- Email: [email protected]
Three-year durability of HBeAg and HBsAg seroconversion after lamivudine for chronic hepatitis B (CHB)
HEPATOLOGY g a l . 34, No. 4, Pt. 2, 2001
AASLD ABSTRACTS
315A
571
572
T-CELL MEDIATED IMMUNE RESPONSES IN PATIENTS W I T H HEPATITIS B E ANTIGEN NEGATIVE CHRONIC HEPATITIS B. Dimitrios Vassi-
FIRST U.S. REPORT OF HEPATITIS B VIRUS GENOTYPE DISTRIBUTION A N D CLINICAL OUTCOME AMONG CHRONIC HEPATITIS B PATIENTS. Natalie H Bzowej, CA Pacific Medical Ctr, San Francisco, CA;
lopoulos, Irene Rapti, Margarita Nikolaou, Stephanos J Hadziyannis, Acad Dept of Medicine, Hippokration Gen Hasp, Athens Greece Background: Although it is widely accepted that liver injury in hepatitis B e antigen (HBeAg) negative chronic hepatitis B (CHB) is immune-mediated, few studies have systematically evaluated the role of T cells in this process. Aim: To study T cell responses in patients with HBeAg (-) CHB. Patients-Methods: 32 HbeAg (-)/anti-HBe (+) patients with chronic HBV infection (21 with CHB and 11 with persistently normal ALT values) were studied and compared to a group of heahhy (n = 15) and control patients (n = 12) with chronic hepatitis C (CHC). Peripheral T lymphocyte subsets (CD3/CD4/CD8) were determined by flow cytometry and the functional capacity of peripheral T cells was assessed by flow cytometric measurement of intracellular interferon-T (IFN-T) production after optimal in vitro stimulation with PMA and ionomycin. Proliferating assays of peripheral blood mononuclear cells (PBMC) were performed using s}mthetic peptides (10-20 amino acids long) that covered the entire HBV core region or corresponded to known T cell epitopes from the surface region (HBs 182-191). Results: Patients with HBeAg (-) CHB displayed an expanded subpopulation of peripheral CD8 + T ceils (41 --- i3 %) compared to HBV patients with normal ALT (33 -- 6 %, p=0.03), healthy controls (32 ± 5 %, p=0.006) and patients with CHC (31 -+ 9 %, p=0.02). Patients with CHB demonstrated higher T cell IFN-7 production (37 -+ 14 %) after optimal in vitro stimulation compared both to HBV patients with normal enzymes (25 + 10 %, p=0.009) and healthy controls (20 + 9 %, p > 0.0001). This enhanced response was particularly seen in the subpopulation of CD4 (+) T cells. T lymphoeytes from patients with CHC displayed similarly high IFN-T production (32 -+ 10 %) comparable to that of patients with CHB. Proliferating responses to overlapping HBV core peptides were found in the majority of patients with CHB (71%, 15/21) but only in 18 % of HBV patients with normal enzymes (2/11, p = 0.004) and 14 % of healthy controls (1/7). One third of patients with CHB (33 %) showed proliferating responses to a T cell epitope from the HBV surface region (HBs, 182-191) that has been previously reported only in patients with acute HBV infection. In contrast, none of the patients with chronic HBV infection and normaI enzymes showed such response. Conclusions: 1) The subset of patients with HBeAg (-) CHB demonstrated an exaggerated T cell immune activation pattern compared to chronically infected patients with persistently normaI ALT values. 2) The observed pattern consisted of a unique expansion in peripheral CD8 + T cell numbers, enhanced T cell production of IFN-y in response to optimal in vitro stimulation and proliferating responses of PBMC to a number of synthetic peptides from the HBV core and surface regions. 3) These T cell changes are relevant to the pathogenesis of liver damage in HBeAg (-) CHB.
Hideaki Kato, Masashi Mizokami, Nagoya City University Medical School, Nagoya Japan; Peggy Newsom, Robert G Gish, CA Pacific Medical Ctr, San Francisco, CA Background: Seven genotypes of Hepatitis B virus (HBV) are recognized. The distribution and influence of HBVgenotypeson clinicaloutcome remain unclear. Aims:To investigatethe epidemiologicaldistributionof HBVgenotypesand genotype-relateddifferencesin the pathogenicityof HBV. Methods: Genotypeswere determinedby semi-nestedPCR and restriction fragmentlength polymorphisasanalysis(RFLP)in 165 patients from our hepatologyclinic.Clinicaldata including age, gender, race, ALT, HBeAgstatus and liver biopsy were reviewed. Results: Refer to table. Conclusions:To the best of our knowledge,this is the first report of HBV genotypedistribution within the USA.These data suggest that: 1) all genotypes(A-G) are found in chronic hepatitis B patients from San Francisco;2) genotypeA and C are the major genotypesin this area; 3) Where route of transmissionis known, A is acquiredmost often sexuallyin Caucasiansand C most often verticallyin Asians.These demographicslikely are a result of diverseimmigrationto the United States. No obvious influence of genotype on severity of disease was noted and the analysis of associationswith variousvirologicalfactorsis currentlyunderway.Thus, influenceof genotypeon clinicaloutcomes,including co-infectionwith multiple genotypesrequires further study. HBV Genotypesand Otiniel Corre{aies GenobJpe
A
B
N Mean Age Gender (M:F:UI MeanALT HBeAg+ fig) Cirrhosis
60 47* 49:5:8
18 39 9:2:5
111 32 (52) 8 (67)
49 7 (a4} 2 (40)
5S 25 (451 7 (4t)
12S 4 BI Tx IIVDA 43 U/O 38 (23) 4 {Z4) 2 (1,2) O O I6 (9,?}
5V II UIO
12V 2C 2NTx i ~VDA 3 (1,8) 45 (27) 0 g O 8 (4,8}
(n)~o)
Transminion R~,uf~e(N) Oauc Asiae Hispanic Black
1 (O,B) I2 (7,3) 2 (! 2) 0 0 1 (o.g}
C
D
E
F
G*~
I 14 l:&g
5 49 5:0:0
8 38 &1:1
61 $ (32) 5 (I00)
g2 1 000} 0 (0)
45 0 (01 I (100}
g4 7 (88) 0 (0}
3V 16 U!O
1C
5U~O
4S 2 B} T× 2U/O
8 (4.8) 2 (1.2) 0 0 2('L2) 7 (42)
0 0 0 1 (0,6) 0 0
56 19 40 48 36:10:10 13:4~2
2 {1,2) 7 (42l 0 O 3 (1.8} 1 (0,6} 0 0 0,** 0 0 u 0 0 0 Abbreviations: S=~:{uaL BI Tx= BtoodTranslus~en;g©A=lnt,avermusdrug use; O=Unkrlawn: O=Oi~er: VaIussfor r~:e representedby N (% ef N patients), ,,T~lemean age of genotype A was signiScentlyNsher than tha! of geno{ype B (p=0,0162i, C (p=0 0260) and G {9=0 0242), **Seven of 8 svbiee~ werec.o-infect~ with genotypaA ~**This group incfuden an East indian sub~t from Afghanistan
573
574
CLINAL PICUTURE OF PATIENTS W I T H YMDD M U T A N T S W H O HAD
THREE-YEAR DURABILITY OF HBEAG A N D HBSAG SEROCONVERSION AFTER LAMIVUDINE FOR CHRONIC HEPATITIS B (CHB). Bernard
NOT BEEN TREATED W I T H LAMIVUDINE. Ryukichi Kumashiro, Tatastya Ide, Satsuki Kobayasi, Shiro Murashima, Kei Ogata, Akiko Hisamochi, Yuriko Koga, Teruko Hino, Takato Ueno, Michio Sara, Kurume University, Kurume City Japan [Background and aim] Mutational changes in the YMDD motif of hepatitis B vurus (HBV) DNA polymerase gene are usually found later than 6 months from the beginning of lamivudine therapy in patients with chronic hepatitis B. We found that there exits YMDD mutants in hepatitis B virus (HBV) carrier who had not been treated with lamivudine (Kobayashi S, et al. 2001,J Hepatology). Aim of this study is to clarify the clinical characteristics of these patients. Methods: YMDD mutations were detected by the mini-sequence method ( Kobayashi S, et al. 2000, Hepatology Research). We studied retrospectively the clinical characteristics of 5 patients with YMDD mutation. Results: Age distrubuted from 26 to 63 with a median of 57. They were 3 males and 2 females. Serum levels of ALT and AST were all normal (median 22 and 18 IU/I, respectively). Hepatitis Bs antigen (HBsAg) was positive in 3 and negative in 2 as determined by RIA. HBeAg was negative in all patients associated with positive anti-HBe. HBV DNA was negative in the sera as determined either by DNA probe assay or transcription amplification and hybribdization (TMA method), with a detection limit of 5000 copies (or genome equivalents) (Kamisango et al. J Clin Microbial 1999). None of these patients were positive for anti-HCV and one was positive for anti-nuclear antibody (homogenous type). Three of them had relatives with HBV related diseases. They were followed in our hospital for 2 to 10 years and during these period serum levels of ALT remained normal except one patients with alcoholic history. In 2 patients who were negative for HBsAg, positive results for HBsAg was documented 13 to 16 years ago in the first visit records. Changes in the YMDD motif were YMDD +YIDD in 3 subjects and YMDD+YVDD+YIDD in 2 subjects. Conclusion: YMDD mutant viruses are present in lamivuvine-untreated asymptomatic HBV carriers as well.
Willems, Hgpital Saint-Luc du Centre Hospitalier de l'Universit~ de Montreal, Montreal Canada; Janusz Cianciara, Medical Academy of Warsaw, Warsaw Poland; Selim Karayalcin, Ankara Univ Medical Sch, Ankara Turkey; Kris V Kowdley, Univ Washington Medical Center, Seattle, WA; Stanislev Plisek, Infekeni Klinika, Hradec Kralove Czech Republic; Mary Woessner, GlaxoSmithKline, Research Triangle Park, NC; Susan McMullen, GlaxoSmithKIine, Research Triangle Prak, NC; Stephen Gardner, GlaxoSmithKline, Research Triangle Park, NC; Eugene Schiff, Univ of Miami, Miami, FL Introduction: 41 CHB subjects who demonstrated HBeAg response (40/41 HBeAg-, HBeAb+) after lamivudine in previous trials are being followed offtreatment in this observational study to assess durability of serologic response. Recruitment occurred within 12 months of completion of the previous qualifying trial. Subjects may be retreated with lamivudine if they experience reactivation. Objective: To assess the durability of HBeAg and HBsAg response to previous lamivudine treatment. Results: 31/41 (76%) subjects have now reached 3 years of follow-up in this 5-year study, 1 of these discontinued at the 3-year visit; 6 additional subjects are on-study but have not yet reached year 3. Five subjects (12%) have d i s c o n t i n u e d - 4 before 3 years and the one at 3 years. Subjects are predominantly male (78%), Caucasian (78%) or Asian (12%), with a mean age of 40.6. At this interim analysis, median duration of study participation is 36.6 months (range 4.8-45.6) and 77% (30/39) of subjects show durable HBeAg seroconversion (HBeAg-, HBeAb +). There are 9 subjects who are non-durable. Eight of these (21%) were retreated; 3 had HBeAg+ve hepatitis B (2 now HBeAg re-seroconverted) and 5 were HBeAg-, but were HBV DNA + ve or had raised ALTs. Normal ALTs were recorded at last visit for 63% (26/41) of subjects. Of the 9 non-durabIe subjects, 7 (78%) were Caucasian, 1 (11%) was Asian and 1 (11%) was Hispanic. Importantly, the number of subjects who have lost HBsAg continues to increase during this observational study. Ten subjects (24%) have now lost HBsAg: 6 were HBsAg negative on entry into this follow-on study and all 6 have maintained this response (4-42 months); 4 additional subjects lost HBsAg (3/4 also were HBsAb+) 2-36 months into this study, with response maintained to last visit. Conclusions: Results from this ongoing study continue to show that HBeAg seroconversion after lamivudine is an appropriate point to stop therapy as post-treatment responses are durable and may lead to HBsAg seroconversion. Subjects with reactivation of disease can respond to a subsequent course of lamivudine.
AASLD ABSTRACTS
315A
571
572
T-CELL MEDIATED IMMUNE RESPONSES IN PATIENTS W I T H HEPATITIS B E ANTIGEN NEGATIVE CHRONIC HEPATITIS B. Dimitrios Vassi-
FIRST U.S. REPORT OF HEPATITIS B VIRUS GENOTYPE DISTRIBUTION A N D CLINICAL OUTCOME AMONG CHRONIC HEPATITIS B PATIENTS. Natalie H Bzowej, CA Pacific Medical Ctr, San Francisco, CA;
lopoulos, Irene Rapti, Margarita Nikolaou, Stephanos J Hadziyannis, Acad Dept of Medicine, Hippokration Gen Hasp, Athens Greece Background: Although it is widely accepted that liver injury in hepatitis B e antigen (HBeAg) negative chronic hepatitis B (CHB) is immune-mediated, few studies have systematically evaluated the role of T cells in this process. Aim: To study T cell responses in patients with HBeAg (-) CHB. Patients-Methods: 32 HbeAg (-)/anti-HBe (+) patients with chronic HBV infection (21 with CHB and 11 with persistently normal ALT values) were studied and compared to a group of heahhy (n = 15) and control patients (n = 12) with chronic hepatitis C (CHC). Peripheral T lymphocyte subsets (CD3/CD4/CD8) were determined by flow cytometry and the functional capacity of peripheral T cells was assessed by flow cytometric measurement of intracellular interferon-T (IFN-T) production after optimal in vitro stimulation with PMA and ionomycin. Proliferating assays of peripheral blood mononuclear cells (PBMC) were performed using s}mthetic peptides (10-20 amino acids long) that covered the entire HBV core region or corresponded to known T cell epitopes from the surface region (HBs 182-191). Results: Patients with HBeAg (-) CHB displayed an expanded subpopulation of peripheral CD8 + T ceils (41 --- i3 %) compared to HBV patients with normal ALT (33 -- 6 %, p=0.03), healthy controls (32 ± 5 %, p=0.006) and patients with CHC (31 -+ 9 %, p=0.02). Patients with CHB demonstrated higher T cell IFN-7 production (37 -+ 14 %) after optimal in vitro stimulation compared both to HBV patients with normal enzymes (25 + 10 %, p=0.009) and healthy controls (20 + 9 %, p > 0.0001). This enhanced response was particularly seen in the subpopulation of CD4 (+) T cells. T lymphoeytes from patients with CHC displayed similarly high IFN-T production (32 -+ 10 %) comparable to that of patients with CHB. Proliferating responses to overlapping HBV core peptides were found in the majority of patients with CHB (71%, 15/21) but only in 18 % of HBV patients with normal enzymes (2/11, p = 0.004) and 14 % of healthy controls (1/7). One third of patients with CHB (33 %) showed proliferating responses to a T cell epitope from the HBV surface region (HBs, 182-191) that has been previously reported only in patients with acute HBV infection. In contrast, none of the patients with chronic HBV infection and normaI enzymes showed such response. Conclusions: 1) The subset of patients with HBeAg (-) CHB demonstrated an exaggerated T cell immune activation pattern compared to chronically infected patients with persistently normaI ALT values. 2) The observed pattern consisted of a unique expansion in peripheral CD8 + T cell numbers, enhanced T cell production of IFN-y in response to optimal in vitro stimulation and proliferating responses of PBMC to a number of synthetic peptides from the HBV core and surface regions. 3) These T cell changes are relevant to the pathogenesis of liver damage in HBeAg (-) CHB.
Hideaki Kato, Masashi Mizokami, Nagoya City University Medical School, Nagoya Japan; Peggy Newsom, Robert G Gish, CA Pacific Medical Ctr, San Francisco, CA Background: Seven genotypes of Hepatitis B virus (HBV) are recognized. The distribution and influence of HBVgenotypeson clinicaloutcome remain unclear. Aims:To investigatethe epidemiologicaldistributionof HBVgenotypesand genotype-relateddifferencesin the pathogenicityof HBV. Methods: Genotypeswere determinedby semi-nestedPCR and restriction fragmentlength polymorphisasanalysis(RFLP)in 165 patients from our hepatologyclinic.Clinicaldata including age, gender, race, ALT, HBeAgstatus and liver biopsy were reviewed. Results: Refer to table. Conclusions:To the best of our knowledge,this is the first report of HBV genotypedistribution within the USA.These data suggest that: 1) all genotypes(A-G) are found in chronic hepatitis B patients from San Francisco;2) genotypeA and C are the major genotypesin this area; 3) Where route of transmissionis known, A is acquiredmost often sexuallyin Caucasiansand C most often verticallyin Asians.These demographicslikely are a result of diverseimmigrationto the United States. No obvious influence of genotype on severity of disease was noted and the analysis of associationswith variousvirologicalfactorsis currentlyunderway.Thus, influenceof genotypeon clinicaloutcomes,including co-infectionwith multiple genotypesrequires further study. HBV Genotypesand Otiniel Corre{aies GenobJpe
A
B
N Mean Age Gender (M:F:UI MeanALT HBeAg+ fig) Cirrhosis
60 47* 49:5:8
18 39 9:2:5
111 32 (52) 8 (67)
49 7 (a4} 2 (40)
5S 25 (451 7 (4t)
12S 4 BI Tx IIVDA 43 U/O 38 (23) 4 {Z4) 2 (1,2) O O I6 (9,?}
5V II UIO
12V 2C 2NTx i ~VDA 3 (1,8) 45 (27) 0 g O 8 (4,8}
(n)~o)
Transminion R~,uf~e(N) Oauc Asiae Hispanic Black
1 (O,B) I2 (7,3) 2 (! 2) 0 0 1 (o.g}
C
D
E
F
G*~
I 14 l:&g
5 49 5:0:0
8 38 &1:1
61 $ (32) 5 (I00)
g2 1 000} 0 (0)
45 0 (01 I (100}
g4 7 (88) 0 (0}
3V 16 U!O
1C
5U~O
4S 2 B} T× 2U/O
8 (4.8) 2 (1.2) 0 0 2('L2) 7 (42)
0 0 0 1 (0,6) 0 0
56 19 40 48 36:10:10 13:4~2
2 {1,2) 7 (42l 0 O 3 (1.8} 1 (0,6} 0 0 0,** 0 0 u 0 0 0 Abbreviations: S=~:{uaL BI Tx= BtoodTranslus~en;g©A=lnt,avermusdrug use; O=Unkrlawn: O=Oi~er: VaIussfor r~:e representedby N (% ef N patients), ,,T~lemean age of genotype A was signiScentlyNsher than tha! of geno{ype B (p=0,0162i, C (p=0 0260) and G {9=0 0242), **Seven of 8 svbiee~ werec.o-infect~ with genotypaA ~**This group incfuden an East indian sub~t from Afghanistan
573
574
CLINAL PICUTURE OF PATIENTS W I T H YMDD M U T A N T S W H O HAD
THREE-YEAR DURABILITY OF HBEAG A N D HBSAG SEROCONVERSION AFTER LAMIVUDINE FOR CHRONIC HEPATITIS B (CHB). Bernard
NOT BEEN TREATED W I T H LAMIVUDINE. Ryukichi Kumashiro, Tatastya Ide, Satsuki Kobayasi, Shiro Murashima, Kei Ogata, Akiko Hisamochi, Yuriko Koga, Teruko Hino, Takato Ueno, Michio Sara, Kurume University, Kurume City Japan [Background and aim] Mutational changes in the YMDD motif of hepatitis B vurus (HBV) DNA polymerase gene are usually found later than 6 months from the beginning of lamivudine therapy in patients with chronic hepatitis B. We found that there exits YMDD mutants in hepatitis B virus (HBV) carrier who had not been treated with lamivudine (Kobayashi S, et al. 2001,J Hepatology). Aim of this study is to clarify the clinical characteristics of these patients. Methods: YMDD mutations were detected by the mini-sequence method ( Kobayashi S, et al. 2000, Hepatology Research). We studied retrospectively the clinical characteristics of 5 patients with YMDD mutation. Results: Age distrubuted from 26 to 63 with a median of 57. They were 3 males and 2 females. Serum levels of ALT and AST were all normal (median 22 and 18 IU/I, respectively). Hepatitis Bs antigen (HBsAg) was positive in 3 and negative in 2 as determined by RIA. HBeAg was negative in all patients associated with positive anti-HBe. HBV DNA was negative in the sera as determined either by DNA probe assay or transcription amplification and hybribdization (TMA method), with a detection limit of 5000 copies (or genome equivalents) (Kamisango et al. J Clin Microbial 1999). None of these patients were positive for anti-HCV and one was positive for anti-nuclear antibody (homogenous type). Three of them had relatives with HBV related diseases. They were followed in our hospital for 2 to 10 years and during these period serum levels of ALT remained normal except one patients with alcoholic history. In 2 patients who were negative for HBsAg, positive results for HBsAg was documented 13 to 16 years ago in the first visit records. Changes in the YMDD motif were YMDD +YIDD in 3 subjects and YMDD+YVDD+YIDD in 2 subjects. Conclusion: YMDD mutant viruses are present in lamivuvine-untreated asymptomatic HBV carriers as well.
Willems, Hgpital Saint-Luc du Centre Hospitalier de l'Universit~ de Montreal, Montreal Canada; Janusz Cianciara, Medical Academy of Warsaw, Warsaw Poland; Selim Karayalcin, Ankara Univ Medical Sch, Ankara Turkey; Kris V Kowdley, Univ Washington Medical Center, Seattle, WA; Stanislev Plisek, Infekeni Klinika, Hradec Kralove Czech Republic; Mary Woessner, GlaxoSmithKline, Research Triangle Park, NC; Susan McMullen, GlaxoSmithKIine, Research Triangle Prak, NC; Stephen Gardner, GlaxoSmithKline, Research Triangle Park, NC; Eugene Schiff, Univ of Miami, Miami, FL Introduction: 41 CHB subjects who demonstrated HBeAg response (40/41 HBeAg-, HBeAb+) after lamivudine in previous trials are being followed offtreatment in this observational study to assess durability of serologic response. Recruitment occurred within 12 months of completion of the previous qualifying trial. Subjects may be retreated with lamivudine if they experience reactivation. Objective: To assess the durability of HBeAg and HBsAg response to previous lamivudine treatment. Results: 31/41 (76%) subjects have now reached 3 years of follow-up in this 5-year study, 1 of these discontinued at the 3-year visit; 6 additional subjects are on-study but have not yet reached year 3. Five subjects (12%) have d i s c o n t i n u e d - 4 before 3 years and the one at 3 years. Subjects are predominantly male (78%), Caucasian (78%) or Asian (12%), with a mean age of 40.6. At this interim analysis, median duration of study participation is 36.6 months (range 4.8-45.6) and 77% (30/39) of subjects show durable HBeAg seroconversion (HBeAg-, HBeAb +). There are 9 subjects who are non-durable. Eight of these (21%) were retreated; 3 had HBeAg+ve hepatitis B (2 now HBeAg re-seroconverted) and 5 were HBeAg-, but were HBV DNA + ve or had raised ALTs. Normal ALTs were recorded at last visit for 63% (26/41) of subjects. Of the 9 non-durabIe subjects, 7 (78%) were Caucasian, 1 (11%) was Asian and 1 (11%) was Hispanic. Importantly, the number of subjects who have lost HBsAg continues to increase during this observational study. Ten subjects (24%) have now lost HBsAg: 6 were HBsAg negative on entry into this follow-on study and all 6 have maintained this response (4-42 months); 4 additional subjects lost HBsAg (3/4 also were HBsAb+) 2-36 months into this study, with response maintained to last visit. Conclusions: Results from this ongoing study continue to show that HBeAg seroconversion after lamivudine is an appropriate point to stop therapy as post-treatment responses are durable and may lead to HBsAg seroconversion. Subjects with reactivation of disease can respond to a subsequent course of lamivudine.