VeteranshealthadministrationhepatitisBtestingandtreatmentwithanti-CD20antibodyadministration

摘要： AIM:ToevaluatepretreatmenthepatitisBvirus(HBV)testing,vaccination,andantiviraltreatmentratesinVeteransAffairspatientsreceivinganti-CD20Abforqualityimprovement.METHODS:WeperformedaretrospectivecohortstudyusinganationalrepositoryofVeteransHealthAdministration(VHA)electronichealthrecorddata.Weidentifiedallpatientsreceivinganti-CD20Abtreatment(2002-2014).Weascertainedpatientdemographics,laboratoryresults,HBVvaccinationstatus(fromvaccinationrecords),pharmacydata,andvitalstatus.ThehighriskperiodforHBVreactivationisduringantiCD20Abtreatmentand12mofollowup.Therefore,weanalyzedthosewhowerefollowedtodeathorforatleast12moaftercompletinganti-CD20Ab.PretreatmentserologictestswereusedtocategorizechronicHBV(hepatitisBsurfaceantigenpositiveorHBsAg+),pastHBV(HBsAg-,hepatitisBcoreantibodypositiveorHBcAb+),resolvedHBV(HBsAg-,HBcAb+,hepatitisBsurfaceantibodypositiveorHBsAb+),likelypriorvaccination(isolatedHBsAb+),HBVnegative(HBsAg-,HBcAb-),orunknown.AcutehepatitisBwasdefinedbytheappearanceofHBsAg+inthehighriskperiodinpatientswhowerepretreatmentHBVnegative.WeassessedHBVantiviraltreatmentandtheincidenceofhepatitis,liverfailure,anddeathduringthehighriskperiod.Cumulativehepatitis,liverfailure,anddeathafteranti-CD20AbinitiationwerecomparedbyHBVdiseasecategoriesanddifferencescomparedusingtheχ2test.Meantimetohepatitispeakalanineaminotransferase,liverfailure,anddeathrelativetoanti-CD20Abadministrationandfollow-upwerealsocomparedbyHBVdiseasegroup.RESULTS:Among19304VHApatientswhoreceivedanti-CD20Ab,10224(53%)hadpretreatmentHBsAgtestingduringthestudyperiod,with49%and43%testedforHBsAgandHBcAb,respectivelywithin6mopretreatmentin2014.Ofthosetested,2%(167/10224)hadchronicHBV,4%(326/7903)pastHBV,5%(427/8110)resolvedHBV,8%(628/8110)likelypriorHBVvaccination,and76%(6022/7903)wereHBVnegative.InthosewithchronicHBVinfection,≤37%receivedHBVantiviraltreatmentduringthehighriskperiodwhile21%to23%ofthosewithpastorresolvedHBV,respectively,receivedHBVantiviraltreatment.Duringand12moafteranti-CD20Ab,therateofhepatitiswassignificantlygreaterinthoseHBVpositivevsnegative(P=0.001).Themortalityratewas35%-40%inchronicorpasthepatitisBand26%-31%inhepatitisBnegative.InthosepretreatmentHBVnegative,16(0.3%)developedacutehepatitisBof4947testedduringanti-CD20Abtreatmentandfollowup.CONCLUSION:WhileHBVtestingofVeteranshasincreasedpriortoanti-CD20Ab,fewHBV+patientsreceivedHBVantivirals,suggestingelectronichealthrecordalgorithmsmayenhancehealthoutcomes. （共9頁）