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Durable HBeAg and HBsAg seroconversions after lamivudine for chronic hepatitis B (CHB)
Viral hepatit&." clinical aspects
P/C06/11 ]
L p,co6/o9 I HEPATITIS VIRUS INFECTIONS IN HEART TRANSPLANT RECIPIENTS: EPIDEMIOLOGY, NATURAL HISTORY, CHARACTERISTICS AND IMPACT ON SURVIVAL E Lunel t, J-E Cadranel 2, M. Rosenheim3, R. Dorent 4, V. Dimartino 5, C. Payan 1, L. Stuvver6, P Opolon 5 Wirologie, Angers, Paris, France. 2Htpatologie, Crcil, Paris, France. 3Sant6 publique, Paris, France. 4Chirurgie cardiaque, Paris, France. 5Htpatologie, Pitit, Paris, France. 6Innogenetics, Ghent, Belgium. We observed a high prevalence of post-surgical hepatitis B (HBV) and C (HCV) virus infection in heart transplants recipients (HTR). The aim of the study was to assess the epidemiology, natural history, clinical and biological characteristics of the infections. Methods: From 1983 to 1992, 874 patients (pts) underwent heart Wansplantation (HI') at PitidSalpdfi~re Hospital, Paris, France, of whom 459 were analysed. 140 pts had post-I-IT hepatitis B, C or non A-E. 69 pts developed HBV infection, 49 pts HCV infection, 11 pts had non A-E hepatitis and 11 had HBVHCV co-infection~ Results: HBV was found to be transmitted from patient to patient, most likely during endomyocardial biopsies. HCV was mainly transmitted through transfusions or the heart donor. Patients were infected by two different HBV genotypes and by different HCV genotypes/subtypes. Only three patients with an HBV genotyp¢ A pr¢¢ore mutant had severe or subfulminant hepatitis. HBV and HCV infection always progressed to chronlcity. Patients generally had a mild ALT elevation, a high level of viral replication, and few severe histological lesions, except for patients infected by precore I-IBV mutants. Patients coinfected by HBV and HCV tended to have more severe liver lesions. The survival rate five ),cars after transplantation was similar in patients with viral hepatitis 0-IBV: 81%, HCV: 89%, B+C coinfection: 100%, NA-E hepatitis: 73%) to that in patients without liver test abnormalities (76%). The actuarial survival curve was also similar in patients with or without liver test abnormalities. Conclusions: in our experience, histological liver lesions do not progress rapidly in patients with post heart transplanL HBV and H C V infection. Hepatitis B or C virus infection seem to have little impact on heart transplant recipientsfive years survival.
P/C06/lO ] OVERT B-CELL NON-HODGKIN'S LYMPHOMA (B-NHL): ROLE OF HEPATITIS C VIRUS (HCV) G. Germanidis, C. Haioun, E Gaulard, L. Cast&a, E Reves, D. Dhumeaux, J.M. Pawlotskv Departments of Bacteriology and Virology, Hematology, Hepatology and Gastroenterology, INSERM U99, Htpital Henri Mondor, Universit6 Paris XII, Cr&eil, France. A 0% to 42% prevalence of chronic HCV infection markers has been reported in patients with B-NHL HCV-associated B-NHL were mainly lymphoplasmocytoid lymphomes-immunocytomas, i.e. B-NHLs associated with type II mixed cryoglobulinemia (MC), or diffuse large B-cell lymphomas. However, aselection bias towards inclusion of patients with symptomatic type II MC could account for the ~oseaved high prevalences of HCV markers in ce~ain series. Aim : To determine the prevalence of HCV infection markers in a large cohort of unselected patients with B-NHL referred to the Department of Hematology of our center. Methods: Between January 1994 and March 1999, 437 consecutive patients with lymphomas, including 312 patients with B-NHL and 125 patients with Hodgkin's disease (control group), were prospectively screened for the presence of anti-HCV antibodies by means of second- or thirdgeneration EIA (Ortho-Clinieal Diagnostics). HCV RNA was sought by PCR (Amplicor HCV, Roche) in the samples positive in EIA. Results: HCV markers (anti-HCV antibodies and HCV RNA in PC'R) were found in 8/312 B-NHLpatients (2.6%), versus in 21125 patients with Hodgkin's disease (1.6% ; p<0.0001). In 4 of the 8 B-NHLpatients with chronic HCV infection, the diagnosis of HCV infection preceded the diagnosis of B-NHLby 4 to 5 years. Detections of HCV infection and B-NHL were simal~neoas in the remaining 4 patients. The B-NHL histotypes in the REALclassification were : mantle cell lymphoma in 3 cases : lymphoplasmocytoid lymphomaimmunocytoma associated with type II MC in 2 cases ; diffuse large B-cell lymphoma in 2 cases ; MALTlymphoma in one case. C o n c l u s i o n s , Thase results, basedon the study of a very large cohort of unselected French patients with B-NHL, do not support a major role of HCV in overt B-I~HL Nevertheless, the 2.6% prevalence of HCV markers in I~NHL patients was higher than that in the French 8enend population (1.0%) and significantly higher than that in the patients with Hodgkin's disease (1.6%). suggesting that a few B-NHLcases could be favored by HCV infection, although likely being multifactor/al. The role of HCV in the emergence of lympho.plasmocytoid lymphomas, B-NHLrelated to type II MC, could he related to continuous antigenic sUmulation. The putative role of ~ in other B-~-IL histotypes remains to he elucidated.
SEQUENCE ANALYSIS OF TWO PKR INHIBITOR HCV PROTEINS IN PATIENTS TREATED WITH HIGH DOSES OF INTERFERON M. Gerotto, E Dal Pero, E Pontisso, A. Alberti Dep. Clin. and Exp. Med., University of Padua, Padua, Italy.
Viral proteins have been implicated in resistance to interferon (IFN) in bepelilis C by blocking the IFN induced protein kinase (PKR). The ISDR motif o f the NS5A protein has been shown to mediate PKR inldbin'on and to be implicated, al~ough with c,onh'oversLal results, in HCV Ib IFN resist~ce. Recently the HCV envelope protein E2 has also been shown to block PKR but no data on its role, if any, during IFN therapy have been so far reported. We have simultaneously analyzed the NS5A-ISDR and the E2-PePHD aa scquanccsin 26 patients with HCV lb treated with high doses of txIFN. Pro- and on-lrealment NS5A and E2 scxlumces w c ~
analyzed in relation to sustained mspon~ as dora pm4ously, and also to the early kinetic of virologic response which allows to bettor define the direct msiviral efficacy of IFN. The NSSA and E2 regions were PCR amplified and sequenced directly and after clonin~ 23% o f patients had wild type (Wt) NS5A-ISDR, 50% had intenmdi_ate type (Int), lgO/~ had m u t ~ (Mut) type and 8% had mixed q~m~ecies. Early response was obs~'ved in 17% with Wt, in 38% with Int, and in 60% with Mut while, sustained ~-~ponse was observed in 17% with Wt, 15% with Int and in 20o/o with Mut. All but one patient had very h o m o g e n o u s E2-PePHD quasispecies with a sequence identical to that o f prototype lb with no relation to the cm'ly and sustained response. No E2 sequence selection
dining th¢=~py was found in any patient. Those data dernons~e association bctw~n NS5A-ISDR and early response to high doses o f IFN. The ~mflicfing data reported on the association with ~ e d may reflect different swategies o f long-t~m treatment The E2 sequence se~ns not to play a major role in IFN msponfivenessin hepatitis C.
I
P/C06/12 [
DURABLE HBeAg AND HI]sAg SEROCONVERSIONS AFTER LAMIVUDINE FOR CHRONIC HEPATITIS B (CHB) E. Schiff1, J. Cianciara 2. S. Karayalcin 3, K. Kowdley4, M. Woessner5, S. McMullen 5, M. Pearcc 5, N. Brown 5, the Int'l Lamivudine Inv. Gp. 1U of Miami, FL. 2Med Acad Warsaw, Poland. 3Ankara U Med Sch, Turkey. 4U of Washington, WA. 5Glaxo Wellcome RTP, NC and Greenford, UK.
Background 43 CHB patients (pts) with HBeAg loss after lamivudine in previous trials were followed off treatment in this on-going study to assess durability of serologic response. Recruitment occurred within 12 months (too) of completion of the qualifying trial. Pts could be retreated with lamivudine if they experienced reactivation. Results At this interim analysis, median duration of study participation was 21 mo (range 0-30) and 86% (37/43) of pts showed durable HBeAg loss. Importantly, 9 pts (21%) also experienced HBsAg seroconversion. Of these, 6 were HBsAg-ve/HBsAb+ve on entry into this follow-on study and all showed a durable response (430 too). 3 achieved HBsAg seroconversion 2-15 mo into this study with response maintained to last visit. There were 6 pts who were non-durable or retreated; 1 pt regained HBeAg for approx. 6 mo then lost HBeAg without retraatment and remained HBeAg seroconverted at last visit (24 mo). 5 pts (12%) were retreated; 3 were HBV DNA+ve with raised ALTs and 2 had HBeAg+ve/HBeAb-ve hepatitis B (1 pt now HBeAg seroconverted). Normal ALTs were recorded at last visit for 65% (28•43) of HBeAg-ve and 89% (8•9) of HBsAg-ve pts. Conclusions HBeAg loss after lamivudine is an appropriate point to stop therapy as post-treatment responses are durable and may lead to HBsAg seroconversion. Pts with reactivation can respond to a subsequent course of lamivudine.
99
P/C06/11 ]
L p,co6/o9 I HEPATITIS VIRUS INFECTIONS IN HEART TRANSPLANT RECIPIENTS: EPIDEMIOLOGY, NATURAL HISTORY, CHARACTERISTICS AND IMPACT ON SURVIVAL E Lunel t, J-E Cadranel 2, M. Rosenheim3, R. Dorent 4, V. Dimartino 5, C. Payan 1, L. Stuvver6, P Opolon 5 Wirologie, Angers, Paris, France. 2Htpatologie, Crcil, Paris, France. 3Sant6 publique, Paris, France. 4Chirurgie cardiaque, Paris, France. 5Htpatologie, Pitit, Paris, France. 6Innogenetics, Ghent, Belgium. We observed a high prevalence of post-surgical hepatitis B (HBV) and C (HCV) virus infection in heart transplants recipients (HTR). The aim of the study was to assess the epidemiology, natural history, clinical and biological characteristics of the infections. Methods: From 1983 to 1992, 874 patients (pts) underwent heart Wansplantation (HI') at PitidSalpdfi~re Hospital, Paris, France, of whom 459 were analysed. 140 pts had post-I-IT hepatitis B, C or non A-E. 69 pts developed HBV infection, 49 pts HCV infection, 11 pts had non A-E hepatitis and 11 had HBVHCV co-infection~ Results: HBV was found to be transmitted from patient to patient, most likely during endomyocardial biopsies. HCV was mainly transmitted through transfusions or the heart donor. Patients were infected by two different HBV genotypes and by different HCV genotypes/subtypes. Only three patients with an HBV genotyp¢ A pr¢¢ore mutant had severe or subfulminant hepatitis. HBV and HCV infection always progressed to chronlcity. Patients generally had a mild ALT elevation, a high level of viral replication, and few severe histological lesions, except for patients infected by precore I-IBV mutants. Patients coinfected by HBV and HCV tended to have more severe liver lesions. The survival rate five ),cars after transplantation was similar in patients with viral hepatitis 0-IBV: 81%, HCV: 89%, B+C coinfection: 100%, NA-E hepatitis: 73%) to that in patients without liver test abnormalities (76%). The actuarial survival curve was also similar in patients with or without liver test abnormalities. Conclusions: in our experience, histological liver lesions do not progress rapidly in patients with post heart transplanL HBV and H C V infection. Hepatitis B or C virus infection seem to have little impact on heart transplant recipientsfive years survival.
P/C06/lO ] OVERT B-CELL NON-HODGKIN'S LYMPHOMA (B-NHL): ROLE OF HEPATITIS C VIRUS (HCV) G. Germanidis, C. Haioun, E Gaulard, L. Cast&a, E Reves, D. Dhumeaux, J.M. Pawlotskv Departments of Bacteriology and Virology, Hematology, Hepatology and Gastroenterology, INSERM U99, Htpital Henri Mondor, Universit6 Paris XII, Cr&eil, France. A 0% to 42% prevalence of chronic HCV infection markers has been reported in patients with B-NHL HCV-associated B-NHL were mainly lymphoplasmocytoid lymphomes-immunocytomas, i.e. B-NHLs associated with type II mixed cryoglobulinemia (MC), or diffuse large B-cell lymphomas. However, aselection bias towards inclusion of patients with symptomatic type II MC could account for the ~oseaved high prevalences of HCV markers in ce~ain series. Aim : To determine the prevalence of HCV infection markers in a large cohort of unselected patients with B-NHL referred to the Department of Hematology of our center. Methods: Between January 1994 and March 1999, 437 consecutive patients with lymphomas, including 312 patients with B-NHL and 125 patients with Hodgkin's disease (control group), were prospectively screened for the presence of anti-HCV antibodies by means of second- or thirdgeneration EIA (Ortho-Clinieal Diagnostics). HCV RNA was sought by PCR (Amplicor HCV, Roche) in the samples positive in EIA. Results: HCV markers (anti-HCV antibodies and HCV RNA in PC'R) were found in 8/312 B-NHLpatients (2.6%), versus in 21125 patients with Hodgkin's disease (1.6% ; p<0.0001). In 4 of the 8 B-NHLpatients with chronic HCV infection, the diagnosis of HCV infection preceded the diagnosis of B-NHLby 4 to 5 years. Detections of HCV infection and B-NHL were simal~neoas in the remaining 4 patients. The B-NHL histotypes in the REALclassification were : mantle cell lymphoma in 3 cases : lymphoplasmocytoid lymphomaimmunocytoma associated with type II MC in 2 cases ; diffuse large B-cell lymphoma in 2 cases ; MALTlymphoma in one case. C o n c l u s i o n s , Thase results, basedon the study of a very large cohort of unselected French patients with B-NHL, do not support a major role of HCV in overt B-I~HL Nevertheless, the 2.6% prevalence of HCV markers in I~NHL patients was higher than that in the French 8enend population (1.0%) and significantly higher than that in the patients with Hodgkin's disease (1.6%). suggesting that a few B-NHLcases could be favored by HCV infection, although likely being multifactor/al. The role of HCV in the emergence of lympho.plasmocytoid lymphomas, B-NHLrelated to type II MC, could he related to continuous antigenic sUmulation. The putative role of ~ in other B-~-IL histotypes remains to he elucidated.
SEQUENCE ANALYSIS OF TWO PKR INHIBITOR HCV PROTEINS IN PATIENTS TREATED WITH HIGH DOSES OF INTERFERON M. Gerotto, E Dal Pero, E Pontisso, A. Alberti Dep. Clin. and Exp. Med., University of Padua, Padua, Italy.
Viral proteins have been implicated in resistance to interferon (IFN) in bepelilis C by blocking the IFN induced protein kinase (PKR). The ISDR motif o f the NS5A protein has been shown to mediate PKR inldbin'on and to be implicated, al~ough with c,onh'oversLal results, in HCV Ib IFN resist~ce. Recently the HCV envelope protein E2 has also been shown to block PKR but no data on its role, if any, during IFN therapy have been so far reported. We have simultaneously analyzed the NS5A-ISDR and the E2-PePHD aa scquanccsin 26 patients with HCV lb treated with high doses of txIFN. Pro- and on-lrealment NS5A and E2 scxlumces w c ~
analyzed in relation to sustained mspon~ as dora pm4ously, and also to the early kinetic of virologic response which allows to bettor define the direct msiviral efficacy of IFN. The NSSA and E2 regions were PCR amplified and sequenced directly and after clonin~ 23% o f patients had wild type (Wt) NS5A-ISDR, 50% had intenmdi_ate type (Int), lgO/~ had m u t ~ (Mut) type and 8% had mixed q~m~ecies. Early response was obs~'ved in 17% with Wt, in 38% with Int, and in 60% with Mut while, sustained ~-~ponse was observed in 17% with Wt, 15% with Int and in 20o/o with Mut. All but one patient had very h o m o g e n o u s E2-PePHD quasispecies with a sequence identical to that o f prototype lb with no relation to the cm'ly and sustained response. No E2 sequence selection
dining th¢=~py was found in any patient. Those data dernons~e association bctw~n NS5A-ISDR and early response to high doses o f IFN. The ~mflicfing data reported on the association with ~ e d may reflect different swategies o f long-t~m treatment The E2 sequence se~ns not to play a major role in IFN msponfivenessin hepatitis C.
I
P/C06/12 [
DURABLE HBeAg AND HI]sAg SEROCONVERSIONS AFTER LAMIVUDINE FOR CHRONIC HEPATITIS B (CHB) E. Schiff1, J. Cianciara 2. S. Karayalcin 3, K. Kowdley4, M. Woessner5, S. McMullen 5, M. Pearcc 5, N. Brown 5, the Int'l Lamivudine Inv. Gp. 1U of Miami, FL. 2Med Acad Warsaw, Poland. 3Ankara U Med Sch, Turkey. 4U of Washington, WA. 5Glaxo Wellcome RTP, NC and Greenford, UK.
Background 43 CHB patients (pts) with HBeAg loss after lamivudine in previous trials were followed off treatment in this on-going study to assess durability of serologic response. Recruitment occurred within 12 months (too) of completion of the qualifying trial. Pts could be retreated with lamivudine if they experienced reactivation. Results At this interim analysis, median duration of study participation was 21 mo (range 0-30) and 86% (37/43) of pts showed durable HBeAg loss. Importantly, 9 pts (21%) also experienced HBsAg seroconversion. Of these, 6 were HBsAg-ve/HBsAb+ve on entry into this follow-on study and all showed a durable response (430 too). 3 achieved HBsAg seroconversion 2-15 mo into this study with response maintained to last visit. There were 6 pts who were non-durable or retreated; 1 pt regained HBeAg for approx. 6 mo then lost HBeAg without retraatment and remained HBeAg seroconverted at last visit (24 mo). 5 pts (12%) were retreated; 3 were HBV DNA+ve with raised ALTs and 2 had HBeAg+ve/HBeAb-ve hepatitis B (1 pt now HBeAg seroconverted). Normal ALTs were recorded at last visit for 65% (28•43) of HBeAg-ve and 89% (8•9) of HBsAg-ve pts. Conclusions HBeAg loss after lamivudine is an appropriate point to stop therapy as post-treatment responses are durable and may lead to HBsAg seroconversion. Pts with reactivation can respond to a subsequent course of lamivudine.
99