上海肝病在线 Shanghai Liver Diseases' Online

从抗HBs AB阳性的受体因骨髓等移植中采用免疫抑制剂致HBV重新激活和发生重症肝炎再论---治疗性复合HBV系列疫苗

临床上，慢乙肝病人因劳累致免疫功能下降，其二对半在大、小三、二阳和HBV阴、阳性之间相互转来转去的情况屡见不鲜。而HBV感染后康复（仅抗HBS抗体阳性）者因其他疾病而采用骨髓等移植治疗过程中因采用免疫抑制剂治疗而致机体内潜伏的HBV重新激活而大量复制，并激活机体不全性的免疫功能（因机体免疫功能低下致特异性免疫功能不能有效产生，加上自然免疫功能低下而致破坏性免疫功代偿激活）产生组织器官损伤，致肝炎复发或甚至重症肝炎产生。与自身免疫病人激素治疗中，因免疫抑制而致CMV等病毒激活而产生慢性CMV等感染相一致。

上述结果说明二个间题：

1）HBV感染后康复（仅抗HBS抗体阳性）者并不表明体内如肝内没有HBV 即血清HBV（复制）抗原和HBVDNA阴性不等于肝脏等器官内HBV阴性，更不等于体内HBV消失。只能说HV在HBV感染康复后复制受抑而局限于机体某些细胞内如DC/APC内；一旦机体免疫功能下降，这些受抑的HBV将重新激活而致肝脏等组织器官病变，好比大平盛世时犯人在监牢中服刑，而一旦社会动乱或战乱，变成乱世则犯人越狱而为非作歹，甚至成邦结伙而独霸一方成为地方一霸；

2）免疫功能是决定HBV感染后康复与否和发病与否的重要因素 即免疫功能决定HBV变异与否和发病与否及发病类型与病情程度，因此肝炎治疗中建立合适的HBV特异性免疫对于HBV清除/控制最为重要，而加强自然免疫功能对于防止发病极为重要。

治疗性复合HBV系列疫苗既能激发／产生多克隆、多位点（针对HBV S、前S1、前S2、C/E、X、DNA多聚酶等多处、多位点） 、强力和全面（细胞与体液）的免疫功能以清除/控制HBV，又能重建/恢复机体的自然免疫功能防止发病。

关于HBV康复者在接受骨髓等移植治疗过程中因采用免疫抑制剂治疗而致机体内潜伏的HBV重新激活而大量复制并发病甚至重症化有大量报道，兹列一些英文文摘于下以供参阅。

Gastroenterology 2002 Mar;122(3):614-24

Resolution of chronic hepatitis B and anti-HBs seroconversion in humans by adoptive transfer of immunity to hepatitis B core antigen.

Lau GK, Suri D, Liang R, Rigopoulou EI, Thomas MG, Mullerova I, Nanji A, Yuen ST, Williams R, Naoumov NV.

BACKGROUND & AIMS: Impaired T-cell reactivity is believed to be the dominant cause of chronic hepatitis B virus (HBV) infection. We characterized HBV-specific T-cell responses in chronic hepatitis B surface antigen carriers who received bone marrow from HLA-identical donors with natural immunity to HBV and seroconverted to antibody to hepatitis B surface antigen. METHODS: T-cell reactivity to HBV antigens and peptides was assessed in a proliferation assay, the frequency of HBV core- and surface-specific T cells was quantified directly by ELISPOT assays, and T-cell subsets were analyzed by flow cytometry. RESULTS: CD4+ T-cell reactivity to HBV core was common in bone marrow donors and the corresponding recipients after hepatitis B surface antigen clearance, whereas none reacted to surface, pre-S1, or pre-S2 antigens. Furthermore, CD4+ T cells from donor/recipient pairs recognized similar epitopes on hepatitis B core antigen; using polymerase chain reaction for the Y chromosome, the recipients' CD4+ T lymphocytes were confirmed to be of donor origin. The frequency of core-specific CD4+ and CD8+ T cells was several-fold higher than those specific for surface antigen. CONCLUSIONS: This study provides the first evidence in humans that transfer of hepatitis B core antigen-reactive T cells is associated with resolution of chronic HBV infection. Therapeutic immunization with HBV core gene or protein deserves further investigation in patients with chronic hepatitis B.

精采华丽篇：接受天然HBV免疫的供体进行BMT致HBV感染者的HBS AG清除，其HBV清除作用与HBC AG特异性TH/CD4T细胞从天然HBV免疫的供体过继给HBV感染的受体有密切关系，即天然HBV免疫的供体的HBC AG特异性TH/CD4T细胞在受体内长期存在于受者体内并发挥其抗HBV免疫的免疫调控作用

J Virol 1995 Jun;69(6):3358-68

Activation of a heterogeneous hepatitis B (HB) core and e antigen-specific CD4+ T-cell population during seroconversion to anti-HBe and anti-HBs in hepatitis B virus infection.

Jung MC, Diepolder HM, Spengler U, Wierenga EA, Zachoval R, Hoffmann RM, Eichenlaub D, Frosner G, Will H, Pape GR.

Institute for Immunology, University of Munich, Germany.

Overcoming hepatitis B virus infection essentially depends on the appropriate immune response of the infected host. Among the hepatitis B virus antigens, the core (HBcAg) and e (HBeAg) proteins appear highly immunogenic and induce important lymphocyte effector functions. In order to investigate the importance of HBcAg/HBeAg-specific T lymphocytes in patients with acute and chronic hepatitis B and to identify immunodominant epitopes within the HBcAg/HBeAg, CD4+ T-cell responses to hepatitis B virus-encoded HBcAg and HBcAg/HBeAg-derived peptides were studied in 49 patients with acute and 39 patients with chronic hepatitis B. The results show a frequent antigen-specific CD4+ T-cell activation during acute hepatitis B infection, a rare HBcAg/HBeAg-specific CD4+ T-cell response among HBeAg+ chronic carriers, and no response in patients with anti-HBe+ chronic hepatitis. An increasing CD4+ T-cell response to HBcAg/HBeAg coincides with loss of HBeAg and hepatitis B virus surface antigen (HBsAg). Functional analysis of peptide-specific CD4+ T-cell clones revealed a heterogeneous population with respect to lymphokine production. Epitope mapping within the HBcAg/HBeAg peptide defined amino acids (aa) 1 to 25 and aa 61 to 85, irrespective of the HLA haplotype, as the predominant CD4+ T-cell recognition sites. Other important sequences could be identified in the amino-terminal part of the protein, aa 21 to 45, aa 41 to 65, and aa 81 to 105. The immunodominant epitopes are expressed in both proteins, HBcAg and HBeAg. Our findings lead to the conclusion that activation of CD4+ T lymphocytes by HBcAg/HBeAg is a prerequisite for viral elimination, and further studies have to focus on the question of how to enhance or induce this type of T-cell response in chronic carriers. The immunodominant viral sequences identified may have relevance to synthetic vaccine design and to the use of peptide T-cell sites as immunotherapeutic agents in chronic infection.

精采篇：HBV清除作用与HBC AG/HBe Ag特异性TH/CD4T细胞激活有密切关系，指示今后的HBV治疗性疫苗应重点注意激活机体的针对HBV的C/E区抗原的免疫作用

Bone Marrow Transplant 2000 Jan;25(1):105-8

Fulminant hepatitis B following bone marrow transplantation in an HBsAg-negative, HBsAb-positive recipient; reactivation of dormant virus during the immunosuppressive period.

Iwai K, Tashima M, Itoh M, Okazaki T, Yamamoto K, Ohno H, Marusawa H, Ueda Y, Nakamura T, Chiba T, Uchiyama T.

Department of Hematology and Oncology, Clinical Sciences for Pathological Organs, Graduate School of Medicine, Kyoto University, Kyoto, Japan.

It is widely accepted that seroconversion of HBsAg to HBsAb indicates clearance of hepatitis B virus. We describe a 50-year-old man with chronic myelocytic leukemia who developed lethal hepatitis B 22 months after allo-BMT. He had been negative for HBsAg and positive for HBsAb before BMT. Hepatitis B virus latently existing in the liver cells before BMT proliferated during the immunosuppressed period causing fatal hepatitis. Recipients with positive HBsAb should be considered to have the potential for active hepatitis B to emerge after BMT. Bone Marrow Transplantation (2000) 25, 105-108.

PMID: 10654023

Eur J Haematol 2000 Jul;65(1):86-7

Reactivation of hepatitis B virus infection in an anti-HBc and anti-HBs positive patient after allogeneic bone marrow transplantation.

Nordbo SA, Skaug K, Holter E, Waage A, Brinch L. Publication Types: Letter

PMID: 10914949

J Viral Hepat 1999 Jan;6(1):73-8 Related Articles, Books, LinkOut Failed adoptive immunity transfer: reactivation or reinfection? Ireland J, Hino K, Lau GK, Cheng CC, Carman WF. Institute of Virology, University of Glasgow, UK. A 26-year-old female bone marrow transplant (BMT) recipient was hepatitis B surface antigen (HBsAg) and hepatitis B e antibody (HBeAb) positive. The donor, her human leucocyte antigen (HLA)-compatible sister, was HBsAg negative but hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb) positive. Twelve weeks post-BMT the patient became HBsAg negative, as determined using a monoclonal antibody-based assay. At 16 weeks post-BMT, HBsAg became undetectable by monoclonal and polyclonal immunoassay with seroconversion to HBsAb; however, at 24 weeks post-BMT the patient again became HBsAg positive. Both the recipient and the donor were retrospectively tested by hepatitis B virus (HBV) polymerase chain reaction (PCR) and found to be positive. The recipient displayed variants at amino acids 4 and 47 of the surface (S) gene prior to BMT. These mutations were not detected 32 weeks post-BMT when the S gene sequence was identical to that of an adr prototype. The donor was found to have four unique amino acid substitutions at positions 30, 98, 101 and 210 of the S gene. However, in vitro-expressed HBsAg from the donor was detected by commercial kits and an immunofluorescence assay, indicating that antigenic alteration did not explain HBsAg negativity. This donor highlights the value of PCR as the gold standard test for current HBV infection. It also demonstrates that discordance between two commercial HBsAg assays may not always be caused by antigenic variants. The second episode of hepatitis may theoretically have been caused by reactivation, selection of an escape mutant by HBsAb, reinfection or recombination. We suggest it was reactivation because none of the donor variants was seen in the recipient post-BMT.

PMID: 10847133

Gastroenterol Clin Biol 1999 Jun-Jul;23(6-7):770-4

[Hepatitis B virus reactivation after allogeneic bone marrow transplantation in a patient previously cured of hepatitis B] [Article in French]

Romand F, Michallet M, Pichoud C, Trepo C, Zoulim F.

Service d'Hepato-Gastroenterologie, Hotel-Dieu, Lyon.

The presence of antibodies to HBs and HBc antigens indicates previous infection with hepatitis B virus but does not necessarily reflect viral clearance. Immunosuppression such as that observed in patients with bone marrow transplantation may be responsible for viral reactivation followed by acute exacerbation after withdrawal of immunosuppressive therapy. We report a case in a patient with natural immunity to hepatitis B who had undergone allogenic bone marrow transplantation with an identical sibling donor one year before for the chronic myelogenous leukemia in the first chronic phase. Ganciclovir treatment resulted in control of hepatitis virus B replication and in biochemical remission. We suggest that prevention relies on serological evaluation and therapy with active or passive immunisation or antiviral drugs in case of a rapid decline of anti-HBs Ab titers to undetectable levels.

PMID: 10470533

Rev Esp Enferm Dig 1999 Mar;91(3):229-30

[Reactivation of HBV following allogeneic bone marrow transplantation: new outlook (the hepatitis B virus and the bone marrow transplant)] [Article in Spanish]

Otero Lopez-Cubero S, Espigado I, Aguilar Reina J, Parody R.

Publication Types: Letter Review Review of Reported Cases

PMID: 10231356

J Gastroenterol Hepatol 1999 Mar;14(3):262-8

Histological changes during clearance of chronic hepatitis B virus infection by adoptive immunity transfer.

Lau GK, Yuen ST, Au WY, Wu PC, Liang R.

Department of Medicine, Queen Mary Hospital, Hong Kong, China. gkklau@hkstar.com

BACKGROUND: Serological clearance of hepatitis B surface antigen (HBsAg) has been described after reception of hepatitis B surface antibody positive marrow, via allogeneic bone marrow transplantation (BMT). Histological changes during the clearance of HBsAg are unknown. METHODS AND RESULTS: We described two chronic hepatitis B carriers (both hepatitis B e antigen negative), who cleared HBsAg after allogeneic bone marrow transplantation. Both received hepatitis B surface and core antibody positive human leucocyte antigen identical donors' marrow and had serological clearance of HBsAg 15 and 7 weeks after allogeneic BMT, respectively. Both events were preceded by hepatic flare. Both patients were also treated with famciclovir for the prevention of hepatitis B reactivation after BMT. Histological examination during the flare showed only mild necroinflammatory activity with multiple foci of confluent necrosis, associated with moderate lymphocytic infiltration. The majority of these lymphocytes were cluster of differentiation (CD) 8 positive. Using immunohistochemistry, there was no detectable hepatic expression of hepatitis B core antigen. However, HBsAg was positive, mainly in the area of confluent necrosis. Using in situ hybridization, hepatitis B virus (HBV) DNA was detected in the nucleus of 5% of hepatocytes, but not in the cytoplasm. CONCLUSIONS: At their last follow up, 22 and 16 months after BMT, the serum of both patients remained HBsAg negative, hepatitis B surface antibody positive and HBV-DNA negative by branched DNA assay.

PMID: 10197497

Transplantation 1998 Sep 15;66(5):616-9

Reverse seroconversion of hepatitis B after allogeneic bone marrow transplantation: a retrospective study of 37 patients with pretransplant anti-HBs and anti-HBc.

Dhedin N, Douvin C, Kuentz M, Saint Marc MF, Reman O, Rieux C, Bernaudin F, Norol F, Cordonnier C, Bobin D, Metreau JM, Vernant JP.

Bone Marrow Transplant Unit, Henri Mondor Hospital, Creteil, France.

BACKGROUND: Reverse seroconversion to hepatitis B virus (HBV), i.e., HBV reactivation in patients with pretransplant antibodies to hepatitis B surface antigen (anti-HBs) and to hepatitis B core antigen (anti-HBc), is rarely re-ported after allogeneic bone marrow transplantation. METHODS: To determine this risk, we studied clinical outcome and serological changes in 37 patients with pretransplant anti-HBs and anti-HBc. RESULTS: In 33 cases, no change in HBV markers was observed in the posttransplant period. In four cases, anti-HBs and anti-HBc were lost, and hepatitis B surface antigen, hepatitis B e antigen, and HBV DNA emerged together with acute hepatitis, after cessation of immunosuppression. The actuarial risk of reactivation in the 37 patients was 20.5% (median follow-up 20 months). No reactivation occurred in patients with anti-HBs-positive donors. CONCLUSION: Although few cases of postallogeneic bone marrow transplantation reverse seroconversion to HBV have been reported, this study demonstrates that the actuarial risk is relatively high and suggests that donor vaccination might be proposed prophylactically or that HBs-specific immunoglobulin infusions might be warranted.

PMID: 9753342

Infection 1998 Jan-Feb;26(1):58-60

Clinical and biochemical reactivation of HBV infection in a thalassemic patient after bone marrow transplantation.

Li Volti S, Pizzarelli G, Galimberti M, Di Gregorio F, Romeo MA, Lucarelli G, Russo G.

I Istituto di Clinica Pediatrica, Universita di Catania, Italy.

The case of a young man affected by homozygous beta-thalassemia is reported who had serologic findings of a prior HBV infection and who presented with clinical and biochemical acute HBV infection probably caused by HBV reactivation after allogeneic bone marrow transplantation. The patient's clinical history suggests that HBV can persist without serological findings of HBsAg and HBV-DNA in persons previously infected by HBV and that HBV reactivation can occur 2 years after allogeneic bone marrow transplantation, as a result of immunosuppressive therapy or an HCV activation.

PMID: 9505184

Transplantation 1998 Oct 15;66(7):883-6

Reactivation of hepatitis B after transplantation in patients with pre-existing anti-hepatitis B surface antigen antibodies: report on three cases and review of the literature.

Blanpain C, Knoop C, Delforge ML, Antoine M, Peny MO, Liesnard C, Vereerstraeten P, Cogan E, Adler M, Abramowicz D.

Department of Nephrology, Hopital Erasme, Brussels, Belgium.

BACKGROUND: Patients who have been exposed to the hepatitis B virus (HBV) and who were able to clear the hepatitis B surface antigen from the serum and to develop anti-hepatitis B surface antigen (anti-HBs) antibodies are not considered at risk for HBV reactivation after solid organ transplantation. METHODS AND RESULTS: We, however, observed three solid organ transplant recipients who demonstrated clinically significant HBV reactivation after transplantation. All patients presented normal liver enzymes and serological stigmates of healed HBV infection at the time of transplantation, as indicated by the absence of hepatitis B surface antigen and the presence of anti-HBs and anti-hepatitis B core antibodies in the serum. Patient 1, a renal transplant recipient, presented HBV reactivation 3 years after transplantation and developed chronic HBV hepatitis. Patient 2 developed HBV reactivation 7 months after a second cadaveric renal graft and died of cirrhosis four and a half years after transplantation. Patient 3, a heart-lung transplant recipient, developed HBV reactivation within months after transplantation, but died of unrelated causes. HBV reactivation in the presence of anti-HBs antibodies has been previously reported in other settings of immunosuppression, mainly in patients with acquired immunodeficiency syndrome and after bone marrow transplantation, and may lead to fatal liver disease. Data from our renal transplant recipients suggest that the incidence of HBV reactivation among patients with anti-HBs and anti-hepatitis B core antibodies is about 5%. CONCLUSIONS: Transplant physicians should be aware of the risk of HBV reactivation in patients presenting with healed HBV infection before transplantation.

PMID: 9798698

J Gastroenterol Hepatol 1998 Nov;13(11):1133-7

Fibrosing cholestatic hepatitis after living related-donor renal transplantation.

Waguri N, Ichida T, Fujimaki R, Ishikawa T, Nomoto M, Asakura H, Nakamaru T, Saitoh A, Arakawa M, Saitoh K, Takahashi K.

Department of Internal Medicine III, Niigata University School of Medicine, Niigata City, Japan.

A 43-year-old man underwent living related-donor renal transplantation because of chronic renal failure in 1991. During the transplant period, both donor and recipient were seronegative for hepatitis B surface antigen (HBsAg). The donor was seropositive for antibody to hepatitis B surface antigen (anti-HBs) due to hepatitis B virus (HBV) vaccination. After transplantation, FK506 and methylprednisolone had been administered to the patient as immunosuppressants. In 1993, HBsAg appeared in his serum. His alanine aminotransferase level elevated gradually during 1995 and then in 1996, general fatigue, ascites and jaundice developed. At this time his serum was positive for hepatitis B e antibody, contained more than 100000 Meq/mL HBV-DNA and 100% precore mutant. Despite subsequent intensive therapy, liver dysfunction progressed and this patient died of hepatic failure 2 months following admission. At autopsy, the liver exhibited cholestasis, fibrosis extending from the portal tracts, mild inflammation and hepatocytes with a ground-glass appearance. In addition, HBsAg and hepatitis B core antigens had accumulated in the hepatocytes. Consequently, the final diagnosis was fibrosing cholestatic hepatitis (FCH) due to precore mutant HBV infection contracted after renal transplantation. It is unclear when and where the recipient liver became HBV infected. Nevertheless, after renal transplantation, while receiving immunosuppressive drugs, HBV appeared to have the potential to cause hepatic failure and FCH may have been a fatal complication for the recipient.

PMID: 9870801

Clin Nephrol 1998 Jun;49(6):385-8

Comment in: Clin Nephrol. 1998 Dec;50(6):392.

Occurrence and management of hepatitis B virus reactivation following kidney transplantation.

Grotz W, Rasenack J, Benzing T, Berthold H, Peters T, Walter E, Schollmeyer P, Rump LC.

Department of Nephrology, Albert-Ludwigs-University Freiburg, Germany.

A 28-year-old woman was kidney transplanted. She had an inapparent hepatitis B virus (HBV) infection 2 years previously. At the time of transplantation she was hepatitis B surface antigen (HBsAg) negative, anti-HBs, anti-HBc, anti-HBe and anti-HCV antibody positive and her transaminase activities were within the normal range. The donor of the kidney allograft was HBV negative. Twelve weeks after transplantation a life-threatening liver failure occurred with a rapid rise of alanine aminotransferase (ALT) to 1427 U/l and a decrease of the prothrombin time to 25% of normal value. Anti-HBs had become negative, anti-HBc and anti-HBe titers had decreased. HBsAg became positive, associated with a HBV DNA of 3 x 10(8) genome equivalents/ml. Azathioprine and prednisone were withdrawn and foscarnet therapy was started. This therapy led to a decrease of ALT activity associated with an elimination of HBsAg and HBV DNA. Eight months after transplantation liver function tests were within the normal range. Graft rejection did not occur despite low or intermittent cessation of immunosuppressive therapy.

PMID: 9696436

Hepatology 1998 May;27(5):1377-82

Persistent viremia after recovery from self-limited acute hepatitis B.

Yotsuyanagi H, Yasuda K, Iino S, Moriya K, Shintani Y, Fujie H, Tsutsumi T, Kimura S, Koike K.

First Department of Internal Medicine, University of Tokyo, Japan.

To define the duration of viremia in the course of acute hepatitis B, we semiquantitatively determined the levels of hepatitis B virus (HBV) DNA in the sera, using polymerase chain reaction (PCR) coupled with Southern blotting, of non-immunocompromised patients with self-limited acute hepatitis B. In the sera of 10 of 11 patients, HBV DNA, which was presumably coated with viral proteins, was detected for a long period after recovery, even at the final observation times, which ranged from 6 to 19 months after disease onset. To characterize the mode of HBV that was present in serum, we immunoprecipitated immune complexes in sera by the addition of anti-human immunoglobulin G (IgG) and determined the levels of HBV DNA separately in the supernatants and pellets. In the acute phase of hepatitis B, high levels of HBV DNA were detected both in the supernatants and pellets at comparative levels. After the convalescent phase, the amount of HBV DNA in the supernatant decreased with respect to that in the pellets. It is notable that, in most cases, serum HBV persisted as a form of immune complex even after the seroconversion to antibody to hepatitis B surface antigen (anti-HBs). These data suggest that the replication of HBV may persist in some organs, most likely in the liver or peripheral blood cells, for a long period after recovery from acute hepatitis B, and the data indicate the possible transmission of HBV from organ transplantation donors who exhibit serological markers of past infection only.

PMID: 9581694

Schweiz Rundsch Med Prax 1998 Feb 4;87(6):205-9

[Clinical significance of hepatitis B virus mutants] [Article in German]

Moradpour D, Blum HE.

Abteilung Innere Medizin II, Medizinische Universitatsklinik Freiburg (D).

Hepatitis B virus (HBV) mutants have recently been identified in patients with acute or fulminant as well as chronic infections. Naturally occurring mutations have been identified in all viral genes and regulatory elements. Mutations in the gene coding for the hepatitis B surface antigen (HBsAg) may result in infection or viral persistence despite the presence of antibodies against HBsAg (anti-HBs) ("vaccine escape" or "immune escape"). Mutations in the gene encoding the pre-core/core protein (pre-core stop codon mutant) result in a loss of hepatitis B e antigen (HBeAg) and sero-conversion to antibodies to HBeAg (anti-HBe) with persistence of HBV replication (HBeAg minus mutant). Mutations in the core gene may lead among others to an immune escape due to a T cell receptor antagonism. Mutations in the polymerase gene can be associated with viral persistence or resistance to nucleoside analogues. Thus, HBV mutations may affect the natural course of infection, viral clearance and response to antiviral therapy. The exact contribution of specific mutations to diagnosis and therapy of HBV infection as well as patient management in clinical practice remain to be established. Publication Types: Review Review, Tutorial

PMID: 9531815

J Hepatol 1997 Dec;27(6):973-8

Detection of different viral strains of hepatitis B virus in chronically infected children after seroconversion from HBsAg to anti-HBs indicating viral persistence.

Bahn A, Gerner P, Martine U, Bortolotti F, Wirth S.

Children's Hospital of the Johannes Gutenberg University, Mainz, Germany.

BACKGROUND/AIMS: Seroconversion to anti-HBs or the loss of HBsAg is usually associated with complete elimination of the replicative hepatitis B virus. Usually in these patients hepatitis B virus DNA (HBV DNA) becomes undetectable. Routine controls of patients who underwent anti-HBs seroconversion by more sensitive tests showed that in some cases the virus persisted in the patient. Therefore the aim of our study was to evaluate if virus persistence could also be found in children with chronic hepatitis B after anti-HBs seroconversion. The virus pool should be characterized before and after seroconversion. METHODS: Viral DNA was extracted from nine HBsAg negative or anti-HBs positive sera of children, previously diagnosed as chronic HBsAg carriers. HBV DNA was amplified by polymerase chain reaction. Subsequently the nucleotide sequences of the polymerase chain reaction product in the a-determinant region (aa 121-161) were analyzed on an automatic fluorescent sequencer. RESULTS: In the sera of seven children, HBV DNA was detected in the HBsAg negative phase of the HBV infection. Mutations in codons 122, 125, 127, 131, 134, 143, 159 and 161 of the S gene could be documented, resulting in amino acid changes. In three patients the sequence analysis revealed changes in the HBV genotype from genotype A (serotype adw) to genotype D (serotype ayw) during seroconversion to anti-HBs. CONCLUSIONS: These data demonstrate that persistence of the hepatitis B virus can also occur in HBsAg negative and anti-HBs positive children. After loss of HBsAg, no specific HBV variant was identified. Although a conclusive explanation for the selection process cannot be provided, it remains a fact that the 'surviving' viral strain was mostly represented by genotype D.

PMID: 9453421

J Am Soc Nephrol 1997 Sep;8(9):1443-7

Hepatitis B virus DNA in serum and blood cells of hepatitis B surface antigen-negative hemodialysis patients and staff.

Cabrerizo M, Bartolome J, De Sequera P, Caramelo C, Carreno V.

Hepatology Unit, Fundacion Jimenez Diaz, Madrid, Spain.

Patients undergoing chronic hemodialysis, as well as dialysis staff members, are at high risk of infection with hepatitis B virus (HBV). We have analyzed by PCR the presence of HBV DNA in serum and peripheral blood mononuclear cells (PBMC) from 33 hepatitis B surface antigen (HBsAg)-negative hemodialysis patients and 24 dialysis unit staff members; eight of the 24 staff members had an acute hepatitis B resolved 13 to 21 yr before. HBV DNA was detected in serum of 19 (58%) patients (12 of 17 with and 7 of 16 without anti-HBV antibodies). HBV DNA was found in PBMC of 18 (54%) patients (13 of 17 with and 5 of 16 without anti-HBV antibodies). In the staff members, serum HBV DNA was found only in the individuals who suffered a previous acute hepatitis (P < 0.005). HBV DNA was detected in PBMC of four of six staff members (all with previous acute hepatitis). In two HBV DNA-positive PBMC samples, viral RNA was detected by reverse transcription-PCR. To ascertain whether the HBV DNA detected in serum was encapsulated, seven HBV DNA-positive serum samples were digested with DNase before PCR. After treatment, HBV DNA remained detectable in four cases. In conclusion, HBV DNA in serum and PBMC is detectable in a high proportion of HBsAg-negative hemodialysis patients and may persist several years after a resolved acute hepatitis B. The viral DNA is encapsulated and remains transcriptionally active in PBMC. In the anti-HBs-negative patients, HBV DNA is, at the present time, the only means for diagnosing a past HBV hepatitis.

PMID: 9294837

J Hepatol 1997 Mar;26(3):517-26

De novo and apparent de novo hepatitis B virus infection after liver transplantation.

Roche B, Samuel D, Gigou M, Feray C, Virot V, Schmets L, David MF, Arulnaden JL, Bismuth A, Reynes M, Bismuth H.

Centre Hepato-Biliaire, Faculte de Medecine, Universite Paris Sud, France.

BACKGROUND/AIMS: The aim of this study was to clarify the aetiology of apparent de novo HBV infection after liver transplantation. METHODS: Twenty out of 570 HBsAg negative patients (3.5%) became HBsAg positive after transplantation and were studied. Donor and recipient sera were retrospectively tested for HBsAg, anti-HBs, anti-HBc, and HBV DNA by PCR. Donor and recipient livers were tested for HBV DNA by PCR on paraffin-embedded tissue. RESULTS: Group 1: HBV infection of donor origin (eight patients): one donor serum was HBsAg positive, three were serum HBV DNA positive, four were liver HBV DNA positive. Group 2: reactivation of latent HBV infection (eight patients) with detection of HBV DNA in pretransplant serum (seven patients) or in native liver (one patient): three were anti-HBs positive, two anti-HBc positive, and three with fulminant hepatitis had no serological HBV markers. Group 3: undetermined origin (four patients) defined by absence of HBV DNA in pretransplant donor and/or recipient sera and liver; however, acquired infection was suspected from two anti-HBs and anti-HBc positive donors. Two patients became HBsAg negative, and five HBV DNA negative. One died from HBV-cirrhosis and two were retransplanted. In the others, the last histology showed cirrhosis (three), chronic hepatitis (nine), acute hepatitis (one), and non-specific change (four patients). CONCLUSIONS: The prevalence of de novo HBV infection in liver transplant patients was 3.5%; the aetiology was determined in 16/20 patients: from the donor in eight, and from the recipient in eight. One should be cautious when donors or recipients are anti-HBc or both anti-HBs and anti-HBc positive.

PMID: 9075658

J Hepatol 1997 Feb;26(2):228-35

Evidence for selection of hepatitis B mutants after liver transplantation through peripheral blood mononuclear cell infection.

Brind A, Jiang J, Samuel D, Gigou M, Feray C, Brechot C, Kremsdorf D.

INSERM U370, CHU Necker, Paris, France.

BACKGROUND/AIMS: Despite anti-HBs immunoglobulin therapy, hepatitis B virus (HBV) infection recurs in a high proportion of patients transplanted for HBsAg positive and serum HBV DNA negative chronic liver disease. The contribution of HBV genetic variability to disease recurrence has not been yet thoroughly addressed. We have therefore undertaken a detailed comparison of preS/S and preC/C sequences in two selected patients with recurrence of HBsAg and HBV DNA after transplantation. METHODS: PreS/S and preC/C regions were amplified by PCR from the serum, peripheral blood mononuclear cell (PBMC) and liver tissues of two patients transplanted for end stage HBV-related cirrhosis. Samples were taken both pre- and post-transplantation. HBV-sequences from four to nine clones were determined and compared. RESULTS: A mixing of different HBV DNA molecules was observed within and between serum, liver and PBMC samples. Sequences from both patients showed mutations in the preC region which abolished HBeAg secretion, and in the preS2 initiation codon which prevented preS2 envelope protein production. In addition, for both patients, deletions in the preS2 domain (3 and 21 base pairs) led to the expression of modified preS1 envelope protein. For one patient, the predominant HBs protein sequence found in the PBMC before transplantation showed four specific mutations. One of these mutations was in the "a" determinant (codon 144, asparagine to glycine change) of the major envelope protein. These mutations were not detected, as predominant mutations, in the liver and serum pre-orthotopic liver transplant samples. In contrast, after liver transplantation, this was the major form identified in serum, liver and PBMC. CONCLUSIONS: Our results have shown the selection of different HBV DNA molecules in liver and mononuclear cells. In addition, they provide direct evidence for the role of PBMC in the infection of liver grafts and support the hypothesis that infection of PBMC might lead to selection of HBV variants which would escape immune therapy. Finally, we provide in vivo evidence for reinfection of the liver by HBV particles lacking preS2 envelope protein expression.

PMID: 9059940

J Hepatol 1997 Sep;27(3):572-7

Hepatitis B associated liver failure following bone marrow transplantation.

Caselitz M, Link H, Hein R, Maschek H, Boker K, Poliwoda H, Manns MP.

Dept. of Gastroenterology and Hepatology, Medical School of Hannover, Germany.

BACKGROUND: Several cases have been reported showing clearance of HBsAg in chronic hepatitis B carriers due to adoptive transfer of immunity by an hepatitis B immunised bone marrow. CASE REPORT: We report on a 27-year-old man with chronic myelocytic leukemia and asymptomatic chronic hepatitis B who received allogeneic bone marrow transplantation (BMT). The donor was his HLA identical brother with natural immunity against hepatitis B. Before BMT the donor had received an additional dose of recombinant hepatitis B vaccine. Twenty days after BMT alanine aminotransferase levels increased and graft versus host disease of the skin was observed. Elevation of liver enzymes was initially attributed to graft versus host disease of the liver and the patient received high doses of steroids in addition to standard immunosuppression. Alanine aminotransferase levels increased up to a maximum on day 52 while the HBV DNA level peaked on day 38 after BMT. A liver biopsy showed reactivation of hepatitis B and treatment with steroids was tapered down. Although alanine aminotransferase and HBV DNA levels decreased, liver function deteriorated. The patient died 130 days after BMT due to liver failure. CONCLUSION: This report indicates that disturbance of the balance between HBV replication and immune control after BMT may result in fatal reactivation of hepatitis B. Careful monitoring, including HBV DNA level and early liver biopsy, of patients with chronic hepatitis B undergoing BMT as well as determination of the HBV immune status of the BMT donor is suggested and necessary.

PMID: 9314136

J Hepatol 1996 Dec;25(6):968-71

Reactivated fulminant hepatitis B virus replication after bone marrow transplantation: clinical course and possible treatment with ganciclovir.

Mertens T, Kock J, Hampl W, Schlicht HJ, Tillmann HL, Oldhafer KJ, Manns MP, Arnold R.

Department of Virology, University of Ulm, Germany.

A female chronic hepatitis B virus carrier (HBV-DNA negative) suffered from simultaneous hepatitis B virus and cytomegalovirus reactivation after in vivo T cell depletion preceding transplantation of an in vitro T cell depleted marrow graft for treatment of acute leukaemia. Interstitial pneumonia developing after bone marrow transplantation was successfully treated with ganciclovir (day 13 until day 46). The initially unnoticed extensive hepatitis B virus replication finally led to clinical hepatitis (day 85) and liver failure (day 96). Liver transplantation was performed, but the patient died from septicaemia. Retrospective analysis of hepatitis B virus DNA revealed that the HBV replication started immediately after T cell depletion and was completely suppressed during ganciclovir administration. Screening for HBV-DNA seems to be mandatory in comparable cases, and antiviral chemotherapy should be seriously considered.

PMID: 9007727

Biomed Pharmacother 1995;49(3):117-24

Fibrosing cholestatic hepatitis and HBV after bone marrow transplantation.

Cooksley WG, McIvor CA.

Clinical Research Centre, Royal Brisbane Hospital Foundation Bancroft Centre, Queensland, Australia.

Liver failure caused by reactivation of hepatitis B virus (HBV) is an uncommon complication of bone marrow transplantation. Fibrosing cholestatic hepatitis is a recently described liver lesion that develops in some patients undergoing liver transplantation for chronic HBV infection. The lesion is characterised by peri portal fibrosis, ballooning degeneration of hepatocytes, prominent cholestasis and paucity of inflammation. Recent data suggests it is a cytopathic effect of the pre-core mutant form of HBV with over-expression of viral antigens. Although only one case has so far been described associated with bone marrow transplantation (BMT) it is likely that increasing use of BMT in people with chronic HBV infection will lead to further patients being recognised. Publication Types: Review Review, Tutorial

PMID: 7647282

Ann Intern Med 1994 Aug 15;121(4):274-5

Fatal reactivation of precore mutant hepatitis B virus associated with fibrosing cholestatic hepatitis after bone marrow transplantation.

McIvor C, Morton J, Bryant A, Cooksley WG, Durrant S, Walker N.

Clinical Research Centre, Bancroft Center, Royal Brisbane Hospital, Queensland, Australia.

PMID: 8037408

Int J Hematol 1993 Oct;58(3):183-8

Reactivation of hepatitis B virus in two chronic GVHD patients after transplant.

Chen PM, Fan S, Liu JH, Chiou TJ, Hsieh SR, Liu RS, Tzeng CH.

Department of Internal Medicine, Veterans General Hospital-Taipei, Taiwan, ROC.

We report two cases of hepatitis B virus reactivation following allogeneic bone marrow transplantation (BMT) for severe aplastic anemia and acute myelocytic leukemia. The presence of antibodies to HBsAg, HBeAg and HBcAg prior to transplant indicated previous infection with hepatitis B virus (HBV). These antibodies disappeared 2 and 4 months after the onset of chronic graft versus host disease (GVHD) following immunosuppressive treatment, but HBsAg reappeared in their sera 6 and 10 months later, respectively. This suggests that chronic GVHD and immunosuppressive drugs can reactivate HBV in HBsAb-positive patients, most likely because of the decrease in quality and function of helper T cells and B cells during chronic GVHD to induce clearance of HBV antibodies and reactivation of HBV. Our observation confirms that patients with HBsAb, HBeAb and HBcAb present in their sera should not be considered to have 'immunity' to HBV after BMT.

PMID: 8148496

Bone Marrow Transplant 1992 Jun;9(6):415-9

Liver disease in patients with liver dysfunction prior to bone marrow transplantation.

Chen PM, Fan S, Hsieh RK, Liu RS, Tzeng CH, Chiou TJ, Liu JH.

Department of Internal Medicine, Veterans General Hospital-Taipei, Taiwan, ROC.

Twenty-two patients with previous hepatic compromise who underwent allogeneic bone marrow transplant (BMT) for treatment of hematologic malignancy or other hematologic disease between 1984 and 1990 were chosen for the present study. After transplant, 19 (86.4%) of the patients developed hepatitis, including six cases (27.3%) of acute hepatitis, 12 (54.6%) of chronic hepatitis and one uncharacterized hepatitis. Nine chronic hepatitis patients were followed-up for 7-56.5 months (medium 35.5 months) with biochemistry studies and ultrasonography. Throughout the observation period, liver cirrhosis or hepatoma were not detected and no patients developed veno-occlusive disease. Furthermore patients who developed hepatitis after transplant had worse prognoses. Based on serial serological survey of the various hepatitis B virus (HBV) antigens and antibodies, we have found that most of the recurrent viral hepatitis in transplant patients could be attributed to the reactivation of the virus. In addition, the use of immunosuppressive drugs, persisting infection by HCV and the development of graft-versus-host disease may also play a role in modulating the course of viral hepatitis in BMT patients.

PMID: 1628124

Dig Dis Sci 1988 Sep;33(9):1185-91

Fulminant hepatitis due to reactivation of chronic hepatitis B virus infection after allogeneic bone marrow transplantation.

Pariente EA, Goudeau A, Dubois F, Degott C, Gluckman E, Devergie A, Brechot C, Schenmetzler C, Bernuau J.

Unite de recherches de Physiopathologie hepatique, INSERM U22, Clichy, France.

A case of hepatitis B reactivation following bone-marrow transplantation for leukemia in a previously healthy HBsAg carrier is reported. A number of changes in HBV serum markers were contemporary to the acute episode. All of them (increase of HBsAg concentration, conversion from anti-HBe to HBeAg, appearance of anti-HBc IgM and of serum HBV-DNA) were suggestive of a "switching-on" of viral replication. Institution of corticosteroid treatment at the onset of the acute phase did not prevent the fatal outcome.

PMID: 3044717

Hepatogastroenterology 1999 Sep-Oct;46(29):2925-30

Reactivation of hepatitis B but not hepatitis C in patients with malignant lymphoma and immunosuppressive therapy. A prospective study in 305 patients.

Markovic S, Drozina G, Vovk M, Fidler-Jenko M. Institute of Oncology, Ljubljana, Slovenia. smarkovic@onko-i.si

BACKGROUNDS/AIMS: The aim of this prospective study was to determine the prevalence of hepatitis B (HBV) and hepatitis C viral (HCV) infection as well as to study the morbidity and mortality of viral reactivations in patients treated with corticosteroid containing chemotherapy. METHODOLOGY: From January 1991 to April 1996, 305 patients admitted for treatment of Hodgkin's disease and non-Hodgkin's lymphoma were tested for HBV, and 181 patients for HCV infection. They were followed-up regularly on a monthly basis with liver biochemistry and viral serology. RESULTS: The prevalence of HBs antigen and hepatitis C antibody was found to be 3.2% and 16% respectively. There were 9 reactivations of HBV among 8 HBs antigen positive patients (78%), one among 35 HBs antigen negative patients (2.8%) and none in HCV positive patients. In 83% of cases, reactivation was connected to chemotherapy and corticosteroids. The overall death rate of HBV reactivation was 37%; in severe hepatitis it was 60%. All fatal reactivations were in anti-HBe positive patients. CONCLUSIONS: The low prevalence of HCV failed to demonstrate an association between hepatitis C viral infection and lymphoma in Slovenia. Reactivation of HBV infection in HBsAg positive malignant lymphoma patients is a common and often fatal complication of treatment.

PMID: 10576374

Br J Cancer 1999 Sep;81(1):69-74

Prevalence of hepatitis B virus marker positivity and evolution of hepatitis B virus profile, during chemotherapy, in patients with solid tumours.

Alexopoulos CG, Vaslamatzis M, Hatzidimitriou G.

Department of Medical Oncology, Evangelismos Hospital, Athens, Greece.

To prospectively evaluate the prevalence of hepatitis B virus (HBV) positivity and study the evolution of HBV profile during cancer chemotherapy, serum HBV markers and liver biochemistry were determined in 1008 of 1402 (72%) cancer patients admitted in our Unit and in all 920 (91 %) who received chemotherapy. We found that 54 (5.3%) were HBsAg carriers while 443 (44%) had at least one HBV marker positive. Of the latter, 405 (91%) were HBcAb+ve, 321 (72%) HBsAb+ve and 212 (48%) HBeAb+ve. No patient was HBeAg+ve. Among 920 chemotherapy receivers, 374 (41%) were HBcAb+ve, 280 (30%) HBsAb+ve and 178 (19%) HBeAb+ve. Fifty (5.4%) were HBsAg carriers (versus 0.6% in Greek blood donors). All 50 were systematically screened for HBsAg and HBsAb status throughout chemotherapy, during follow-up or until their death, and liver biochemistry was performed before each chemotherapy course. Stable antigenaemia was observed in 43/50 (86%) while 7/50 (14%) developed clinical and/or biochemical hepatitis. Six of these seven developed serum anti-HBs antibodies with an associated decrease of serum HBsAg titres. We conclude that reactivation of HBV infection during chemotherapy is not rare (14%), while disappearance of HBs antigenaemia is neither a frequent nor usually a permanent phenomenon.

PMID: 10487614