Hepatic failure in pregnancy successfully treated by online hemodiafiltration: Chronic hepatitis B virus infection without viral genome mutation

Abstract

A 23-year-old nulliparous woman, a hepatitis B virus (HBV) carrier with stable liver functions, presented with exacerbation of viral replication (HBV DNA level >9.0 log copies/mL) in gestational week 26. During the subsequent follow up without antiviral therapy, she was hospitalized with progression to hepatic failure in gestational week 35. Following initiation of antiviral therapy with lamivudine, emergent cesarean delivery was conducted for fetal safety. Liver atrophy and persistent hepatic encephalopathy (stage 2) necessitated artificial liver support (ALS) involving online hemodiafiltration (HDF) and plasma exchange. She regained full consciousness after the sixth online HDF session. ALS was terminated after the seventh online HDF session. On day 33 of hospitalization, she was discharged home without sequelae. Genetic analysis of the HBV strain isolated from her serum showed that this strain had genotype C. Direct full-length sequencing identified no known mutations associated with fulminant hepatitis B. HBV-related hepatic failure observed in the present case might have been related to perinatal changes in the host immune response.

Artificial liver support systems

“…This study demonstrated that hemodiafiltration had a higher survival rate than plasma exchange. Ammonia was also effectively decreased 51 . A total of 70.2% of patients had an improvement in hepatic encephalopathy grade.…”

“…It works in addition to plasma exchange by removing substances causing hepatic encephalopathy as well as waste substances to be metabolized in the liver for excretion 50 . It also supplies biological substances such as blood coagulation factors 51 . It is believed to have a greater capacity for blood purification and therefore support impaired liver function and the substances responsible for hepatic encephalopathy better than the MARS system 52 .…”

“…Yokoi et al . compared hemodiafiltration with plasma exchange in 90 patients with fulminant hepatitis 51 . This retrospective cohort study compared four treatment methods (including hemodiafiltration alone).…”

“…50 It also supplies biological substances such as blood coagulation factors. 51 It is believed to have a greater capacity for blood purification and therefore support impaired liver function and the substances responsible for hepatic encephalopathy better than the MARS system. 52 The main advantage is the reduction of cost of blood purification therapy in comparison with other artificial liver systems.…”

The Administration of Tenofovir Disoproxil Fumarate for Pregnant Japanese Women with Chronic Hepatitis B

“…Although chronic HBV infection typically remains stable during and after pregnancy, hepatitis flares occasionally occur in this period, presumably due to the dramatic hormonal and immunological alterations of pregnancy (8)(9)(10)(11)(12). The acute exacerbation is often self-limiting but may progress to hepatic decompensation or liver failure (8,9,11,12). This is one of the reasons for the initiation or continuation of antiviral therapy for HBV-infected women during pregnancy (8)(9)(10)(13)(14)(15).…”