Clinical course of 161 untreated and tenofovir‐treated chronic hepatitis B pregnant patients in a low hepatitis B virus endemic region

Hepatitis B immunoprophylaxis failure is linked to high maternal viraemia. There is limited North American data on hepatitis B outcomes in pregnancy. Pregnant hepatitis B carriers were enrolled January 2011–December 2014 and offered tenofovir in the 3rd trimester if hepatitis B virus (HBV)‐DNA was >7‐log IU/mL. Outcomes were determined in treated vs untreated patients. In total, 161 women with 169 pregnancies (one twin, 170 infants; median age 32 years), 18% (29/161) HBeAg+ and median HBV‐DNA 2.51 log IU/mL (IQR 1.66–3.65; range 0.8–8.1) were studied. 14.3% (23/161) received tenofovir due to high viral load (16/23, median 74 days, IQR 59–110) or due to liver disease (7/23). In 10/16 treated due to high viraemia, with confirmed adherence, follow‐up HBV‐DNA showed a 5.49 log decline (P = 0.003). In treatment naïve mothers, median alanine aminotransferase (ALT) increased from 17 IU/L (IQR 12–24) to 29 (IQR 18–36) post‐partum (P = 1.5e‐7). In seven highly viraemic mothers who declined therapy (HBV‐DNA >8‐log IU/mL); median ALT increased ~3X from baseline (P < 0.01). 26% (44/169) had Caesarean section with no difference in treated vs untreated subjects. No tenofovir‐treated mothers had renal dysfunction. Data were available on 167/170 infants; in 50.8% (85/167) who completed immunoprophylaxis, 98.8% (84/85, including 12 exposed to tenofovir in utero) were HBV immune. One infant born to an HBeAg+ mother with HBV‐DNA >8‐log IU/mL failed immunoprophylaxis. In this prospective Canadian cohort study, most untreated mothers experienced mild HBV flares. Tenofovir in pregnancy is well tolerated and reduces viral load prior to parturition.     

Incidence and risk factors for incomplete HBV DNA suppression in HIV/HBV‐co‐infected patients initiating tenofovir‐based therapy

Suppression of hepatitis B virus (HBV)‐DNA to undetectable levels is an important goal for HIV/HBV‐co‐infected patients receiving anti‐HBV‐active antiretroviral therapy (ART), and current guidelines recommend that this outcome should be reached by 1 year of treatment. However, the proportion of patients that fail to achieve an undetectable HBV DNA at this time point and its determinants remain unknown in clinical practice. The objective of this study was to determine the incidence and risk factors for incomplete HBV suppression following 1 year of tenofovir‐based ART. We performed a cohort study among tenofovir‐treated HIV/HBV‐co‐infected patients. Patients had HBV viraemia, initiated tenofovir‐based ART and had HBV DNA measured at 1 year of therapy. The primary outcome was incomplete HBV suppression (HBV DNA ≥2.6 log IU/mL) at 1 year. Logistic regression determined odds ratio (ORs) of incomplete HBV suppression for risk factors of interest. Among 133 patients, 54% (95% CI, 46–63%) had incomplete HBV suppression at 1 year. Incomplete suppression was associated with higher baseline HBV DNA (OR, 1.46 per log IU/mL increase; 95% CI, 1.1–1.94) and detectable HIV viraemia at 1 year (OR, 2.52; 95% CI, 1.19–5.32). Among 66 patients with suppressed HIV RNA at 1 year, 28 (42%) failed to achieve an undetectable HBV DNA. Failure to suppress HBV DNA by 1 year occurred in a sizeable proportion of tenofovir‐treated HIV/HBV‐co‐infected patients. Higher HBV DNA and detectable HIV viraemia were risk factors for incomplete HBV suppression.     

Four‐year study of lamivudine and adefovir combination therapy in lamivudine‐resistant hepatitis B patients: influence of hepatitis B virus genotype and resistance mutation pattern

Summary. To investigate the efficacy of long‐term lamivudine (3TC) and adefovir dipivoxil (ADV) combination therapy in 3TC‐resistant chronic hepatitis B virus (HBV) infected patients, we analysed 28 3TC‐resistant patients treated with the combination therapy during 47 months (range, 9–75). At 12, 24, 36, and 48 months, the rates of virological response with undetectable HBV DNA (≤2.6 log copies/mL) were 56, 80, 86, and 92%, respectively. Among 17 hepatitis B e antigen (HBeAg)‐positive patients, HBeAg disappeared in 24% at 12 months, 25% at 24 months, 62% at 36 months, and 88% at 48 months. When HBV genotypes were compared, patients with genotype B achieved virological response significantly more rapidly than those with genotype C (P = 0.0496). One patient developed virological breakthrough after 54 months, and sequence analysis of HBV obtained from the patient was performed. An rtA200V mutation was present in the majority of HBV clones, in addition to the 3TC‐resistant mutations of rtL180M+M204V. The rtN236T ADV‐resistant mutation was observed in only 25% clones. In vitro analysis showed that the rtA200V mutation recovered the impaired replication capacity of the clone with the rtL180M+M204V mutations and induced resistance to ADV. Moreover, rtT184S and rtS202C, which are known entecavir‐resistant mutations, emerged in some rtL180M+M204V clones without rtA200V or rtN236T. In conclusion, 3TC+ADV combination therapy was effective for most 3TC‐resistant patients, especially with genotype B HBV, but the risk of emergence of multiple drug‐resistant strains with long‐term therapy should be considered. The mutation rtA200V with rtL180M+M204V may be sufficient for failure of 3TC+ADV therapy.     

Add‐on combination therapy with adefovir dipivoxil induces renal impairment in patients with lamivudine‐refractory hepatitis B virus

Summary. Combination therapy with adefovir dipivoxil (ADV) and lamivudine (LAM) is recommended for patients infected with LAM‐refractory hepatitis B virus (HBV). However, the effects of such therapy on renal function and serum phosphorus levels have not been fully evaluated. Combination therapy with ADV and LAM was given to 37 patients infected with LAM‐refractory HBV, including 17 with hepatic cirrhosis. Serum HBV DNA levels decreased to below 2.6 log₁₀ copies/mL in 23 (62%) of 37 patients at 12 months, 25 (78%) of 32 patients at 24 months, and 16 (84%) of 19 patients at 36 months. Except for one cirrhotic patient, serum alanine aminotransferase levels were below 50 IU/L in all patients during combination therapy. Serum creatinine levels increased in 14 (38%) of 37 patients, and serum phosphate levels decreased to below 2.5 mg/mL in 6 (16%) of 37 patients during combination therapy. Patients who received combination therapy for 36 months or longer had a significantly incidence of elevated serum creatinine levels. Fanconi syndrome occurred in a 57‐year‐old woman with cirrhosis after ADV was added to LAM. Combination therapy with ADV and LAM can maintain biochemical remission in patients with LAM‐refractory HBV. However, the dosing interval of ADV should be adjusted according to renal function and serum phosphate levels in patients receiving long‐term treatment.     

HBV‐specific T‐cell responses in healthy seronegative sexual partners of patients with chronic HBV infection

Summary. The hepatitis B virus (HBV) is frequently transmitted by sexual intercourse. Thus, HBV‐guidelines recommend vaccination. However, we have identified healthy hepatitis B surface antigen and anti‐HBc‐negative unvaccinated sexual partners of patients with chronic hepatitis B. We investigated whether HBV‐specific cellular immune responses were present that could explain the apparent protection against HBV infection. In six anti‐HBc‐negative HBV‐exposed sexual partners, HBV‐specific T‐cell responses were studied by proliferation assay and cytometric bead array after stimulation with 74 overlapping peptides spanning the HBV core, pre‐S and S‐encoding regions. Eleven HBV‐unexposed individuals served as negative controls. HBV‐DNA was undetectable in serum and peripheral blood mononuclear cells in all cases. HBV‐specific cytokine secretion was observed in 4/6 seronegative partners, but only in 1/11 controls. Proliferative responses were detectable in 5/6 partners and 0/11 controls. HBV‐specific cytokine secretion exists in healthy seronegative virus‐exposed individuals. HBV core‐directed immune responses indicate past, but controlled viral replication. T‐cell immunity may prevent clinical manifestation of HBV infection in the absence of humoral immunity.     

An observational study on long‐term renal outcome in patients with chronic hepatitis B treated with tenofovir disoproxil fumarate

In patients with chronic hepatitis B (CHB), long‐term effects of tenofovir disoproxil fumarate (TDF) on renal function have been controversial. This study aimed to analyse the real‐world long‐term effects of TDF on renal function in Korean patients with CHB. We analysed a cohort of 640 treatment‐naïve patients with CHB who were treated with TDF between May 2012 and December 2015 at Severance Hospital, Seoul, Republic of Korea. The mean age was 48.3 years old, and 59.5% were male. The proportions of hypertension and diabetes mellitus (DM) were 11.6% and 14.2%, respectively, and that of liver cirrhosis was 20.8%. During the 5‐year follow‐up, using a linear mixed model, serum creatinine increased from 0.77 ± 0.01 mg/dL to 0.85 ± 0.02 mg/dL (P < .001), and eGFR decreased from 102.6 ± 0.6 mL/min/1.73 m² to 93.4 ± 1.4 mL/min/1.73 m² (P < .001). In subgroup analysis, eGFR was statistically more decreased in patients with age > 60 than ≦60 years old (P = .027), and in patients with diuretic use than without diuretic use (P = .008). In multivariate analysis, the independent risk factors for eGFR decrease > 20% were baseline eGFR < 60mL/min/1.73 m² (P = .034) and the use of diuretics (P < .001). CHB patients on TDF experienced greater reduction in renal function with age > 60 and with diuretic use compared to those without these characteristics. Baseline eGFR < 60 mL/min/1.73 m² and use of diuretics were independent risk factors of eGFR decline of more than 20% on TDF therapy.     

Hepatitis B virus DNA in patients with hepatitis B‐related liver cirrhosis with or without hepatocellular carcinomas: a matched case‐control study

OBJECTIVE: The relationship between serum viremia and the development of hepatocellular carcinoma (HCC) in patients with hepatitis B virus (HBV)‐related cirrhosis remains unclear. We aimed at calculating odds ratios (OR) for the presence of HCC over a range of HBV DNA levels in these patients. METHODS: Patients were identified retrospectively and 155 pairs of matched, treatment‐naive HBV‐related cirrhotic patients with and without HCC were recruited. Their serum HBV DNA levels were measured at HCC diagnosis, or at the equivalent age in non‐HCC patients, and correlations between the presence of HCC and different DNA levels were calculated using conditional logistic regression. RESULTS: The median HBV DNA level was significantly higher in HCC patients than in non‐HCC patients (5.15 vs 4.83 log₁₀ copies/mL, P = 0.024). The overall OR for HCC in patients with HBV DNA ≥ 3 log₁₀ copies/mL was 2.13, compared with patients with levels <3 log₁₀ copies/mL. Compared with patients with <3 log₁₀ copies/mL, the OR for HCC were 2.39 and 2.61 for patients with 4 to <5 and 5 to <6 log₁₀ copies/mL, respectively, while the OR for DNA levels of ≥6 log₁₀ copies/mL were not significantly different. CONCLUSION: In HBV‐related cirrhosis, a detectable serum HBV DNA was associated with the presence of HCC, but the likelihood of having HCC did not successively increase with increasing serum HBV DNA levels: patients with serum HBV DNA levels between 4 and <6 log₁₀ copies/mL were most likely to present with HCC.     

Hepatitis C virus‐specific CD8+ T cell frequencies are associated with the responses of pegylated interferon‐α and ribavirin combination therapy in patients with chronic hepatitis C virus infection

Aim: Hepatitis C virus (HCV)‐specific cytotoxic T lymphocytes (CTLs) play critical roles in elimination of the HCV‐infected hepatocytes. However, the mechanism of HCV elimination by pegylated interferon‐α (peg‐IFNα) plus ribavirin is not fully understood. We examined HCV‐specific CTL responses during this combination therapy. Methods: CD8+ T cells were isolated from 16 HCV infected patients treated by this combination therapy and were subjected to IFN‐γ enzyme‐linked immunospot (ELISPOT) assay. Results: The numbers of IFN‐γ spots against HCV Core or NS3 protein‐derived peptides in HCV patients before treatment were similar to those in healthy donors, and those in HCV patients significantly increased 4 weeks after the initiation of combination therapy. All HCV Core or NS3 proteins‐derived peptides specific CD8+ T cells responses in pre‐treated patients were not associated with ALT levels and HCV viral loads of HCV patients before treatment. And those in pre‐treated patients were similar between sustained virologic responder (SVR) patients and non‐SVR patients. Significant increase of HCV Core or NS3 proteins‐derived peptides specific CD8+ T cells responses between before and 4 weeks after this combination therapy were observed in SVR patients, but not in non‐SVR patients. Conclusions: These results demonstrated that significant increase of HCV‐specific CD8+ T cells at 4 weeks after the initiation of IFN treatment might be associated with the elimination of HCV. Our findings suggest that the reactivity against HCV Core and NS3 proteins‐derived peptides might be useful in predicting the clinical outcome of the combination therapy of peg‐IFNα and ribavirin.     

Effects of pegylated interferon‐α based therapies on functional cure and the risk of hepatocellular carcinoma development in patients with chronic hepatitis B

Chronic hepatitis B virus (HBV) infection continues to pose a serious global health threat and a significant socio‐economic burden in many areas of the world. Almost all current clinical practice guidelines on the management of chronic hepatitis B (CHB) infection recommend that eligible patients pursue the optimal treatment endpoint, which is defined as HBsAg loss with or without anti‐HBs seroconversion. This review describes the effects of various regimens containing pegylated interferon (peg‐IFN)‐alpha on functional cure and the outcome of hepatocellular carcinoma (HCC) in patients with CHB. Peg‐IFN‐α monotherapy is a treatment option recommended by local and international clinical practice guidelines to help more CHB patients achieve a sustained off‐treatment virological response, which is particularly appropriate for relatively young patients who demand a finite treatment approach. Peg‐IFN‐α add‐on or sequential therapy in patients who have achieved a suppressed viral load after nucleos(t)ide analog (NA) therapy may offer further benefits on HBeAg seroconversion and HBsAg decline, although the effects of de novo combination therapy with peg‐IFN‐α and NAs on long‐term outcomes remain unclear. Evaluation of baseline and on‐treatment predictors is useful for selecting the patients who are likely to achieve additional benefits. Furthermore, some recent studies have shown that peg‐IFN‐α–based therapy results in better prevention of HBV‐related hepatocellular carcinoma (HCC), especially in high‐risk patients.     

PD‐1 expression on CTL may be related to more severe liver damage in CHB patients with HBV genotype C than in those with genotype B infection

Compared with Chronic hepatitis B (CHB) patients infected with genotype B, those infected with genotype C have higher hepatic histopathological activity and higher level of alanine aminotransferase (ALT). Our previous studies suggest that this phenomenon is related to lower level of HBV specific cytotoxic T lymphocyte (CTL) of patients infected with genotype C than those infected with genotype B, but its mechanism was not clear. The aim of present study was to explain the possible mechanism of lower level of HBV specific CTL and more serious liver function damage of patients infected with genotype C than those infected with genotype B through study on relationship between expression of HBV specific CTL surface programmed death receptor‐1 (PD‐1) and viral genotypes of CHB patients. A total of 100 CHB patients were studied, human leukocyte antigen (HLA)‐A2 positive, hepatitis B virus (HBV) DNA>10³ copies/ml, of which 48 cases were genotype C (48%) positive, and 52 cases were genotype B positive (52%). Expression of Peripheral blood HBV specific CTL surface PD‐1, levels of HBV specific CTL, HBV DNA, ALT and total bilirubin (TBil) of patients infected with genotype C and B were compared. Expression of HBV specific CTL surface PD‐1 of CHB patients infected with genotype C was significantly higher than that of patients infected with genotype B, t = 17.57, P < 0.001, level of HBV specific CTL was significantly lower than that of patients infected with genotype B, t = 23.64, P < 0.001, level of HBV DNA was significantly higher than that of patients infected with genotype B, t = 9.43, P < 0.001, level of ALT was significantly higher than that of patients infected with genotype B, t = 13.42, P < 0.001. Expression of peripheral blood HBV specific CTL surface PD‐1 of CHB patients infected with genotype C was significantly higher than that of patients infected with genotype B, resulting in lower level of HBV specific CTL and higher level of HBV DNA of patients infected with genotype C than those of patients infected with genotype B. So liver function damage of CHB patients infected with genotype C was more serious than those infected with genotype B.     

Add‐on peginterferon alfa‐2a to nucleos(t)ide analogue therapy for Caucasian patients with hepatitis B ‘e’ antigen‐negative chronic hepatitis B genotype D

Nucleos(t)ide analogues (NAs) and peginterferon have complementary effects in chronic hepatitis B, but it is unclear whether combination therapy improves responses in genotype D‐infected patients. We conducted an open‐label study of peginterferon alfa‐2a 180 μg/wk added to ongoing NA therapy in hepatitis B e antigen (HBeAg)‐negative, genotype D‐infected patients with hepatitis B virus DNA <20 IU/mL. The primary endpoint was proportion of patients with ≥50% decline in serum HBsAg by the end of the 48‐week add‐on phase. Seventy patients received treatment, 11 were withdrawn at week 24 for no decrease in HBsAg, and 14 withdrew for other reasons. Response rate (per‐protocol population) was 67.4% (29/43) at week 48 (95% confidence interval [CI]: 51, 81) and 50.9% (28/55) at week 96 (95% CI: 38, 66). Median serum HBsAg decreased throughout peginterferon alfa‐2a treatment and was significantly lower than baseline at weeks 48, 72 and 96 (P < 0.001). Decreases in HBsAg of ≥0.5‐log₁₀ and ≥1‐log₁₀ were documented in 19 (44.2%) and 6 (14.0%) patients at week 48 and 6 (10.9%) and 17 (30.9%) patients at week 96. The proportion of patients with HBsAg <1000, <500, <100 and <10 IU/mL at ≥1 timepoint during treatment was 78.6% (n = 44), 57.1% (n = 32), 21.4% (n = 12) and 7.1% (n = 4). Interferon gamma‐induced protein 10 increased from baseline up to week 48, with week 12 levels significantly associated with response at week 48. Addition of peginterferon alfa‐2a to ongoing NA therapy significantly decreased HBsAg levels in HBeAg‐negative patients with genotype D infection (ClinicalTrials.gov NCT01706575).     

Unconventional T cells in chronic hepatitis B patients on long‐term suppressive therapy with tenofovir followed by a Peg‐IFN add‐on strategy: A randomized study

HBV eradication in chronic hepatitis B (CHB) subjects is rarely achieved with either nucleos(t)ide analogues (NA) or pegylated interferon (Peg‐IFN), which both have a limited effect in restoring immune responses. Thirty CHB subjects on long‐term treatment with tenofovir (TDF) and HBV suppression were enrolled and randomized 1:2 to either receive Peg‐IFN‐α‐2a add‐on therapy or continue TDF alone. We studied γδ T and iNKT frequency and function (by flow cytometry) at baseline, at 12 weeks and 12 weeks after the end of treatment. A higher reduction in qHBsAg occurred in the add‐on group compared with the NA group at W12 (P = .016) and at W24 (P = .012). A decline of qHBsAg ≥0.5 log₁₀ at week 24 occurred in 4 of 10 patients in the add‐on arm and 1 of 20 in the NA arm, respectively (P = .03). HBsAg loss was seen in 20% of subjects in the add‐on group and in none of the NA group. Compared to HBV negative, CHB on TDF showed lower frequency of iNKT (P = .03) and γδ T cells (P = .03) as well as fewer γδ T cells expressing Vδ2 T‐cell receptors (P = .005). No changes in unconventional T‐cell frequency and function were shown in both add‐on and NA patients nor were differences detected between the two treatment groups. We report persistent impairment of unconventional T cells in CHB. Despite a greater qHBsAg decline of add‐on patients, our data failed to detect any effect of Peg‐IFN treatment on unconventional T cells.