S. Akarca’, 0. Sebnem’, T. Demirbas2, U. Gurgen’, F. Gunsar’, G. Ersoz’, Y. Batur’. ‘Gastroenterology, Ege University, I&s Turkey; 2General Surgery, Ege University, I&s Turkey; ‘Pathology, Ege University, I&s Turkey; 4Pediattics, Ege University, Izmis Turkey; ‘Radiology, Celal Bayar University, Manisa, Turkey

Significant hepatic steatosis (HS) have been shown on routine liver biopsy in donor candidates, without any biochemical dysfunction. If a liver biopsy, preoperatively, is necessary in all living liver donors is debatable. The aim of this study was to determine if there are any predictors of HS that may establish a threshold for obtaining a biopsy. Patients and Methods: 70 living liver donor candidates, with normal liver biochemistry, underwent a liver biopsy, and the degree of HS (as percentage) has been determined. Age, sex, body weight, height, body mass index (BMI), serum cholesterol (chol), and triglycerides (TG) are studied. The density of the liver and spleen was measured in Hounsfield units (HU) for unenhanced CT (HUl), and dynamic bolus CT (HU2). We investigated if degree of hepatic steatosis has any correlation with the parameters above by using Spearman correlation test. Results: The degree of HS has a correlation with age, serum chol, TG, prekontrast liver HU density. Additionally prekontrast liver-minus-spleen density difference (LHUl-SHU) has significant correlation with HS; p values has been shown in table 1. However, gender, body weight, height, BMI showed no correlation with HS. Parameter

HUl

HU2

chol

TG

Speamlan r

0, 34

-0, 25

-0, 15

0,23

0,27

0,3x

0, 34

P value

0, 01

0, 05

0, 24

0,07

0,03

0,oo

0, 01

age

HU2IHUl

LHUl-SHU

Conclusions: Living liver donor candidates with older age, increased serum-chol and -TG levels should be considered as high risk group for HS. Additionally quatitative density analysis of CT scans looks like a useful guide to detect HS.

I

513

POSlTRANSPLANTATION EFFECTIVE

STRATEGY

HBV VACCINATION:

NOT AN

IN THE PROPHYLAXIS

OF HBV

RECURRENCE Z. Karasu’,

Y. Tokat’, U.S. Akarca’, A. Celebi’, C. Arikan2, M. Kilic’, D. Nart4, T. 0zacar3, T. Demirbas’, S. Erensoy3, F. Gunsar’, G. Ersoz’, Y. Batur’. ‘Gastroenterology, Ege University, I&s Turkey; 2Pediattics, Ege University, I&s Turkey; ‘Clinical Microbiology, Ege University, I&s Turkey; 4Pathology, Ege University, I&s Turkey; ‘General Surgery, Ege University, I&s Turkey Administration of anti-HBs immunoglobulins (HBIg) and lamivudine to prevent hepatitis B (HBV) reinfection after liver transplantation is highly effective. But especially long term administration of HBIg is expensive. Recently, posttransplant HBV vaccination is reported to be an alternative prophylaksis strategy, that enables discontinuation of HBIG. To investigate

149

the efficacy of HBV vaccination in patients transplanted for HBV cirrhosis, we administered double cam-se of double dose recombinant HBV vaccine (Genhavac B; containing pre-S 1, pre-S2, and S). The first cycle is scheduled as 0, l-, and 6-month, and, in non-responders, second cycle is scheduled as 0, l-, 2-month. Inclusion criteria were: i) pretransplant nonreplicative HBV infection, ii) at least 12 months of HBIG plus lamivudine administration, iii) seronegativity for HBsAg and HBV-DNA (by PCR). Vaccination started one month after HBIg discontinuation, and lamivudine (200 mglday) was given throughout the study. Results: 14 patients included into the study. Only 1 patient seroconverted (anti-HBs titer: 37 IU/L) after the first cycle. At the time of writing, 10 patient completed second cycle and no other patient responded. The responding patient was followed for 10 months after seroconversion. His anti-HBs titers decreased below 10 UI/I_ at 4th month, but following a booster dose he developed an anti-HBs titer of 80 IU/L. Additional booster doses are needed for every 3 months to continue his anti HBS positive. During follow up period (1-l 1 months), no patients developed recurrent HBV infection. Conclusion: Posttransplantation HBV vaccination does not seem like an effective strategy in the prophylaxis of HBV recurrence.

I 514

LONG TERM RESULTS

OF ALPHA-INTERFERON

MONOTHERAPY S. Kaymakoglu’, Y. Cakaloglu’, A. Danalioglu’, K. Demir’, F. Akyuz’, N. Aksoy’, D. Oner2, S. Badur2, F. Besisik’, Z. Mungan’, U. Cevikbas3, A. Okten’. ‘Istanbul Medical Faculty, Dept. Of Gastroenterohepatology, Istanbul, Turkey; 21stanbul Medical Faculty, Dept. Of Microbiology, Istanbul, Turkey; ‘Istanbul Medical Faculty, Dept. Of Pathology, Istanbul, Turkey

Aim: To evaluate long term results of alpha-interferon therapy in patients with anti-HBe (+) chronic hepatitis B (CHB). Material: Eighty anti-HBe (+) naive patients (62 male, mean age 39.9yrs) with biopsy proven CHB and detectable HBV-DNA (by molecular hybridisation) plus elevated ALT levels were enrolled. Each patient received interferon-alpha in various doses (4.5.lOMU) for 6 months. ALT normalization with undetectable HBV-DNA was accepted as end-treatment response, maintaining of this response for at least six months as sustained response (SR), and at least twelve months as end of follow up response. Result: All patients were precirrhotic and infected by genotype D except one G. At the end of treatment, 44 patients (55%) responded. Responders were followed in a mean of 27.9&19.8 (6-76) months and 26 patients (59%) showed recurrence (of these, 65.4% in first year). SR rate was 22.5%, end of follow up response 21.25%. Control biopsy were done in 16 (88.9%) of 18 with SR and histological improvement (decreasing of activity index [AI] > 2 points/stage > 1) were observed in 15 (83.3%) The difference between the responders and nonresponders as gender, initial ALT level, interferon dosage, histological stage and AI was not significant. In multivariate analysis younger age (p=O.O4) and GGT level (p=O.O37) were independent factors for prediction of SR. Conclusion: Nearly half of the patients with anti-HBe (+) CHB responds to alpha-interferon monotherapy. Although the high recurrence rates are observed in first year of follow up period, SR continues in about one fourth of patients.

I

515

CLINICAL DURING

SIGNIFICANCE LAMIVUDINE

OF HBV CORE GENE MUTATIONS

THERAPY

Y.S. Kim, J.Y. Jang, Y. Kim, Y.G. Cheon, J.H. Moon, Y.D. Cho, M.S. Lee,

C.S. Shim, B.S. Kim. Department Of Gastroenterology, Hyang Univ. Hasp, Seoul, South Korea

Soon Chun

Background: HBV core peptides are important immunologic targets of cytotoxic T lymphocyte. Missense mutation of the core gene frequently

150 occurs in immune clearance of chronic HBV infection, and mutation clustering region is closely related to T- or B-cell epitopes. Lamivudine is a potent inhibitor of RNA-dependent DNA polymerase of HBV. However its efficacy is limited by emergence of drug-resistant mutant. Aim: This study was carried out to identify the change of HBV core gene sequence during the corn--se of lamivudine therapy and investigate whether the core gene mutation is related with the severity of liver disease. Method: HBV core and polymerase sequences were analysed from the sera of 1.5 patients with CH (B) who experienced HBV DNA breakthrough during lamivudine therapy by PCR-direct sequencing method, which were compared to that from lamivudine-na ve 26 patients with HBeAg-positive CH (B). Results: All patients with the breakthrough harbored YMDD mutants (7 YVDD, 8 YIDD). Number of missense mutation of core gene was low (0.8/patient) in the patients (n=5) whose serum ALT were normal or minimally elevated after HBV DNA breakthrough. On the other hand, the mutations were frequently detected (3Xpatient) in the patients (n=lO) who showed fluctuation of serum ALT after HBV DNA breakthrough. 3 patients with severe flare-up of hepatitis showed higher missense mutations (4,6/patient). Missense mutations were concentrated in the core codon 87. 100, 130-135 and 5-13, which were same as mutation clustering regions of the HBeAg-positive CH (B). Conclusion: Missense mutations of HBV core gene are frequent in lamivudine-resistant mutant HBV, and they are concentrated at the same site with lamivudine-na ve CH (B). It is probable that missense mutations of core gene are related to the disease severity after development of lamivudine-resistance.

I516

ROLE MEDIATORS PLATELET

OF INFLAMMATION

HEMOSTASIS

IN CHRONIC

IN ACTIVATION VIRAL HEPATITISES

A.V. Yagoda’, P.V. Korov’, N.I. Geyvandova’, D.S. Zuprunova2, Sh. M. Kchubiev3. ‘Department Of Internal Diseases, State Medical Academy, Stavropol, Russia; 2Regional Hospital, Stavropol, Russia; ‘Municipal Hospital, Cherkessk, Russia In inflammation the polymorphonuclear and mononuclear leukocytes produce cytokines, which can activate platelets and stimulate intravascular coagulation and microcirculation disorders. Aim: To estimate relationship between platelet function and production of cytokines in chronic viral hepatitis B and C (CH). Methods: We have examined 34 patients with CH and 10 healthy volunteers. We have studied spontaneous (APs) and induced (AH) platelet aggregation (epinephrine, ADP, collagen and platelet activating factor); beta-thromboglobulin (TG) and platelet factor 4 (PF) serum concentration; cyclic nucleotides (CAMP and cGMP) contents in platelets; synthesis in leukocytes cytokines (interleukine-1, interleukine-6 and tumor necrosis factor-alpha) and cytokines serum concentration. Results: In patients APi was decreased, whereas ATs, CAMP, cGMP, TG, TF were increased (p < 0, 05). Cytokines production in the leukocytes and cytokines serum concentration were raised in comparison with the control (p < 0, 05). The lowest parameters APi, cGMP and highest parameters APs, CAMP, level TG and PF were determined in group of the patients with maximal production cytokines in the leukocytes and high cytokines serum concentration compared to patients with minimal and moderate synthesis cytokines in leukocytes (p < 0, 05). Conclusions: There is platelet’ dysfunction induced by disturbances of transmembrane signal transduction and intravascular platelet activation in CH. The reason of platelet’ dysfunction apparently is the increased synthesis mediators of inflammation.

I517

THE SEQUENTIAL

ANALYSIS

HBV-DNA

LAMIVUDINE

DURING

HOMOGENEOUS

OF THE PRECORE THERAPY

PATIENTS INFECTED

REGION

OF

IN

WITH HBV GENOTYPE

C IN JAPAN

R. Kuwahara, R. Kumashiro, S. Murashima, K. Ogata, K. Tanaka, A. Hisamochi, T. Hino, T. Ide, E. Tanaka, Y. Koga, M. Sata. The Second Department Of Internal Medicine, Kwume University School Of Medicine, Kwume, Japan Background: Lamivudine has become a main therapeutic option for chronic HBV infection. It inhibits HBV replication and significantly increases the rate of e-seroconversion. It has been reported that spontaneous or interferon (IFN) -induced seroconversion from HBeAg to anti-HBe has usually been associated with the development of a stop codon in the precore region. It is said that the mutation at nucleotide 1896 is paralleled by seroconversion in general and that the nucleotide at 1896 reflects the activity of hepatitis. However, the difference between lamivudine-induced seroconversion and spontaneous or II+-induced one is not known. Aim: To investigate the correlation between the evolution of the precore mutations and lamivudine-induced seroconversion. Patients/Methods: Forty-five patients infected with HBV genotype C and received lamivudine for more than 1 year at our hospital from 1995 to 2002 were enrolled in this study. Using molecular methods, the nucleotides sequence of the precore region was determined before and after 1 year of lamivudine therapy. Result: Among 29 patients who were HBeAg-positive before lamivudine therapy, 12 patients (41.3%) lost HBeAg during the 1 year of lamivudine therapy. Of these, 8 patients (66.7%) still had precore wild HBV at 1 year. After 1 year of lamivudine therapy, the reversion to precore wild HBV was detected in 3 (25%) of 4 patients who became HBeAg-negative, in 1 (50%) of 2 patients who were persistently HBeAg-positive, and in 7 (63.6%) of 11 patients who were persistently HBeAg-negative. Twelve (75%) of 16 patients who were persistently HBeAg-positive had precore wild HBV before and after 1 year of lamivudine therapy. Conclusion: Lamivudine-induced seroconversion is different from spontaneous or II+-induced one, in view of the change in nucleotides in the precore region. Despite loss of HBeAg, two thirds of patients still had precore wild HBV after 1 year treatment with lamivudine. And during 1 year of lamivudine therapy, the reversion from precore mutant HBV to precore wild HBV was observed in approximately one-fourth of patients treated with lamivudine.

I518

HCV INFECTION MAJOR:

IN ADULT PATIENTS WITH B-THALASSEMIA

10 YEARS

FOLLOW

UP

K. Thomopoulos’, A. Tsamandas2, A. Kourakli-Symeonidou’, M. Christofidou3, C. Labropoulou-Karatza’. ‘Internal Medicine, Pa&as University Hospital, Pa&as, Greece; 2Pathology, Pa&as University, Pa&as, Greece; ‘Microbiology, Pa&as University, Pa&as, Greece Background/Aim: The natural history of HCV infection in multitransfused patients with b-thalassemia major is not precisely known. The aim of the study is to present data of 10 years follow up of adult thalassemic patients. Methods: We studied 74 patients with b-thalassemia major, who were in follow up for HCV infection since 1992. The patients were transfused for 27, 5&6 years with 38&5 units of packed red cells per year and received parenteral iron chelation therapy. Age 30&7 years and sex M/F 34/40, ferritin: 2.100&1.220 ng/ml.All patients were antiHCV positive by third generation ELISA and were tested by PCR for HCVRNA. 57 Patients had liver biopsy at 1993 and 27 had second biopsy 8 years later. Results: 12 Patients (16%) had persistently normal transaminases and negative HCVPCR. 7 Patients (9.4%) had persistently normal transaminases but positive HCVPCR. 45 Patients were treated with Interferon monotherapy and 16 (35.5%) had sustained biochemical and virological response. The second biopsy showed progression of fibrosis only 1 point in Ishak