User:Samir/B

=HBV= Things to add to HBV article, hepadnavirus, components: Virology of B: DNA virus, incorporates into nucleus, cccDNA forms template for - strand of DNA (2 ways to form cccDNA)

Waiting period
Chronic B AASLD guidelines 6/12 waiting period **

Who to test

 * Hyperendemic areas
 * MSM
 * IVDU
 * Close contacts of affected
 * Pregnancy
 * Dialysis patients
 * HIV +

Role of liver biopsy

 * 1) In ascertaining cirrhosis in patients in whom treatment is being considered (i.e. ALT > 1.5-2x ULN, DNA +, irrespective of eAg status) with interferon and ? of cirrhosis comes up (high AST:ALT, low plt, low plt:AST ratio)
 * 2) In patients with fluctuations of ALT on therapy
 * 3) In making a determination on whether to treat high risk patients (Asian males, those with family Hx of HCC, very high DNA)

Extrahepatic manifestations of B

 * PAN
 * Papular acrodermatitis of childhood
 * Neuropathy (mononeuritis multiplex)
 * Membranous vs. membranoproliferative GN
 * Serum sickness (4/12)

HBV and pregnancy

 * Lamivudine Rx in pregnancy (? data) -> begin Tx at end
 * Interferon contraindicated in pregnancy
 * Vaccinate child, and give HBIG single dose (ref)

HBV and chemotherapy
When to give Lam vs. interferon to prevent activation? Evidence (good evidence for PEG and C)

Interferon contraindications

 * Cirrhosis
 * BM suppression
 * Solid organ transplant other than liver
 * Severe hyper or hypothyroidism
 * Pregnancy
 * Uncontrolled depression

Screening
AFP AND US for high risk: In general:
 * Cirrhotics with B
 * Active hepatitis (be it biochemical or histological)
 * Carriers: Asian males > 40, Asian females > 50, Africans > 20, FHx HCC, High DNA, pronged activity (from Morris Sherman's AASLD guidelines Hepatology Nov 2005)

Interferon

 * Interferon-2-alfa, 5 MU d or 10 q / MWF, SE: N/V flu-like/malaise itchiness/hair loss depression, suicidality hyper/hypothyroidism cytopenias
 * Duration=24/52 (eAg+) 1 yr (eAg-)
 * Efficacy (defined by eAg->eAb OR eAg- -> absence of DNA)
 * eAg + 33% (durable 80%)
 * eAg - 60-70% BUT NOT DURABLE (20%)

Lamivudine

 * NRTI (cytidine)
 * HIV -: 100 q d HIV +: 150 bid (ensure that HAART is given to prevent mutation)
 * Rx duration 52 weeks all comers
 * Efficacy
 * (eAg + 17-32% poorly durable 50% - 80%)
 * (eAg - 60-70%, durable <10%)
 * SE = rare, well tolerated, N/V, rare pancreatitits, mutants incl. YMDD
 * Mention that it can be used in cirrhotics
 * resistance 1 yr = 20% / 5 yr = 70% !! vs. adefovir ~ 2% @ 5 yrs.
 * treat for 6/12 AFTER seroconversion, no date for eAg -

Adefovir
NRTI (AMP) Can be added to YMDD Rx 10 daily S/E = nephropathy
 * Rx 1 yr
 * 24%/51%
 * Not durable
 * Decompensated cirrhotics - risk of HRS 2o nephrotoxicity!
 * rtN236T is Downstream to YMDD motif