Relation between laboratory test results and histological hepatitis activity in individuals positive for hepatitis B surface antigen and antibodies to hepatitis B e antigen

BACKGROUND: Hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B e antigen (anti-HBe) commonly coexist, and laboratory tests are often requested to assess histological hepatitis activity. An optimum panel of tests has not been found and the usefulness of hepatitis B virus (HBV) DNA assays in this context has not been established. We assessed various blood tests to find which best predicted hepatitis activity. METHODS: Routine plasma biochemical liver tests and serum HBV DNA (hybridisation and PCR assays) were assessed prospectively in 123 patients positive for HBsAg and anti-HBe. We scored histological hepatitis activity (hepatitis activity index) and determined whether chronic active hepatitis (chronic hepatitis with portal and periportal lesions) was present. We analysed the relation between laboratory data and the hepatitis activity index or risk of chronic active hepatitis by multiple regression and multiple logistic regression, respectively. FINDINGS: The analyses provided models for predicting either the hepatitis activity index or the risk of chronic active hepatitis. Aspartate aminotransferase was the most important test in the two models. The contribution of HBV DNA and other assays, especially alanine-aminotransferase activity, were of no practical importance. INTERPRETATION: Because screening by aspartate-aminotransferase activity could not be improved by the addition of other assays or HBV DNA, patients positive for HBsAg and anti-HBe could be screened for chronic active hepatitis with a single assay and counselling of patients can be improved if proper reference values are used.     

Proteins of hepatitis B surface antigen

Purified 22-nm forms of hepatitis B surface antigen (Hbsag) representing the three major antigenic subtypes (adw, ayw, and adr) were analyzed for their constituent polypeptides by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. No consistent difference in either the number or relative distributions of the polypeptides was observed for the various subtypes. Seven polypeptides were designated as P-1 through P-7 in order of their decreasing mobilities. By comparison with protein standards, their molecular weights were estimated as 23, 29.5, 36, 41.5, 53.5, 72, and 97 thousand. The P-1 and P-2 components represented the major polypeptides; P-2 and P-5 might by glycoproteins, based on their reaction with periodic acid-Shiff reagent. Each polypeptide contains cysteine residues. HBSAg was radiolabeled with 3H or 14C by reductive methylation or iodinated with 125I by the chloramine-T or lactoperoxidase procedures. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of labeled HBSAg yielded patterns identical to those obtained with protein stain. Comparison of HBSAg labeled by the chloramine-T and lactoperoxide procedures indicated that there was no distinction between internal or external components within the 22-nm structure.     

Nonspecific test reaction for antibodies to hepatitis B surface antigen in chronic HBAg carriers

Anti-HBs was undetectable in the plasma of 303 HBsAg-positive blood donors. The apparent reactivity of anti-HBs in the chromatographically isolated IgG fractions of these antigen-positive donors was shown to be nonneutralizable by HBsAg. The false-positive antiHBs reactions were apparently due to the isolation and concentration of IgG from the plasma which was initially nonreactive for anti-HBs.     

False negative hepatitis B surface antigen detection in dialysis patients due to excess surface antigen: postzone phenomenon

Renal dialysis patients are well known to have a high incidence of hepatitis B carrier state. In studying a group of 63 long-term dialysis patients, 10 were found to be positive for hepatitis B surface antigen by radioimmunoassay (RIA). Surprisingly, however, only three of these RIA positive patients were positive by counter immunoelectrophoresis (CIEP). The discrepancy could not be accounted for by the difference in sensitivity of the two methods. The cause for the negative reactions by CIEP in seven patients was found to be the marked excess surface antigen in these sera which produced false negative results by the postzone phenomenon. After dilution all seven sera were positive by CIEP, requiring a dilution up to 1/20 to produce a positive result. Also, all seven sera were positive by the less sensitive Ouchterlony double diffusion.     

Aggregation of recombinant hepatitis B surface antigen in Pichia pastoris

The combination of immunoaffinity and size-exclusion chromatography (SEC) is a powerful tool to analyze multiprotein particle assembly. This approach was used to investigate the source of aggregation of recombinant hepatitis B surface antigen (HBsAg) detected in purified material. As HBsAg aggregation does not originate in the stresses, such as the concentration of HBsAg solutions, temperature and chaotropic agents, it is less probable that the HBsAg aggregate is produced during the process. To test whether aggregation takes place in vivo, crude yeast extract containing the expressed HBsAg was fractioned on a Sephacryl S-400 column just after cell disruption, and each fraction immunopurified individually. As a result, the HBsAg aggregate was isolated from a fraction corresponding to the elution of large particle aggregates only, not native HBsAg particles. It was biologically active, which demonstrates aggregate formation by specific assembly of partially or wholly folded HBsAg intermediates.     

Examination of the polypeptides of hepatitis B surface antigen

When the polypeptides of hepatitis B surface antigen were examined by SDS-polyacrylamide gel electrophoresis under a variety of conditions, anomalous results were found to be due to (i) variable and at times incomplete dissociation of polypeptides after boiling with 1% SDS and reducing agent, (ii) reaggregation of solubilized material under certain electrophoretic conditions and during laboratory manipulations, and (iii) the variable presence of additional components in hepatitis B surface antigen prepared from certain individual donors. When these factors were taken into account, two major components were consistently identified by discontinuous buffer polyacrylamide gel electrophoresis, of apparent mol. wt. 60000 to 70000 and 12000 to 14000. However, in view of the demonstrated limitations of this technique in examining HBsAg polypeptides, alternative methods are necessary to confirm the true mol. wt. of the unique virus-specified amino acid sequence present.     

Immune responses to the hepatitis B surface antigen and liver-specific lipoprotein in acute type B hepatitis

A serial prospective study of cellular immunity to HBsAg and liver-specific membrane lipoprotein was undertaken in 21 adults with acute hepatitis type B. Cellular immunity to HBsAg as determined by leucocyte migration inhibition with partially purified HBsAg as antigen was detected in all the patients during the recovery phase of the illness and was already detectable at the time of admission in 13 (62%) of the cases. In five of the remaining eight the titre of HBsAg in the serum at this time was high and in the whole series there was an inverse correlation between the degree of migration inhibition on admission and the peak HBsAg titre suggesting that antigen or possibly antigen/antibody complexes might be interfering with the demonstration of cellular immunity in vitro. Using a combination of minimum migration index recorded during the recovery period peak HBsAg titre, it was possible to compute the peak aspartate aminotransferase level with reasonable accuracy, a finding consistent with the hypothesis that the severity of the illness is related to both the number of infected hepatocytes and the vigour of the immune response to HBsAg. Evidence of an immune response to the liver-specific hepatocyte membrane lipoprotein was present in 50% of the patients tested at the time of admission, but was transient, having disappeared in every case by four weeks. The minimum migration index recorded with HBsAg as antigen was significantly lower in those with detectable sensitisation to the lipoprotein and it is possible that this autoimmune reaction is also generated by the interaction of T cells with viral antigenic determinants on the liver cell surface.     

A humanized antibody with specificity for hepatitis B surface antigen

A murine monoclonal antibody H67 was characterized for the binding specificity, which showed that H67 recognizes a disulfide-bond-dependent conformational epitope of common a antigenic determinant on the hepatitis B surface antigen. The result suggested that this antibody may have the potential of replacing hepatitis B immune globulin in the prevention of hepatitis B virus (HBV) infection. Therefore, we have constructed the humanized antibody HuS10 by grafting the complementarity determining regions and some framework amino acid residues of H67 onto the most homologous human antibody variable regions, 21/28 for heavy chain variable region and B1 and J kappa 2 for light chain variable region, followed by combining with human constant regions C gamma 1 and C kappa. The affinity of the HuS10 was the same as that of the H67, 8 x 10(8) x 10(8)M-1, and the HuS10 neutralized the in vitro infection of adult human hepatocyte primary culture by adr or ayw subtype of HBV. The neutralization assay showed that the HuS10 had approximately 2,000-times higher specific activity than commercially available polyclonal HBIG. These results suggest that the humanized antibody will be useful in the prevention or treatment of HBV infection.     

False-positive HIV-1 test results in a low-risk screening setting of voluntary blood donation. Retrovirus Epidemiology Donor Study

CONTEXT: Persons at risk of human immunodeficiency virus 1 (HIV-1) infection, have been classified incorrectly as HIV infected because of Western blot results, but the frequency of false-positive Western blot results is unknown. OBJECTIVES: To determine the frequency of false-positive HIV-1 Western blot results in US blood donors and to make projections to other screened populations. Secondarily, to validate an algorithm for evaluating possible false-positive cases. DESIGN: A retrospective cohort study of HIV-1 enzyme immunoassay (EIA) and Western blot results from large blood donor screening programs in which donors with suspected false-positive Western blot results underwent HIV-1 RNA polymerase chain reaction (PCR) testing and follow-up HIV-1 serology. SETTING: Five US blood centers participating in the Retrovirus Epidemiology Donor Study. PARTICIPANTS: More than 5 million allogeneic and autologous blood donors who successfully donated blood at 1 of the 5 participating centers from 1991 through 1995. MAIN OUTCOME MEASURES: Rate of false positivity by Western blot and true HIV-1 infection status as determined by HIV-1 RNA PCR and by serologic follow-up of blood donors more than 5 weeks after donation. RESULTS: Of 421 donors who were positive for HIV-1 by Western blot, 39 (9.3%) met the criteria of possible false positivity because they lacked reactivity to p31. Of these, 20 (51.3%) were proven by PCR not to be infected with HIV-1. The false-positive prevalence was 4.8% of Western blot-positive donors and 0.0004% (1 in 251000) of all donors (95% confidence interval, 1 in 173000 to 1 in 379000 donors). CONCLUSIONS: A false diagnosis of HIV-1 infection can result from the combination of EIA and Western blot testing in blood donor and other HIV-1 screening programs. Individuals with a positive Western blot result lacking the p31 band should be counseled that, although they may be HIV infected, there is uncertainty about this conclusion. These individuals should be further evaluated by RNA PCR testing (if feasible) and HIV serologic analysis on a follow-up sample.     

Serial changes in titers of antibody to hepatitis B surface antigen after immunization of infants born to mothers with hepatitis B e antigen

The purpose of this study is to identify the existence of hepatovenous intrahepatic anastomosis in normal men. A total of thirteen livers were investigated during the early autopsies of normal men who died in accidents. Perfusion venography of branches of hepatic veins using meglucamine diatrizoate was done in six cases; this method we used had not been reported in the literature. In one case, portal venography was performed. And in the other six cases, liver substance staining was done by injecting the ink through the middle hepatic vein, and such staining of the liver was observed by light microscope. The results show, (1) there are intrahepatic anastomoses between the hepatic veins within the liver; (2) there are anastomoses between the middle hepatic vein and the accessory hepatic veins; and (3) shunts exist between portal veins and hepatic veins. The above findings provide an anatomical basis for the performance of irregular hepatectomy and the rationale for one or two hepatic veins ligation should such veins were traumatized or invaded by liver cancer.     

The prevalence of hepatitis B surface antigen in commercially prepared plasma products

Commercially available lots of plasma derivatives prepared between 1957 and 1975 were tested for hepatitis B surface antigen (HBsAg) by radioimmunoassay. In all, 69 per cent of lots of plasma protein fraction, 40 per cent of factor IX concentrate, 20 per cent of normal serum albumin, 13 per cent of antihemophilic factor, 3 per cent of fibrinogen, and 0.7 per cent of immune serum globulin lots tested were HBsAg-positive. There was great variation in the prevalence of HBsAg-positive lots of each product among the different manufacturers, reflecting not only differences in methods of processing plasma, but also differences in donor populations. Those manufacturers relying upon volunteer donor plasma or placental source material demonstrated lower rates of HBsAg-positive lots of final products than those relying upon commercial donor plasma. There was a marked decrease in the prevalence of positive lots during the period 1971 to 1973, coincident with the onset of routine plasma donor screening for HBsAg. However, current requirements for plasma screening have not resulted in totally HBsAg-free plasma products. Use of more sensitive and more reliable tests for HBsAg will probably reduce contamination of plasma pools with HBsAg to undetectable levels. Despite HBsAg-status, however, the "high-risk" plasma products (fibrinogen, antihemophilic factor, factor IX concentrate) must still be considered capable of transmitting hepatitis and used only with the strictest indications.     

High prevalence of e antigen among healthy blood donors carrying hepatitis B surface antigen in Japan

Hepatitis B surface antigen (HBsAg) was detected by an immune adherence haemagglutination method in the serum samples of 292 voluntary, apparently healthy blood donors at four regional blood centres in Japan. Their serum samples were concentrated 3-fold and tested for e antigen (e Ag) and antibody to e (anti-e) by immunodiffusion. The e Ag was found in 41 samples (14.0%) and anti-e in 57 (18.6%). When 100 randomly selected serum samples containing HBsAg were tested as they were (unconcentrated), and at 3- and 5-fold concentrations, e Ag was detected in 3, 16 and 27, respectively, and anti-e in 10, 21 and 26. Subtypes of HBsAg were similar in carriers with e Ag and with anti-e. There is a high prevalence of e Ag in healthy individuals in Japan. There are also high rates of vertical transmission of hepatitis B virus from mothers to children, as well as a high incidence in the past of post-transfusion hepatitis. This is further evidence that e antigen is a marker for the infectivity of hepatitis B virus in carriers.     

Dane particle-associated DNA polymerase and e antigen: relation to chronic hepatitis among carriers of hepatitis B surface antigen

Thirty-nine carriers of hepatitis B surface antigen (HBs Ag) were studied with respect to e antigen and Dane particle-associated DNA polymerase activity and their relation to chronic hepatitis. Most of these individuals were followed for four or five years. A strong correlation between e antigen and DNA polymerase activity was found. Of the 22 e antigen-positive patients, 21 showed polymerase activity; none of the 13 e antigen-negative patients (one of whom had antibody to e antigen) had such activity. Three of four patients who became e antigen-negative after being e antigen-positive showed loss of polymerase activity. An independent clinical evaluation showed a strong correlation between chronic hepatitis and positive reactions in the tests for e antigen and DNA polymerase. The results emphasize the possibility of differentiating between groups of chronic carriers of HBs Ag by testing for e antigen and Dane particle-associated DNA polymerase activity. The differentiation may have important clinical implications.