Research ArticleHepatitis B surface antigen serum level is associated with fibrosis severity in treatment-naïve, e antigen-positive patients
Introduction
Chronic infection with hepatitis B virus (HBV) remains a considerable global healthcare problem despite the greatly reduced rates of infection observed since the introduction of a vaccine in the early 1980s. The disease is estimated to be responsible for 0.5–1.2 million deaths per year, with the Asia Pacific region accounting for 75% of the estimated 350 million individuals living with chronic hepatitis B (CHB) [1], [2]. The disease has a relatively low prevalence in Europe and the USA, but the rates of infection within high-risk groups, such as injection drug users, sex workers, and immigrant populations from areas with high prevalence, underlines the need for additional measures that reduce the burden of the disease [2], [3].
HBV infection is not cytopathogenic and the virus persists within the nuclei of infected hepatocytes as covalently closed circular DNA (cccDNA) minichromosomes and viral DNA sequences integrated into the host genome [2]. The quantification of serum HBV DNA is an established measure of viral load and a standard diagnostic tool for evaluating disease progression, candidacy for antiviral therapy, monitoring of treatment response, and for distinguishing patients with active disease from ‘inactive carriers’ [2]. A strong association between serum HBV DNA level and risk of hepatocellular carcinoma (HCC) has also been demonstrated [4], [5]. Hepatitis B surface antigen (HBsAg), which forms the protein envelope of the virus, is generally considered diagnostic for HBV infection [2]. HBsAg is secreted from infected cells and circulates within the serum as non-infectious spherical and filamentous structures, which can outnumber complete virions from 100- to 100,000-fold [6]. Seroclearance of HBsAg is commonly regarded as the clinical end point closest to cure and is associated with reduced progression to more serious liver disease [7], [8], [9]. There is growing interest in the use of quantitative HBsAg (qHBsAg) as a prognostic marker in CHB patients [10]. Serum HBsAg levels have been demonstrated to be clinically useful for identifying the stage of disease [11], [12], for distinguishing true inactive carriers from patients with hepatitis B e antigen-negative (HBeAg[−]) disease [13], [14], [15], [16], and for predicting response to interferon therapy [17], [18]. Recent research has also demonstrated that HBsAg levels are associated with the risk of progression to HCC, especially in patients with low HBV DNA levels [19], [20]. Little is currently known about the association between HBsAg or HBV DNA levels and the severity of liver disease at any specific time point. In contrast to HBV DNA [4], [5], only one published study has investigated the potential correlation between HBsAg levels and the stage of fibrosis [21]. This study was restricted to selected, hepatitis B e antigen-positive (HBeAg[+]) CHB patients and did not include analysis of viral genotype. The aim of this cross-sectional study was to therefore investigate the potential relationship between serum HBsAg and HBV DNA levels and the severity of liver lesions in a large cohort of unselected, consecutive, well-characterized, treatment-naïve CHB patients infected with different HBV genotypes.
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Patients
Unselected, consecutive, treatment-naïve CHB patients were assessed at the Hôpital Beaujon in Paris, France, between 2000 and 2008. Inclusion criteria for patients were: HBsAg-positive, known HBeAg status, scheduled liver biopsy, and absence of HCV, HDV, or HIV co-infection. Serum samples and liver biopsies were obtained on the same day in all cases.
Diagnostic tests
Serum ALT levels were expressed as IU/ml. HBsAg levels in patient serum samples were measured using the Elecsys® HBsAg II quant assay (Roche
Study population
406 unselected, consecutive, treatment-naïve CHB patients were included in the study: 101 patients (25%) were HBeAg(+) and 305 patients (75%) were HBeAg(−) (Table 1). There were more men than women in the study population, with 75% of patients in both HBeAg(+) and HBeAg(−) groups being male. Mean alanine aminotransferase (ALT) levels were significantly higher in HBeAg(+) patients and there was a significantly greater proportion of patients with normal ALT in the HBeAg(−) group. Both the
Discussion
Our study population represents a well-characterized CHB cohort from the multicultural city of Paris, which had not been pre-selected in any way and had not received previous treatment for HBV infection. All patient serum samples were taken on the same day as liver biopsies and therefore represent an accurate ‘snapshot’ of the state of disease occurring within each patient at that specific time. We observed a strong correlation between HBsAg and HBV DNA levels in the serum of treatment-naïve
Financial support
The study was funded in part by Roche Diagnostics.
Conflict of interest
Michelle Martinot-Peignoux has acted as a speaker and expert for Roche Diagnostics.
Patrick Marcellin has received research grants from and acted as an investigator, speaker, and expert for Roche Diagnostics. Richard Batrla and Friedemann Krause are employees of Roche Diagnostics. All other authors declare no conflict of interest.
Acknowledgements
The authors thank Roche Diagnostics for financial support and David Wateridge, associated with Elements Communications (Westerham, UK), for providing editorial assistance with the preparation and submission of the final draft of the manuscript, which was funded by Roche Diagnostics.
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