Alanine aminotransferase course, serum hepatitis B virus DNA, and liver stiffness measurement for therapeutic decisions in hepatitis B e antigen-negative chronic hepatitis B.

AIM: To evaluate the utility of the combination of alanine aminotransferase (ALT) course, hepatitis B virus (HBV) DNA level, and liver stiffness measurement (LSM) for determining significant liver disease in hepatitis B e antigen (HBeAg)-negative patients. METHODS: Three hundred and ninety nine consecutive HBeAg-negative patients with HBV DNA >2000 IU/mL and documented serial measurements of ALT were enrolled to undergo LSM followed by liver biopsy. RESULTS: Using ALT <40 IU/L as a normal value, 142 patients had persistently normal ALT (PNALT), whereas 257 had persistently or intermittently elevated ALT (PIEALT) in the prior year. Among patients with HBV DNA of 2000-19 999, 20 000-199 999, and ≥200 000 IU/mL, significant pathological lesions defined as the presence of moderate to severe necroinflammation and/or significant fibrosis by METAVIR scoring was present in 40%, 45%, and 71% of the PIEALT group, and 15%, 31%, and 36% of the PNALT group, respectively. In PNALT patients with HBV DNA <20 000 IU/mL, liver biopsy could be avoided in 88% when LSM <7 kPa is used as an indicator of non-significant liver histology but 12% of those who indeed had significant pathological lesions would be missed. In PIEALT patients with HBV DNA ≥20 000 IU/mL, the need for liver biopsy could be reduced by 53% with a false positive rate of 14% when LSM ≥7 kPa is used as a predictor of significant pathological lesions. CONCLUSION: The combination of serial ALT, viral load, and LSM appears to be a promising non-invasive tool. A management algorithm for HBeAg-negative patients comprising these non-invasive measures is proposed with liver biopsy being pursued in selected cases.

Pitfalls in classifying lymphomas.

BACKGROUND: Although the WHO classification (2001) requires a great deal of morphologic, immunophenotypic, genetic, and clinical features for classifying lymphomas, it is still feasible to misdiagnose under limited resources, especially a limited panel of antibodies used for immunophenotyping. To identify pitfalls in classifying lymphomas among hematopathologist, general pathologists, and pathology residents under this situation. MATERIAL AND METHOD: Newly diagnosed lymphoma cases from 1 July 2002 to 30 June 2003 at Siriraj Hospital were included for two rounds of individually blinded review by a hematopathologist, two general pathologists, and three pathology residents. Final diagnoses were given by consensus. Pitfalls were determined from misdiagnosis, in each case analyzed in terms of frequency. RESULTS: One hundred and four lymphoma cases included 61 diffuse large B-cell lymphoma (DLBCL, 58.6%), 12 MALT lymphoma (11.5%), eight follicular lymphoma (FL, 7.7%), seven classical Hodgkin lymphoma (HL, 6.7%), four unspecified peripheral T-cell lymphoma (PTCL, 3.8%), three Burkitt lymphoma (BL, 2.9%), two subcutaneous panniculitis-like T-cell lymphoma (SPTCL, 1.9%), and seven other uncommon types (1% each). Pitfalls were low infrequency on diagnosis of DLBCL, nodular sclerosis HL, and SPTCL (8% each), but not different among the participants only in DLBCL. Pitfalls in diagnosis of MALT lymphoma, mixed cellularity HL, BL, unspecified PTCL, and FL were 60%, 50%, 33%, 29%, and 24%, respectively. However, considering hematopathologist and non-hematopathologist groups, pitfalls in the former were lower, especially in the uncommon types of lymphoma. CONCLUSION: Pitfalls in classifying lymphomas are common. Interest in hematopathology reduces misdiagnosis in lymphomas other than DLBCL.

Prevalence and clinicopathologic findings of antiphospholipid syndrome nephropathy in Thai systemic lupus erythematosus patients who underwent renal biopsies.

AIM: To determine the prevalence of antiphospholipid syndrome nephropathy (APSN) in Thai systemic lupus erythematosus (SLE) patients who underwent renal biopsy and to compare the relationship of renal histopathology and other significant clinical parameters between SLE patients with and without APSN. METHODS: A retrospective analysis was undertaken in systemic lupus erythematosus patients (n = 150, 44 <15 years old, 106 0e;15 years old) who underwent renal biopsy. The specimens were evaluated for histological features of APSN and other significant clinical parameters. The result of antiphospholipid antibodies, clinical course, and renal function from chart review were analysed. RESULTS: The prevalence of APSN in systemic lupus erythematosus patients who underwent renal biopsies was 34% (16% in <15-year-old group, 41.5% in > or =15-year-old group). APSN was associated with more severe hypertension (P = 0.002 for systolic and P = 0.004 for diastolic blood pressure), acute renal failure (P = 0.003), persistent heavy proteinuria (P < 0.001 for 4+ proteinuria), severe lupus nephritis (class III and IV, P = 0.014, high activity and chronicity indices, P < 0.001) and a tendency to progress to end-stage renal disease. CONCLUSION: Systemic lupus erythematosus patients who underwent renal biopsies in our institute showed a prevalence of APSN comparable to those in western countries. The presence of APSN was significantly higher in the adult than in the paediatric population. Its association with poor prognostic indicators suggests poor renal outcome. Clinicians should be aware of this condition in order to give proper care to systemic lupus erythematosus patients.