Lesson of the month 2: Severe reactivation of hepatitis B after immunosuppressive chemotherapy

Dyson, Jessica; Hudson, Mark; McPherson, Stuart

doi:10.7861/clinmedicine.14-5-551

Cited by 5 publications

(4 citation statements)

References 24 publications

(29 reference statements)

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“…In addition, six 30-min education sessions were delivered to staff involved in the management of patients on immunosuppression or chemotherapy. Each session included a case example of an HBsAg-negative/anti-HBcAb-positive patient with lymphoma who developed liver failure secondary to HBV reactivation on R-CHOP chemotherapy 23 , followed by the rationale for HBV testing and prophylaxis. Following the introduction of this hospital guideline, there was a marked increase in appropriate HBV screening in patients before receiving rituximab from 19 to 78%.…”

Section: Discussionmentioning

confidence: 99%

“…The risks associated with reactivation of HBV with rituximab treatment were highlighted in our own unit recently when an anti-HBcAb-positive, HBsAg-negative patient with diffuse large B-cell lymphoma developed severe fibrosing cholestatic hepatitis secondary to HBV reactivation with rituximab (as part of the R-CHOP regimen) that required a prolonged hospital admission despite initiation of antiviral therapy 23 . The aim of this work is to describe the introduction of a hospital-wide policy on HBV testing in patients before treatment with rituximab and to assess its impact.…”

Section: Introductionmentioning

confidence: 99%

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Improving testing for hepatitis B before treatment with rituximab

Dyson

Jopson

et al. 2016

European Journal of Gastroenterology &Amp; Hepatology

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Aims/Objectives/BackgroundIndividuals with current or previous infection with the hepatitis B virus (HBV) can experience viral reactivation when treated with immunosuppression. Rituximab, an anti-CD20 antibody used to treat many diseases, has potent immunosuppressant effects with a high risk of causing HBV reactivation. Reactivation can range from elevated liver enzymes to acute severe hepatitis with liver failure and a significant mortality risk. HBV screening and appropriate use of prophylactic antiviral therapy can prevent reactivation. This work describes the introduction of a local policy for HBV testing in patients before rituximab treatment and assesses its impact.Methods and ResultsA baseline review (before policy introduction) of 90 patients showed that only 21 (23%) had hepatitis B surface antigen (HBsAg) and 17 (19%) had hepatitis B core antibody (anti-HBcAb) tested before receiving rituximab. Following introduction of the policy (on the basis of international guidelines), improved laboratory reporting protocols and targeted education sessions, two further reviews of HBV testing rates among patients being initiated onto rituximab were performed. There was a marked increase in pre-rituximab testing for HBsAg from 23 to 79% and for anti-HBcAb from 19 to 78%. Throughout the study period, a total of one (0.8%) HBsAg-positive and six (4.7%) anti-HBcAb-positive patients were identified.ConclusionsThis work clearly indicates that simple strategies can markedly improve appropriate HBV screening. In our cohort, 6% (of whom only 43% had recognized HBV risk factors) required antiviral prophylaxis, which emphasizes the importance of universal screening before rituximab. Reinforcement of the guidelines and ongoing education is needed to further increase testing rates.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Improving testing for hepatitis B before treatment with rituximab

Dyson

Jopson

et al. 2016

European Journal of Gastroenterology &Amp; Hepatology

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“…When chemotherapy is administered intermittently, or after it is stopped, patients gradually recover immune function. Liver cells, which contain HBV, exhibit strong immune-mediated reactions, resulting in severely damaged liver function (Keam et al, 2011;Dyson et al, 2014). Reactivation of HBV replication is related to glucocorticoids.…”

Section: Discussionmentioning

confidence: 99%

Risk factors for damaged liver function after chemotherapy in hepatitis B virus carriers with non-Hodgkin lymphoma

Fan

Liu

et al. 2015

Genet. Mol. Res.

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ABSTRACT. The goal of this study was to investigate damaged liver function after chemotherapy in hepatitis B virus (HBV) carriers with non-Hodgkin lymphoma (NHL) and to evaluate risk factors associated with a high risk of damaged liver function. Clinical histories of 134 HBV carriers with NHL who were treated with chemotherapy were obtained and analyzed for the occurrence of damaged liver function and other related high-risk factors. Analysis showed that 76 patients (56.7%) had damaged liver function after chemotherapy: 6 patients (7.9%) had I degree, 17 patients (22.4%) had II degree, 20 patients (26.3%) had III degree, and 33 patients (43.4%) had IV degree damage. After treatment, 18 patients (23.7%) continued to receive chemotherapy according to their original schedule, 39 patients (51.3%) delayed chemotherapy, 16 patients (21.1%) stopped chemotherapy, and 3 patients (3.9%) died. Analysis of a binary multivariate logistic regression model showed that administration of steroids was a high-risk factor for damaged liver function after chemotherapy in NHL patients. The incidence of damaged liver function after chemotherapy is high among HBV carriers with NHL; therefore, administration of steroid chemotherapy is a high-risk factor.

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“…The survival influence of steroid therapy was significant on complete or partial responders (Lille score <0.45) but was negligible on null responders (Lille score ≥0.45). Some clinicians had reported that the immunosuppressive therapy could activate HBV infections, eventually resulting in liver failure in patients with current or past HBV infections [ 73 , 74 ]. Regarding these facts, the Food and Drug Administration (FDA) had warned on HBV reactivation with immunosuppressive drugs [ 75 ].…”

Section: Application Of Glucocorticoidmentioning

confidence: 99%

Treatment of AECHB and Severe Hepatitis (Liver Failure)

Wang

Dou

et al. 2019

Acute Exacerbation of Chronic Hepatitis B

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This chapter describes the general treatment and immune principles and internal management for AECHB and HBV ACLF, including ICU monitoring, general supportive medications/nutrition/nursing, immune therapy, artificial liver supportive systems, hepatocyte/stem cell, and liver transplant, management for special populations, frequently clinical complications and the utilization of Chinese traditional medicines. Early clinical indicators of severe hepatitis B include acratia, gastrointestinal symptoms, a daily increase in serum bilirubin >1 mg/dL, toxic intestinal paralysis, bleeding tendency and mild mind anomaly or character change, and the presence of other diseases inducing severe hepatitis. Laboratory indicators include T-Bil, PTA, cholinesterase, pre-albumin and albumin. The roles of immune indicators (such as IL-6, TNF-α, and fgl2), gene polymorphisms, HBV genotypes, and gene mutations as early clinical indicators. Intensive Care Unit monitor patients with severe hepatitis include intracranial pressure, infection, blood dynamics, respiratory function, renal function, blood coagulation function, nutritional status and blood purification process. Nursing care should not only include routine care, but psychological and special care (complications). Nutrition support and nursing care should be maintained throughout treatment for severe hepatitis. Common methods of evaluating nutritional status include direct human body measurement, creatinine height index (CHI) and subject global assessment of nutrition (SGA). Malnourished patients should receive enteral or parenteral nutrition support. Immune therapies for severe hepatitis include promoting hepatocyte regeneration (e.g. with glucagon, hepatocyte growth factor and prostaglandin E1), glucocorticoid suppressive therapy, and targeting molecular blocking. Corticosteroid treatment should be early and sufficient, and adverse drug reactions monitored. Treatments currently being investigated are those targeting Toll-like receptors, NK cell/NK cell receptors, macrophage/immune coagulation system, CTLA-4/PD-1 and stem cell transplantation. In addition to conventional drugs and radioiodine, corticosteroids and artificial liver treatment can also be considered for severe hepatitis patients with hyperthyreosis. Patients with gestational severe hepatitis require preventive therapy for fetal growth restriction, and it is necessary to choose the timing and method of fetal delivery. For patients with both diabetes and severe hepatitis, insulin is preferred to oral antidiabetic agents to control blood glucose concentration. Liver toxicity of corticosteroids and immune suppressors should be monitored during treatment for severe hepatitis in patients with connective tissue diseases including SLE, RA and sicca syndrome. Patient with connective tissue diseases should preferably be started after the antiviral treatment with nucleos(t)ide analogues. An artificial liver can...

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Lesson of the month 2: Severe reactivation of hepatitis B after immunosuppressive chemotherapy

Cited by 5 publications

References 24 publications

Improving testing for hepatitis B before treatment with rituximab

Improving testing for hepatitis B before treatment with rituximab

Risk factors for damaged liver function after chemotherapy in hepatitis B virus carriers with non-Hodgkin lymphoma

Treatment of AECHB and Severe Hepatitis (Liver Failure)

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