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 Table of Contents 
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 6  |  Page : 2381-2385  

Role of tenofovir and telbivudine in treatment of hepatitis B related acute on chronic liver failure


1 Civil Surgeon Office, Munshiganj, Bangladesh
2 Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
3 Department of Hepatology, Dhaka Medical College Hospital, Dhaka, Bangladesh
4 Department of Anatomy and Embryology, Ehime University Graduate School of Medicine, Ehime, Japan
5 Department of Primary Care and Microbiology, Brahminbaria Medical College, Brahminbaria, Bangladesh
6 Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan

Date of Submission23-Nov-2020
Date of Decision02-Feb-2021
Date of Acceptance23-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Mamun A Mahtab
Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Bangladesh. Postal Address: House # 109, Road # 4, Block # B, Banani, Dhaka - 1213
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_2302_20

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  Abstract 


Introduction: ACLF is characterized by acute deterioration of liver function in patients with chronic liver disease. HBV is one of the most important causes of both acute insult and underlying chronic liver disease in ACLF. Reactivation of HBV is one of the common causes of ACLF in our region. ACLF requires multiple organ support and is associated with high short and medium term mortality. This is the reason why early, rapid reduction of HBV DNA is essential in treating ACLF-B. Methods: Consecutive patients of ACLF-B due to spontaneous reactivation of HBV (ALT> 5xULN or >2 x baseline and HBV DNA >20,000 IU/ml) were randomized into tenofovir group (300mg/day) and telbivudine group (600mg/day) along with standard medical treatment. Clinical and laboratory parameters were evaluated at baseline, day-7, day-14, day-30 and day-90. HBV DNA was evaluated at baseline and after three months of therapy. Primary end point was survival or death at three months. Secondary end point was improvement of liver function assessed by Child-Turcotte Pugh score and MELD score at three months. Results: 30 patients were enrolled in the study and 15 of them received tenofovir and 15 patients received telbivudine. Most of the baseline parameters showed no difference except serum AST and serum creatinine level that showed statistically significant difference between two groups. After antiviral therapy both groups showed significant clinical improvement along with CTP and MELD scores. However statistically significant improvement between tenofovir and telbivudine groups was only seen with MELD score. Survival rate was 80% in tenofovir group and 60% in telbivudine group, but this was not statistically significant. Low serum albumin at baseline was predictor of mortality. Conclusion: In patients of ACLF-B, antiviral therapy with both tenofovir and telbivudine improve liver function, but there is no statistically significant difference in survival between tenofovir and telbivudine.

Keywords: ACLF-B, HBV, telbivudine, tenofovir


How to cite this article:
Malakar D, Mahtab MA, Manik AH, Alam SM, Das DC, Mamun AA, Khan MS, Rahman Z, Rahman S, Akbar SM. Role of tenofovir and telbivudine in treatment of hepatitis B related acute on chronic liver failure. J Family Med Prim Care 2021;10:2381-5

How to cite this URL:
Malakar D, Mahtab MA, Manik AH, Alam SM, Das DC, Mamun AA, Khan MS, Rahman Z, Rahman S, Akbar SM. Role of tenofovir and telbivudine in treatment of hepatitis B related acute on chronic liver failure. J Family Med Prim Care [serial online] 2021 [cited 2021 Jul 26];10:2381-5. Available from: https://www.jfmpc.com/text.asp?2021/10/6/2381/320465




  Introduction Top


Acute on chronic liver failure (ACLF) is characterized by acute deterioration of liver function in patients with chronic liver disease.[1] Asian-Pacific Association for the Study of Liver Disease (APASL) defines ACLF as an acute hepatic insult manifesting as jaundice and coagulopathy, complicated within 4 weeks by clinical ascites and/or encephalopathy in a patient with previously diagnosed or undiagnosed chronic liver disease/cirrhosis and is associated with a high 28-day mortality.[2]

Chronic hepatitis B virus (HBV) infection is a serious health problem worldwide. It has been estimated that more than 2,00,000 and 3,00,000 chronic HBV-infected people die worldwide each year due to HBV-related liver cirrhosis and hepatocellular carcinoma (HCC).[3] Some CHB patients develop acute exacerbations of HBV leading to liver failure and even death. ACLF-B is associated with mortality ranging from 30% to 70%.[4] Liver transplantation remains only definitive therapy for patients with ACLF, but limited donor availability, high cost and lack of availability limit its usefulness in the management of patients of ACLF. Besides many patients cannot eventually be transplanted due to hemodynamic instability, raised intracranial pressure, reduced cerebral perfusion pressure and bacterial and/or fungal infections. Mortality due to ACLF-B may be prevented with antiviral therapy drugs during the golden window period. It is assumed that antiviral drugs reduce HBV load and reduce hepatocyte death with improved survival outcome.[5] It has been shown that nucleos (t) ide analogues significantly reduce HBV DNA[6] with significantly lower 3-month mortality (44.8% vs. 73.3%) and also reduced reactivation (1.80% vs. 18.4%).[4]


  Methodology Top


It was an observational study carried out on patients admitted at the in-patient department of Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka. Prior to the commencement of this study, the research protocol was approved by the Institutional Review Board (IRB) of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. Clinically suspected patients of ACLF-B were admitted through the out-patient department. Necessary investigations were done after admission. Patients of ACLF-B of age >18 years of both sexes were enrolled as study population. Patients of ACLF-B with undetectable HBV DNA, underlying cirrhosis due to any other etiology other than HBV, patients testing positive for anti-HAV IgM, anti-HEV IgM and anti-HCV IgM, coexistent HCC, patients on antiviral, cytotoxic, or immune-modulator drugs and with co-morbidity like heart failure, malignancy and uncontrolled diabetes were excluded. In all, 30 patients were recruited. After enrollment, the patients were randomized into two groups (A and B). Group A was selected for tenofovir and group B for telbivudine. Tenofovir 300 mg orally daily was given on an empty stomach at least 1 h before or 2 h after breakfast and telbivudine 600 mg orally daily in the morning along with standard medical therapy and was followed up for next 3 months. Data were collected on admission, at days 7, 14, 30, and 90. In case of death, cause of death was evaluated.

Every patient was received standard medical treatment including intravenous antibiotics, lactulose, supervised diet, and close monitoring. Patients were also treated with albumin and proton pump inhibitors when required. Enteral or parenteral nutrition was ensured to those patients where caloric requirement was not fulfilled orally.

All data were presented as mean ± SD and analyzed by SPSS. Qualitative data were analyzed by Chi-square test and quantitative data were be analyzed by Student's t-test. The Wilcoxon rank sum was used to compare laboratory parameters and measurement obtained in the first and last visits. A statistically significant result was considered when P value < 0.05.


  Result Top


The mean age was found 43.5 ± 13.5 years in tenofovir group and 44.0 ± 14.3 years in telbivudine group. The majority patients were males in both groups [Table 1]: 100.0% patients in both groups had jaundice and ascites. Altered level of consciousness was found 26.7% in tenofovir group and 20% in telbivudine group [Table 2].
Table 1: Distribution of the study patients by demographic variables

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Table 2: Distribution of the study patients by symptom and sign

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Mean Child–Turcotte Pugh (CTP) score was 12.2 ± 0.8 in tenofovir group and 12.1 ± 0.8 in telbivudine group, while mean Model of end stage liver disease (MELD) score was 25.3 ± 2.7 in tenofovir group and 25.6 ± 5.4 in telbivudine group [Table 3]. Virological status of the study patients is shown in [Table 4](i) and [Table 4](ii).
Table 3: Baseline investigations of the study patients

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All patients in both groups had coagulation failure. Liver failure was seen 86.7% in tenofovir group and 66.7% in telbivudine group, cerebral failure in 26.7% in tenofovir group and 20% in telbivudine group, kidney failure in 26.7% in tenofovir group and 20% in telbivudine group, while circulatory failure seen in 6.7% cases in both groups [Table 5].
Table 5: Distribution of the study patients by organ failure between two groups

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Pretreatment CTP score was 12.2 ± 0.8 in tenofovir group and 12.1 ± 0.8 in telbivudine group. After 3 months of therapy, CTP score was 7.5 ± 2.0 in tenofovir group and 7.5 ± 1.9 in telbivudine group. The differences were not statistically significant (P > 0.05) between two groups [Table 6]. On the other hand, pretreatment MELD score was 25.3 ± 2.7 in tenofovir group and 25.6 ± 5.4 in telbivudine group. After 3 months of therapy, MELD score was 12.08 ± 2.84 in tenofovir group and 14.41 ± 1.76 in telbivudine group. MELD score significantly improved in tenofovir group than telbivudine group [Table 7].
Table 6: CTP score at different follow-up two groups

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Table 7: MELD score at different follow-up in both groups

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Hepatic encephalopathy (HE) was the cause of death in 33.3% patients in both groups, hepatorenal syndrome (HRS) in 33.3% patients in tenofovir group and 16.7% in telbivudine group and HE plus HRS was found 33.3% in both groups. HRS and variceal bleeding was the cause of death in 16.7% in telbivudine group [Table 8]. Mean serum albumin was 2.6 gm/dl in the survivors and 2.4 gm/dl in those who died. Difference in serum albumin was statistically significant (P < 0.05) between the two groups.
Table 8: Cause of death of the study patients

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  Discussion Top


In this study, there is a significant improvement in CTP and MELD scores after 3 months of tenofovir therapy. Similarly, an Indian study showed significant improvement in MELD score in tenofovir group but not in placebo group in ACLF-B.[7] In our study, telbivudine group also showed a significant improvement in CTP and MELD scores. Although no significant difference was found in CTP score between two groups, MELD score showed a better improvement in tenofovir group than telbivudine, which was statistically significant.

After 3 months of antiviral therapy, 80% survived in tenofovir group and 60% in telbivudine group, but there was no statistically significant difference between the groups. A Chinese group has also demonstrated better survival in ACLF-B with telbivudine compared placebo.[8]

There is also significant clinical improvement (i.e., jaundice, ascites, and HE) in both groups, but not significant between groups. Our study did not observe any adverse event in either group. However, in two patients, renal dose adjustment for tenofovir was required due to HRS. Garg and colleagues have shown in their study that in ACLF-B, none of the patients developed significant renal failure that could be attributed to tenofovir.[7]

Various baseline parameters were analyzed to predict mortality. Serum bilirubin, INR, creatinine, HBV DNA and MELD score were higher among the dead but none of these were statistically significant. Serum albumin was higher in the survivor group, which was statistically significant.

Various evolving therapies have recently been shown for the management of chronic liver diseases. The present antiviral therapeutic approach with those novel approaches would be useful for the patients with ACLF.[9],[10],[11],[12]


  Conclusion Top


This study was done to compare the outcome with tenofovir and telbivudine in the patients with ACLF-B. It can be concluded that both groups experienced significant improvement of serum bilirubin, albumin, INR, and CTP and MELD scores. Both groups also have HBV DNA suppression. However, tenofovir therapy significantly improved MELD score compared to telbivudine therapy. Survival rate was also higher in tenofovir group than telbivudine group at 3 months, but this was not statistically significant.

Acknowledgement

The study was conducted at Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jalan R, Gines P, Olson JC, Mookerjee RP, Moreau R, Arroyo V, et al. Acute-on chronic liver failure. J Hepatol 2012;57:1336-48.  Back to cited text no. 1
    
2.
Sarin SK, Kedarisetty CK, Abbas Z, Amarapukar D, Bihari C, Chan AC, et al. Acute-on-chronic liver failure: Consensus recommendations of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int 2014;8:453-71.  Back to cited text no. 2
    
3.
Perz JF, Armstrong GL, Farringto LA, Hutin YJ, Bell BP. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol 2006;45:529-38.  Back to cited text no. 3
    
4.
Shi Y, He Y, Wu W, Huang J, Yang Y, Garcia-Tsao G, et al. Efficacy and safety of nucleos(t)ide analogue in the treatment of HBV-related acute-on-chronic liver failure: A meta-analysis. Ann Hepatol 2013;12:364-72.  Back to cited text no. 4
    
5.
Philips CA, Sarin SK. Potent antiviral therapy improves survival in acute on chronic liver failure due to hepatitis B virus reactivation. World J Gastroenterol 2014;20:16037-52.  Back to cited text no. 5
    
6.
Lin B, Pan CQ, Xie D, Xie J, Xie S, Zhang X, et al. Entecavir improves the outcome of acute-on-chronic liver failure due to the acute exacerbation of chronic hepatitis B. Hepatol Int 2013;7:460-7.  Back to cited text no. 6
    
7.
Garg H, Sarin SK, Kumar M, Garg V, Sharma BC, Kumar A. Tenofovir improves the outcome in patients with spontaneous reactivation of hepatitis B presenting as acute-on-chronic liver failure. Hepatology 2011;53:774-80.  Back to cited text no. 7
    
8.
Zhang Y, Xi Q, Dai X, Guo Y, Xu X, Yang Q, et al. A modified MELD model for Chinese Pre-ACLF and ACLF patients and it reveals poor prognosis in pre-ACLF patients. PLoS One 2013;8:e64379.  Back to cited text no. 8
    
9.
Al Mahtab M, Mohammad Fazle Akbar S, Chandra Podder D, Kumar Saha P, Jahan M, Begum L, et al. Relationship between hepatitis B viral deoxyribonucleic acid load and hepatocellular carcinoma. Euroasian J Hepatogastroenterol 2014;4:66-7.  Back to cited text no. 9
    
10.
Hussain M, Al Mahtab M, Islam S, Ahmed N, Rahman S, Khan M. Therapy targeting stem cell in patients with decompensated cirrhosis of liver in a tertiary treatment care center of Bangladesh. Euroasian J Hepatogastroenterol 2017;7:111-2.  Back to cited text no. 10
    
11.
Al Mahtab M, Akbar SM, Begum Mf, Islam Md A, Rahim Md A, Alam SM. Stem cell therapy for cirrhosis of liver in Bangladesh: Specific design compatible for developing country. Euroasian J Hepatogastroenterol 2018;8:121-5.  Back to cited text no. 11
    
12.
Mf Akbar S, Al-Mahtab M, I Khan S. Nature of host immunity during hepatitis B virus infection and designing immune therapy. Euroasian J Hepatogastroenterol 2018;8:42-6.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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