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Chronic hepatitis B virus (HBV) infection is an important issue among dialysis patients. It could result in nosocomial transmission and infection outbreaks in dialysis units. Vaccination, in addition to universal precautions, regular virologic screening and segregation policy, appear to be of paramount importance in the effective control of HBV infection in a hemodialysis unit, especially in view of the recent discovery of occult hepatitis B infection. Apart from infection control considerations, chronic HBV infection also poses particular problems to dialysis patients in terms of diagnosis and treatment of hepatic complications and pre-transplant management. This review summarizes the recent knowledge and understanding regarding the natural history, clinical presentation and outcome of chronic hepatitis infection in uremic patients and limitations of various existing diagnostic measures in the management of hepatic complications. It seems that chronic HBV infection is associated with high risk of hepatic complications in uremic individuals. Biochemical markers and HBV DNA are, however, inconclusive and liver biopsy remains the only definitive means to establish the activity of liver disease in dialysis patients. In this review, we propose an algorithm for approaching this group of patients and discuss the indications of liver biopsy, options of anti-viral therapy and pre-transplant workup in dialysis patients with chronic hepatitis B infection.

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Hepatitis B virus (HBV) infection and its complications are global health problems. Approximately 400 million people are chronic HBV carriers worldwide. The spectrum of chronic HBV infection ranges from asymptomatic hepatitis B surface antigen (HBsAg) carrier state to chronic hepatitis with progression to cirrhosis and end-stage liver disease. It is estimated that 15% to 40% of people with chronic HBV will progress to cirrhosis. Several extrahepatic syndromes are associated with chronic HBV infection. These syndromes contribute significantly to morbidity and mortality. The mechanism of extrahepatic syndromes seen with chronic viral hepatitis appears to be immune-mediated. including deposition of circulating immune complexes, induction of local immune complex formation by viral antigens, reaction with tissue antigens by viral-induced autoantibodies, or a direct viral reaction to extrahepatic tissue sites. Polyarteritis nodosa (PAN) is a rare, but serious, systemic complication of chronic HBV infection affecting the small- and medium-sized vessels. PAN ultimately involves multiple organ systems, some with devastating consequences, though the hepatic manifestations are often more mild. HBV-associated glomerulonephritis (GN) occurs mainly in children, predominantly males, in HBV endemic areas of the world. In children, GN is usually self-limited with only rare progression to renal failure. In adults, course of GN may be more relentless, progressing slowly to renal failure. A serum-sickness like "arthritis-dermatitis" prodrome is also seen in some patients acquiring HBV infection. The joint and skin manifestations are varied, but the syndrome spontaneously resolves after the onset of clinical hepatitis without significant sequelae. Occasionally, the arthritis following the acute prodromal infection may persist; however, joint destruction is rare. The association between HBV and mixed essential cryoglobulinemia remains controversial. Finally, skin manifestations of HBV infection typically present as palpable purpura. Though papular acrodermatitis of childhood has been reported to be caused by chronic HBV, this association remains controversial.

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Alanine transaminase (ALT) levels have been routinely used in assessment of patients with chronic HBV infection for making the treatment decisions. ALT is traditionally considered to be marker of hepatocellular injury. Various studies using interferon, peg interferon, Lamivudine, Adefovir have shown the importance of elevated ALT levels in predicting the response rate to therapy. Various guidelines have recommended treating the patients of chronic hepatitis B with elevated transaminases and suggested that patients with normal ALT should not be treated. This approach needs a reappraisal. Information available to us in last decade compels to us reevaluate importance of ALT in management of chronic hepatitis B infection. With the help of available information it is reasonable to conclude that the ALT levels have poor predictability for progression of liver disease and planning treatment in patients with CHB. To conclude, patients with CHB infection with normal ALT should be considered for treatment based on the HBV DNA levels assessed by sensitive real time PCR and histological activity. Patients age and family history of liver cancer are two important parameters in considering aggressive approach in these patients.

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Entecavir is the newest and most potent nucleoside analog to be licensed worldwide for the treatment of chronic hepatitis B infection. It has been shown to be more effective than lamivudine and adefovir in direct head-to-head comparison trials. It is also useful in the treatment of lamivudine-refractory patients. Entecavir is safe with no significant difference in adverse effects compared to lamivudine and adefovir. Available data for up to 2 years of continuous therapy showed no development of viral resistance in nucleos(t)ide-naοve patients. Resistance to entecavir occurs only in patients previously exposed to lamivudine and occurs at a rate of 9% after 2 years of continuous therapy with entecavir.

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Malnutrition is prevalent in all forms of liver diseases. A number of factors contribute to malnutrition in patients with hepatic failure. Early diagnosis of malnutrition is essential to allow appropriate treatment, since malnutrition is an important predictor of complications of liver disease and mortality. Disease-specific nutritional therapy should be considered for acute liver failure, sepsis, transplantation, and encephalopathy. This article provides an overview of the nutritional management of acute and chronic liver disease and discusses the need for further intervention studies before appropriate rational treatment guidelines can be formulated.

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Hepatitis B is a well-recognized global public health problem. It is estimated that nearly 2 billion people around the world have serologic evidence of past or present hepatitis B virus (HBV) infection, while 350 million people are chronically infected. This worldwide burden of hepatitis B mandates accurate and timely diagnosis of patients infected with HBV and the use of treatment strategies derived from evidence-based guidelines. HBV is a DNA virus that produces a series of viral protein products. Serologic and nucleic acid testing are critical to disease prevention and treatment objectives. Information from such testing helps determine patients' infectivity and immune status, appropriate monitoring strategies, and the efficacy of treatment, as well as providing data that contributes to a better understanding of the natural history and epidemiology of the disease. This article reviews the clinical use of serologic and nucleic acid tests as markers of disease activity.

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Hepatitis B virus is a microorganism formed in the excess of surface antigen which is devoid of nucleic acid. Surface antigen of HBV was from the beginning the natural candidate for the vaccine which was thus produced by isolation of plasma HBsAg and later substituted by recombinant protein(s). The Extended Program of Immunization was beneficial for the reduction of HBV incidence in the populations of many participating countries. It is further postulated that HCC incidence in the world was also reduced at least in the portion caused by hepatitis B virus. Persistence of anti-HBV immunity was first measured by quantitative anti-HBs assay determined at 1 month post vaccination cycle, and then at different time points, even up to 12-15 years. The frontier of 10 IU/L (mIU/ml) is a mark of sustained immunity. However, cellular immunity studies revealed that this kind of response is very important in the defense against the virus and may last longer than the detectable antibodies. It was shown that 'full' surface vaccines, i.e. preS+S, may give stronger immunity and are good even for neonates. The next generation vaccines are DNA-based and plant-based HBV vaccines. This last category raises many hopes and with sufficient immunogenicity could ensure the most comfortable route of administration.

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Hepatitis B virus (HBV) is a global health problem. Effective and individualized treatment of chronic hepatitis B to prevent progression to end-stage liver diseases and hepatocellular carcinoma is thus needed. HBV has been designated eight genotypes (A-H) based on genome sequence divergence. Each genotype has its distinct geographic and ethnic distribution. The epidemiology of HBV genotypes and their implications on the responses to antiviral therapy have become increasingly recognized. Recent studies suggested that sustained responses to standard interferon in patients with genotype A or B are better than those with genotype C or D. However, conflicting results exist regarding the response to peginterferon. Furthermore, therapeutic responses to nucleoside/nucleotide analogous are comparable among different HBV genotypes. In summary, clinical and pathogenic differences exist among HBV genotypes and future research should focus on molecular and virologic mechanisms underlying the clinical phenotypes of different HBV genotypes.

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Chronic hepatitis B virus (HBV) infection affects over 350 million individuals worldwide. Chronic hepatitis B is associated with complications of end-stage liver disease, including cirrhosis and hepatocellular carcinoma. Six drugs have been approved for the treatment of chronic hepatitis B: interferon-alpha, pegylated interferon-alpha, lamivudine, adefovir dipivoxil, entecavir and recently telbivudine. Most agents designed to target hepatitis B are hindered by the development of resistance, poor tolerability or limited efficacy; therefore, the search for new agents and treatment strategies continues. Telbivudine is the latest approved anti-HBV agent; it is an orally administered nucleoside analog that selectively inhibits HBV replication. It has demonstrated potent activity against HBV in clinical studies, with good tolerance, lack of mitochondrial toxicity and no dose-limiting side effects. This review focuses on telbivudine, the latest oral antiviral agent for the treatment of chronic hepatitis B.

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Hepatitis B virus (HBV) infects approximately more than 350 million people worldwide, especially in Asia, Africa, southern Europe and Latin America. Except for interferon-α, most anti-HBV drugs are derived from the anti-herpes and anti-HIV drugs. Because of the high cost of hepatitis B medications, herbs-also called 'complementary and alternative therapies' in modern Western science-are widely used for treatment of chronic hepatitis B in developing countries. Herbals confer their activities not only by inhibiting HBV secretion but also by building up immunity against viruses. After studying the anti-HBV mechanism of herbs, scientists were encouraged to find that novel anti-HBV drugs target viral secretion, whereas nucleoside analogues target viral polymerase. The complementary and alternative anti-HBV therapies published in scientific peer-reviewed journals are reviewed and discussed in this article.

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The literature on hepatitis B virus (HBV) in immunocompromised patients is heterogeneous and refers mainly to the pre-antivirals era. Today a rational approach to the problem of hepatitis B in these patients provides for: a) the evaluation of HBV markers and of liver condition in all subjects starting immunosuppressive therapies (baseline), b) the treatment with antivirals (therapy) of active carriers, c) the pre-emptive use of antivirals (prophylaxis) in inactive carriers, especially if they are undergoing immunosuppressive therapies judged to be at high risk, d) the biochemical and HBsAg monitoring (or universal prophylaxis, in case of high risk immunosuppression) in subjects with markers of previous contact with HBV (HBsAg-negative and antiHBc-positive), in order to prevent reverse seroconversion. Moreover it is suggested a strict adherence to the criteria of allocation based on the virological characteristics of both recipients and donors in the general setting of transplants, and in liver transplantation the universal prophylaxis with nucleos(t)ides analogues (frequently combined with specific anti-HBV immunoglobulins) in HBsAg-positive candidates and in HBsAg-negative recipients of antiHBc-positive grafts should be adopted.

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Chronic hepatitis B remains a major public health problem, affecting approximately about 350 million people globally. The number of hepatitis B virus (HBV) infected children has not been fully documented. The natural history of HBV infection reflects the dynamic host-virus interactions related to the condition of the host immune system; hence, the clinical course of HBV differs between children and adults. The immaturity of immune system in young children is responsible for the fact that nearly 90% of HBV infections acquired in infancy and 40-70% HBV infections before the age of 3 years result in chronic carrier state of the virus. Therefore a large population is in need of effective and save treatment of this disease. Significant advances have been made during the last decades in the treatment of chronic hepatitis B. The epidemiological situation of HBV infection, its natural history, clinical outcome with its serious long-term consequences and therapeutical approach in children are reviewed in the paper.

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