Emergence of YMDD Motif Mutant Hepatitis B Virus during Short-term Lamivudine Therapy

Background/Aims: The emergence of lamivudine-resistant mutant hepatitis B virus (HBV), with aminoacid substitution in the YMDD motif of DNA polymerase, has been reported in the long-term lamivudine use group. However there is no report about the emergence of mutant viruses during the short-term lamivudine therapy. The objective of this study was to investigate the emergence of YMDD mutant HBV during short-term lamivudine therapy. Methods: We evaluated twenty-eight chronic hepatitis B patients who were HBeAg and HBV DNA positive and treated with lamivudine 100mg p.o. daily for 12 weeks. First, we investigated the emergence of YMDD mutants by nested polymerase chain reaction (PCR) method developed by Chayama et al in 19 patients who lost HBV DNA during lamivudine therapy but showed HBV DNA re-emergence 2 weeks after the end of therapy. Second, DNA subcloning and sequencing of HBV DNA polymerase including YMDD motif was undertaken in one patient's serial blood samples at 0, 8, 12 weeks to confirm the results of nested PCR. Results: YMDD motif mutation was detected in 17(90%) out of 19 patients at the end of therapy and the type of mutations were YIDD only. At the end of therapy, mutant was predominant in 5 patients, both mutant and wild type were similar in proportion in 3 patients, and wild type was predominant in 9 patients. When we carried out nested PCR serially with samples of 0, 2, 4, 8, 12, 14 weeks after initiation of therapy in 5 patients who were mutant predominant at 12 weeks, YIDD mutant began to be detected from 2 weeks in 4 patients and from 4 weeks in one patient. However, rapid turnover from mutant to wild type happened after the end of therapy, so only wild type was detected in 3 patients and wild type became predominant in 2 patients at 2 weeks after the end of therapy. All the sequencing results of serial blood samples in one patient were consistent with nested PCR data. Conclusions: The presence of YMDD motif HBV polymerase mutant may be possible before administration of lamivudine in Korean chronic hepatitis B patients. Nested PCR assay would be an useful method to detect YMDD mutant.ope

The Effect of Long-term Lamivudine Therapy for Chronic Liver Disease due to Hepatitis B Virus

Background/Aims : We studied to evaluate the virological and biochemical responses to lamivudine and to detect YMDD mutants in patients who received long-term lamivudine therapy. Method : We conducted a one-year trial of lamivudine in 45 Korean patients with chronic liver disease due to hepatitis B virus. The patients were treated with a single oral average dose of 100 mg of lamivudine every day for 12 months. Results : The suppression of serum HBV DNA was sustained in 77.8% of the patients and the normalization of serum ALT in 80%. The proportions of patients with HBeAg seroconversion were 25%. YMDD mutants were detected in 4 of 8 patients who showed sustained HBV DNA and serum ALT response (n=31) and in 3 of 8 patients who showed HBV DNA or serum ALT breakthrough (n=9). The response to lamivudine therapy in HBeAg-negative patients was excellent. Conclusion : Lamivudine therapy resulted in a significant virological and biochemical improvements and were well tolerated. But, YMDD mutants were detected during lamivudine therapy.ope

Alcohol Abuse Related Medical Complications and Treatment

Alcohol abuse is related to a wide variety of medical complications including liver diseases, pancreatitis, cardiovascular diseases, immunological abnormalities, malignant neoplasms, endocrine disturbances, and kidney problems. The liver is the organ most severely affected by alcoholism. Alcoholic liver disease (ALD) remains a major cause of morbidity and mortality in Korea. The mainstay of therapy for alcohol-related medical problems is cessation of drinking. This article summarizes alcohol-related medical complications and treatment with focus on alcoholic liver injury.ope

Long - term Efficacy and Durability of Lamivudine Therapy in Patients with Chronic Hepatitis B

Background / Aims : It has been reported in patients with chronic hepatitis B, that the response rate of lamivudine therapy increases in proportion to the duration of the therapty. What was not well known was the durability of the therapeutic response after the cessation of lamivudine therapy in patients with chronic hepatitis B. Patients and Methods : We retrospectively analyzes 73 patients with chronic hepatitis B who were treated with lamivudine 100 mg orally once daily and followed up for more than 12 months between April 1997 and March 1999. Sixty-three patients were initially hepatitis B e antigen (HBeAg) positive and Hepatitis B virus (HBV) DNA positive(group Ⅰ). Ten patients were HBeAg negative and HBV DNA positive (group Ⅱ). Results : The response rates of group Ⅰ and group Ⅱwere 68.3% and 70.0% at 12 months, respectively(p=NS). In group I, cumulative HBeAg seroconversion rates art 1 year, 2years, and 3 years were 30.2%, 38.8%, and 42.4%, respectively. The cumulative durability of response was higher in group I than in group II (64.6% vs 33.3% at 1 year ; 35.4% vs 22.2% at 22.2% at 2 years p=.079); lamivudine therapy for more than 6 months after HBeAg seroconversion than for less than 6 months (90.0% vs 40.0% at 1 year ; 90.0% vs 20.0% at 2 years ; p=.013). Conclusions : The long-term response to lamivudine therapy showed no difference between HBeAg - negative/HBV DNA-positive and HBeAg - positive patients. The HBeAg serocinversion rate increased in proportion to the duration of lamivudine therapy. The durability of response.ope

NADPH oxidase signal transduces angiotensin II in hepatic stellate cells and is critical in hepatic fibrosis

Angiotensin II (Ang II) is a pro-oxidant and fibrogenic cytokine. We investigated the role of NADPH oxidase in Ang II–induced effects in hepatic stellate cells (HSCs), a fibrogenic cell type. Human HSCs express mRNAs of key components of nonphagocytic NADPH oxidase. Ang II phosphorylated p47phox, a regulatory subunit of NADPH oxidase, and induced reactive oxygen species formation via NADPH oxidase activity. Ang II phosphorylated AKT and MAPKs and increased AP-1 DNA binding in a redox-sensitive manner. Ang II stimulated DNA synthesis, cell migration, procollagen α1(I) mRNA expression, and secretion of TGF-β1 and inflammatory cytokines. These effects were attenuated by N-acetylcysteine and diphenylene iodonium, an NADPH oxidase inhibitor. Moreover, Ang II induced upregulation of genes potentially involved in hepatic wound-healing response in a redox-sensitive manner, as assessed by microarray analysis. HSCs isolated from p47phox–/– mice displayed a blunted response to Ang II compared with WT cells. We also assessed the role of NADPH oxidase in experimental liver fibrosis. After bile duct ligation, p47phox–/– mice showed attenuated liver injury and fibrosis compared with WT counterparts. Moreover, expression of smooth muscle α-actin and expression of TGF-β1 were reduced in p47phox–/– mice. Thus, NADPH oxidase mediates the actions of Ang II on HSCs and plays a critical role in liver fibrogenesis.ope

Clinical characteristics and prognosis of hepatocellular carcinoma in relation to the type of hepatitis virus

Background : Hepatocellular carcinoma(HCC) is one of the important causes of cancer-related mortality and morbidity in East Asia, including Korea. Most of the hepatocellular carcinoma in Korea are associated with hepatitis B and C virus infection. The clinical characteristics and prognosis of the patients with HCC were evaluated in relation to the type of hepatitis virus. Methods : A retrospective analysis of the clinical data and survival rate was done in 603 patients(M:F=4.9:1, mean age; 54.2 years) who were admitted to Yonsei medical center from April, 1991 through April, 1994. Results : Among 603 patients, tests for HBsAg and anti-HCV was done simultaneously in 455 patients. Out of the 455 HCC patients, 303 patients (66.6%) were classified as Group B(HBsAg+ve, anti-HCV-ve), 102 patients (22.4%) were classified as Group C (HBsAg-ve, anti-HCV+ve), 45 patients (9.9%) were classified as Group non-BC (HBsAg-ve, anti-HCV-ve), and 5 patients (1.1%) were classified as Group BC (HBsAg+ve, anti-HCV+ve). The mean age of the patients in Group C was older than that of Group B (64.9 vs. 51.3 yr) (p400 ng/mL) was significantly higher in Group B than in Group C (70.0 vs. 52.0%)(p<0.05). According to the gross type, nodular type was more common in Group C than in Group B(72.0 vs. 38.1%) (p<0.01). The incidence of portal vein thrombosis was significantly lower in Group C compared with that in Group B (16.7 vs. 31.4%)(p<0.05). The number of the patients whose tumor size of less than 5 cm was significantly higher in Group C than in Group B (35.3 vs. 17.8%) (p<0.05). Using multivariant analysis, independent prognostic factors were found to be Child grading, FP level, size of the tumor, gross type, and the type of hepatitis virus. The cumulative survival rate of 1, 2, and 3 year in each Group was 31.5%, 17.5%, and 10.8%, respectively in Group B, and 55.7%, 30.2%, and 21.6%, respectively in Group C. The median duration of survival of Group B was significantly shorter than that of Group C(5.0 vs. 13 months)(p<0.05). Conclusion : About 90 % of HCC was associated with hepatitis B or C viral infection in Korea. Hepatitis B virus associated HCC had poorer prognosis compared with hepatitis C virus associated HCC in Korea.ope

Peginterferon Alfa-2a, Lamivudine, and the Combination for HBeAg-positive Chronic Hepatitis B. N Engl J Med 2005;352:2682-2695

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Role and cellular source of nicotinamide adenine dinucleotide phosphate oxidase in hepatic fibrosis

Reactive oxygen species (ROS) generated by nicotinamide adenine dinucleotide phosphate oxidase (NOX) is required for liver fibrosis. This study investigates the role of NOX in ROS production and the differential contribution of NOX from bone marrow (BM)-derived and non-BM-derived liver cells. Hepatic fibrosis was induced by bile duct ligation (BDL) for 21 days or by methionine-choline-deficient (MCD) diet for 10 weeks in wild-type (WT) mice and mice deficient in p47phox (p47phox knockout [KO]), a component of NOX. The p47phox KO chimeric mice were generated by the combination of liposomal clodronate injection, irradiation, and BM transplantation of p47phox KO BM into WT recipients and vice versa. Upon BDL, chimeric mice with p47phox KO BM-derived cells, including Kupffer cells, and WT endogenous liver cells showed a ∼25% reduction of fibrosis, whereas chimeric mice with WT BM-derived cells and p47phox KO endogenous liver cells, including hepatic stellate cells, showed a ∼60% reduction of fibrosis. In addition, p47phox KO compared to WT mice treated with an MCD diet showed no significant changes in steatosis and hepatocellular injury, but a ∼50% reduction in fibrosis. Cultured WT and p47phox KO hepatocytes treated with free fatty acids had a similar increase in lipid accumulation. Free fatty acids promoted a 1.5-fold increase in ROS production both in p47phox KO and in WT hepatocytes. CONCLUSION: NOX in both BM-derived and non-BM-derived cells contributes to liver fibrosis. NOX does not play a role in experimental steatosis and the generation of ROS in hepatocytes, but exerts a key role in fibrosis.ope

A case report of acute emphysematous cholecystitis that cured by percutaneous transhepatic gallbladder drainage

Emphysematous cholecystitis is an unusual variant of acute cholecystitis caused by gas-forming organisms. It is characterized by the presence of gas in the gall bladder lumen, wall or pericholecystic tissues. It is thought to be a rare but life-threatening disease with high morbidity and mortality rates than those for other types of acute cholecystitis. Management of emphysematous cholecystitis is surgical removal of gallbladder. Recently, percutaneous cholecystostomy drainage is employed in patients with complications such as perforation and in those who have high surgical risk. It is demonstrated to lower the surgical mortality rates, but it still does not obviate the need for surgical removal of the gallbladder. Percutaneous cholecystostomy may be used for definite therapeutic procedure of emphysematous cholecystitis and we report a case of emphysematous cholecystitis that was cured by the percutaneous cholecystotomy without surgical procedure.ope

Clinical Implication of Automatically Analysed AFP - L3 and PIVKA - 2 in the Diagnosis of Hepatocellular Carcinoma

Background / Aims : Prothrombin induced by Vitamin K Antagonist-Ⅱ(PIVKA-Ⅱ)and alpha-fetoprotein(AFP)subtype reacting with Lens Culinaris Agglutinin(AFP-L3)are known as specific tumor markers for HCC. Recently a more sensitive ELA method for PIVKA-Ⅱand an automatic analyzer with Liquid Phase Binding Assay method(LBA method)for AFP-L3 have been developed. The aim of this study was to evaluate the feasibility of PIVKA-Ⅱ and AFP-L3 measured by newly developed methods as complementary tumor markers to AFP in the diagnosis of HCC. Methods : The serum concentration of AFP, PIVKA-Ⅱ, and a fraction of AFP-L3 were determined from 188 patients with HCC and 118 patients with various liver diseases including tumors of the liver. AFP was measured by EIA, PIVKA-Ⅱ by sensitive EIA, and AFP-L3 by the LBA method with LiBASys Auto-analyzer. The cutoff values for AFP, PIVKA-Ⅱ, AND AFP-L3 WERE 400ng/mL, 40 Mau/mL, AND 15%, respectively. Results : The sensitivity and specificity of serum PIVKA-Ⅱwere 69.2% and 76.5%, respectively. Sixty-two(51.2%) of 121 patients with HCC, in which AFP was less than 400ng/mL were PIVKA-Ⅱ positive. The specificity and specificity of serum AFP-L3 were 48.8% and 90.8%, respectively. When AFP-L3 was used in combination with PIVKA-Ⅱ,31(46.3%) of the 67 patients with small less than 3cm HCC were positive for at least one of these markers. Conclusion : PIVKA-Ⅱ measures by sensitive EIA may be useful for the diagnosis of HCC with low AFP level. AFP-L3 and PIVKA-Ⅱ may improve the detection rate of small HCCs less than 3cm.ope