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ACG 2018: Highlights In Pediatric Research
img-buttonIn this installment of Expert Picks, Anjali Malkani, MD, and Chethan Ramprasad, MD, highlight some of the most noteworthy research on pediatric gastroenterology presented at this year’s annual meeting of the American College of Gastroenterology.
Anjali Malkani, MD
Professor in the Department of Pediatrics at the Quillen College of Medicine of Eastern Tennessee State University, in Johnson City
P0735. Hepatitis A and B seroimmunity in vaccinated children with cirrhosis (Bhatt H, et al)
The aim of this study was to assess immune response to vaccination against hepatitis A and hepatitis B virus in children with cirrhosis. The response to vaccination in adults with cirrhosis is lower compared with that in healthy adults, noted the authors, and HAV antibody titers are lower in patients with decompensated cirrhosis versus compensated cirrhosis. Children with cirrhosis who do not receive full coverage after vaccination, or whose coverage wanes over time, can experience rapid decompensation of their livers.
The investigators, led by Heli Bhatt, MBBS, MPH, of Indiana University School of Medicine’s Riley Hospital for Children, in Indianapolis, prospectively enrolled children between the ages of 6 months and 17 years with biopsy-proven cirrhosis or clinically evident portal hypertension, as defined by the Childhood Liver Disease Research Network. All the children had completed the three-dose HBV vaccination series and/or two-dose HAV vaccination series. They excluded children with noncirrhotic causes of portal hypertension and those with a medical history of HAV or HBV infection. To evaluate their response to vaccination, the investigators measured hepatitis B surface antibody (HBsAb) titers less than 10 IU/L and nonreactive hepatitis A antibody (HAVAb) titers. In addition to looking at the response to vaccination, the authors reviewed physical exam findings, endoscopic findings and laboratory results from the children’s electronic health records.
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To date, the authors have enrolled 12 patients: four boys and eight girls, with a mean age of 9.33 years. Ten patients have underlying diagnosis of biliary atresia, and half of these patients have biopsy-proven cirrhosis. The investigators noted that one-third of the patients had platelet levels less than 150,000/mm2, and half of the patients had splenomegaly.
The investigators found that the incidences of HBsAb less than 10 IU/L and nonreactive HAVAb were 41.7% and 16.7%, respectively. However, all children with HBsAb levels less than 10 IU/L and nonreactive HAVAb were older than 5 years of age. In that group, the incidences were 62.5% and 25%, respectively. The two black children in the study were nonreactive to HAVAb, whereas none of the white children were (P=0.015); and one of the two black children (50%) had reactivity to HBsAb versus four of the 10 white children (P=1.0). The investigators also found low HBsAb levels in 50% of children with documented splenomegaly (vs. 33% of those without splenomegaly; P=0.34) and HBsAb less than 10 IU/L in 60% of children with thrombocytopenia (vs. 29% in those without thrombocytopenia; P=1.18).
Dr. Malkani: There is a high incidence of low immune reactivity to HBV and HAV vaccination in children with cirrhosis. Reactivity seems to be lost with increasing age of the patients, with low response more common in children over 5 years of age. Low reactivity also was seen among black children. We, as clinicians, need to be cognizant to check the immunity status of children with cirrhosis, despite vaccination, and revaccinate to prevent acute decompensation with HAV or HBV. There are no recommendations as to how often these children need to be monitored for immune status. |
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