Vitmain B12 as Severity and Prognostic Marker in Chronic Liver Disease.

INTRODUCTION: Chronic liver disease is an immuno-compromised state is well known established fact but there are falsely elevated vitamin B12 levels in patients with chronic liver disease, which can be used as severity and prognostic marker. This study was designed to investigate the association between vitamin B12 levels and liver disease severity and long term prognosis in patients with chronic liver disease. MATERIALS: An observational longitudinal study was carried over a period of 6 months among indoor patients admitted in department of medicine of a tertiary care hospital in North-Eastern India. A total of 50 patients diagnosed with chronic liver disease were enrolled. Serum vitamin B12 concentration and other blood parameters were determined. The data were analyzed accordingly by descriptive statistics using Spss for the result. RESULT: The study population were predominantly male with mean age 50.80 ± 10.35. Mean total serum vitamin B12 concentration was significantly higher in patients with chronic liver disease (1639 ± 504 pg/ml) when compared to normal people (650 ± 300pg/ml). Also among patients with chronic liver disease Child-Pugh C (1858 ± 359pg/mL) had higher B12 levels when compared to those with Child-Pugh B (1076 ± 370 pg/mL). Out of 50 people, 4 were died and their mean B12 was (2113 ± 112 pg/ml). CONCLUSION: Falsely increased B12 levels are due to increased excretion of vitamin B12 in to serum from the liver and these serum B12 levels correlates with the severity and prognosis of the patient. References Sugihara T, Koda M, Okamoto T, et al. Falsely elevated serum vitamin B12 levels were associated with the severity and prognosis of chronic viral liver disease. Yonago Acta Med 2017;60(1):31-39. Dou J, Xu W, Ye B, et al. Serum vitamin B12 levels as indicators of disease severity and mortality of patients with acute-on-chronic liver failure. Clin Chim Acta 2012;413(23-24):1809-1812.

Epidemiology, Genotyping, Mutational and Phylogenetic Analysis of Hepatitis B Virus Infection in North-east India.

BACKGROUND/OBJECTIVE: Hepatitis B virus (HBV) infection is a major public health problem globally. Northeast India is home to indigenous tribes with different ethnicity and high rates of drug abuse and HIV infection. The study was designed to estimate the burden of HBV infection across various spectrums of liver diseases from this region. HBV genotypes and subgenotypes play a role in the chronicity of disease, response to treatment and its progression. As very limited data are available from this region, we tried to elucidate the role of HBV genotypes, HBV mutants and their phylogenetic analysis. METHOD: We designed a prospective multicentric study, and included 7464 liver disease cases, 7432 blood donors and 650 health care workers, who were screened for HBV infection. HBV DNA positive patients were genotyped and subjected to surface protein, precore and core mutation and phylogenetic analysis. RESULTS: The prevalence of HBV infection with respect to different types of liver diseases, blood donors and health care workers was 9.9% (1550/15,546). 49.5% (768/1550) cases were found to be HBV DNA positive. The most common genotype was found to be genotype D 74.2% (570/768), followed by genotype C 6.5% (50/768), A 4.4% (34/768) and I 0.9% (7/768). CONCLUSION: This study highlights the high hepatitis B burden in Northeast India, reflecting lacunae in health care needs of the region. Also, the different genotype distribution and presence of mutations may translate into different rates of liver disease progression, prognosis and ultimately, clinical significance. However, further prospective cohort study from Northeast India is warranted, to elucidate the clinical significance of multiple genotypes and mutation in this unique population.

INASL Position Statements on Prevention, Diagnosis and Management of Hepatitis B Virus Infection in India: The Andaman Statements.

Hepatitis B Virus (HBV) infection is one of the major causes of morbidity, mortality and healthcare expenditure in India. There are no Indian consensus guidelines on prevention, diagnosis and management of HBV infection. The Indian National Association for Study of the Liver (INASL) set up a taskforce on HBV in 2016, with a mandate to develop consensus guidelines for diagnosis and management of HBV infection, relevant to disease patterns and clinical practices in India. The taskforce first identified contentious issues on various aspects of HBV management, which were allotted to individual members of the taskforce who reviewed them in detail. A 2-day round table discussion was held on 11th and 12th February 2017 at Port Blair, Andaman & Nicobar Islands, to discuss, debate, and finalize the consensus statements. The members of the taskforce reviewed and discussed the existing literature threadbare at this meeting and formulated the 'INASL position statements' on each of the issues. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong: 1, weak: 2) thus reflects the quality (grade) of underlying evidence (A, B, C, D). We present here the INASL position statements on prevention, diagnosis and management of HBV in India.

Etiology and mode of presentation of chronic liver diseases in India: A multi centric study.

There is a paucity of health policy relevant data for chronic liver disease from India, impeding formulation of an interventional strategy to address the issue. A prospective, multicentric study to delineate the etiology and clinical profile of chronic liver disease in India is reported here. A centrally coordinated and monitored web-based data repository was developed (Feb, 2010 to Jan, 2013) and analyzed. Eleven hospitals from different parts of India participated. Data were uploaded into a web based proforma and monitored by a single centre according to a standardized protocol. 1.28% (n = 266621) of all patients (n = 20701383) attending the eleven participating hospitals of India had liver disease. 65807 (24·68%) were diagnosed for the first time (new cases). Of these, 13014 (19·77%, median age 43 years, 73% males) cases of chronic liver disease were finally analyzed. 33.9% presented with decompensated cirrhosis. Alcoholism (34·3% of 4413) was the commonest cause of cirrhosis while Hepatitis B (33·3%) was predominant cause of chronic liver disease in general and non-cirrhotic chronic liver disease (40·8% out of 8163). There was significant interregional differences (hepatitis C in North, hepatitis B in East and South, alcohol in North-east, Non-alcoholic Fatty Liver Disease in West) in the predominant cause of chronic liver disease. Hepatitis B (46·8% of 438 cases) was the commonest cause of hepatocellular Cancer.11·7% had diabetes. Observations of our study will help guide a contextually relevant liver care policy for India and could serve as a framework for similar endeavor in other developing countries as well.

Thyroid Profile of Patients with Non-alcoholic Fatty Liver Disease

Introduction: Non-alcoholic fatty liver disease (NAFLD) is associated with various metabolic abnormalities such as obesity, insulin resistance, and dyslipidemia. The prevalence of NAFLD is increasing gradually, which may progress to non-alcoholic steatohepatitis (NASH), cirrhosis of liver, and hepatocellular carcinoma. The important association of NAFLD and metabolic disease can lead to endocrinopathy, including thyroid diseases. Methodology: Serologically diagnosed NAFLD patient was evaluated biochemically for liver function and thyroid function to evaluate any association between these two. Results: The study shows female preponderance (63.3%) NAFLD. It was observed that 77.50% were having normal transaminase level and 22.50% had raised transaminase levels (NASH). Subclinical hypothyroidism was present among 18.30%, overt hypothyroidism was 7.50%, and hyperthyroidism was 0.80%. Among the individuals with normal transaminase level, 20.50% were hypothyroid (15.10% subclinical and 5.40% overt), and persons with raised transaminase levels (NASH), 44.44% were hypothyroid (29.63% subclinical and 14.81% overt). Conclusion: This study shows that though there was a female preponderance of NAFLD, raised transaminase was more common among male and so is the hypothyroidism. This may form a matrix to the future study for cause and effect relationship of NAFLD and thyroid disease

Prevalence of Blood-Borne Viral Infections among Blood Donors of Tripura.

BACKGROUND: Blood-borne viral infections, like hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV), are most common during blood transfusion. Morbidity and mortality resulting from the transfusion of infected blood have far reaching consequences not only for the recipients themselves but also for their families, communities and the wider society. AIMS: The study was designed to determine the prevalence of HBV, HCV and HIV among voluntary and replacement blood donors of Tripura, India, and to study the trends of HBV, HCV and HIV infections in the population. MATERIALS AND METHODS: This study is a retrospective cross-sectional study. The data was collected for consecutive 8 years from 2005 to 2013. Analyses were done in respect of total blood collection and HBV, HCV and HIV infections among the donors. RESULTS: Among all donors, 91.8% was voluntary donors and 8.2% was replacement donors. The average HBV, HCV and HIV positivity was 1.2% (95% CI: 1.155-1.255), 0.109% (95% CI: 0.0950.125) and 0.093% (95% CI: 0.080-0.108) respectively. Among these, HBV seropositivity was 1.19% among voluntary donors and 1.33% among replacement donors and, in case of HCV and HIV, the seropositivity among voluntary and replacement donors were 0.109%, 0.11% and 0.089%, 0.145% respectively. HBV positivity was reduced in 8 years, whereas those of HCV and HIV remain unchanged. CONCLUSION: The most important observation of this study is gradual decrease in prevalence of HBV (p = 0.0018), whereas change in prevalence of HCV and HIV was not statistically significant. This might be due to mass hepatitis B vaccination program in Tripura.How to cite this article: Bhaumik P, Debnath K. Prevalence of Blood-Borne Viral Infections among Blood Donors of Tripura. Euroasian J Hepato-Gastroenterol 2014;4(2):79-82.

Current Profile of Hepatitis C in Tripura, India

Introduction: Viral hepatitis is one of the common causes of chronic liver disease. Hepatitis C is the second most importantcause of chronic viral hepatitis. Globally, an estimated 71 million people have chronic hepatitis C infection. In 2015, there were1.75 million new hepatitis C virus (HCV) infections. Approximately 399,000 people die each year due to HCV-related cirrhosisand hepatocellular carcinoma. Highest numbers of infections are noted in Egypt. South East Asian region countries are alsohaving high prevalence. The prevalence in India is around 1%. In Tripura, blood bank-based study shows prevalence around0.1%. Higher prevalence was seen in patient on maintenance hemodialysis.Objectives: The study was designed to determine. (1) Mode of transmission of hepatitis C in Tripura, (2) To evaluate genotypicpattern of hepatitis C infection in Tripura, (3) To evaluate coinfection with human immune deficiency virus (HIV)/hepatitis B virus (HBV).Materials and Methods: It was a cross-sectional study done on 60 consecutive hepatitis C patients attended the liver clinic ofHepatitis Foundation of Tripura between January 2018 and December 2018.Results: The study reveals that in this group, 65% hepatitis C patients were males and 35% were females and 63.3% patientsare from rural areas whereas 36.7% patients are from urban areas. Study shows that there is shift of age among hepatitis Cpatients from older to the younger group. It was observed that 5% of hepatitis C patients had coinfection with HIV infectionbut no coinfection with HBV. Regarding mode transmission of hepatitis C, 30% are through blood transmission, 20% throughdrug abuse, 16.7% patients through sexual route, 11.6% patients through dialysis, 1.7% prenatal transmission, and 20%remain unknown. Genotype 3 was 75% (3a was found in 55% and 20% were genotype 3b,) and genotype 1 was 25% (21.7%genotype 1a and 3.3% were genotype 1b). In the study group, 18% were in decompensated chronic liver disease.Discussion: The prevalence of HCV infection seems to be increasing among people who inject drugs in Tripura. Malepreponderance in this study may be due to more exposure to drugs among males. Higher prevalence of Hepatitis C amongthe rural people may be due to increase quackery practice in the rural areas.

A rare HBV subgenotype D4 with unique genomic signatures identified in north-eastern India--an emerging clinical challenge?

BACKGROUND/AIMS: HBV has been classified into ten genotypes (A-J) and multiple subgenotypes, some of which strongly influence disease outcome and their distribution also correlate with human migration. HBV infection is highly prevalent in India and its diverse population provides an excellent opportunity to study the distinctiveness of HBV, its evolution and disease biology in variegated ethnic groups. The North-East India, having international frontiers on three sides, is one of the most ethnically and linguistically diverse region of the country. Given the paucity of information on molecular epidemiology of HBV in this region, the study aimed to carry out an in-depth genetic characterization of HBV prevailing in North-East state of Tripura. METHODS: From sera of chronically HBV infected patients biochemical/serological tests, HBV DNA quantification, PCR-amplification, sequencing of PreS/S or full-length HBV genomes were done. HBV genotype/subgenotype determination and sequence variability were assessed by MEGA5-software. The evolutionary divergence times of different HBV subgenotypes were estimated by DNAMLK/PHYLIP program while jpHMM method was used to detect any recombination event in HBV genomes. RESULTS: HBV genotypes D (89.5%), C (6.6%) and A (3.9%) were detected among chronic carriers. While all HBV/A and HBV/C isolates belonged to subgenotype-A1 and C1 respectively, five subgenotypes of HBV/D (D1-D5) were identified including the first detection of rare D4. These non-recombinant Indian D4 (IndD4) formed a distinct phylogenetic clade, had 2.7% nucleotide divergence and recent evolutionary radiation than other global D4. Ten unique amino acids and 9 novel nucleotide substitutions were identified as IndD4 signatures. All IndD4 carried T120 and R129 in ORF-S that may cause immune/vaccine/diagnostic escape and N128 in ORF-P, implicated as compensatory Lamivudine resistance mutation. CONCLUSIONS: IndD4 has potential to undermine vaccination programs or anti-viral therapy and its introduction to North-East India is believed to be linked with the settlement of ancient Tibeto-Burman migrants from East-Asia.