Comparison of anti-HBe-positive and HBe-antigen-positive chronic hepatitis B in France

Copyright © Journalof Hepatology 1994

Journal of Hepatology 1994; 20:636-640 Printed in Denmark. All rights reserved Munksgaard. Copenhagen

Journal of Hepatology ISSN 0168-8278

Comparison of anti-HBe-positive and HBe-antigen-positive chronic hepatitis B in France Jean Pierre Zarski ''2, Patrick Marcellin 3, Marielle Cohard 1"2, Jean Michel Lutz 1, Catherine Bouche ~, Abb6s Rais ~ and a F r e n c h Multicentre G r o u p * t Clinique d'H~patogastroent?rologie, Centre Hospitalier Universitaire, "Laboratoh'e de Virologic, Centre Hospitalier Universitaire, Grenoble and -~Service d'H~patologie. H6pital Beaujon. Cliehy, France

(Received 25 January 1993)

Two groups of patients with HBV DNA-positive chronic active hepatitis B, from 20 French hospitals, separated according to HBe status, were prospectively subjected to a comparative analysis of various epidemiological, clinical, biochemical, serologic and histologic features. There were 61 patients with anti-HBe and 215 patients with HBeAg. At diagnosis, 25 variables were compared between the two groups. Some of the patients were followed up for 1 year. Anti-HBe chronic hepatitis B occurred with a prevalence of 22.1%. In the anti-HBe-chronic hepatitis B group, the patients were older, and more often of Southern European origin; the source of infection was more frequently unknown, hepatitis B markers were more frequently observed within the family, and the estimated duration of liver disease was longer. Serum HBV D N A levels were lower in the anti-HBe-positive group. No difference was observed in ALT levels at diagnosis and during follow up in the patients studied. Cirrhosis was more frequent in the anti-HBe-positive group. There was no difference in histological activity score between the two groups. These results suggest that anti-HBe-positive, chronic active hepatitis B is not rare in France, and that the higher occurrence of cirrhosis in this group may be related to a longer duration of the disease. © Journal of Hepatology. Key words: Chronic active hepatitis; Epidemiology; Hepatitis B virus; Pre C mutant

Patients with chronic hepatitis B show serological evidence of hepatitis B virus (HBV) replication. In addition to hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg) and HBV DNA, are usually detectable in serum from those patients and hepatitis B core antigen (HBcAg) is usually detectable by immunofluorescence in the liver (1). However, some patients with chronic hepatitis B do not fit the "usual" serological profile. A subset of patients have HBV D N A in serum and HBcAg in the liver, while no HBeAg is detectable in the serum but antibody to HBeAg (anti-HBe) is observed (2-6). It has been suggested that this type of chronic hepatitis is associated with a severe outcome and with an unusual response to

therapy (6-9). Recently, a genomic variation responsible for the absence of HBeAg has been identified (10-12). HBeAg is derived by proteolysis from the translation product of the entire precore/core open reading frame. A mutation is frequently found, consisting of a single base change (adenine in place of guanidine) at nucleotide 1896 in the preterminal codon of the precore region. This mutation creates a stop codon (TAG) that prevents the production of HBeAg. "Anti-HBe-positive" patients with chronic hepatitis B are more common in Mediterranean populations, for example in Spain, Italy and Greece, and in South-East Asia, than in Northern European populations, for example, from Germany or England, or from

Correspondence to. Dr Jean-Pierre Zarski, Clinique d'H6patogastroent6rologie CHRU de Grenoble, BP 217 - 38043 Grenoble, Cedex 9, France * Participating medical centres (Investigators, Medical Centers): T. Andreani (Paris, St Antoine), M. Antoni (Marseille), Y. Bacq (Tours), P. H. Bernard (Bordeaux), C. Buffet (Bic6tre), B. Champigneulle (Nancy), S. Chaussade (Paris, Cochin), D. Grasset (Montauban), H. Jouanolle (Rennes), P. Marcellin, C. Degott, J. P. Benhamou (Clichy), J. M. Metreau, E. S. Zafrani (Paris, Creteil), X. Moreau (Olliarles), D. Ouzan (St Laurent du Var), D. Pasquier, F. le Marc Hadour (Grenoble), S. Pol, F. Carnot (Paris, Laennec), T. Poynard (Paris, Clamart), P. Rougie, H. Godinot, C. Trepo, M. Chevallier (Lyon), D. Valla (Paris, Piti6 Salpetri+re) and D. Vetter (Strasbourg).

ANTI-HBe-POSITIVECHRONIC HEPATITIS B IN FRANCE the United States. These patients also appear to differ from those with HBeAg, in several important features. Since this form is relatively uncommon, there has been no study of the characteristics of anti-HBe-positive chronic B hepatitis in a non-endemic area. The aims of the present study were to determine the prevalence of anti-HBe chronic hepatitis B in France and to compare the epidemiological, clinical, biochemical, serologic and histologic features in 61 anti-HBe-positive patients and 215 patients with HBeAg-positive chronic active hepatitis B, prospectively studied in 20 French centres between 1989 and 1991. Patients and Methods

Patients Two hundred and seventy-six HBsAg-positive patients with chronic hepatitis admitted consecutively to 20 French centres between 1989 and 1991 were included in this study. Chronic active hepatitis B was defined as follows: i) increased aminotransferase activity for at least 12 months; ii) detectable serum HBV DNA, as shown by the hybridization method at the moment of diagnosis; and iii) liver histology showing chronic active hepatitis with or without cirrhosis. The 276 patients were divided into two groups, according to their HBe status: group 1 consisted of 61 patients with serum anti-HBe, and without serum HBeAg, and group 2 comprised 215 patients with serum HBeAg. Patients with detectable antibodies to human immunodeficiency virus (HIV), hepatitis delta virus (HDV) or hepatitis C virus (HCV), and those with hepatocellular carcinoma were excluded. Methods Epidemiological characteristics were assessed in all patients from all participating centres. Characteristics included age, birthplace and geographical origin, sex, sexual behaviour, source of HBV infection, history of acute hepatitis, known duration of chronic hepatitis and family history of hepatitis. Clinical features included hepatomegaly, splenomegaly, oesophageal varices, and ascites. The history of acute hepatitis was defined by any jaundice episode and/or alanine aminotransferase (ALT) levels of more than 10 upper limit normal. The known duration of chronic hepatitis was determined by the known duration of increased ALT and in some cases from an episode of acute hepatitis. Past or present HBV infection in husbands, wives and children of the patients (HBsAg, antiHBs and anti-HBc antibodies) was investigated. Laboratory tests included ALT, HBsAg, anti-HBc, HBe-Ag and anti-HBe. HBV markers were detected using enzymelinked immunoabsorbent assays (Abbott Laboratories,

637 North Chicago, IL, USA). Serum HBV DNA was determined by a quantitative method (Genostics TM Abbott). The sensitivity limit of this test was 1.5 pg/ml. The natural course of the liver disease was analysed in 40 anti-HBe chronic hepatitis B patients and 85 HBeAg chronic hepatitis B patients over a 1-year period; ALT levels and serum HBV DNA were measured every 3 months. Liver biopsies were performed in all patients at diagnosis, and evaluated under code by two independent observers, using different methods; i) conventional histological diagnosis (chronic active hepatitis, cirrhosis); ii) histological activity scoring, as described by Knodell et al. (13); and iii) immunohistochemical detection of HBsAg and HBeAg. Data analysis Statistical analysis of data was performed using the Fisher exact test and the Student t test. Results were expressed as mean_SD and a percentage. The frequency of cirrhosis in the two groups was estimated using the relative risk, adjusted for age. Results

The prevalence of anti-HBe-positive chronic active hepatitis B was 61/276 (22.1%). Comparative epidemiological features are shown in Table 1. The groups did not differ in sex distribution. The average age was higher in patients who were anti-HBe-positive. Patients with HBeAg-positive chronic hepatitis were more likely to have a known source of infection (especially sexual contacts or risk populations). In the seven anti-HBe-positive risk patients the supposed mode of transmission was haemodialysis (n= 1), health care (n=2), or prolonged stay in Africa (n=4). Among the 54 HBeAg-positive risk patients, the supposed mode of transmission was haemodialysis (n=8), haemophilia (n=l), health care (n=10), institutionalised mental handicap (n=2), malignant pathology (n= 1) or prolonged stay in Asia or Africa (n=32). No statistical difference was observed between the two groups concerning this risk. The geographical origin differed in the two groups: there were more Northern Europeans in the HBeAg-positive group, and more Southern Europeans in the anti-HBe-positive group. Hepatitis B markers were more frequently observed in the families of the anti-HBe-positive group. The results of clinical, biochemical and serologic features are shown in Table 2. No difference was observed between the two groups with respect to history of acute hepatitis. The estimated duration of chronic hepatitis was longer in the anti-HBe chronic hepatitis B group. The two

J. P. ZARSKI et al.

638 TABLE 1 Epidemiological features in the two studied groups Anti-HBe (+) (n=61)

HBeAg (+) . (n=215)

Male

57 (84%)

179 (83%)

Age (Mean-+l SD)

44---12.3

36+_10.0

p<0.01

Supposed mode of transmission Blood transfusion Sexual Drug addict lntrafamilial Risk population Unknown

10 (16%) 8 (13%) 2 (3%) 4 (7%) 7 (12%) 30 (49%)

21 (10%) 62 (29%) 3 (1%) 12 (6%) 54 (25%) 63 (29%)

NS p<0.01 NS NS p<0.02 p<0.01

Geographic origin Northern Europe Southern Europe Africa Asia Others

30 (49%) 13 (22%) 8 (13%) 8 (13%) 2 (3%)

Hepatitis B markers in the family

15 (25%)

174 (80.5%) 5 (2%) 21 (10%) 14 (7%) 1 (0.5%) 26 (12%)

NS

p<0.01 p<0.01 NS NS NS p<0.02

Data represent n (%)

TABLE 2 Clinical, biochemical and serologic features in the two studied groups. Anti-HBe (+) (n=61) History of acute hepatitis Assumed duration of chronic hepatitis (a) years (mean--- 1 SD) Clinical symptoms ALT (N) (ULN)* (mean_l SD)a 3 months 6 months 12 months HBV DNA (pg/ml) (mean-+l SD)b 3 months 6 months 12 months

HBeAg (+) (n=215)

12 (20%)

44 (20%)

7+--5.6

5---4,5

NS

16 (26%)

53 (25%)

NS

5---4.5 7-+5.4 5-+4.6 4-+3.7

4---4,2 17-+ 14.0 4-+3.8 5-+4.3

NS p<0.05 NS NS

60-+78.2 75---68.1 80-+72.3 4+3.5

137-+117.4 169+--157.2 132-+ 114.1 144---122.3

p<0.05 p<0.05 p<0.05 p<0.001

p<0.05

Data represent n (%). ULN*=upper limit normal. NS=not significant. a The assumed duration of chronic hepatitis was calculated in 50 cases in the anti-HBe(+) group and 167 cases in the HBeAg(+) group. b ALT and serum HBV DNA levels were determined at 3, 6 and 12 months in only 40 patients in the anti-HBe(+) group and 85 patients in the HBeAg(+) group.

groups did not differ with regard to s y m p t o m s and A L T levels. Serum HBV D N A levels were lower in anti-HBepositive patients. The time course o f A L T levels observed in patients during the 1-year follow up did not differ between the two groups. Over the same period, H B V D N A levels remained lower in anti-HBe-positive patients than in HBeAg-positive patients, and an intermittent negativity was noted in four anti-HBe-positive patients, without normalisation o f aminotransferases. C o m p a r a t i v e histologic features are shown in Table 3. Cirrhosis was more c o m m o n in patients with anti-HBepositive chronic hepatitis B. The relative risk o f cirrhosis

was 2.2 without adjustment for age, and 1.4 after adjustment for age (95% confidence interval; 0 . 9 8 - 2 . 3 7 - p = 0.06). The two groups did not differ in histologic score; the histologic score p a r a m e t e r s included periportal piecemeal necrosis, lobular activity a n d portal inflammation. The difference observed for fibrosis was nearly significant (p=0.09). Results for H B c A g detection in the liver were available in 37 anti-HBe-positive a n d 119 H B e A g positive patients (Table 3). N o difference was observed between the two groups with respect to the presence o f HBcAg. H B c A g was m o r e cytoplasmic than nuclear in patients with anti-

ANTI-HBe-POSITIVE CHRONIC HEPATITIS B IN FRANCE

639

TABLE 3 Histologic features in the two studied groups

Cirrhosis Histologic score* Periportal piecemeal necrosis Lobular activity Portal inflammation Fibrosis HBcAg (IF)** Nuclear HBcAg Cytoplasmic HBcAg

Anti-HBe (+) (n=61)

HBeAg(+) (n=215)

23 (38%) 9.5-+3.4 2-+ 1.2 2+-1.1 3+-0.9 3+-0.9 23 (62%) 11 (48%) 12 (52%)

36 (17%) 8.5 +-3.23 2+-1.4 2+-1.2 3+-0.8 2+- 1.2 92 (77%) 67 (73%) 25 (27%)

p<0.05 NS NS NS NS NS NS p<0.05 p<0.05

Data represent n (%). NS=not significant. * Histologic score accorded to Knodell et al. is expressed as mean--I SD. ** Results of HBcAg by immunofluorescence(IF) were calculated on 37 patients in the anti-HBe Group and 119 patients in the HBeAg group. The data represent the number of patients with detectable HBcAg (%).

HBe-positive chronic hepatitis B and more nuclear than cytoplasmic in HBeAg-positive patients.

Discussion Anti-HBe-positive chronic hepatitis B is more common in the Far East (14-16) and in the Mediterranean area (2-5) than in Northern Europe. In our prospective study, the prevalence was 22.1%. This relatively high prevalence indicates that anti-HBe chronic hepatitis B is not uncommon in France. Our results indicate that the characteristics of anti-HBe chronic hepatitis B are similar in France, when compared with other countries: anti-HBe-positive patients were older than HBe-Ag-positive patients. Indeed, age was not different from that observed in other series of patients with anti-HBe-positive chronic hepatitis B, ranging from 40 to 50.6 years (2,3,6,14,15,16). The difference between anti-HBe-positive patients and HBeAg-positive patients might be due to a longer time elapsing since contamination occurred, in childhood for example. The mode of transmission of anti-HBe-positive hepatitis seems to have been different. The higher frequency of cases with unknown source of infection, shown in this study, has also been reported by other researchers (2,6,18). In HBeAg chronic hepatitis B, the mode of transmission was more frequently related to homosexual contact or a particular risk, especially a prolonged stay in a high-risk transmission country. This difference might be due to the lower serum HBV D N A levels in anti-HBe chronic hepatitis B patients, and the resulting lower risk of transmission. Sixty-two percent of patients in this study with anti-HBepositive chronic hepatitis B were born in France. This result shows that anti-HBe-positive chronic hepatitis B can be observed in a non-endemic area. However, the patients were more often older than HBe-Ag-positive patients, and

of Southern European origin, and the disease was community acquired. These features suggest that the duration of the liver disease is longer in these patients than in HBeAg-positive patients. The clinical features and ALT levels in the anti-HBepositive patients in our study are consistent with results of previous reports (2,5). Indeed, serum HBV D N A levels were lower in anti-HBe-positive patients than in HBe-Agpositive patients. Fluctuations in ALT and serum HBV D N A levels have also been described previously (2,5). The intermittent positivity of serum HBV D N A levels in some subjects underlines the importance of serial serological measurements in identifying HBV D N A replication in this group. The difference in estimated duration of chronic hepatitis was also reported earlier (2,5). This difference is usually very difficult to confirm because the mode of contamination is unclear and HBV infection is often community acquired, and thus the duration of the disease is unknown. Cirrhosis was more frequent in anti-HBe-positive patients than in HBeAg-positive patients, as has been observed also in other studies (2,3,6). However, histologic activity, as assessed by Knodell scoring, did not differ between the two groups. These results suggest that, in the population studied, the higher prevalence of cirrhosis was more likely to be related to the longer duration of the liver disease, probably due to contamination early in life, than to a more active disease. In conclusion, the prevalence of anti-HBe-positive chronic hepatitis B is relatively high in France. The characteristics of anti-HBe-positive chronic hepatitis B in France are not different from those described in endemic areas. The higher prevalence of cirrhosis in patients with anti-HBe-positive chronic hepatitis may be related to the duration of the disease being longer because contamination may have occurred in childhood.

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