Hepatitis B Virus-Associated Polyarteritis Nodosa

Abstract

Hepatitis B virus-associated polyarteritis nodosa (HBV-PAN) is a typical form of classic PAN whose pathogenesis has been attributed to immune-complex deposition with antigen excess. We conducted the current study to 1) analyze the frequency of HBV infection in patients with PAN, in light of the classification systems described since 1990; 2) describe the clinical characteristics of HBV-PAN; 3) compare the evolution according to conventional or antiviral treatment; and 4) evaluate long-term outcome. One hundred fifteen patients were included in therapeutic trials organized by the French Vasculitis Study Group and/or referred to our department for HBV-PAN between 1972 and 2002. To determine the frequency of HBV-PAN during the 30-year period, we analyzed a control group of patients with PAN without HBV infection, followed during the same period and diagnosed on the same bases. Depending on the year of diagnosis, different treatments were prescribed. Before the antiviral strategy was established, some patients were given corticosteroids (CS) with or without cyclophosphamide (CY). Since 1983, treatment for patients with HBV markers has combined 2 weeks of CS followed by an antiviral agent (successively, vidarabine, interferon-alpha, and lamivudine) combined with plasma exchanges (PE).Ninety-three (80.9%) patients entered remission during this period and 9 (9.7%) of them relapsed; 41 (35.7%) patients died. For the 80 patients given the antiviral strategy as intention-to-treat, 4 (5%) relapsed and 24 (30%) died vs 5 (14.3%) relapses (not significant [NS]) and 17 (48.6%) deaths (NS) among the 35 patients treated with CS alone or with CY or PE. HBe-anti-HBe seroconversion rates for the 2 groups, respectively, were: 49.3% vs 14.7% (p < 0.001). Patients who seroconverted obtained complete remission and did not relapse.Thus, HBV-PAN, a typical form of classic PAN, can be characterized as follows: when renal involvement is present, so is renal vasculitis; glomerulonephritis due to vasculitis is never found; antineutrophil cytoplasmic antibodies (ANCA) are not detected; relapses are rare, and never occur once viral replication has stopped and seroconversion has been obtained. Combining an antiviral drug with PE facilitates seroconversion and prevents the development of long-term hepatic complications of HBV infection. The major cause of death is gastrointestinal tract involvement. Importantly, the frequency of HBV-PAN has decreased in relation to improved blood safety and vaccination campaigns.

Hepatitis C virus–associated polyarteritis nodosa

“…Quantitative variables are presented as medians, interquartile ranges (IQRs), or the mean Ϯ SD. The comparisons between our HCV-PAN patients and those with HBV-PAN from Guillevin et al (18) were made using a Z test for the average age comparison and a Fisher's exact test for the frequency comparisons. To compare variables according to the HCVrelated PAN or MC-type vasculitis, a Fisher's exact test was performed.…”

“…We next compared the main characteristics of our 31 HCV-PAN patients with the 115 HBV-PAN patients previously reported by Guillevin et al (18). The main data are summarized in Table 3.…”

“…HBV-PAN usually becomes clinically manifest less than 1 year after viral exposure (18), whereas in HCV-PAN, the vasculitis occurs 20 years after the contamination. HCV-PAN patients tend to be older and more frequently of female sex.…”

Treatment of Hepatitis B Virus-Associated Nephropathy

“…Hepatitis B-associated PAN is a typical form of PAN whose pathogenesis has been attributed to immune complex deposition with antigen excess [27]. By concept, PAN is characterized by arteritis in medium-sized and small arteries without involvement of smaller vessels (e.g.…”

“…Wegener and microscopic polyangiitis) in that antineutrophil cytoplasmic antibodies (ANCA) are not detected, relapses are rare, never occur once viral replication has been stopped and/or seroconversion occurs. Importantly, the frequency of hepatitis B-associated PAN has decreased due to widespread HBV immunization [27]. …”