- Email: [email protected]
Clonal T-cell expansions in interferon-alpha treated patients with chronic hepatitis C
Poster Sessions
142
RNA. 61 patients (34 of Group 1 and 27 of Group 2) have completed the first 6 months. Results: At the end of 6 months either biochemical (BR) and virological (VR) response rates were similar for Groups 1 and 2 (BR: 79% vs 78%; VR: 62% vs 59%, respectively). Slight differences, however, were observed in clearance dynamics between Group 1 and Group 2 after one (47% vs 30%) and three months (59% vs 4t%) of therapy. Conclusions: A virological response rate of about 60% may be due to IFN 5 MU therapy, irrespective of induction treatment.
-~
YMDD MUTATION IN PATIENTS RECEIVING DIFFERENT REGIMES OF LAMIVUDINE THERAPY
M. Yuen, E. Sablon, C. Hui, J. Yuan, C. Yuen, C. Lai. Queen Mary
Hospital, Hong Kong, lnnogenetics, Gent, Belgium Aim: To study whether suboptimal regimes of lamivudine (lam) would increase the frequency of YMDD mutation. Method: 159 Chinese HBV patients (M:F 118:41; median FU 29.6 mths) were recruited. 73 received lam 100 mg daily (group 1); 27 received lain 25 mg daily for 2 yrs then 100 mg dally (group 2); 46 received famciclovir (fam) 500 mg thrice daily for 12 wks then lam 100 mg daily (group 3); 13 received other regimes. YMDD mutation was checked by LIPA assay (Innogenetics, Beligum). Results: 87 patients (54.7%) had YMDD mutation (either alone or mixed with wild type). 43 patients (49.4%) had elevated HBV DNA levels. Of these, 11 (12.6%) had elevated ALT levels. The incidence of YMDD mutation with elevated HBV DNA at end of year 1, 2, 3 and 4 for group I and group 2 were 2.74% vs. 0%; 12.3% vs. 14.8%; 22.5% vs. 37%; 60.7% vs. 63% respectively. (all p = NS). Comparing group 1 and group 3, there was no difference in the incidence of YMDD mutation and the B domain codon 528 mutation associated with fam therapy. 26 patients (16.4%) had HBeAg seroconversion. Two patients had HBeAg seroconversion after the emergence of YMDD mutants. Only one patient had YMDD mutation after HBeAg seroconversion. Conclusions: Suboptimal dose of lam and pretreatment with faro before the standard dose of lam did not increase the risk of YMDD mutation. Occurrence of YMDD mutation after HBeAg seroconversion was rare.
Cnndmion: The low mutation rates in the whole genome and the X gene may explain the high HBV DNA and HBeAg levels in patients with HBV associated polyarteritis nodosa. High HBeAg levels might be a key factor for formation of immune complexes leading to vasculitis.
[-~
OCCULT HBV INFECTION IN PATIENTS WITH CHRONIC HEPATITIS C (CHC): FREQUENCY AND CLINICAL IMPACT
P. Fabris, D. Brown, G. Tositti, L. Bozzola, M.T. Giordani, F. de Lalla, C. Woong, G.M. Dusheiko. Department of lnfectious Diseases, S.
Bortolo, Italy; Centrefor Hepatology and Gastroenterology, Royal Free Hospital, London, UK Aims: To evaluate the prevalence of occult HBV infection and its impact on liver biochemistry, HCV viral load, and liver histology in patients with CHC. Methods: Fifty-one frozen liver biopsies from patients (84% IVDUs) with CHC and 10 from a control group (7 HBsAg+, 2 AIH, and 1 cryptogenic chronic hepatitis) were studied. DNA was extrated with QIAGEN method and amplified with nested PCR by using primers for S, Core and X genes. Results: The overall HBV-DNA positivity was 29.4% (43% in patients with and 24% in patients without markers of previous HBV infection). Three samples were positive for S gene, 9 for Core gene, 3 for both S gene and Core gene and 0 for X gene. By contrast, all specimens from HBsAg + patients were positive for S, Core and X gene. No significant differences were found between patients with or without HBV-DNA in terms of ALT, HCV VL (1048 x 103 vs 2053 x 103 copiesdml), grading (6.4 vs 5.5) and staging (1.3 vs 1.5). Using EUROHEP standards to spike negative samples the sensitivity of the extraction was seen to be at least 373 copies/sample. The sensitivity of the PCR was at least 10 copies/reaction. Conclusions: The different pattern of HBV-DNA positivity compared to HBsAg+ positive controls, together with the absence of any significant influence on HCV replication, transaminases and histology suggests that in most patients it may be either an integrated or low level episomal replicative form.
~7"1"-~ HEPATITISB VIRUS FULL-LENGHT GENOME ANALYSIS OF PATIENTS WITH HEPATITIS B VIRUS ASSOCIATED POLYARTERITIS NODOSA
[--~
CLONAL T-CELL EXPANSIONS IN INTERFERON-ALPHA TREATED PATIENTS WITH CHRONIC HEPATITISC
A. Erhardt, A. Sagir, L. Guillevin, D. Blondin, D.H. Ussinger.
Heinrich-Heine Universitaet Duesseldorf, Germany
Gutenberg Universitaet Mainz; L Department of lnternal Medicine, Germany
Objective: HBV associated polyarteritis (PAN) is regarded as immune-complex disease, but the exact pathogenetic mechanism is as yet unknown. Aim of the study was to identify genetic factors of the hepatitis B virus predisposing to PAN. Methods: A complete HBV genome analysis was performed by DNA sequencing in 23 patients with HBV PAN. All patients were HBsAg and HBV DNA positive and apart from one HBeAg positive. PAN was confirmed in all patients by angiography or biopsy. HBV sequences of PAN patients were compared to 21 full-length sequences of databank entries and to sequences of the core gene and X gene of 54 HBeAg-positive patients with chronic hepatitis B. For clinical parameters PAN patients were compared to 66 patients with chronic HBeAg-positive hepatitis B. Results: HBeAg-positive patients with HBV associated PAN were clinically characterized by i) more advanced age, ii) higher HBV DNA levels in serum and iii) higher HBeAg levels than HBeAg-positive patients without HBV associated polyarteritis nodosa. Genetically, patients with HBV associated PAN were characterized by a low mutation rate in the HBx gene and the BCP both transcriptionally relevant regions within the HBV genome. No universal characteristic mutation was found in patients with PAN.
To detect clonal T-cell expansions associated with viral clearance or persistence in patients with chronic hepatitis C virus infection the repertoire of variable Vbeta-chains of the T-cell receptors (TCR Vbeta) were analysed by reverse transcription-polymerase chain reaction (RTPCR) and complementarity-determining region (CDR) 3 length assay (spectratyping). RNA was extracted from peripheral blood lymphocytes (PBL) derived from chronic HCV patients with sustained complete therapy response (SCR, n = 4) and non-response (NR, n = 6) before, during and after IFN-alpha treatment. Patients who will develop SCR had significant overexpression of TCR Vbeta 17 before onset of therapy, TCR Vbeta 5.1, 17 and 21 during therapy and TCR Vbeta 5.1, 16, 17, 23 and 24 after treatment. Similarly, patients who will develop NR had significant overexpression of TCR Vbeta 4, 5.1 and 17 before treatment with IFN-alpha, TCR Vbeta 5.1 and 17 during therapy and significant overexpression of TCR Vbeta 5.1, 12, 13.1 and 17 after therapy. T-cell clones were isolated and supplied to the molecular analysis to reveal pathogenetic relevant T-cell expansions. In conclusion, IFN-alpha induced a significant modulation of the TCR Vbeta repertoire in patients with chronic HCV without correlation to the therapy outcome. This could indicate that not the recruitment of
B. Heberer, A. Heinemann, S. Pingel, P. Galle, H. Loehr. Johannes
Category 6: Viral hepatitis: clinical aspects different T-cell populations but the level of T-cell induction is decisive for potential viral clearance.
~-0-~ CHRONIC HEPATITIS C AND TREATMENT OUTCOME: CORRELATIONS WITH APOPTOSIS, SOLUBLE HLA CLASS I AND SOLUBLE FAS LIGAND F. Torre l, N. Campo 1, p. Contini 1, R. Giusto 1, I. Comino 1, p. Ceppa 2, R. Fiocca 3, G. Icardi 2, E Indiveri 1, F. Puppo 1, A. Picciotto 1.
1Department of Internal Medicine, University of Genoa; 2Department of Health Science, University of Genoa; 3DICMI, University of Genoa, Italy Introduction: HCV clearance depends on the inhibition of viral replication and on infected cells elimination. Soluble HLA class I molecules is considered an indirect marker of immune activation. Soluble Fas ligand presents an apoptotic-inducing capacity and seems to down-regulates CTL Fas ligand mediated apoptotic activity. Aim: To evaluate apoptosis, indirect apoptotic and indirect immune activity indexes in relation to long term treatment response. Patients: 46 chronic hepatitis, C patients treated with IFN -2b, 3 MU tiw for 6-12 months with a follow up >2 years (range: 3-8 yrs). 23 were sustained biochemical and virological responders (SRs); 23 were non responders (NRs). Methods: HCV-RNA, soluble HLA class I and soluble Fas Ligand levels were evaluated at baseline, 1st mth, 3rd ruth, end of treatment, 6th mth of follow up, end of follow up. Apoptosis was detected in liver tissue by TUNEL technique an apoptotic index was calculated. Results: Apoptosis did not correlate with baseline ALT levels or virological characteristics. At baseline, a negative correlation was found between HCV-RNA levels and sFas-L levels (R: -0.389; p = 0.018). According to outcome, SRs presented a negative correlation between sFas-L vs fibrosis (R: -0.713; p = 0.004) and sFas-L vs apopt0sis; (R: -0.610; p = 0.026). A larger variability in sFas-L levels was present in SRs compared to NRs, with a progressive decrement that reach a significance at the end of follow up (Mann-Whitney, p = 0.001). In SRs, sHLA showed a significant point by point variation (Anova by ranks, p = 0.02) compare to the fiat, constant pattern of NRs. Conclusions: SRs seem to present a more activated immune system than NRs. In SR, the baseline inverse correlation of sFas-L vs apoptosis and viraemia may reflect the cell-immune activity and a preferential cytokines mediated antiviral activity.
~5-]
COURSE OF VIROLOGIC BREAKTHROUGHS (VBTs) UNDER LAMIVUDINE (LAM) THERAPY IN PATIENTS(PTS) WITH PRECORE MUTANT HBV RELATED CHRONIC LIVER DISEASE (CLD)
G.V. Papatheodoridis, E. Dimou, V. Papadimitropoulos, A. Laras, S. Hadziyannis. Academic Dept. of Medicine, Hippokration Hospital of
Athens, Greece YMDD mutants emerge in most of pts with HBeAg ( - ) CLD under long-term LAM, but their course remains unclear. We report the course of VBTs detected by a sensitive PCR in 30 pts with precore mutant HBV treated with long-term LAM. All pts had elevated ALT and HBV viremia before LAM; all achieved initial biochemical and virologic (neg. HBV DNA) response. LFFs were evaluated monthly and IgM anti-HBc (IMx, Abbott) and serum HBV DNA (Monitor, Roche; sens.400 cp/ml) every 3 mos and on every biochemical breakthrough (BBT). YMDD mutants were detected in all 30 pts in a median of 15 (6-48) mos after LAM start; M552I in 22 and M552V in 8 (+L528M in 6). Duration of LAM therapy after VBT (reappearance of HBV DNA) was 9 (0-33) mos; BBTs developed in 16 pts. The cumulative probability of BBT was 59% at 6, 69% at 12 and 100% at 24 mos after VBT. There was no difference in the characteristics at baseline or at VBT onset between pts
143
with or without BBT. In the 16 pts with BBT a) IgM anti-HBc and HBV DNA increased from the VBT onset to 6 (0.115 to 0.256, P = 0.01) and to 3 mos later (0.0034 to 0.596 Mcp/ml, P = 0.005) respectively; b) ALT exceeded baseline in 14 and reached acute hepatitis levels in 6; c) ALT peaked at the BBT onset in 13 or within the next 3 mos in 3. Compared to the BBT onset, ALT decreased after 6 mos (188 vs 123 IU/L, P = 0.015) but remained abnormal in all but 1 patient; HBV DNA relatively decreased after 6 (21 vs 2 Mcp/ml, P = 0.07) but increased again after 12 mos (15 Mcp/mi). Conclusions: In pts with precore mutant HBV CLD, VBTs are followed by increasing viremia levels culminating in development of BBTs in practically all pts. ALT and HBV DNA levels peak close to the BBT onset, decreasing thereafter but remaining abnormal with fluctuating levels. Thus, optimal monitoring with sensitive PCR assays permits early recognition of VBTs and may have therapeutic implications.
(-~
PEGYLATED (40 KDA) INTERFERON ALFA-2A (PEGASYS®) IN NEW COMBINATIONTHERAPIES: A REPORT OF A RANDOMIZED, MULTICENTER EFFICACY AND SAFETY STUDY
A.M. Di Bisceglie, D.E. Bernstein, V.R. Rustgi, N. Gitlin, L.J. Jeffers, D. Simon, J. Campagna, S.C. Pappas. St Louis University/Bethesda
Hospital., North Shore University Hospital, Manhasset, NY Georgetown University, Fairfax, VA, Atlanta Gastroenterology Associates, Atlanta, GA, University of Miami School of Medicine, Miami, FL, A., Jacobi Medical Center, Bronx, NY, Roche Laboratories lnc, Nutley, NJ, USA Background: Interferon (IFN) monotherapy in previously untreated patients with chronic hepatitis C (CHC) leads to a sustained virological response (SVR) in 10%-19% of treated patients; ribavirin (RBV) added to IFN monotherapy increases SVR. PEGASYS ® is also associated with higher SVR. Further increases in SVR may be possible by combining PEGASYS® with the antiviral and immunomodulatory agents RBV, amantadine, and mycophenolate mofefil (CellCept®). Objective: To investigate the efficacy and safety of PEGASYS ® when used in combination with antiviral and immunomodulatory agents. Methods: Previously untreated patients with CHC were randomized into one of 4 groups: A: IFN c~-2b+RBV (REBETRON TM) (n -- 55); B: PEGASYS®+mycophenolate (n = 58); C: PEGASYS®+amantadine (n = 21); D: PEGASYS®+amantadine+RBV (n = 19). Patients were stratified according to genotype and viral load (low vs. high). Treatment was for 48 weeks with 24 weeks of follow-up. The outcome of therapy was assessed as virological response (HCV RNA < 50 IU/mL and >2 log drop from baseline using the AMPLICOR MONITOR TM HCV Test v. 2.0) or biochemical response. Results: The baseline patient characteristics were: mean age 45 46.3 y, male 66%, mean ALT 109 4- 70.4 U/L, high viral load 67%, HCV genotype 1 73%. One hundred and forty patients (87.5%) have completed >24 weeks of treatment. No unexpected side effects related to the study medications have been noted. Group
A B C D
Therapy
IFN u-2b + RBV PEGASYS® + mycophenolate PEGASYS® + amantadine PEGASYS® + amantadine + RBV
Week 24 HCV RNA > 2 log drop
HCV RNA neg.
Normal ALT
34/52 37/54
31/52 30/54
39/50 29/55
16/17
13/17
9/17
15/17
11/17
13/17
Conclusions: These preliminary findings reveal a trend for the Week 24 antiviral effect of all 3 PEGASYS ® combinations to be similar to or greater than that with conventional combination therapy.
142
RNA. 61 patients (34 of Group 1 and 27 of Group 2) have completed the first 6 months. Results: At the end of 6 months either biochemical (BR) and virological (VR) response rates were similar for Groups 1 and 2 (BR: 79% vs 78%; VR: 62% vs 59%, respectively). Slight differences, however, were observed in clearance dynamics between Group 1 and Group 2 after one (47% vs 30%) and three months (59% vs 4t%) of therapy. Conclusions: A virological response rate of about 60% may be due to IFN 5 MU therapy, irrespective of induction treatment.
-~
YMDD MUTATION IN PATIENTS RECEIVING DIFFERENT REGIMES OF LAMIVUDINE THERAPY
M. Yuen, E. Sablon, C. Hui, J. Yuan, C. Yuen, C. Lai. Queen Mary
Hospital, Hong Kong, lnnogenetics, Gent, Belgium Aim: To study whether suboptimal regimes of lamivudine (lam) would increase the frequency of YMDD mutation. Method: 159 Chinese HBV patients (M:F 118:41; median FU 29.6 mths) were recruited. 73 received lam 100 mg daily (group 1); 27 received lain 25 mg daily for 2 yrs then 100 mg dally (group 2); 46 received famciclovir (fam) 500 mg thrice daily for 12 wks then lam 100 mg daily (group 3); 13 received other regimes. YMDD mutation was checked by LIPA assay (Innogenetics, Beligum). Results: 87 patients (54.7%) had YMDD mutation (either alone or mixed with wild type). 43 patients (49.4%) had elevated HBV DNA levels. Of these, 11 (12.6%) had elevated ALT levels. The incidence of YMDD mutation with elevated HBV DNA at end of year 1, 2, 3 and 4 for group I and group 2 were 2.74% vs. 0%; 12.3% vs. 14.8%; 22.5% vs. 37%; 60.7% vs. 63% respectively. (all p = NS). Comparing group 1 and group 3, there was no difference in the incidence of YMDD mutation and the B domain codon 528 mutation associated with fam therapy. 26 patients (16.4%) had HBeAg seroconversion. Two patients had HBeAg seroconversion after the emergence of YMDD mutants. Only one patient had YMDD mutation after HBeAg seroconversion. Conclusions: Suboptimal dose of lam and pretreatment with faro before the standard dose of lam did not increase the risk of YMDD mutation. Occurrence of YMDD mutation after HBeAg seroconversion was rare.
Cnndmion: The low mutation rates in the whole genome and the X gene may explain the high HBV DNA and HBeAg levels in patients with HBV associated polyarteritis nodosa. High HBeAg levels might be a key factor for formation of immune complexes leading to vasculitis.
[-~
OCCULT HBV INFECTION IN PATIENTS WITH CHRONIC HEPATITIS C (CHC): FREQUENCY AND CLINICAL IMPACT
P. Fabris, D. Brown, G. Tositti, L. Bozzola, M.T. Giordani, F. de Lalla, C. Woong, G.M. Dusheiko. Department of lnfectious Diseases, S.
Bortolo, Italy; Centrefor Hepatology and Gastroenterology, Royal Free Hospital, London, UK Aims: To evaluate the prevalence of occult HBV infection and its impact on liver biochemistry, HCV viral load, and liver histology in patients with CHC. Methods: Fifty-one frozen liver biopsies from patients (84% IVDUs) with CHC and 10 from a control group (7 HBsAg+, 2 AIH, and 1 cryptogenic chronic hepatitis) were studied. DNA was extrated with QIAGEN method and amplified with nested PCR by using primers for S, Core and X genes. Results: The overall HBV-DNA positivity was 29.4% (43% in patients with and 24% in patients without markers of previous HBV infection). Three samples were positive for S gene, 9 for Core gene, 3 for both S gene and Core gene and 0 for X gene. By contrast, all specimens from HBsAg + patients were positive for S, Core and X gene. No significant differences were found between patients with or without HBV-DNA in terms of ALT, HCV VL (1048 x 103 vs 2053 x 103 copiesdml), grading (6.4 vs 5.5) and staging (1.3 vs 1.5). Using EUROHEP standards to spike negative samples the sensitivity of the extraction was seen to be at least 373 copies/sample. The sensitivity of the PCR was at least 10 copies/reaction. Conclusions: The different pattern of HBV-DNA positivity compared to HBsAg+ positive controls, together with the absence of any significant influence on HCV replication, transaminases and histology suggests that in most patients it may be either an integrated or low level episomal replicative form.
~7"1"-~ HEPATITISB VIRUS FULL-LENGHT GENOME ANALYSIS OF PATIENTS WITH HEPATITIS B VIRUS ASSOCIATED POLYARTERITIS NODOSA
[--~
CLONAL T-CELL EXPANSIONS IN INTERFERON-ALPHA TREATED PATIENTS WITH CHRONIC HEPATITISC
A. Erhardt, A. Sagir, L. Guillevin, D. Blondin, D.H. Ussinger.
Heinrich-Heine Universitaet Duesseldorf, Germany
Gutenberg Universitaet Mainz; L Department of lnternal Medicine, Germany
Objective: HBV associated polyarteritis (PAN) is regarded as immune-complex disease, but the exact pathogenetic mechanism is as yet unknown. Aim of the study was to identify genetic factors of the hepatitis B virus predisposing to PAN. Methods: A complete HBV genome analysis was performed by DNA sequencing in 23 patients with HBV PAN. All patients were HBsAg and HBV DNA positive and apart from one HBeAg positive. PAN was confirmed in all patients by angiography or biopsy. HBV sequences of PAN patients were compared to 21 full-length sequences of databank entries and to sequences of the core gene and X gene of 54 HBeAg-positive patients with chronic hepatitis B. For clinical parameters PAN patients were compared to 66 patients with chronic HBeAg-positive hepatitis B. Results: HBeAg-positive patients with HBV associated PAN were clinically characterized by i) more advanced age, ii) higher HBV DNA levels in serum and iii) higher HBeAg levels than HBeAg-positive patients without HBV associated polyarteritis nodosa. Genetically, patients with HBV associated PAN were characterized by a low mutation rate in the HBx gene and the BCP both transcriptionally relevant regions within the HBV genome. No universal characteristic mutation was found in patients with PAN.
To detect clonal T-cell expansions associated with viral clearance or persistence in patients with chronic hepatitis C virus infection the repertoire of variable Vbeta-chains of the T-cell receptors (TCR Vbeta) were analysed by reverse transcription-polymerase chain reaction (RTPCR) and complementarity-determining region (CDR) 3 length assay (spectratyping). RNA was extracted from peripheral blood lymphocytes (PBL) derived from chronic HCV patients with sustained complete therapy response (SCR, n = 4) and non-response (NR, n = 6) before, during and after IFN-alpha treatment. Patients who will develop SCR had significant overexpression of TCR Vbeta 17 before onset of therapy, TCR Vbeta 5.1, 17 and 21 during therapy and TCR Vbeta 5.1, 16, 17, 23 and 24 after treatment. Similarly, patients who will develop NR had significant overexpression of TCR Vbeta 4, 5.1 and 17 before treatment with IFN-alpha, TCR Vbeta 5.1 and 17 during therapy and significant overexpression of TCR Vbeta 5.1, 12, 13.1 and 17 after therapy. T-cell clones were isolated and supplied to the molecular analysis to reveal pathogenetic relevant T-cell expansions. In conclusion, IFN-alpha induced a significant modulation of the TCR Vbeta repertoire in patients with chronic HCV without correlation to the therapy outcome. This could indicate that not the recruitment of
B. Heberer, A. Heinemann, S. Pingel, P. Galle, H. Loehr. Johannes
Category 6: Viral hepatitis: clinical aspects different T-cell populations but the level of T-cell induction is decisive for potential viral clearance.
~-0-~ CHRONIC HEPATITIS C AND TREATMENT OUTCOME: CORRELATIONS WITH APOPTOSIS, SOLUBLE HLA CLASS I AND SOLUBLE FAS LIGAND F. Torre l, N. Campo 1, p. Contini 1, R. Giusto 1, I. Comino 1, p. Ceppa 2, R. Fiocca 3, G. Icardi 2, E Indiveri 1, F. Puppo 1, A. Picciotto 1.
1Department of Internal Medicine, University of Genoa; 2Department of Health Science, University of Genoa; 3DICMI, University of Genoa, Italy Introduction: HCV clearance depends on the inhibition of viral replication and on infected cells elimination. Soluble HLA class I molecules is considered an indirect marker of immune activation. Soluble Fas ligand presents an apoptotic-inducing capacity and seems to down-regulates CTL Fas ligand mediated apoptotic activity. Aim: To evaluate apoptosis, indirect apoptotic and indirect immune activity indexes in relation to long term treatment response. Patients: 46 chronic hepatitis, C patients treated with IFN -2b, 3 MU tiw for 6-12 months with a follow up >2 years (range: 3-8 yrs). 23 were sustained biochemical and virological responders (SRs); 23 were non responders (NRs). Methods: HCV-RNA, soluble HLA class I and soluble Fas Ligand levels were evaluated at baseline, 1st mth, 3rd ruth, end of treatment, 6th mth of follow up, end of follow up. Apoptosis was detected in liver tissue by TUNEL technique an apoptotic index was calculated. Results: Apoptosis did not correlate with baseline ALT levels or virological characteristics. At baseline, a negative correlation was found between HCV-RNA levels and sFas-L levels (R: -0.389; p = 0.018). According to outcome, SRs presented a negative correlation between sFas-L vs fibrosis (R: -0.713; p = 0.004) and sFas-L vs apopt0sis; (R: -0.610; p = 0.026). A larger variability in sFas-L levels was present in SRs compared to NRs, with a progressive decrement that reach a significance at the end of follow up (Mann-Whitney, p = 0.001). In SRs, sHLA showed a significant point by point variation (Anova by ranks, p = 0.02) compare to the fiat, constant pattern of NRs. Conclusions: SRs seem to present a more activated immune system than NRs. In SR, the baseline inverse correlation of sFas-L vs apoptosis and viraemia may reflect the cell-immune activity and a preferential cytokines mediated antiviral activity.
~5-]
COURSE OF VIROLOGIC BREAKTHROUGHS (VBTs) UNDER LAMIVUDINE (LAM) THERAPY IN PATIENTS(PTS) WITH PRECORE MUTANT HBV RELATED CHRONIC LIVER DISEASE (CLD)
G.V. Papatheodoridis, E. Dimou, V. Papadimitropoulos, A. Laras, S. Hadziyannis. Academic Dept. of Medicine, Hippokration Hospital of
Athens, Greece YMDD mutants emerge in most of pts with HBeAg ( - ) CLD under long-term LAM, but their course remains unclear. We report the course of VBTs detected by a sensitive PCR in 30 pts with precore mutant HBV treated with long-term LAM. All pts had elevated ALT and HBV viremia before LAM; all achieved initial biochemical and virologic (neg. HBV DNA) response. LFFs were evaluated monthly and IgM anti-HBc (IMx, Abbott) and serum HBV DNA (Monitor, Roche; sens.400 cp/ml) every 3 mos and on every biochemical breakthrough (BBT). YMDD mutants were detected in all 30 pts in a median of 15 (6-48) mos after LAM start; M552I in 22 and M552V in 8 (+L528M in 6). Duration of LAM therapy after VBT (reappearance of HBV DNA) was 9 (0-33) mos; BBTs developed in 16 pts. The cumulative probability of BBT was 59% at 6, 69% at 12 and 100% at 24 mos after VBT. There was no difference in the characteristics at baseline or at VBT onset between pts
143
with or without BBT. In the 16 pts with BBT a) IgM anti-HBc and HBV DNA increased from the VBT onset to 6 (0.115 to 0.256, P = 0.01) and to 3 mos later (0.0034 to 0.596 Mcp/ml, P = 0.005) respectively; b) ALT exceeded baseline in 14 and reached acute hepatitis levels in 6; c) ALT peaked at the BBT onset in 13 or within the next 3 mos in 3. Compared to the BBT onset, ALT decreased after 6 mos (188 vs 123 IU/L, P = 0.015) but remained abnormal in all but 1 patient; HBV DNA relatively decreased after 6 (21 vs 2 Mcp/ml, P = 0.07) but increased again after 12 mos (15 Mcp/mi). Conclusions: In pts with precore mutant HBV CLD, VBTs are followed by increasing viremia levels culminating in development of BBTs in practically all pts. ALT and HBV DNA levels peak close to the BBT onset, decreasing thereafter but remaining abnormal with fluctuating levels. Thus, optimal monitoring with sensitive PCR assays permits early recognition of VBTs and may have therapeutic implications.
(-~
PEGYLATED (40 KDA) INTERFERON ALFA-2A (PEGASYS®) IN NEW COMBINATIONTHERAPIES: A REPORT OF A RANDOMIZED, MULTICENTER EFFICACY AND SAFETY STUDY
A.M. Di Bisceglie, D.E. Bernstein, V.R. Rustgi, N. Gitlin, L.J. Jeffers, D. Simon, J. Campagna, S.C. Pappas. St Louis University/Bethesda
Hospital., North Shore University Hospital, Manhasset, NY Georgetown University, Fairfax, VA, Atlanta Gastroenterology Associates, Atlanta, GA, University of Miami School of Medicine, Miami, FL, A., Jacobi Medical Center, Bronx, NY, Roche Laboratories lnc, Nutley, NJ, USA Background: Interferon (IFN) monotherapy in previously untreated patients with chronic hepatitis C (CHC) leads to a sustained virological response (SVR) in 10%-19% of treated patients; ribavirin (RBV) added to IFN monotherapy increases SVR. PEGASYS ® is also associated with higher SVR. Further increases in SVR may be possible by combining PEGASYS® with the antiviral and immunomodulatory agents RBV, amantadine, and mycophenolate mofefil (CellCept®). Objective: To investigate the efficacy and safety of PEGASYS ® when used in combination with antiviral and immunomodulatory agents. Methods: Previously untreated patients with CHC were randomized into one of 4 groups: A: IFN c~-2b+RBV (REBETRON TM) (n -- 55); B: PEGASYS®+mycophenolate (n = 58); C: PEGASYS®+amantadine (n = 21); D: PEGASYS®+amantadine+RBV (n = 19). Patients were stratified according to genotype and viral load (low vs. high). Treatment was for 48 weeks with 24 weeks of follow-up. The outcome of therapy was assessed as virological response (HCV RNA < 50 IU/mL and >2 log drop from baseline using the AMPLICOR MONITOR TM HCV Test v. 2.0) or biochemical response. Results: The baseline patient characteristics were: mean age 45 46.3 y, male 66%, mean ALT 109 4- 70.4 U/L, high viral load 67%, HCV genotype 1 73%. One hundred and forty patients (87.5%) have completed >24 weeks of treatment. No unexpected side effects related to the study medications have been noted. Group
A B C D
Therapy
IFN u-2b + RBV PEGASYS® + mycophenolate PEGASYS® + amantadine PEGASYS® + amantadine + RBV
Week 24 HCV RNA > 2 log drop
HCV RNA neg.
Normal ALT
34/52 37/54
31/52 30/54
39/50 29/55
16/17
13/17
9/17
15/17
11/17
13/17
Conclusions: These preliminary findings reveal a trend for the Week 24 antiviral effect of all 3 PEGASYS ® combinations to be similar to or greater than that with conventional combination therapy.