The authors have declared that no competing interests exist.
Conceived and designed the experiments: QX GL. Performed the experiments: KZ XY. Analyzed the data: JL XP. Wrote the paper: XP. Contributed reagents: YZ. Contributed materials: XL. Contributed analysis tool: HS. Revised the manuscript: QX GA.
Many chronic hepatitis B (CHB) patients recur after off-therapy and have to accept prolonged consolidation therapy with NUCs. We investigated the rate of HBV relapse after stopping NUCs therapy with different time period of prolonged consolidation therapy in HBeAg positive CHB patients, and analyzed the associated-factor of recurrence.
We recruited 162 HBeAg-positive CHB patients who met the standard of stopping NUCs therapy recommended by the 2005 APASL. Patients in group A, without the prolonged consolidation therapy, were as controls. Patients in group B were divided into 3 subgroups (group B1, 7 (range 3–11) months of the prolonged consolidation therapy; group B2, 17 (range 13–20) months of the prolonged consolidation therapy; group B3, 28 (range 25–34) months of the prolonged consolidation therapy). Virologic relapse was defined as an increase in serum HBV DNA to >103copies/ml after off-therapy.
One hundred and thirty-six patients (group A, 40 patients; group B1, 54 patients; group B2, 23 patients; group B3, 19 patients) were eligible for this study. The cumulative rates of relapse in group B at 6 months and 48 months were 29.2%, 41.7% after off-therapy, respectively. The cumulative rates of relapse in group B were statistically lower than that in group A at the same time periods. The cumulative rate of relapse in group B3 or group B2 was statistically lower than that in group B1, respectively. On multivariate analysis by Cox’s proportional hazard model, age at off-therapy, baseline ALT and the different time period of the prolonged consolidation therapy were associated with the relapse of HBV after off-therapy.
Consolidation therapy with NUCs after HBeAg seroconversion should be further prolonged. Age at off-therapy, ALT at baseline and the time period of the prolonged consolidation therapy could provide information to direct anti-viral therapy.
There are approximately 350–400 million people chronically infected with hepatitis B virus (HBV) in the world
Nowadays, 4 kinds of nucleos(t)ide analogues (NUCs), Lamivudine (LAM), Adefovir Dipivoxil (ADV), Telbivudine (LDT), Entecavir (ETV) are used to treat chronic HBV infection in China. NUCs can effectively inhibit replication of HBV, but not eradicate HBV in hepatocyte. Many CHB patients recur after NUCs are discontinued. So CHB patients have to accept long-term therapy of NUCs. Long-term therapy brings many problems to CHB patients, such as high expenses, HBV drug resistance, etc.
Different researches recommend different end points of therapy with NUCs. According to guidelines recommended by the Asian Pacific Association for the Study of the Liver (APASL)
In the present study, we analyzed the relapse rate of HBV and the associated-factor of recurrence after stopping NUCs therapy with the different time period of the prolonged consolidation therapy in HBeAg positive CHB patients. These patients met the standard of stopping therapy recommended by the 2005 APASL guideline
Patient recruitment started in January 2001 and the last patient follow-up was in March 2012. We recruited 162 HBeAg-positive CHB patients who were referred to Department of Infectious Diseases, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. These patients met the standard of stopping NUCs therapy recommended by the 2005 APASL. The standards for diagnosis of CHB have been previously described in detail
All patients were treated with ADV, ETV, LAM or LDT, respectively. The standard of stopping therapy recommended by the 2005 APASL was as follows: anti-HBe seroconversion, HBV DNA<103copies/ml (detection on 2 occasions at least 6 months apart). According to the different time period of the prolonged consolidation therapy with NUCs, patients were divided into 2 groups: group A and group B. Group A included 40 patients without the prolonged consolidation therapy. Group B was then categorized into B1, B2 and B3, depending on the time period of the prolonged consolidation therapy. Group B1 included 54 patients with 7 (range 3–11) months of the prolonged consolidation therapy. Group B2 included 23 patients with 17 (range 13–20) months of the prolonged consolidation therapy. Group B3 included 19 patients with 28 (range 25–34) months of the prolonged consolidation therapy. Sera of all patients were collected at baseline, and at 1, 2, 3, 4, 5, 6, 9, 12, 18, 24, 30, 36, 42, 48 months after off-therapy, respectively. HBV DNA, HBsAg, HBeAg, anti-HBe, ALT were analyzed, respectively. The standard of virological relapse was serum HBV DNA to >103copies/ml.
Liver biochemistry was assayed by routine automated analysis system (Beckman Coulter, Fullerton, CA). HBV serological markers, including HBsAg, anti-HBs, HBeAg and anti-HBe were assayed by a chemiluminescent micro particle enzyme immunoassay (Abbott, Chicago, IL). The detection of serum HBV DNA level was previously described in detail
Data were expressed as mean±SD or median. The Kaplan-Meier method was used to calculate the cumulative rate of relapse. Log-rank test was used to compare the cumulative rate of relapse among groups. The Cox’s proportional hazards regression model was adopted to determine the predictive factor for relapse, among various variables including age at off-therapy, gender, baseline HBV DNA level, baseline ALT level, baseline AST level, baseline TBIL level, baseline ALB level, time to virologic response, type of NUCs, the duration of the prolonged consolidation therapy and total treatment duration. Receiver operating characteristic curve (ROC curve) was used to calculate cut off value of the relevant predictive factor for relapse. All statistical analysis was performed using SPSS v16.00 statistical analysis software (SPSS Inc, Chicago, IL). Differences were considered statistically significant at a value of
One hundred and sixty-two HBeAg-positive CHB patients were recruited in the present study. After excluding 16 patients lost in follow-up period and 10 patients whose sera were not collected at baseline, 136 patients were eligible for this analysis. Sixty patients were treated with ADV, while 37 patients with ETV, 26 patients with LAM, 13 patients with LDT. Baseline characteristics of the 136 patients in this study were shown in
Factors | Group A | Group B1 | Group B2 | Group B3 | F(X2/Z) value | |
Gender(M/F) | 28/12 | 46/8 | 18/5 | 13/6 | (3.982) | 0.226 |
Age (Year) | 34.5±10.5 | 36.3±9.6 | 34.4±8.7 | 35.5±9.2 | 0.365 | 0.779 |
HBV DNA(log10 copies/ml) | 5.8±1.3 | 5.7±1.3 | 6.2±1.2 | 6.0±0.8 | 1.436 | 0.242 |
ALB(g/L) | 45.1±3.8 | 44.2±3.9 | 44.7±3.7 | 42.3±6.1 | 1.948 | 0.125 |
ALT (U/L) | 93(66–217) | 75(56–134) | 75(55–186) | 128(74–448) | (/4.164) | 0.244 |
AST(U/L) | 73(43–140) | 78(56–147) | 108(56–1725) | 96(70–209) | (/3.670) | 0.299 |
TBIL(µmol/L) | 15(10–19) | 15(11–24) | 15(11–21) | 15(10–25) | (/1.518) | 0.678 |
Period of prolonged consolidation therapy (month) | 0(0–0) | 7(3–11) | 17(13–20) | 28(25–34) | ||
Time to HBeAg seroconversion (month) | 28(14–40) | 30(22–48) | 34(30–50) | 32(21–55) | ||
Time to undetectable HBV DNA (month) | 17(14–27) | 18(19–33) | 25(22–43) | 22(19–39) | ||
Total treatment duration (month) | 35.8±5.0 | 40.1±6.4 | 45.9±7.3 | 59.3±17.3 | ||
HBV genotype | All C |
After off-therapy, the cumulative rates of relapse at 1, 2, 3, 4, 5, 6, 9, 12, 18, 24, 30, 36, 48 months were calculated, respectively. As shown in
Group A, 40 patients without the prolonged consolidation therapy. Group B, 96 patients with the different time period of the prolonged consolidation therapy. Group B1, 54 patients with 7 (range 3–11) months of the prolonged consolidation therapy. Group B2, 23 patients with 17 (range 13–20) months of the prolonged consolidation therapy. Group B3, 19 patients with 28 (range 25–34) months of the prolonged consolidation therapy. Fig. 1A showed the difference in the cumulative rate of relapse between group A and group B (
Subsequently, we compared the cumulative rates of relapse among group B1, group B2 and group B3. As shown in
Cox’s regression analysis revealed that HBV recurrence after off-therapy was associated with age at off-therapy (RR = 1.04; 95% CI, 1.021∼1.069;
Factor | |||||
Age at off-therapy | 0.044 | 13.462 | 0.000 | 1.045 | (1.021, 1.069) |
ALT at baseline | −0.001 | 5.818 | 0.016 | 0.999 | (0.997, 1.000) |
Different period of prolonged consolidation | −0.027 | 4.672 | 0.031 | 0.974 | (0.951, 0.998) |
Note: B, regression coefficient; Wald,
Subsequently, ROC curves of the three relevant predictive factors were drawn and cut off values of them were calculated, respectively. Cut off value of age at off-therapy, ALT level at baseline, and the time period of the prolonged consolidation therapy, for predicting HBV recurrence, was 37 years old, 80 U/L, 11 months, respectively.
Then we measured the differences in the cumulative rates of relapse between age≤37 and age>37, ALT>80 U/L and ALT≤80 U/L, the time period of the prolonged consolidation therapy>11 months and that ≤11 months, respectively. The cumulative rate of relapse in patient ≤37 years old at off-therapy (45.3%) was statistically lower than that in patient >37 at off-therapy (62.5%) (
Fig. 2A showed the difference in the cumulative rate of relapse between age≤37 and age>37 (
In the present study, we found that the relapse rate of HBV after off-therapy gradually decreased with the increase of the time period of the prolonged consolidation therapy in HBeAg positive CHB patients. Age at off-therapy, baseline ALT level and the time period of the prolonged consolidation therapy were associated with recurrence of HBV after NUCs were discontinued. If patient was ≤37 years old at off-therapy, or ALT at baseline was >80 U/L, or the time period of the prolonged consolidation therapy was >11 months, the cumulative rate of relapse would significantly decrease after off-therapy.
For patients with HBV infection, it is best to eradicate HBV in hepatocyte, but there is no drug to eradicate HBV in hepatocyte worldwide. NUCs are widely used to treat CHB because they can suppress the replication of HBV and decrease the load of HBV DNA. However, patient with CHB often recurs because the load of HBV DNA rapidly rises after off-therapy
Covalently closed circular DNA (cccDNA), which functions as the template for the transcription of viral gene, is required for the maintenance of HBV infection
The sustained durability in patient whose age was ≤37 was higher in the present study. Chien et al
ALT level at baseline is an important predictive factor for the efficacy of antiviral therapy. Yan et al
It is reported that genotype B is related with spontaneous HBeAg seroconversion, and that genotype B patient has a significantly higher rate of spontaneous HBeAg seroconversion than genotype C patient
In sum, we have demonstrated that the APASL recommendations for stopping anti-viral therapy in HBeAg-positive CHB patients are inadequate. We, therefore, believe that the consolidation therapy with NUCs after HBeAg seroconversion should be further prolonged and the standard of stopping therapy should be further evaluated.
Taken together, in the present study, we investigated the relapse rate and the associated-factor of recurrence after stopping NUCs therapy with the different time period of the prolonged consolidation therapy in HBeAg positive CHB patients. We revealed that the cumulative rate of relapse in patient with the prolonged consolidation therapy was statistically lower than that in patient without the prolonged consolidation therapy. Age at off-therapy, baseline ALT level and the different time period of the prolonged consolidation therapy were associated with HBV recurrence after off-therapy. Our results demonstrated that the consolidation therapy with NUCs after HBeAg seroconversion should be further prolonged, and that age at off-therapy, ALT at baseline and the time period of the prolonged consolidation therapy could provide information to direct anti-viral therapy.