Routine serum laboratory parameters for the staging of fibrosis in patients with chronic hepatitis C

162

I557

NEEDS ASSESSMENT INFORMATION

FOR HEPATITIS

C IN UK PROVIDES

FOR EUROPE

J. Parkes’,

B. Bennett Lloyd2, P.J. Roderick’, W.M.C. Rosenberg3. ‘Public Health Medicine Liver Epidemiology Group Health Care Research Unit Southampton General Hospital Southampton UK; 2Liver Epidemiology Group Health Care Research Unit Southampton General Hospital Southampton UK; ‘Hepatology School Of Medicine & Liver Epidemiology Group Southampton General Hospital Southampton UK, Background: Hepatitis C virus (HCV) infection is a major healthcare problem world-wide. There is a need to determine current service configuration, workload, processes of care, and capacity to inform planning and implement improvements. Aim: To determine the workload and configuration of current services available to manage patients with HCV, and to identify models of good practice in the UK. Methods: A questionnaire survey conducted on a purposive sample of consultant members of BASL (n=49), Infectious Disease consultants (n=42), a 1 in 5 sample of GUM and GI physicians (n=47 & 186) stratified by Health Region. In-depth field interviews and semi-structured telephone interviews were conducted where novel or innovative models of care were identified. Results: Questionnaire response rate was 75%. 40% of respondents provided a complete service - Hepatology (34%); GI (50%); ID (16%). Total number of patients managed by the respondents was >23,000 with upward trend over past 3 years; 12,500 have been treated. There is variation in criteria for treatment despite national guidelines. Eligibility for treatment was 25.49% with 50.74% receiving treatment. Identified barriers to quality of care include staffing capacity, patient non-attendance, and funding of treatment. Models of good care included cross-speciality working, & outreach clinics in prison and drug/alcohol settings. Conclusions: Detailed quantitative and qualitative data from this survey will inform the future planning of Hepatitis C services in UK and will provide information to professionals working in other European countries. Preliminary data suggest significant variation in service delivery and identifies critical barriers.

I558

META-ANALYSIS

OF ISDR MUTATIONS

INTERFERON-ALPHA CHRONIC

AND

(IFNA) SENSITIVITY

nificant difference in the secondary structure of IFNa-sensitive or resistant strains. Testing for number of mutations in the ISDR can be useful for predicting IFNa efficacy in individual patients. However, the patterns of mutations in the ISDR suggest that ISDR by itself may not intrinsically determine sensitivity to IFNa-therapy. Thus, the significance patterns and numbers of mutations in the ISDR remains to be established.

I

559

HCV GENOTYPE ANTIVIRAL

1 RESISTANCE

TO INTERFERON

(IFN) ALFA

EFFECT: ROLE OF THE NONSTRUCTURAL

NS5A

PROTEIN AND THE PUTATIVE ISDR

J.-M. Pawlotskv, R. Brillet, C. Hezode, l? Chouteau, D. Dhumeaux. Hopital Hem-i Mondos Universite Paris XII, Creteil, France The sustained virological response of HCV genotype 1 to IFN therapy has been suggested to be related to NSSA protein sequence. In vitro studies suggested that NSSA could inhibit intracellular effecters of IFN antiviral action. We assessed whether IFN blocking effectiveness of HCV replication at day 1 (i.e., IFN direct antiviral effect) is related to NSSA amino acid sequence. 16 genotype lb patients received 3 MU of II+-alfa 2b at day 0 and HCV RNA reduction was measured after 24 hours (IFN blocking effectiveness): 5 patients did not respond, 11 had a viremia reduction between 72% and 99.8%. Full-length NSSA quasispecies were characterized by analyzing 18-25 clones per patient. Overall, 356 full-length NSSA sequences were generated and compared with in viva IFN antiviral effect. Phylogenetic analysis of NSSA quasispecies showed no distinctive clustering according to IFN antiviral efficacy. Putative functional NSSA regions were analyzed, including the Pm-binding region, the V3 and V4 variable regions, the transcriptional activation domain, the core-binding domain, the Grb2-binding domain, the ApoAl-binding domain, the nuclear localization signal, the cytoplasmic retention domain and the so-called “interferon sensitivity determining region” (ISDR). No relationship between NSSA sequence and IFN antiviral effect was shown in any functional regions, and residues potentially involved in protein interactions did not differ according to IFN blocking effectiveness. In conclusion, in contrast with in vitro reports, we show that NSSA does not mediate intrinsic HCV genotype 1 resistance to IFN antiviral effect in viva and that there is no ISDR in the NSSA protein.

IN PATIENTS WITH

HEPATITIS C VIRUS (HCV) GENOTYPE

1B

INFECTION

M. Pascu’, M. Hoehne2, B. Wiedenmann’, U. Hopf’, E. Schreier2, T. Berg’. ‘Department Of Internal Medicine, Division Of Hepatology And Gastroenterology, Campus V&how, Charite Medical School, Berlin, Get-many; 2Robert Koch Institut, Berlin, Get-many Conflicting results were reported regarding the correlation between the number of mutations in the NSSA gene (aa 2209.2248), the interferonsensitivity-determining-region (ISDR), and IFNa effectiveness in HCV genotype lb infected patients. The aim of this meta-analysis was to investigate the relationship between the number and pattern of mutations in the ISDR and IFNa response. SR was defined as negative serum HCV-RNA for 6 months after treatment. Any other behaviour of HCV-RNA was considered nonresponse (NR). A database, comprising 1161 ISDR strains (903 IFNa-resistant and 258 IFNa-sensitive) from 27 published studies, was constructed and analysed by logistic regression analysis. Cumulative analyses revealed a strong correlation between number of ISDR-mutations and IFNa sensitivity (p4 mutations), respectively. The distribution of intermediate and mutant types varied strongly according to geographical area (Europe: 63.9% vs. 12.3%, Japan: 36.8% vs. 18.6%). High mutation frequency in the ISDR was associated with a low viremia (p
I560

ROUTINE

SERUM

STAGING

OF FIBROSIS

LABORATORY

PARAMETERS

FOR THE

IN PATIENTS WITH CHRONIC

HEPATITIS C

M. Penz’, C. Oesterreicher’, F. Wrba2, C. Datz3, M. Gschwandtler4, H. Hofer’, G. Novacek’, A. Gangl’, l? Ferenci’. ‘Internal Medicine Ix University Of Vienna, Wien, Austria; 2Clinical Pathology, University Of Vienna, Wien, Austria; ‘Internal Medicine, General Hospital, Salzburg, Austria; 41nternal Medicine, KH Rudolfstzftung, Wien, Austria Background: The role of liver histology in chronic hepatitis C (CHC) has shifted from diagnosis to the assessment of prognosis. Several studies addressed the question whether this information can be also obtained by noninvasive tests. Methods: Liver biopsies were performed in two cohorts, an estimation (male/female=292/170; mean age=41.5&12.1 a) and a validation group (78/34; 44.3~t10.4). Sections were graded/staged according to Ludwig. Blood chemistry was done the same day. By multivariate logistic regression analysis a score (Vienna score) based on AFP, platelet count, ALT/AST ratio and pseudocholinesterase discriminated advanced fibrosis (F3-4) best from FO-2 in the estimation group. A cut-off of >0.41 identified F3-4 with a specifity of 95% and a sensitivity of 41%. This and two published scores (Bonacini, 1997, Foms, 2002) were evaluated in the validation group by calculating the areas under the receiver operating characteristic (ROC) curves. Results: Areas under the ROC-curve were: Bonacini-Score: 0.72, FornsScore: 0.84, Vienna-Score: 0.82 (NS). The specificity (94%), sensitivity

Category 6: Viral hepatitis: (48 and 47%), positive predictive value [PPV] (90%) and negative PV (61 and 60%) of the Foms- and Vienna-Scores were similar. The sensitivity of the Bonacini-Score was 8% but the PPV was 100%. By using either the Vienna or the Form score, a biopsy could have been (avoided in 77 (69%) and 78 (70%) patients, respectively. A differentiation of FO-Fl vs. F2-F4 using this three scoring systems was not feasible. Conclusion: Scores based on a combination of routine laboratory tests may replace liver biopsy to detect advanced stages of fibrosis in CHC.

I561

HEPATITIS C VIRUS (HCV) RELAPSES OF ANTI-HCV

THERAPY

HIV-COINFECTED

FOLLOWING

ARE MORE FREQUENT

THE END

IN

PATIENTS

M. Perez-Olmeda’, l? Rios’, M. Romero2, M. Nunez’, Diseases, .I. Garcia-Samaniego2, V. Soriano’. ‘Service Of ” Infectious ” Hospital Carlos Iii, Madrid, Spain; 2Liver Units Hospital Carlos Iii, Madrid, Spain Background: The response to IFN plus RBV seems to be significantly lower in HIV-positive individuals with chronic hepatitis C (CHC) than in HCV-monoinfected patients (overall 25% versus .50%, respectively). The reasons to explain this lower benefit are not well known, although both a compromise in the initial HCV clearance and/or a higher rate of relapse may result in a much poor sustained response rate. Patients and Methods: The rate of HCV relapses was examined in 58 HCV/HIV-coinfected subjects with end treatment response after a standard therapy with RBV plus IFN (31 on pegylated IFN and 27 on regular IFN). All subjects received a fixed dose of RBV (400 mg bid). Therapy was provided for 6 months in subjects with HCV genotypes 2 or 3, and for 12 months in those with genotypes 1 or 4. All patients had CD4 counts >300 cells/mm3 and HIV-RNA < 10,000 copies/ml. Results: 19 (32.7%) patients relapsed after discontinuing therapy, a rate which is significantly higher than that reported in HIV-negatives (1520%). There were no significant differences between the rate of relapses considering different HCV genotypes (33.3% for HCV-2/3 versus 31.5% for HCV-114) and/or the use of either regular or pegylated interferon forms (37% versus 29.6%). The relapse rate was not influenced by the CD4 count, HIV-RNA, or the use of antiretroviral therapy. Conclusion: HCV relapses after treatment are more frequent in HIVcoinfected patients. The efficacy of extended periods of anti-HCV therapy should be examined in HIV-coinfected patients with CHC who are initial responders to therapy.

I

562

PREDICTIVE (12 WEEKS)

VALUE OF EARLY VIROLOGICAL TO PEGYLATED

IN HIV-HCV COINFECTED

INTERFERON

RESPONSE

PLUS RIBAVIRIN

PATIENTS

M. Perez-Olmeda I, L. Martin-Carbonero I, M. Romero2, l? Rios I, M. Nunez I, V. Soriano I, J. Garcia-Samaniego 2. ‘Service Of Infectious Diseases, Hospital Carlos III, Madrid, Spain; 2Liver UnitsHo&tal Carlos III, Madrid, Spain Background: Treatment of CHC offers cm-e to 60% of HIV-neg patients. Response rates seem to be lower in HIV+ patients with more side effects. Therefore, early predictors of lack of response may allow discontinuing anti-HCV therapy when no response is expected. Reductions in HCV-RNA >2 logs at 12 weeks of therapy have a negative predictive value (NPV) of 97%. No data are available in coinfected patients. Patients and Methods: 89 HIV-HCV patients who completed treatment with IFN+RBV were analyzed (63 PEG-IFN and 26 regular IFN). All received 800 mg of RBV. HCV genotypes were: 1-4 (62%) and 2-3 (38%). Treatment was administrated 6 months in genotypes 2-3 and 12 months in genotypes 1-4. SVR occurred in 29 patients, 45 were non-responders and the remaining 15 relapsed. Results: A drop in HCV-RNA > 2 logs was seen in 38 (43%) and 52 (58%) patients at 4 and 12 weeks. Only 18 (48%) and 29 (56%) of those subjects,

clinical aspects

163

reached SVR. In contrast, SVR occurred in 11 (38%) and 0 patients who did not show a >2 log drop at weeks 4 and 12. NPV was 100% at week 12. There were no differences between genotypes, baseline HCV-RNA, and use of either pegylated or regular IFN. In patients with HCV 2-3, a high rate of relapse in early responders was noticed (67% of total relapsers) Conclusions: The use of an early time-decision point at 12 weeks is valid for HIV+ patients. Extending treatment beyond 6 months in genotypes 2-3 might provide a higher SVR.

I563

HBV DNA QUANTIFICATION

BY REAL-TIME

PCR

L. Pliskova2, K. Hrochova2, V. Stepanova3. ‘Department If Znfectiuos Dis., University Hospital, Hradec Kralove, Czech Republic; 2Znst. Clin. Biochem. And Diagn., University Hospital, Hradec Kralove, Czech Republic; ‘Inst. Of Clin. Microbiology, University Hospital, Hradec Kralove, Czech Republic S. Plisek’,

Background: Quantification of serum HBV DNA in patients with chronic hepatitis B is an important method for the monitoring HBV replication. HBV DNA level is important as a decision limit for the introducing therapy. Aims: To introduce and compare two methods of HBV DNA quantification in serum. To determine cut-off level of HBV DNA to differentiate patients with chronic hepatitis replicating and non replicating the virus. Material and Methods: We examined 68 serum samples from patients with chronic hepatitis B (devided into 3 groups according to serological markers) and 10 control serum samples. Group 1: 27 patients in replication phase (HBsAg pos. HBeAg pos). Group 2: 23 patients after successful Interferon-alfa treatment (HBsAg pos, HBeAg neg, antiHBe pos). Group 3: 18 asymptomatic HBsAg carriers. Methods: Real-time PCR - LightCycler Roche (FRET probes) and Rotorgene Corbett Research (FAM-BHQ probe) were used. Results: Validation of both methods: Linearity was 1.2E3 - 1.2E8 copies of HBV DNA/ml; the coefficients of variation for repeatability and reproducibility were in all cases lower than 15%. Correlation coefficient obtained by linear regression analysis in the tested groups of patients was 0, 995. The avarage concentrations of HBV DNA (copies/ml): Group 1: LightCycler 1, 9E8, Rotorgene 1, 0E8; group 2: LightCycler 6, 4E4, Rotorgene 8, lE4; group 3: LightCycler 1, 5E3, Rotorgene 1, 9E3. Control group: HBV DNA negative. ROC analysis was used to evaluate the results. Cut-off level of HBV DNA for LightCycler was 4, 21E5 and for Rotorgene 1, 5E5. Conclusion: Both methods are well accepted in the routine praxis.

I564

CLINICAL DISEASE

AND HISTOLOGICAL

EVALUATION

OF LIVER

IN PATIENTS WITH TRANSFUSION-DEPENDENT

BETA-THALASSEMIA:

A MULTICENTER

STUDY

D. Prati, M. Maggioni, l? Rebulla, G. Fiorelli, G. Coggi, M.D. Cappellini. ‘Dipartimento Di Medicina Interna, Universita’ Di Milano, Milan, Italy; 2ZstitutoDi Anatomia Patologica, Universita’ Di Milano, Milan, Italy Background: Liver disease is frequent in patients with transfusiondependent b-thalassemia (B-TM). Information on liver histology in these patients derive from studies conducted before the identification of hepatitis C virus (HCV) and the introduction of iron chelation protocols. Aim: To describe the histopathological features of liver disease in patients with B-TM. Patients and Methods: Among the Cooleycare Cooperative Group, 5 clinical centers were included in the study on the basis of the number of patients in charge and the distribution on the Italian territory. The 319 patients (161 males, 158 females, median age 28 yrs, range 7-50) attending these centers were considered. Liver biopsy was performed in the 138 (43%) patients who had no contraindication and accepted the procedure. Results: Anti-HCV was found in 124 (89%), 70% of whom were viremic. ALT abnormalities were found in 109 patients (79%) 28 of whom (26%) were HCV RNA negative. The grading score (Ishak’s) was 5.O~t2.2 in viremics vs 2.5~t2.3 in HCV RNA in nonviremics (p<.OO5), while the