B. Cherubini

Hepatitis B surface antigen serum levels help to distinguish active from inactive hepatitis B virus genotype D carriers.

BACKGROUND & AIMS The accurate identification of inactive (serum HBV-DNA persistently <or=2000 IU/mL) hepatitis B virus (HBV) carriers (IC) is difficult because of wide and frequent HBV-DNA fluctuations. We studied whether hepatitis B surface antigen (HBsAg) serum levels (HBsAgsl) quantification may contribute to diagnosis of HBV phases in untreated hepatitis B e antigen-negative genotype D asymptomatic carriers. METHODS HBsAgsl were measured at baseline and end of follow-up and correlated with virologic and biochemical profiles of 209 consecutive carriers followed-up prospectively (median, 29; range, 12-110 months). HBV phases were defined after 1-year monthly monitoring of HBV-DNA and transaminases. RESULTS HBsAgsl were significantly lower in 56 inactive carriers (IC) than 153 active carriers (AC): median, 62.12 (range, 0.1-4068) vs median, 3029 (range, 0.5-82,480) IU/mL; P<.001. Among AC, HBsAgsl were lower in 31 AC whose viremia remained persistently <20,000 IU/mL (AC1) than in 122 AC with fluctuations>or=20,000 IU/mL (AC2): 883 (0.5-7838) vs 4233 (164-82,480) IU/mL, P=.002. HBV infection was less productive in IC and AC1 than AC2 (log10 HBV-DNA/HBsAgsl ratios 0.25 and 0.49 vs 2.06, respectively, P<.001) and in chronic hepatitis than cirrhosis (1.97 vs 2.34, respectively; P=.023). The combined single point quantification of HBsAg (<1000 IU/mL) and HBV-DNA (<or=2000 IU/mL) identified IC with 94.3% diagnostic accuracy, 91.1% sensitivity, 95.4% specificity, 87.9% positive predictive value, 96.7% negative predictive value. During follow-up, HBsAgsl were stable in AC but declined in IC (yearly median decline, -0.0120 vs -0.0768 log10 IU/mL, respectively, P<.001), 10 of whom cleared HBsAg. CONCLUSIONS HBsAgsl vary during chronic hepatitis B e antigen-negative genotype D infection and are significantly lower in IC. Single-point combined HBsAg and HBV-DNA quantification provides the most accurate identification of IC, comparable with that of long-term tight monitoring.

Response to peginterferon alfa-2a (40KD) in HBeAg-negative CHB: On-treatment kinetics of HBsAg serum levels vary by HBV genotype

BACKGROUND & AIMS We investigated whether HBV genotype influences on-treatment HBsAg kinetics and/or the end-of-treatment HBsAg levels associated with long-term virological response in HBeAg-negative chronic hepatitis B patients treated with peginterferon alfa-2a±lamivudine in the Phase III trial. METHODS All patients (n=230) who participated in long-term follow-up were included according to the availability of HBsAg level measurements. Long-term virological response was defined as HBV DNA ≤ 10,000cp/ml (1786IU/ml) at 5 years post-treatment. Genotype-specific end-of-treatment HBsAg levels associated with long-term virological response (identified by ROC analysis) were assessed in 199 patients with HBsAg measurements available at baseline and end-of-treatment. HBsAg kinetics according to genotype and long-term virological response were investigated in the 117 patients with additional samples available at weeks 12, 24, and 72. RESULTS Baseline HBsAg levels were significantly higher for A than B, C, and D genotypes (p<0.05). On-treatment HBsAg kinetics varied according to HBV genotype. The difference between responders and non-responders was greatest for genotype A from weeks 12-24; for genotypes B and D from baseline to week 12; there was no significant difference over any timeframe for genotype C. High positive predictive values for long-term virological response could be obtained by applying end-of-treatment genotype-specific cut-offs: 75%, 47%, 71%, and 75% for genotypes A (<400IU/ml), B (<50IU/ml), C (<75IU/ml), and D (<1000IU/ml), respectively. CONCLUSIONS On-treatment HBsAg kinetics vary between HBV genotypes. Genotype-specific monitoring timeframes and end-of-treatment thresholds could ameliorate response-guided treatment of HBeAg-negative chronic hepatitis B.

Repeated Measurements of Hepatitis B Surface Antigen Identify Carriers of Inactive HBV During Long-term Follow-up

BACKGROUND & AIMS Measurements of hepatitis B surface antigen (HBsAg) and hepatitis B virus (HBV) DNA might help to identify carriers of inactive HBV. We assessed the performance of repeated measurements of HBsAg over a median time period of 8 years. METHODS We performed a retrospective study of 292 HBe antigen-negative patients with chronic HBV infection, normal levels of alanine aminotransferase (ALT), levels of HBV DNA <20,000 IU/mL, and no cirrhosis who visited the outpatient clinics at 8 tertiary care centers in Europe, Asia, and Australia from 1990 through 2011. Patients were determined to be carriers of inactive HBV (level of HBV DNA <2000 IU/mL and serum levels of ALT that remained normal) or to have HBV activity (level of HBV DNA fluctuating >2000 IU/mL and/or abnormal levels of ALT) after each year of follow-up. Patients were followed for a median time of 8 years (range, 4-9 years). Dynamic regression analysis was used to study changes in level of HBsAg and HBV phase and to update the risk of HBV activity. RESULTS One year after study enrollment, 189 patients (65%) had inactive HBV and 103 patients (35%) had HBV activity. Based on dynamic analysis, the probability that a patient would have HBV at any following year differed according to level of HBsAg; odds were 97% for patients with initial level of HBsAg <100 IU/mL, 85% for patients with initial levels 100-1000 IU/mL, and 76% for patients with initial levels >1000 IU/mL (P < .001). Having inactive virus for any 2 consecutive years predicted having inactive virus in any third year. However, 15% of patients with level of HBsAg >100 IU/mL had HBV activity in the third year. The combination of HBsAg level <100 IU/mL and HBV DNA level <2000 IU/mL identified patients whose virus remained inactive for the entire follow-up period, with 98% specificity and a positive predictive value of 97%, for all HBV genotypes. Patients with HBV activity who had levels of HBV DNA <5000 IU/mL and decreases in HBsAg of 0.5 log IU/mL or more for 1 year had a high probability of becoming carriers of inactive HBV in the next year. CONCLUSIONS In a retrospective, dynamic analysis of almost 300 patients with chronic HBV infection, we found that levels of HBsAg <100 IU/mL identify patients with inactive virus with a high level of specificity. HBsAg levels should therefore be used to define phases of HBV infection in HBe antigen-negative patients.

A Serum MicroRNA Signature Is Associated with the Immune Control of Chronic Hepatitis B Virus Infection

Background and Aims The virus/host interplay mediates liver pathology in chronic HBV infection. MiRNAs play a pivotal role in virus/host interactions and are detected in both serum and HBsAg-particles, but studies of their dynamics during chronic infection and antiviral therapy are missing. We studied serum miRNAs during different phases of chronic HBV infection and antiviral treatment. Methods MiRNAs were profiled by miRCURY-LNA-Universal-RT-miRNA-PCR (Exiqon-A/S) and qPCR-panels-I/II-739-miRNA-assays and single-RT-q-PCRs. Two cohorts of well-characterized HBsAg-carriers were studied (median follow-up 34–52 months): a) training-panel (141 sera) and HBsAg-particles (32 samples) from 61 HBsAg-carriers and b) validation-panel (136 sera) from 84 carriers. Results Thirty-one miRNAs were differentially expressed in inactive-carriers (IC) and chronic-hepatitis-B (CHB) with the largest difference for miR-122-5p, miR-99a-5p and miR-192-5p (liver-specific-miRNAs), over-expressed in both sera and HBsAg-particles of CHB (ANOVA/U-test p-values: <0.000001/0.000001; <0.000001/0.000003; <0.000001/0.000005, respectively) and significantly down-regulated during- and after-treatment in sustained-virological-responders (SVR). MiRNA-profiles of IC and SVR clustered in the heatmap. Liver-miRNAs were combined with miR-335, miR-126 and miR-320a (internal controls) to build a MiR-B-Index with 100% sensitivity, 83.3% and 92.5% specificity (−1.7 cut-off) in both training and validation cohorts to identify IC. MiR-B-Index (−5.72, −20.43/14.38) correlated with ALT (49, 10/2056 U/l, ρ = −0.497, p<0.001), HBV-DNA (4.58, undetectable/>8.3 Log10 IU/mL, ρ = −0.732, p<0.001) and HBsAg (3.40, 0.11/5.49 Log10 IU/mL, ρ = −0.883, p<0.001). At multivariate analysis HBV-DNA (p = 0.002), HBsAg (p<0.001) and infection-phase (p<0.001), but not ALT (p = 0.360) correlated with MiR-B-Index. In SVR to Peg-IFN/NUCs MiR-B-Index improved during-therapy and post-treatment reaching IC-like values (5.32, −1.65/10.91 vs 6.68, 0.54/9.53, p = 0.324) beckoning sustained HBV-immune-control earlier than HBsAg-decline. Conclusions Serum miRNA profile change dynamically during the different phases of chronic HBV infection. We identified a miRNA signature associated with both natural-occurring and therapy-induced immune control of HBV infection. The MiR-B-Index might be a useful biomarker for the early identification of the sustained switch from CHB to inactive HBV-infection in patients treated with antivirals.

OC.09.3: MODELLING HCV DYNAMICS ACCORDING TO IL28B POLYMORPHISM SHOWS DIFFERENT ANTIVIRAL EFFECTS OF PEGIFNS/RIBAVIRIN AND PROVIDES A NEW ACCURATE TOOL FOR TREATMENT MANAGEMENT

Material and methods: 418 consecutive NUC-naive patients with chronic hepatitis B were recruited in 18 Liver Units in Italy and treated with ETV 0.5 mg for 30 months (2-38). Liver function tests and HBV DNA, assessed by a sensitive assays, were performed every 3 months. Virological breakthrough was defined as >1 log U increase of viremia, a “blip” was the reoccurrence of detectable viremia ( 9.0) and ALT were elevated in 85% of the patients. During ETV treatment, 90% of the patients achieved undetectable HBV DNA: virological response rates were 67%, 86%, 92%, 95% and 96% at month 6, 12, 18, 24, and 30. The corresponding features for ALT normalization were 69%, 81%, 85%, 87% and 93%. After achieving undetectable HBV DNA, few patients had blips of viremia which were not confirmed in the following visits in the vast majority of cases. Primary non response at week 12, partial virological response at week 48 and virological breakthroughs occurred in < 1%, 14% and < 1% of the patients. TDF was added to ETV in 17 patients with partial virological response. Of the 39 partial virologial responders at week 48 not rescued with TDF and followed for additional 6-9 months, only 20 (50%) cleared viremia spontaneously. No major safety issues were reported. Median serum creatinine remained unchanged during treatment: from 0.90 (0.50-9.0) at baseline to 0.90 (0.91 (0.50-8.0) mg/dl at the last visit. A greater than 0.3 or 0.5 mg/dl increase of serum creatinine in the last visit versus baseline occurred in 3% and 0.6% of the patients, respectively. Blood phosphorus levels dropped below 2.3 mg/dl in 1% of the patients. Conclusions: The vast majority of NUC-naive patients treated with ETV monotherapy in field practice achieved and maintained a virological response through 30 months.

249 ACCURATE PERSONALIZATION OF PEG-IFN+RBV TREATMENT DURATION BASED ON THE DECLINE OF HCV INFECTED CELLS COMPUTED DURING THE 1ST MONTH OF THERAPY

248 PREVENTIVE EFFECT OF ANTI-VIRAL THERAPY ON THE DEVELOPMENT OF HEPATOCELLULAR CARCINOMA IN PATIENTS WITH CHRONIC HEPATITIS C OR B: A META-REGRESSION APPROACH C.C. Cheng, Y.C. Shen, C. Hsu, F.C. Hu, A.L. Cheng. Department of Medical Research, National Center of Excellence for Clinical Trial and Research, Department of Oncology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan R.O.C. E-mail: chiachi@ntuh.gov.tw

639 MODELLING INFECTED CELL DYNAMICS BY WEEK 4 HCV RNA AND ALT KINETICS ALLOWS FOR INDIVIDUAL TAILORING OF TREATMENT DURATION IN CHRONIC HEPATITIS C PATIENTS

Introduction: Non-sustained response to interferon-based therapies is generally considered treatment failure. However, studies have shown histologic benefits for partial virologic responders. This retrospective analysis assessed histologic response in patients with varying durations of HCV undetectability. Methods: Patients (HCV genotypes 1−6) with baseline and follow-up liver biopsies from 6 Phase III interferon-based trials were analyzed. Blinded biopsies were evaluated by a single pathologist. Improvement or deterioration in necroinflammation and fibrosis were defined as increase or decrease of 1 Metavir score from baseline to 24-weeks post-end of treatment (post-EOT). Breakthroughs and relapsers were defined as patients who initially achieved HCV-RNA undetectability but became HCV-RNA detectable while on treatment or post-EOT, respectively. Results: A total of 1586 patients were analyzed (86% white, 69% male, 59% >40 years, 64% genotype 1). Median baseline necroinflammation and fibrosis scores (range) were 2.0 (0, 3) and 1.0 (0, 4), respectively. Over 70% of patients received peginterferon alfa-2a monotherapy or peginterferon alfa-2a/ribavirin combination therapy. Mean treatment duration was 45 weeks. There was a positive correlation between duration of HCV undetectability and necroinflammation and fibrosis improvement, and an inverse correlation with necroinflammation and fibrosis worsening (Table). SVR patients had the greatest histologic benefit. Relapsers had significantly greater benefits compared with non-responders (P< 0.0001 for both necroinflammation and fibrosis using baseline-adjusted CochranMantel-Haenszel correlation with modified ridit scores). Similarly, relapsers plus breakthroughs had significantly greater benefits compared with non-responders (necroinflammation P=.0001; fibrosis P=.0005). Conclusions: Even in the absence of SVR, histologic improvement was seen in patients with non-sustained viral clearance. The long-term effects of this benefit on clinical outcomes in CHC patients with mild-moderate fibrosis are unknown and need further study.