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Inoyatova Flora Ilyasovna M. D., Professor, Academician of the Academy of Sciences of Uzbekistan, Head of Hepatology Department of Republican Specialized Scientific Practical Medical Center of Pediatrics,
Tashkent, Uzbekistan E-mail: [email protected] Abdullaeva Feruza Gafurovna, Ph D., Junior Researcher of Hepatology Department of Republican Specialized Scientific Practical Medical Center of Pediatrics,
Tashkent, Uzbekistan E-mail: [email protected]
THERAPY OF CHRONIC HEPATITIS IN CHILDREN WITH DIFFERENT HBSAG STATUS
Abstract. For the assessment of the efficacy of three-stage antiviral therapy of chronic hepatitis B we observed 32 sick children in the age from 7 to 18 years old. In fourteen of them we revealed HBsAg (-) negative seroprofile, and these children composed comparison group for the children with HBsAg (+) positive hepatitis (18 children). as a result of the research it was determined that, application of three-stage scheme of antiviral therapy of chronic hepatitis B in children using a-Interferon (Viferon) agents and Lamivudine demonstrated diverse efficiency for both suppression of viral replication and decrease of cytolytic activity. The best virologic effect was achieved in HBsAg-positive patients.
Keywords: children, chronic hepatitis B, HBV markers, antiviral therapy.
In spite of the successful results in the control ofHBV infection, wide spread implementation of specific immune prophylaxis and significant decrease in the registration of acute forms of the disease, chronic hepatitis B is still one of the most complex
problems of the world health care [1; 3; 5; 11]. Every year about million people die because of liver pathologies conditioned by HBV. Hepatitis B is the reason of the greater part (up to 65%) of chronic pathologies of liver in children. At the same time increase in the duration of infecting in the infection foci leads to the growth of a specific weight of mutant strains, which in its turn causes formation of the high concentration of chronic infection with development of primary latent forms of the pathology (above 50.0%), with difficult diagnostics, and, finally, genotype variety and capability of the virus for various gene mutations, and that in some cases is the reason of non-effective vaccination (2-40%) [3; 4; 6; 8; 9]. Today the therapy of chronic hepatitis B (CHB) is the most difficult and unsolved problem in children's hepatology. The therapy of chronic HBsAg-mutant hepatitis B almost is not developed. Reference data are limited by single researches [2; 7; 10; 12]. That makes it necessary to search actively for new agents affecting the virus and its replication, to create various schemes and possible combinations of therapy, especially severe forms of CHB associated with mutant HBV strains. Majority of antiviral agents, except a-Interferon possessing mostly immune stimulating effect, cannot be used
in pediatric practice due to the absence of special permission. Exclusion is permitted in children's hepatology Lamivudine, the mechanism of action ofwhich is based on the suppression ofvi-ral DNA polymerase. As a rule, its one-moment intake together with a-Interferon therapy was considered effective for children with CHB. According to some data Lamivudine by means of suppressing viremia can restore distorted T-cell mediated immune response to HBV epitopes, and thus, promote immune modulating effect of interferon [5; 10]. Variation of its efficacy varies within 17-57%.
In relation to that, the objective of this work was to assess the efficacy of three-stage antiviral therapy of CHB in children with various HBsAg statuses.
Materials and methods: 80 children suffering CHB in the age from 7 to 18 years old were studied. 32 sick children were selected into therapeutic group, among whom there were 18 patients with HBsAg (+) positive hepatitis and 14 with HBsAg (-) negative one, linked with gene S-mutation, in our opinion. All studied children had HBV-DNA in blood serum with viral load rate 105-108 copies/mL. Classification of the patients according to the activity of the pathology revealed minimal degree in 31.2% of the children, moderate one in 43.7%, and expressed one in 25.0% of the children. The duration of CHB among the studied children was equal to 4.5 ± 0.4 years. 30 almost healthy children served to be the control.
CHB diagnosis was confirmed on the basis of clinical, epidemiological, common clinical laboratory and instrumental tests for liver. Testing ofbiochemical parameters and serological data of HBsAg, HBsAb, HBeAg, HBeAb, total HBcorAb was performed in clinical-experimental laboratory of the RSSPMC of Pediatrics of the MH of the RUz with the help of HUMAN commercial kits (Germany) and ROCHE test systems (Switzerland). HBV-DNA definition was performed by means of PCR in real-time mode using Vector-West test system (Novosibirsk) with «iCyclerQ5» (Bio-Rad, USA) thermo cycler for the amplification of nucleic acids.
Inclusion of the patients was performed taking into account the predictors of the efficacy of the stability of the response to antiviral therapy: more than 2 folds increased level of amino transferases, moderate viremia, and high histological activity. For all children we applied three-stage scheme of antiviral therapy the duration ofwhich was 12 months: I stage -Lamivudine for 20 weeks, II stage - Lamivudine combined with a-interferon for 1 month, and later only a-interferon for 24 weeks. Lamivudine was prescribed to the children under 12 calculated 3mg\kg\day, and above 12 one hundred mg per os once a day after meal every day. Viferon per rectum
Positive dynamics was also noted in the manifestations of dyspeptic syndrome; only in the comparison group these values were non-reliably decreased compared to the group of children before the therapy (p > 0.05). During the therapy extra renal symptoms such as palmar erythema, capillary net on cheeks, venous collaterals, and vascular spiders diminished together with the frequency of detection in all studied patients registered before the therapy, and at the end of the therapy varied only within 16.6%-27.7% (p < 0.05-0.001). The frequency and expression of hepatic-lienal syndrome clearly decreased in both groups. So, hepatomegaly was noted only in 25.9% of the children and only under 3cm (p < 0.05). At the same there was notable tendency for decrease of the density
100 thousand IU/kg/day twice a day for 10 days with further transfer to double dose three times a week. Assessment of the therapeutic efficacy was performed on the basis of the criteria recommended by European Liver Pathologies Study Association (2011), taking into account AlAT and HBV-DNA values in the process of the therapy - primary remission (PR), during 6 months after its finish - stable remission (SR), and for 24 months after the end of the therapy - long-lasting one (LLR).
Statistical processing of the data was performed by means of variation statistic method using Student's t-criterion with special Excell-2012 software.
Results of the study. Application of the step-by-step partially combined scheme of antiviral therapy of CHB in children using a-interferon agents and nucleoside analogue (Lamivudine) showed significant efficacy according to clinical laboratory data, and dependence on serological status ofHBV S-gene. That scheme of the therapy had the most notable impact on the dynamics of clinical symptoms in children with CHB-HBsAg (+) hepatitis (Table 1). Analysis of asthenovegetative syndrome symptoms (weakness, prostration, fatigue, etc.) showed decrease of the registration of these symptoms more than 2.6 folds compared to these values before the therapy (p < 0.001).
of liver consistence. Splenomegaly was registered more than 5 times less among treated patients (p < 0.01).
The applied scheme had a positive effect on the dynamics of the cytolysis syndrome indicators. So in children with HBsAg positive CHB the average AlAT diminished 2.7 folds and was equal to 0.69 ± 0.03 mmol/ls (p < 0.001, compared to ore the therapy 1.92 ± 0.09 mmol/ls), reaching normalization in 17 (94.4%) children. Similar changes were observed in AsAT values, the average amount of which before the therapy was 1.18 ± 0.08 mmol/ls, and after the therapy 0.41 ± ± 0.02 mmol/ls (p < 0.001). That allowed us judge about the development of biochemical response in that category of children in 94.4% cases.
Table 1. - Dynamics of clinical syndromes at the background CHB therapy applied in children (% ± m)
Clinical syndromes HBsAg (+) hepatitis (n=18) HBsAg (-) hepatitis (n=14)
Before therapy After therapy P Before therapy After therapy P
Asthenovegetative syndrome 64.7 ± 5.4 5.5 ± 7.4 < 0.001 96.4 ± 9.3 44.0 ± 13.2 < 0.001
Dyspeptic syndrome 67.3 ± 11.7 11.1 ± 7.4 < 0.01 88.0 ± 10.9 52.3 ± 13.2 > 0.05
Extra hepatic symptoms 72.2 ± 8.7 20.8 ± 9.7 < 0.001 100.0 76.7 ± 10.9 > 0.05
Cholestatic syndrome 25.9 ± 11.1 3.6 ± 5.3 < 0.05 78.5 ± 9.3 42.8 ± 13.2 < 0.02
Hepatomegaly 33.3 ± 11.7 25.9 ± 9.8 < 0.05 57.2 ± 0.0 33.2 ± 9.3 > 0.05
Splenomegaly 55.5 ± 11.7 11.1 ± 7.4 < 0.01 100.0 64.2 ± 12.8 < 0.05
P -reliability of differences between the values before and after the therapy
Table 2.- Dynamics of biochemical parameters during the applied therapy of CHB in children
Values HBsAg (+) (n=18) HBsAg (-) (n=14) Control
Before therapy After P Before therapy After P
AlAT, mkmol/ls 1.92 ± 0.09 * 0.69 ± 0.03 * < 0.001 2.53 ± 0.19 * 0.82 ± 0.03 * < 0.001 0.39 ± 0.03
AsAT, mkmol/ls 1.18 ± 0.08 * 0.41 ± 0.02 * < 0.001 1.53 ± 0.11 * 0.44 ± 0.02 * < 0.001 0.23 ± 0.02
Total bilirubin, mkmol/ls 16.2 ± 0.31 * 14.7 ± 0.41 < 0.001 31.8 ± 1.83 * 23.2 ± 0.46 * < 0.01 14.8 ± 0.57
Conjugated bilirubin, mkmol/ls 4.32 ± 0.40 * 1.95 ± 0.25 < 0.05 13.4 ± 1.83 * 5.7 ± 0.29* < 0.001 1.8 ± 0.06
Total protein, g/L 65.3 ± 0.63 * 71.2 ± 0.63 < 0.001 62.9 ± 0.80 * 66.3 ± 0.43 * < 0.01 71.3 ± 0.86
Albumin, % 48.8 ± 0.73 * 52.3 ± 0.59* < 0.01 44.1 ± 1.21 * 48.6 ± 0.31 * < 0.01 54.5 ± 0.72
Gamma-globulin,% 19.3 ± 0.53 * 15.7 ± 0.22 < 0.001 24.5 ± 0.62 * 19.7 ± 0.36 * < 0.001 15.7 ± 0.47
Thymol test, U. 6.09 ± 0.26 * 4.4 ± 0.14 < 0.001 11.5 ± 0.54 * 7.95 ± 0.26 * < 0.001 4.5 ± 0.28
P - reliability of differences between the values before and after the therapy; * - reliability of differences compared to control group (p < 0.05-0.001)
Under the influence of the performed therapy the values of cholestatic syndrome changed. Reliable decrease was registered in the values of total and conjugated bilirubin, the amount of which after the therapy was 14.7 ± ± 0.41 mkmol/ls (p < 0.001) and 1.95 ± 0.25 mkmol/ls (p < 0.05), respectively (Table 2). The rise of liver synthetic function (hepatoprive syndrome) was indicated by a re-
liable (p < 0.01-0.001) increase of average albumin (up to 52.3 ± 0.59%) and total protein (up to 71.4 ± 0.63 g/L). In the values characterizing mesenchymal inflammatory syndrome we also registered clear normalizing effect of the applied therapy, expressed in the decrease in the results of gamma globulin (up to 15.7 ± 0.22%) and thymol test (up 4.4 ± 0.14 U, p < 0.001).
Figure 1. Marker profile of HBsAg (+) children during the therapy (%):* - reliability of differences between the values before and after the therapy (p < 0.05-0.001)
These changes were revealed in the children with HBsAg-negative CHB. Though the values of biochemical parameters did not approach the control ones, these reliably improved compared to the values registered before the therapy. For instance, the average AlAT diminished 3.0 folds and was equal to 0.82 ± 0.03 mkmol/ls, reaching normalization in 12 (85.7%) children with CHB with negative seroprofile (p < 0.001, compared to the values before the therapy 2.53 ± ± 0.19 mkmol/ls). Similar dynamics was noticed also in ASAT, the average amount of which before the therapy was 1.53 ±
± 0.11 mkmol/ls, and after the therapy 0.44 ± 0.02 mkmol/ls (p < 0.001). In the manifestation of cholestatic syndrome there was notable decrease of the concentration of hepatic enzymes, and particularly, total and conjugated bilirubin up to 23.2 ± 0.46 mkmol/ls and 5.7 ± 0.29 mkmol/ls, respectively (p < 0.01 to the values before the therapy). After the therapy we observed reliable rise (p < 0.01-0.001) of the average albumin (up to 48.6 ± 0.31%) and total protein (up to 66.3 ± 0.43 g/L), and decrease of gamma globulin (up to 19.7 ± 0.36%) and thymol test (up to 7.95 ± 0.26 U).
Results of the assessment of the dynamics of marker profile during the therapy indicate its positive impact on the elimination of HBV (Fig.1). So, in patients with HBsAg (+) CHB, after three-stage therapy the frequency of HBeAg detection significantly decreased, and it was determined in the blood of 4 (22.2%) children (p < 0.001). Seroconversion of HBeAg to HBeAb occurred in 33.3% of the children (before the therapy 44.4%; after the therapy 77.7%, p < 0.05). Decrease of the frequency of detection was registered in case of
120 100 80 60 40 20 0
In the group of children with HBsAg negative it was possible to notice similar effect of the therapy on HBV markers (Fig. 2). After the therapy in the mentioned group six (42.8%) children had synthesis of HBsAg (p < 0.01). While HBsAb almost did not change (before the therapy 100.0%, after the therapy 92.8%). Summary HBcorAb stayed at the original level. In the process of the therapy the number of HBeAg-positive patients decreased to 42.9%, among whom 35.8% pf the children had seroconversion to HBeAb (p < 0.05). Similar to HBsAg-positive group of children, patients with HBsAg (-) CHB had expressed dynamics in HBV-DNA (before therapy 100.0%, after therapy 42.8%, p < 0.001), and that let us note the development ofvirologic remission in 57.2% cases.
Thus, the data obtained in the process of our research indicate positive effects of the proposed three-stage therapy, application of which led to the improvement of feeling; most of the studied biochemical indicators reached normal values, and as a result, that promoted development of remission judged according to clinical indicators in children with HBsAg (+) hepatitis in 50.6% cases and HBsAg (-) CHB in 40.9% cases. Biochemical response was received in 94.4% and 85.7%; viro-logic one in 66.7% and 57.2% cases, respectively.
Allergic reactions or side effects were not registered in any child. Development of Lamivudine-resistant strains was not revealed as well.
HBsAg persistence in 33.3% (p < 0.02), which was verified in 11 (61.1%) children at the end ofthe therapy, and that correspondingly led to the increase of HBsAb (55.5%, p < 0.05). However, in the values of HBcorAb we followed insignificant decrease of detection (to 5.6%, p > 0.05). Expressed dynamics was registered in the values of HBV-DNA (before the therapy 100.0%, after the therapy 33.3%, p < 0.001), which indicated development of virologic remission in 66.7% children with HBsAg (+) hepatitis.
In follow-up observation for 12 months the efficacy of the performed antiviral therapy was assessed in compliance with EUROHEP Consensus program. Analysis of AlAT and HBV-DNA in the process of the observation provided determination of more stable response in children with HBsAg+ hepatitis. Primary remission was registered in 66.7% cases, stable in 61.1%, and long-lasting one in 55.5% cases. And absence of remission was noted in one third (33.3%) of the children. A little bit less expressed dynamics was observed among the children with HBsAg (-) CHB, in 57.1%, 50.0% and 35.7% cases, respectively. Absence of remission was observed in 42.8% of the children.
Conclusion. Thus, the data obtained in the process of our research indicate positive effects of the proposed three-stage therapy of CHB, application of which led to the improvement of feeling; most of the studied biochemical indicators reached normal values, and as a result, that promoted development of remission judged according to clinical indicators in children with HBsAg in blood serum in 50.6% cases and HBsAg (-) hepatitis in 40.9% cases. Biochemical response was received in 94.4% and 85.7%; virologic one in 66.7% and 57.2% cases, respectively. But the best effect was achieved in HBsAg-positive patients.
Figure 2. Marker profile of HBsAg (-) children during the therapy (%):* - reliability of differences between the values before and after the therapy (p < 0.05-0.001)
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