Cumulative incidence of HCC is low in patients treated with ETV, but ETV does not eliminate the risk of HCC. Discriminatory performance of HCC risk scores was limited, particularly in Caucasians, at baseline and during therapy.

Entecavir (ETV) is a potent inhibitor of viral replication in nucleos(t)ide analogue (NA)-naïve chronic hepatitis B (CHB) patients. The aim of this study was to investigate the long term efficacy and safety of ETV in NA-naïve CHB patients, particularly in those with detectable hepatitis B virus (HBV) DNA after 48 weeks, in whom treatment adaptation is suggested by current guidelines. In a multicenter cohort study, we investigated 333 CHB patients treated with entecavir monotherapy. The NA-naïve population consisted of 243 patients, whereas 90 were NA-experienced. Virological response (VR) (HBV DNA <80 IU/ mL) was achieved in 48%, 76%, and 90% of hepatitis B e antigen (HBeAg)-positive and in 89%, 98%, and 99% of HBeAg-negative NA-naïve patients at weeks 48, 96, and 144, respectively. Thirty-six of 175 (21%) NA-naïve patients with at least 48 weeks of follow-up had a detectable load at week 48 (partial virological response [PVR]). Twenty-nine (81%) patients with PVR reached VR during prolonged ETV monotherapy, and none of them developed ETV-resistance. Among 22 patients with HBV DNA <1,000 IU/mL at week 48, VR was achieved in 21 (95%) patients, compared with eight of 14 (57%) patients with HBV DNA !1,000 IU/mL. Continuous HBV DNA decline was observed in most patients without VR during follow-up, and in three patients adherence was suboptimal according to the treating physician. ETV was safe and did not affect renal function or cause lactic acidosis. Conclusion: ETV monotherapy can be continued in NA-naïve patients with detectable HBV DNA at week 48, particularly in those with a low viral load because long-term ETV leads to a virological response in the vast majority of patients. (HEPATOLOGY 2011;54:443-451) C urrent treatment guidelines consider nucleos(-t)ide analogues (NAs) and pegylated interferon as first-line treatment for chronic hepatitis B (CHB). The ultimate goal of treatment is prevention of cirrhosis, hepatic decompensation, and hepatocellular carcinoma.1 Entecavir (ETV) is a cyclopentyl guanosine analogue that has shown superior biochemical, virological, and histological efficacy compared with lamivudine (LAM) in large phase III trials.2,3 Moreover, genotypic resistance to ETV is rare in NA-naïve

Therefore, beside the structural alterations (fibrosis, nodule formation), there is a complex dynamic component that contributes to increasing hepatic vascular resistance and splanchnic vasodilata-tion. Understanding this pathophysiology has revealed markers that are associated with the presence of PH and varices. On the other hand, variation of the genes that encode proteins involved in sys-temic and splanchnic vasodilatation have been found to be associated with the presence of esophageal varices. 8 Therefore, variation of these genes could play a role in addition to predicting the presence of esophageal varices, as well as their likelihood of bleeding. In this issue of the journal, Yang and colleagues have analyzed 951 patients with cirrhosis of various etiologies. The main aim was to evaluate additional blood markers and genetic risk for the prediction of the presence of esophageal varices in cirrhosis. Also, they performed a 2-year follow-up to evaluate predictors for esophageal varices (EV) bleeding. The authors also studied another 650 independent patients to confirm the association between genetic variants and presence of EVs, namely for validation cohort. 9 The factors analyzed in this study included plasma levels of soluble CD163 (sCD163), VEGF and HO-1, genetic polymorphisms of HO-1, VEGF, and vascular endothelial growth factor receptor 2 (VEGFR2). Soluble CD163 is a specific marker of activated macrophages, another potential biomarker for PH in cirrhosis. The activation of Kupffer cells may be involved in PH by the release of vasoconstrictor substances. Recently, Grønbaek et al. have shown that sCD163 plasma concentration in cirrhosis is almost three times higher than in controls, and sCD163 was an independent predictor of the hepatic venous pressure gradient. 10 Yang et al. 9 found that serum sCD163 level was elevated in patients with cirrhosis complicated by esophageal varices, and this marker could potentially be used to predict the presence of EVs in clinical practice. The genetic elements of the Yang study identified that patients with esophageal varices showed significantly higher frequencies of risk genotypes of HO-1, SS in (GT)n repeat, and AA in T(-413)A than corresponding wild-type genotypes. Further, cir-rhotic patients carrying C(+405)G GG and C(+936)T TT risk genotype of VEGF, and Val(-297)Ile Ile/Ile risk genotype of VEGFR2 had a higher likelihood of developing EVs than those carrying wild-type genotype. Therefore, in addition to traditional markers (platelet count and splenomegaly), the authors showed that high serum sCD163 level and these polymorphisms in the HO-1 and VEGF predict the presence of esophageal varices in patients with cirrhosis. Further, the combination of platelet count, serum sCD163 level, and those risk haplotypes of HO-1 and VEGF conferred higher predictive values for varices than platelet count alone. Finally, patients with these same risk haplotypes (HO-1 and VEGF) have a higher chance of esophageal variceal bleeding than those not carrying these haplotypes. In con...

Nucleos(t)ide analogues strongly inhibit viral replication in chronic hepatitis B (CHB) infection, but knowledge of their long-term effect on serum hepatitis B surface antigen (HBsAg) levels and HBsAg loss is lacking. Seventy-five CHB patients with virological response (VR) to ETV or TDF were included. HBsAg decline 2 years after VR was most pronounced in HBeAg-positive patients. Age, alanine aminotransferase, and HBeAg loss were associated with HBsAg decline in HBeAg-positive patients. Predicted median time to HBsAg loss was 36 years for HBeAg-positive and 39 years for HBeAg-negative patients. Thus, most patients treated with ETV and TDF will probably need decades of therapy to achieve HBsAg loss.

Receipt of TDF therapy by HIV/HBV-coinfected patients for up to 6 years led to a significant decrease in HBsAg in the HBeAg-positive population. HBsAg kinetics early during treatment were predictive of HBsAg seroclearance and correlated with an increased CD4 cell count, underlining the importance of immune restoration in HBV clearance.

Antibiotics are among the most frequently prescribed drugs in medicine. Their use, however, is often limited by associated renal toxic effects. The most common manifestation of these toxic effects is decreased glomerular filtration rate. However, they can also occur while renal function remains near to normal. This Review focuses on antibiotic-associated fluid, electrolyte and acid-base disorders that do not greatly reduce glomerular filtration. Renal tubules can be affected by antibiotics at various locations. In the proximal tubule, toxic effects of tetracyclines and aminoglycosides can result in complete proximal tubular dysfunction, also known as Fanconi syndrome. Aminoglycosides (and capreomycin) can also affect the loop of Henle and lead to a Bartter-like syndrome. In the collecting ducts, antibiotics can cause a diverse range of disorders, including hyponatremia, hypokalemia, hyperkalemia, renal tubular acidosis, and nephrogenic diabetes insipidus. Causative antibiotics include trimethoprim, amphotericin B, penicillins, ciprofloxacin, demeclocycline and various antitubercular agents. Here, we describe the mechanisms that disrupt renal tubular function. Integrated with the physiology of each successive nephron segment, we discuss the receptors, transporters, channels or pores that are affected by antibiotics. This insight should pave the way for pathophysiology-directed treatment of these disorders.

Serum hepatitis B surface antigen (HBsAg) levels reflect intrahepatic hepatitis B virus (HBV) covalently closed circular DNA and may be a valuable addition to HBV DNA in the management of patients with chronic hepatitis B (CHB). Among HBeAg-negative CHB patients with low HBV DNA levels, HBsAg quantification may help distinguish those with active CHB from true inactive carriers with a very favourable prognosis, thus limiting the need for long-term intensive monitoring of ALT and HBV DNA levels. In patients treated with peginterferon (PEG-IFN), achievement of a decline in HBsAg during therapy appears to be an important marker for treatment outcome, and several groups have proposed stopping rules based on HBsAg thresholds. A recently described stopping rule incorporating a combination of HBsAg and HBV DNA levels can accurately identify HBeAg-negative patients, especially those with HBV genotype D, not responding to PEG-IFN. Current applications of HBsAg levels in the monitoring of patients treated with nucleo(s)tide analogues are still being evaluated. First data from these studies show that HBsAg decline, and thus subsequent clearance, is confined to those with an active immune response to HBV, such as HBeAg-positive patients with elevated ALT, or those who achieve HBeAg clearance.

Host-induced flares are associated with presence of only wild-type hepatitis B virus (HBV) and result in decline and clearance of HBV DNA, hepatitis B e antigen, and hepatitis B surface antigen (HBsAg). Monitoring of HBsAg levels during and after flares may help predict a favorable treatment outcome.