The paradoxical changes of membrane and soluble herpes virus entry mediator in hepatocellular carcinoma patients.

BACKGROUND AND AIM: The herpes virus entry mediator (HVEM) network has become new directions in targeting novel checkpoint inhibitors for cancer therapy. However, the changes of membrane-bound HVEM (mHVEM) and soluble HVEM (sHVEM) in hepatocellular carcinoma (HCC) are not fully understood. This study aims to study the changes of mHVEM and sHVEM in HCC patients. METHODS: Serum samples were collected from 65 HCC patients, from which sHVEM levels were examined by enzyme-linked immunosorbent assay. Expressions of mHVEM on peripheral lymphocytes from 20 HCC patients were determined using flow cytometry, and associations between mHVEM on T and B cells were analyzed. RESULTS: The levels of mHVEM were downregulated on peripheral lymphocytes in HCC patients, with a strong positive correlation between mHVEM expression on T and B cells. In contrast, the levels of soluble HVEM were upregulated in the serum of HCC patients. Furthermore, we found that the increase in sHVEM level was correlated with advanced stages HCC. CONCLUSION: Our data demonstrated paradoxical changes of membrane and soluble HVEM in the peripheral blood of HCC patients for the first time. These data supported the notion that roles of HVEM are likely to be immunosuppressive rather than activating tumor immunity. Future studies are warranted to further explore the translational values of mHVEM and sHVEM in peripheral blood as diagnostic markers and therapeutic targets.

Residual amount of HBV DNA in serum is related to relapse in chronic hepatitis B patients after cessation of nucleos(t)ide analogs.

OBJECTIVE: To investigate the relationship between relapse and the levels of the residual amount of HBV DNA in serum at cessation in chronic hepatitis B patients meeting 2008 Asian Pacific Association for the Study of the Liver (APASL) nucleos(t)ide analogs (NAs) cessation criteria. METHODS: A total of 72 chronic hepatitis B patients who took NAs and had reached 2008 APASL cessation criteria entered the study. Patients were followed up for 6 months or longer after antiviral therapy was stopped. Serum HBV DNA level at cessation was detected by a highly sensitive polymerase chain reaction assay with detection limitation of 2 IU/mL. RESULTS: Of all the 72 patients, 42 patients (65.3%) relapsed after NA cessation. The detectable rate of the trace amount of HBV DNA at cessation was 41.7% by highly sensitive polymerase chain reaction reagents. The detectable rate of patients with consolidation treatment duration of <18 months was higher than that with consolidation duration of ≥18 months (47.5% vs. 15.4%, P=0.034), and the detectable rate of patients with HBeAg seroconversion within 6 months of treatment was lower than that of ≥6 months (25.0% vs. 61.5%, P=0.036). The residual amount of HBV DNA and detectable rate at cessation showed significant differences between relapsed and nonrelapsed patients (130.4±420.90 vs 44.6±155.16 IU/mL, P=0.004; 55.3% vs. 16.0%, P=0.001). The cutoff value predicting relapse was 2.24 IU/mL, with a sensitivity of 0.553 and specificity of 0.840. CONCLUSIONS: Residual amount of HBV DNA in serum at NA cessation is associated with HBV relapse. The cutoff value predicting relapse was 2.24 IU/mL, with a sensitivity of 0.553 and specificity of 0.840.

Health care workers in Pearl River Delta Area of China are not vaccinated adequately against hepatitis B: a retrospective cohort study.

BACKGROUNDS: Health-care workers' (HCWs) exposure to bodily fluids puts them at risk of hepatitis B virus HBV infection. This study investigated HBV vaccination practices and outcomes in HCWs and assessed postvaccination seroprotection across HCWs in different departments. METHODS: A survey of HCWs in a Chinese public general hospital was carried out with a retrospective cohort of 1420 hospital HCWs (458 males and 962 females). HBV vaccination status (10-µg/dose used) was investigated in the cohort from vaccination records from the period of 1988 to 2008. Blood samples were collected and tested for hepatitis B surface antigen (HBsAg) and HBV antibodies (anti-HBs). RESULTS: The overall vaccination (complete course) and HBsAg carrier rates among HCWs were 40.42 % (574/1420) and 6.13 % (87/1420), respectively. Vaccination rates differed by department, with HCWs in internal medicine (39.5 %) and emergency (42.0 %) departments having particularly low rates. The natural infection rate was 7.53 % (107/1420) among HCWs. HCWs in the department of infectious diseases (vaccination rate, 57.8 %) had the highest rate of antibody produced by natural infection (88.2 %). CONCLUSION: The vaccination rate was a disappointingly low among HCWs in Pearl River Delta Area of China. HCWs working in infectious diseases departments and technicians were at particularly likely to have been infected with HBV. A concerted effort is needed to bring vaccination rates up among Chinese HCWs in Pearl River Delta Area of southern China.

High level of IL-27 positively correlated with Th17 cells may indicate liver injury in patients infected with HBV.

BACKGROUND: Interleukin-6/IL-12 family cytokines play a key role in inflammatory diseases via their effects on the differentiation or regulation of T helper cells. AIMS: The aim of this study was to determine the role of interleukin-27 (IL-27) and its association with helper T cells in hepatitis B virus (HBV)-infected patients. METHODS: Samples were assessed from 51 HBV-infected patients [28 chronic hepatitis B (CHB) subjects and 23 acute-on-chronic liver failure (ACLF) subjects] and 18 normal controls (NC). Serum IL-27 levels were examined by enzyme-linked immunosorbent assay. Circulating helper T cells were determined using flow cytometry and associations between IL-27 expression and helper T cells were analysed. RESULTS: Serum IL-27 levels rose in HBV-infected patients (502.88 ± 23.35 pg/ml) compared to (NC, 277.14 ± 23.96 pg/ml, P < 0.0001). Furthermore, it significantly increased in patients with ACLF (587.90 ± 33.08 pg/ml) when compared with CHB (433.04 ± 26.57 pg/ml, P = 0.001). However, no statistically significant differences were observed between IL-27 and the presence of HBeAg. High levels of IL-27 then positively correlated with Tbil levels (r = 0.401, P = 0.004), but negatively associated with prothrombin time activity levels (r = -0.496, P < 0.001), and a slightly negative correlation trend with HBV-DNA loads (r = -0.228, P = 0.107) existed in these HBV-infected subjects. Additionally, frequency of circulating interleukin-17-producing CD4(+) T cells (Th17 cells) increased in HBV-infected patients (ACLF, mean, 5.39%; CHB, median, 3.12%) as compared to NC subjects (median, 2.22%, P < 0.0001). Moreover, correlation analysis showed that serum IL-27 level was positively associated with circulating Th17 cells (r = 0.342, P = 0.036). CONCLUSION: These results provided evidence that IL-27 was positively correlated with Th17 cells commitment, and may exerted a proinflammatory effect in the development of liver injury in HBV-infected patients.

Dynamic changes of clinical features that predict the prognosis of acute-on-chronic hepatitis B liver failure: a retrospective cohort study.

OBJECTIVE: The natural history of acute-on-chronic hepatitis B liver failure (ACHBLF) is complex and highly variable. However, the global clinical characteristics of this entity remain ill-defined. We aimed to investigate the dynamic patterns of the natural progression as well as their impact on the outcomes of ACHBLF. METHODS: The clinical features and disease states were retrospectively investigated in 54 patients with ACHBLF at the China South Hepatology Center. The clinical and laboratory profiles including hepatic encephalopathy (HE), hepatorenal syndrome (HRS), and spontaneous bacterial peritonitis (SBP) were evaluated. The disease state estimated by the model for end-stage liver disease (MELD) score and the dynamic patterns during the clinical course of ACHBLF were extrapolated. RESULTS: Twenty-two patients died during the 3-month follow-up period (40.74%). The patients were predominantly male (88.89%). Baseline characteristics showed that there were significant differences in only hepatitis B virus (HBV) DNA levels and platelet count between the deceased and surviving patients (P=0.014 and P=0.012, respectively). Other baseline characteristics were similar in both groups. The dynamic state of the MELD score gradually increased from an initial hepatic flare until week 4 of ACHBLF progression. There were notable changes of the dynamic state of the MELD score at two time points (week 2 and week 4) during ACHBLF progression. The MELD scores were significantly greater in the death group (24.80 ± 2.99) than in the survival group (19.49±1.96, P<0.05) during the clinical course of ACHBLF; the MELD scores of the survival group began to decrease from week 4, while they continued to rise and eventually decreased as more patients died. The gradients of the ascent and descent stages could predict exactly the severity and prognosis of ACHBLF. CONCLUSIONS: The natural progression of ACHBLF could be divided approximately into four stages including ascent, plateau, descent, and convalescence stages according to different trends of liver failure progression, respectively. Thus, the special patterns of the natural progression of ACHBLF may be regarded as a significant predictor of the 3-month mortality of ACHBLF.

[A pilot study of peginterferon alfa-2a combined with short-term lamivudine therapy in HBeAg-positive chronic hepatitis B patients].

OBJECTIVES: To investigate the efficacy of by combining a 12-week course of lamivudine in those HBeAg-positive hepatitis B patients receiving peginterferon alfa-2a (peg-IFN alpha-2a) therapy. METHODS: A total of 58 patients initiated a 52-week course of peginterferon alfa-2a were enrolled and divided into 3 groups. The patients with HBV DNA undetectable or HBeAg negative at week 12 were divided into group A, in this group treatment continued to week 52 with peg-IFN alpha-2a alone; The rest patients were divided into group B1 and B2, in group B1, lamivudine was combined at a course of 12 weeks, while in group B2 treatment continued to week 52 with peg-IFN alpha-2a alone. Clinical responses were assessed at week 52. RESULTS: 8 out of 58 patients achieved undetectable HBV DNA or HBeAg loss at week 12 and divide into group A. In this group the HBV DNA loss rate, HBeAg seroconversion rate, HBsAg loss rate and ALT normalization rate were 100% (8/8), 75% (6/8), 0% (0/8) and 100% (8/8) respectively at the end of treatment. In this group the HBV DNA loss rate, HBeAg seroconversion rate, HBsAg loss rate and ALT normalization rate were 100% (8/8), 75% (6/8), 0% (0/8) and 100%(8/8) respectively at the end of treatment. The rest 50 patients without early response to peg-IFN alpha-2a at week 12 were divided into group B1 (24 patients enrolled) and B2 (26 patients). At the end of treatment, the HBV DNA loss rate, HBeAg seroconversion rate, HBsAg loss rate and ALT normalization rate in Group B1 were 50% (12/24), 38% (9/24), 4% (1/24) and 63% (15/24) respectively, and 31% (8/26), 27% (7/26), 0% (0/26) and 35% (9/26) respectively in group B2. CONCLUSION: Those patients with early responses to peg-IFN alpha-2a therapy can achieve high clinical responses at the end of 52-week treatment. The combining therapy of lamivudine for a course of 12-weeks can improve the clinical responses for the patients without early responses to peg-IFN alpha-2a.

BTLA identifies dysfunctional PD-1-expressing CD4+ T cells in human hepatocellular carcinoma.

Although immunotherapy targeting programmed cell death 1/programmed cell death ligand 1 (PD-1/PD-L1) pathway is being applied in clinic, the response outcomes are heterogeneous, suggesting existences of distinctive subsets within PD-1-expressing T cells that react differently to PD-1/PD-L1 blockade. However, markers to demarcate these subsets in human cancers remain unclear. Here, we found that both PD-1 and B and T lymphocyte attenuator (BTLA) were significantly upregulated on CD4+ T cells from tumor compared with those from paired non-tumor liver in hepatocellular carcinoma (HCC) patients. Interestingly, over 85% BTLA+ CD4+ T cells were PD-1-expressing cells and represented about 50% PD-1+ CD4+ T cells in tumors, and that level of BTLA+PD-1+ tumor CD4+ T cells were selectively associated with advanced stage HCC. BTLA+ identified highly dysfunctional PD-1-expressing CD4+ T cell subset, whereas BTLA- defined PD-1+ CD4+ T cells undergoing activation in HCC. Importantly, blockade of PD-L1 could restore the ability of IFNγ/TNF-α production in BTLA+PD-1+ tumor CD4+ T cells but partially suppressed the activation of BTLA-PD-1+ CD4+ T cells. Moreover, we provided evidence that BTLA signals also participated in suppressing CD4+ T cell function in HCC. In conclusion, BTLA could identify distinct function of PD-1 expressing CD4+ T cells in human cancer, which might not only advance our understanding of inhibitory receptor blockade, but also provide new targets for clinical predictors of response to these immunotherapies.

Tumoral indoleamine 2, 3-dioxygenase 1 is regulated by monocytes and T lymphocytes collaboration in hepatocellular carcinoma.

Indoleamine 2, 3-Dioxygenase 1 (IDO1) in cancer cells plays a critical role in tumor immunosuppression. However, the precise mechanisms regulating tumoral IDO1 expression in tumor milieus remain unclear. Here, we reported that IDO1 expression in tumor cells of hepatocelluar carcinomas (HCC), displayed a discrete rather than uniform pattern. In vitro culture, human hepatoma cell lines did not constitutively express IDO1. Interestingly, co-culture with peripheral blood mononuclear cells (PBMC) significantly induced and maintained IDO1 expression in these tumor cells, predominantly through IFN-γ. Mechanistically, we showed that IDO1 expression in tumor cells was only induced when co-cultured with both T lymphocytes and monocytes. Moreover, the cooperation between T lymphocytes and monocytes played an indispensable role on the tumoral IDO1 expression in immunocompromised mice. Taken together, our data supported the notion that IDO1 expression in tumor cells might serve as a counter-regulatory mechanism regulated by immune system, and provided new insights into the collaborative action of different inflammatory cells in tumor immunosuppression.

iTRAQ-based proteomic analysis of hepatic tissues from patients with hepatitis B virus-induced acute-on-chronic liver failure.

The pathogenesis of hepatitis B virus (HBV)-induced acute-on-chronic liver failure (ACLF), a serious and prevalent medical condition, is not clear, particularly with regard to which proteins are expressed in the course of the disease. The aim of the present study was to identify the differences in hepatic tissue protein expression between normal human subjects and patients with ACLF using isobaric tags for relative and absolute quantification (iTRAQ)-based proteomic analysis and to verify the results using western blot analysis. The iTRAQ method was used to analyze the protein contents of hepatic tissue samples from 3 patients with HBV-induced ACLF and 3 normal healthy subjects. The results were verified by subjecting the hepatic tissues from 2 patients with HBV-induced ACLF and 4 healthy subjects to western blot analysis. In total, 57 proteins with ≥1.5-fold differences between patients with HBV-induced ACLF and healthy subjects were identified using iTRAQ. Among these 57 proteins, 4 with the most marked differences in their expression and the most significant association with liver disease were selected to be verified through western blot analysis: Keratin, type-I cytoskeletal 19; α-1-acid glycoprotein 1 (α1-AGP); carbonic anhydrase-1; and serpin peptidase inhibitor and clade A (α-1 anti proteinase, antitrypsin) member 1 (SERPINA1). The results of the western blot analyses were nearly identical to the iTRAQ results. Identifying the differences in liver protein expression in patients with HBV-induced ACLF may provide a basis for studies on the pathogenesis of ACLF. Future studies should focus particularly on α1-AGP, carbonic anhydrase 1 and SERPINA1.

An albumin, collagen IV, and longitudinal diameter of spleen scoring system superior to APRI for assessing liver fibrosis in chronic hepatitis B patients.

OBJECTIVES: The aim of this study was to screen the non-invasive indexes correlated with liver fibrosis and establish a scoring system for the diagnosis of liver fibrosis in hepatitis B patients. METHODS: Data of 34 non-invasive indexes were collected for 208 hepatitis B patients. Correlation analysis and stepwise discriminant analysis was used to screen out indexes useful for the diagnosis of liver fibrosis. Finally, a scoring system composed of indexes screened out by stepwise discriminant analysis was established for the assessment of liver fibrosis. RESULTS: Twenty-one indexes correlating with liver fibrosis were screened out by correlation analysis; hyaluronic acid had the highest r-value, 0.456. A scoring system including albumin, collagen IV, and the longitudinal diameter of the spleen was established. The areas under the receiver operating characteristic curves (AUC) for this scoring system and the aspartate aminotransferase to platelet ratio index (APRI) in differentiating S3-4 from S0-2 were 0.79 (95% confidence interval (CI) 0.72-0.85) and 0.27 (95% CI 0.18-0.35), respectively. With a cut-off value of <3, the presence of significant fibrosis (S3-4) could be excluded by this scoring system with a negative predictive value of 86.1% and sensitivity of 86.8%. With a cut-off of >6, the presence of S3-4 fibrosis could be correctly identified with a positive predictive value of 73.6% and specificity of 87.6%. Using this scoring system, 53.4% of patients could be classified correctly and avoid liver biopsy. CONCLUSIONS: The scoring system provides a simpler method to identify significant fibrosis (S3-4) in chronic hepatitis B patients.

Durability of efficacy after telbivudine off-treatment in chronic hepatitis B patients.

BACKGROUND/AIMS: Current international guidelines indicate that finite therapy with nucleos(t)ide analogues (NAs) is possible in chronic hepatitis B (CHB) patients. Here we evaluate the durability of efficacy after telbivudine (LdT) off-treatment. METHODS: 39 CHB patients with normalized ALT, undetectable HBV-DNA and HBeAg seroconversion for at least 48 weeks were observed after telbivudine discontinuation. We analyzed the follow-up clinical condition of off-treatment, calculated the cumulative clinical relapse rate, and explored the predictive factors for clinical relapse. RESULTS: Totally 8 patients encountered clinical relapse in the first 60 weeks after telbivudine discontinuation. The cumulative clinical relapse rates at week 24, 48, 60 and 204 were respectively 2.6%, 7.7%, 16.3% and 23.3%. No significant difference was found between cumulative clinical relapse rates of HBeAg(+) and HBeAg(-). No significant baseline or on-treatment factors for clinical relapse were found. CONCLUSION: The present study demonstrated that most CHB patients maintained sustained response and HBeAg seroconversion following telbivudine off-treatment. Clinical relapses may often occur in the early period, with low clinical relapse rate. More follow-up data will be on-going and complemented in the further studies.

Serum proteomics analysis and comparisons using iTRAQ in the progression of hepatitis B.

The aim of this study was to analyze the changes in serum protein levels in the progression of hepatitis B using isobaric tags for relative and absolute quantitation (iTRAQ) analysis, in addition to comparing the serum protein levels of patients with chronic hepatitis B (CHB), patients with hepatitis B virus-induced acute-on-chronic liver failure (HBV-induced ACLF) and normal individuals. Protein analysis was performed on 15 serum samples using iTRAQ. The study population included healthy controls (n=5), patients with CHB (n=5) and patients with HBV-induced ACLF (n=5). Western blotting was used to verify the results in an additional nine serum samples from healthy controls, patients with CHB and patients with HBV-induced ACLF (n=3, respectively). Using iTRAQ analysis, 16 different serum proteins with ≥1.5-fold differences in expression levels were identified in the patients with CHB and ACLF compared with the healthy controls. Five of those proteins, C-reactive protein precursor, hemoglobin ß chain variant Hb S-Wake, apolipoprotein J precursor, platelet factor 4 precursor and vitronectin, which demonstrated the greatest differences in their expression levels and the most significant correlation with liver diseases, were subsequently verified using western blotting. The western blotting results were consistent with the results from the iTRAQ. Two of the five proteins are not classified by biological process, and the biological functions of all the proteins in HBV-induced ACLF remain unclear. This preliminary study demonstrated that a correlation between the expression of various serum proteins and the different pathogenetic conditions induced by HBV may exist. The analysis of a larger number of samples is required to identify potential protein biomarkers that may be involved in the pathogenesis and progression of hepatitis B.

Diethylene glycol poisoning and liver function following accidental diethylene glycol injection.

The aim of the present study was to investigate the hepatotoxic effects of accidental intravenous diethylene glycol (DEG) poisoning in patients with liver disease. Clinical manifestations were recorded and liver function tests were carried out for 64 patients with liver disease who had been accidentally treated intravenously with DEG. Comparisons were made between the poisoned and non-poisoned groups. Of the 64 cases with preexisting liver disease, 15 cases (23.4 %) developed toxic presentations after exposure to DEG. All cases were men. Twelve of the 15 poisoned patients (80 %) died within seven days. The intravenous administration of DEG resulted in only mild liver function impairment. Gender (p = 0.039) and the severity of jaundice prior to DEG administration were risk factors related to the occurrence of toxin-induced renal failure (p < 0.006). The results suggest that DEG may worsen liver damage in patients with preexisting liver disease. However, our study demonstrated only mild, transient alterations in patients' baseline liver functions. Severe liver damage secondary to DEG was only occasionally seen in patients with concomitant renal failure.

Amniotic-fluid-derived mesenchymal stem cells overexpressing interleukin-1 receptor antagonist improve fulminant hepatic failure.

Uncontrolled hepatic immunoactivation is regarded as the primary pathological mechanism of fulminant hepatic failure (FHF). The major acute-phase mediators associated with FHF, including IL-1ß, IL-6, and TNF-α, impair the regeneration of liver cells and stem cell grafts. Amniotic-fluid-derived mesenchymal stem cells (AF-MSCs) have the capacity, under specific conditions, to differentiate into hepatocytes. Interleukin-1-receptor antagonist (IL-1Ra) plays an anti-inflammatory and anti-apoptotic role in acute and chronic inflammation, and has been used in many experimental and clinical applications. In the present study, we implanted IL-1Ra-expressing AF-MSCs into injured liver via the portal vein, using D-galactosamine-induced FHF in a rat model. IL-1Ra expression, hepatic injury, liver regeneration, cytokines (IL-1ß, IL-6), and animal survival were assessed after cell transplantation. Our results showed that AF-MSCs over-expressing IL-1Ra prevented liver failure and reduced mortality in rats with FHF. These animals also exhibited improved liver function and increased survival rates after injection with these cells. Using green fluorescent protein as a marker, we demonstrated that the engrafted cells and their progeny were incorporated into injured livers and produced albumin. This study suggests that AF-MSCs genetically modified to over-express IL-1Ra can be implanted into the injured liver to provide a novel therapeutic approach to the treatment of FHF.