Evaluation of hepatitis B viraemia levels in patients with HBeAg-negative chronic hepatitis B virus infection.

OBJECTIVES: To evaluate patients with chronic hepatitis B virus (HBV) infection and low-level viraemia in terms of determining HBV DNA cut-off values and levels of alanine aminotransferase (ALT) and other possible markers for discriminating between chronic hepatitis B e-antigen (HBeAg)-negative patients and hepatitis B surface antigen (HBsAg) inactive carriers. METHODS: HBV-infected patients who were HBeAg-negative with undetectable HBV DNA by standard hybridization assay and high (HBeAg-negative group, n = 81) or normal (HBsAg inactive carrier group, n = 77) ALT levels were enrolled. Quantitative polymerase chain reaction assay using a COBAS Amplicor HBV monitor test was performed to detect low HBV DNA levels. RESULTS: The HBV DNA level was found to be significantly higher in the HBeAg-negative chronic HBV group (mean ± SD 94,477 ± 167,528 copies/ml) compared with the HBsAg inactive carrier group (mean ± SD 19,215 ± 57,970 copies/ml). CONCLUSIONS: A low level of viral replication may persist in chronic HBV-infected patients who are HBeAg-negative, and the level of HBV DNA was higher in the HBeAg-negative group than in the inactive HBsAg carrier group. Necroinflammation also persisted in the HBeAg-negative group and these patients had a higher level of ALT than the inactive HBsAg carriers.

A pilot study of 2 years of interferon treatment in patients with chronic delta hepatitis.

High dose interferon treatment for 1 year is the only established treatment for chronic hepatitis D, but it is associated with a high relapse rate after treatment discontinuation. In this study, patients were treated with 10 MU interferon alpha 2b, thrice weekly for 2 years. Twenty-three patients were recruited and 15 completed the 2-year treatment and 6 months follow-up periods. Treatment response was assessed biochemically [normal alanine aminotransferase (ALT)], virologically (undetectable hepatitis D virus RNA) and histologically (at least 2 point decrease in the Knodell score) at the end of treatment (EOT) and at the end of follow-up. Out of 15 patients who finished the 2-year treatment period, seven patients (47%) had a biochemical response but only two (13%) had a normal ALT after follow-up. ALT decreased from the baseline value of 143.1 +/- 121.7 (mean +/- SD) to 39.7 +/- 20.6 (P < 0.01) at EOT. Virological response was observed in six patients at EOT and in two patients at follow-up. Two patients lost hepatitis B surface antigen. Of the 12 patients with paired liver biopsies, a histological improvement was observed in eight patients. Interferon treatment leads to a complete or partial response in a substantial number of patients but 2 years of treatment does not appear to increase sustained response rates over 1 year treatment.

Hepatitis B virus genotype D prevails in patients with persistently elevated or normal ALT levels in Turkey.

BACKGROUND: The clinical relevance of hepatitis B virus (HBV) genotypes are poorly understood and it is unclear if the prevalence of HBV genotypes differs with the various clinical features of HBV carriers. The aim of our study was to examine the prevalence of the HBV genotype in a group of patients with chronic hepatitis B, compared to a group with chronic inactive hepatitos B surface antigen (HbsAg) carriers. PATIENTS AND METHODS: HBV genotypes were determined in 32 patients with chronic hepatitis B and in 12 chronic inactive HBsAg carriers. 35 males and nine females with a mean age of 33.95 +/- 13.04 were studied. Serum samples were examined for the presence of HBV DNA by polymerase chain reaction (PCR). Samples negative in first round PCR were further amplified with nested PCR. The PCR product was sequenced with the Cy5/5.5 dye primer kit on a Long Read Tower automated DNA sequencer. RESULTS: HBV DNA was detectable in 29 (66%) and 44 (100%) patients by the PCR with universal primers and nested-PCR, respectively. All patients were found to be infected with HBV genotype D. Genotype D was the only detected type found in different clinical forms of chronic HBV infection, in all hepatitis B e antigen (HbeAg)-positive and negative patients, in all patients who had elevated or normal alanine transaminase (ALT) levels and in all ages. CONCLUSION: In the present study we could not find any association between genotype D and distinct clinical phenotypes. Genotype D is the predominant type among hepatitis B carriers residing in our region and is not associated with more severe liver diseases. This genotype did not influence clinical manifestations in carriers with chronic hepatitis B virus infection. However, additional large-scale longitudinal studies are needed to find the relationship of HBV genotypes to liver disease severity and clinical outcomes.

Specific hepatitis B vaccine therapy in inactive HBsAg carriers: a randomized controlled trial.

BACKGROUND: Hepatitis B virus (HBV) vaccine therapy has two major areas of application: for preventive purposes and for treating patients with chronic hepatitis B. This study aimed to investigate the effect of therapeutic vaccination of inactive hepatitis B surface antigen (HbsAg) carriers using a recombinant hepatitis B vaccine in a randomized-controlled study. PATIENTS AND METHODS: The 71 studied patients had never received prior antiviral therapies, were anti-HBe positive, had undetectable HBV-DNA and persistently normal alanine transaminase levels. 31 patients were given three 20 mg intramuscular injections of a preS2/S vaccine (GenHevac-B) on days 0, 30 and 60 and the remaining 40 patients were included in the control group. The efficacy of vaccination was evaluated by testing for HBsAg seroconversion to anti-HBs. Post-vaccination follow-up was for 12 months after the first dose. RESULTS: At the end of the follow-up, three out of 31 patients (10%) who received vaccine therapy were able to clear HBsAg from their sera and concomitantly develop anti-HBs antibodies. In contrast, none of the 40 control patients who did not received vaccine therapy had decreased their levels of HBsAg or elicited anti-HBs antibodies (p = 0.079). In three vaccinated patients serum HBsAg became undetectable approximately by the 3rd month of vaccine therapy and HBsAg seroconversion was seen to be durable in all patients in the follow-up period. CONCLUSION: This study offers the first direct evidence, based on a controlled study, that the recombinant HBV vaccine has no great effect in enhancing the rate of HBsAg seroconversion in inactive HBsAg carriers. More efficient strategies, such as an increase in the dose and number of immunizations, should be evaluated further in large controlled trials.

Risk factors for hepatocellular carcinoma in Turkey.

The contribution of hepatitis B, hepatitis C, and excess alcohol intake to the development of hepatocellular carcinoma in Turkey was assessed. The study was conducted through a questionnaire sent to seven major medical referral centers in different regions of Turkey and is based on 207 patients seen in the period 1994-1997. Of the seven centers, two were located in West Turkey (54 patients), two were in Central Turkey (85 patients), and two were in south and southeast Turkey (68 patients). In 196 of the 207 patients (94.7%), there was a history of chronic liver disease, and in 180 patients (87%) liver cirrhosis was documented. Of the 207 patients, 116 (56%) had hepatitis B, 48 (23.2%) had hepatitis C, and 33 (15.9%) had a history of excess alcohol intake. Anti-delta testing was available in 69 of 116 patients with hepatitis B, and anti-HDV was positive in 13 of these patients (13/69, 18.8%). Of the 33 patients with a history of heavy alcohol intake, 18 had concomitant chronic viral hepatitis infection, and alcohol alone was the etiology of hepatocellular carcinoma in only 15 cases (7.2%). The distribution of etiologic factors was not homogenous in different geographical regions in Turkey. In central, south, and southeastern Turkey, the predominant etiology of hepatocellular carcinoma was hepatitis B, whereas in western Turkey the impact of hepatitis B, hepatitis C, and alcohol was similar. This study indicates that hepatitis B virus infection is the leading cause of hepatocellular carcinoma in Turkey, followed by hepatitis C infection and alcoholic liver disease.

Horizontal transmission of HBV infection among students in Turkey.

In this study, the HBsAg carrier state and the role of horizontal transmission were investigated among primary and high school students in southeastern Anatolia where HBsAg seropositivity is remarkably high. In total, 350 students from primary school first grade, 350 students from fifth grade, 400 students from high school eleventh grade and 400 healthy adults as a control group were studied. In all cases HBsAg and anti-HBs were screened by ELISA. HBsAg positivity was 2.4% in first grade, 6.1% in fifth and 6.7% in eleventh grade students. Anti-HBs positivity was 14% in first grade, 20% in fifth and 21% in eleventh grade students. HBsAg positivity was 9% and anti-HBs, 49% in the control group. There is a significant difference between first and fifth grade students for HBsAg positivity (2.1% vs 6.1% and P<0.05). This difference decreased during the high school years (6.2% and P>0.05). There is also a similar statistically significant difference for anti-HBs positivity during the primary school years (14% vs 20%, P<0.05). These findings show that the risk of horizontal transmission of HBV is especially important during elementary school years between the ages of 7 and 11 y. All infants or at least elementary school first grade students in Turkey should have HBV vaccinations.

Gastric luminal somatostatin secretion of normals and patients with pernicious anemia and with Zollinger-Ellison syndrome.

We studied the release of gastric luminal somatostatin-like immunoreactivity (SLI) in response to a pentagastrin infusion (0.9 microgram/kg/hr, intravenous) in five normal volunteers, five patients with pernicious anemia, and two patients with Zollinger-Ellison syndrome. In addition, we studied the gastric luminal SLI secretion in response to a gastric luminal acid perfusion in two patients with pernicious anemia. Our results have shown that: (1) pentagastrin caused a parallel increase in luminal hydrogen ions and SLI release in normal volunteers; (2) Zollinger-Ellison patients had elevated basal acid and SLI levels that did not increase further with pentagastrin; (3) pentagastrin did not increase gastric acid or luminal SLI secretion in pernicious anemia patients; and (4) in pernicious anemia patients, a gastric luminal acid perfusion caused a significant increase in gastric luminal SLI over baseline values. In conclusion, gastric luminal hydrochloric acid appears to be a factor which stimulates the secretion of luminal SLI in human beings.

Mechanism of release of gastric luminal somatostatin-like immunoreactivity in response to pentagastrin and sham feeding in man.

We studied in five healthy volunteers whether the cholinergic pathway regulated the secretion of gastric intraluminal somatostatin-like immunoreactivity (SLI) in response to stimuli of pentagastrin infusion (0.9 micrograms/kg/h, intravenously) and sham feeding. We measured gastric secretory volume, hydrogen ion output, and SLI at base line, during pentagastrin infusion, after sham feeding, and after applications of atropine (0.0, 0.7, 7.0 micrograms/kg, intramuscularly) given before pentagastrin and sham feeding. The stimuli were given randomly, at separate times on different days. After each stimulus, eight 15-min gastric juice collections were made; samples were adjusted to pH 7, pepstatin-A and aprotinin were added, and samples were extracted with acetone to determine SLI by radioimmunoassay. Pentagastrin and sham feeding significantly increased gastric luminal SLI secretion, which appeared to correlate with the increases in volume and acid output. Atropine at 7 micrograms/kg significantly suppressed gastric volume, acid, and SLI outputs stimulated by sham feeding; however, responses to pentagastrin stimulation remained unchanged. To conclude, the cholinergic mechanism regulates gastric intraluminal SLI response to sham feeding but not to pentagastrin infusion.

Luminal gastric somatostatin-like immunoreactivity in response to various stimuli in man.

This study investigates release of somatostatin-like immunoreactivity (SLI) into the gastric lumen of five healthy human subjects in response to pharmacological stimuli (pentagastrin and secretin) and physiological stimuli (sham feeding and intrajejunal perfusion of elemental diet). Basal and poststimulation gastric juice aspirates were collected at 15-min intervals, extracted with acetone, and SLI determined by radioimmunoassay, with these results: A considerable amount of SLI was secreted during the basal period. Pentagastrin stimulated SLI release quickly and was associated with increased acid secretion. Both secretin and sham feeding increased SLI only slightly. During intrajejunal perfusion of the elemental diet, SLI increased significantly, was associated with decreased acid secretion, and rapidly returned to basal level when elemental diet was replaced by saline. Basal levels of gastric luminal SLI thus showed distinct changes in response to each stimulus. Although the physiological action of luminal SLI remains to be studied, its levels may reflect gastric D-cell activities.

A new criterion in the assessment of bentiromide as a test of exocrine pancreatic function in alcoholics.

Bentiromide (N-benzoyl-L-tyrosyl-p-aminobenzoic acid; Bz-Tyr-PABA) is a useful agent in the assessment of exocrine pancreatic function. Bz-Tyr-PABA is hydrolyzed by chymotrypsin in the intestine with liberation of PABA and its metabolic products, arylamines. This study was undertaken to determine the normal values for absorption and excretion of arylamines in normal volunteers and in alcoholics without detectable disorders of the pancreas, liver, or small intestine. After an overnight fast, basal blood and urine samples for baseline arylamine levels were collected, followed by oral administration of 500 mg of bentiromide. A 6-h urine collection was instituted, and 90- and 120-min plasma samples were obtained. The results were analyzed comparing normals and alcoholics: The mean concentration of arylamines was significantly higher in alcoholics than nonalcoholic subjects in baseline urine and in plasma at 90 and 120 min; no significant difference was found between alcoholics and nonalcoholics when comparing mean arylamine levels in 6-h urines. In summary, cumulative 6-h urine arylamine levels are more reliable as a criterion than 90- and 120-min plasma levels in the assessment of exocrine pancreatic function in alcoholics.

Light and electron microscopic studies of diet-induced hepatic changes in mice.

Adult mice were fed a choline-deficient ethionine enriched (CDE) diet for 24, 48 or 72 h. They were then fasted for 24 or 48 h prior to sacrifice. All tissues were studied by light and electron microscopy. Animals fed the CDE diet for 24 h exhibited cells with vacuolated cytoplasm, and the accumulation of lipid in these cells was clearly abnormal. Animals fed the CDE diet for 24 h and subsequently a regular diet for 48 h displayed normal hepatocytes, suggesting that the alterations at 24 h were reversible. Following 48 or 72 h of feeding the CDE diet, abundant lipid-laden cells were observed in the hepatic lobules, and at the electron microscope level these cells were undergoing frank degeneration. Evidence indicated that changes after 48 or 72 h were irreversible.

Effects of somatostatin and a somatostatin agonist on diet-induced pancreatitis in mice.

We examined the effects of somatostatin-14 and the potent somatostatin agonist (N-acetyl-[Des(Ala1,Gly2),p-Cl-Phe6,D-Trp8]-somatostatin amide) on choline deficient, ethionine enriched diet (CDED)-induced acute pancreatitis in mice. Serum amylase determinations were performed, and specimens from the pancreas were examined by light and electron microscopy. No significant beneficial effects of somatostatin or its agonist were found in this model of acute pancreatitis.

Pancreatic immunoreactive somatostatin and diabetes mellitus.

Pancreatic secretions were collected during endoscopic retrograde cholangiopancreatography from 15 subjects without pancreatic, biliary, or hepatic diseases, 11 patients with non-insulin-dependent diabetes, and 11 patients with insulin-dependent diabetes. Pancreatic secretion was stimulated by the intravenous administration of one unit of secretin per kilogram of body weight. Immunoreactive somatostatin (IRS) in the pancreatic juice of the nondiabetic subjects ranged from 43 to 97 pg/ml, in non-insulin-dependent diabetics from 5 to 3872, and in the insulin-dependent diabetics from 0 to 2093. IRS in insulin-dependent diabetics under good plasma glucose control ranged from 0 to 281 pg/ml, compared to those under poor control who ranged from 518 to 2093 pg/ml. These results indicate that IRS in pancreatic juice is higher in poorly controlled insulin-dependent diabetics than in well controlled insulin-dependent diabetics and nondiabetics. Whether these changes in IRS are purely secondary phenomena or play some pathogenetic role in the disturbed metabolism of diabetes remains to be proven. The chromatographic profile of IRS in pancreatic juice on both gel filtration and high-performance liquid chromatography has indicated that these IRS moieties represent somatostatin 14 and somatostatin 28.