C. Pasquazzi

Hepatotoxicity development during antiretroviral therapy containing protease inhibitors in patients with HIV: The role of hepatitis B and C virus infection

&NA; Summary: To evaluate the occurrence of hepatotoxicity in patients during antiretroviral therapy (ART) that contains protease inhibitors and the role of hepatitis viruses in its development, we performed a retrospective study including 1325 HIV‐infected patients treated with ART for at least 6 months. Presence or absence of hepatitis viruses, alanine aminotransferase (ALT), total bilirubin, CD4 cell count, and plasma HIV RNA levels were evaluated. Hepatotoxicity developed in a few study subjects without coinfection, whereas it was significantly higher in coinfected patients. Univariate logistic regression analysis showed that viral hepatitis coinfections are independent risk factors for hepatotoxicity. After 6 months of treatment, ritonavir was associated with higher rates of severe hepatotoxicity in the coinfected group; in fact, ritonavir seems to be the most strongly hepatotoxic agent among coinfected patients. After 12 months of therapy, hepatotoxicity occurred more frequently in patients with hepatitis C virus who did not respond to antiretroviral therapy (ART), whereas patients who did respond to ART showed decreased ALT levels. Hepatotoxicity is not exclusively an effect of drug toxicity, and the presence of hepatitis coinfection is an independent risk factor. Moreover, chronic hepatotoxicity mainly occurs in patients who did not respond to therapy. Conversely, patients who did respond to ART seemed to show improvement of chronic liver infection.

Correlation of serum aminotransferases with HCV RNA levels and histological findings in patients with chronic hepatitis C: The role of serum aspartate transaminase in the evaluation of disease progression

Objectives To investigate whether HCV RNA levels can be considered to be predictors of hepatocellular injury in patients with chronic hepatitis C, and whether aminotransferase levels are markers of liver damage. Methods We performed a retrospective study on 112 patients with chronic hepatitis C. For each patient, we considered the baseline alanine aminotransferase (ALT) and serum aspartate transaminase (AST) levels, baseline HCV RNA, HCV genotype, histological evaluation and the mean aminotransferase levels measured in the 6 months following liver biopsy. Results We found a statistically significant correlation between HCV RNA and aminotransferase levels measured during the follow-up (AST: r = 0.24, P = 0.01; ALT: r = 0.27, P = 0.004). We also observed a statistically significant correlation between HCV RNA levels and histological activity index (HAI) (r = 0.25, P = 0.008), as well as between the HAI and both baseline AST (r = 0.34, P = 0.0002) and ALT levels (r = 0.23, P = 0.01). These findings were confirmed by the mean aminotransferase values during follow-up. In the regression analysis, the fibrosis score was significantly and independently associated with baseline AST and ALT values. Conclusions Our results demonstrate a statistically significant correlation of aminotransferase values with the histological parameters, and an even stronger correlation with the AST values. Our study therefore suggests that aminotransferase values, especially AST, may correlate with liver damage.

Multiclass HCV resistance to direct-acting antiviral failure in real-life patients advocates for tailored second-line therapies

Despite the excellent efficacy of direct‐acting antivirals (DAA) reported in clinical trials, virological failures can occur, often associated with the development of resistance‐associated substitutions (RASs). This study aimed to characterize the presence of clinically relevant RASs to all classes in real‐life DAA failures.

Undetectable phospho‐STAT1 in peripheral blood mononuclear cells from patients with chronic hepatitis C who do not respond to interferon‐α therapy

Abstract: Background: Recent studies have suggested that phosphorylated signal transducers and activators of transcription 1 (STAT1) plays an important role in interferon (IFN)‐mediated biological functions, including antiviral activity. Moreover, it has been demonstrated that suppressors of the cytokine signal 1 (SOCS1) negatively regulates IFN activities.

Alanine aminotransferase decrease in HIV-hepatitis C virus co-infected patients responding to antiretroviral therapy

Diaz et al. [1] recently reported a case of the normalization of liver enzymes in an HIV–hepatitis C virus (HCV) co-infected patient after potent antiretroviral therapy (ART). The authors suggested that ART may diminish the risk of hepatitis C progression to cirrhosis [1]. We previously found alanine aminotransferase (ALT) levels to be decreased in HIV–HCV co-infected patients responding to ART [2]. The aim of this study was to evaluate the occurrence of hepatotoxicity in patients during ART containing protease inhibitors (PI) and the role of hepatitis viruses in its development. A total of 1325 HIV patients treated with ART for at least 6 months were enrolled. The presence or absence of hepatitis viruses, ALT, CD4 cell count, and plasma HIV-RNA levels were retrospectively evaluated. The occurrence of hepatotoxicity was defined by a serum ALT increase relative to the upper limit of normal values. For patients with elevated pretreatment serum ALT, liver toxicity was classified by considering the increase relative to baseline values. A total of 616 out of 1325 patients (46.5%) were anti-HCV positive (384 men, 232 women, mean age 35 8.6 years). Of these patients, 453 individuals (73.5%) were intravenous drug users, 77 patients (12.5%) were heterosexual, 41 patients (6.7%) were homosexual and 45 patients (7.3%) showed other HIV transmission routes. One hundred and four HCV-co-infected patients (16.9%) were chronic alcohol abusers. Hepatotoxicity was found in 92 out of 616 HCV-co-infected patients after 6 months, in 71 out of 474 HCV-co-infected patients after 12 months, and in 42 out of 227 HCV-coinfected patients after 24 months of treatment. Univariate logistic regression analysis showed that HCV co-infection is an independent risk factor for the development of hepatotoxicity after 6 [odds ratio (OR) 6.79, 95% confidence interval (CI) 4.57–10.09; P , 0.0001], 12 (OR 5.76, 95% CI 3.66–9.16; P , 0.0001) and 24 months of treatment (OR 12.14, 95% CI 5.28–27.91; P , 0.0001). In HCV-co-infected patients, after 12 months of treatment, the incidence of hepatotoxicity was higher in patients with no CD4 cell increase when compared with patients with a CD4 cell count increase (20.9 versus 10.2%; P 1⁄4 0.017, OR 2.3, 95% CI 1.15–4.7). Moreover, after 12 months of treatment, the incidence of liver toxicity was significantly greater in HCV-co-infected patients with an increase in HIV viral load compared with patients with stable or decreased HIV-RNA levels (34 versus 13%; P 1⁄4 0.018). Conversely, after 12 and 24 months of therapy, in HCV-co-infected patients, the ALT decrease was found to be higher in patients with a CD4 cell count increase comcompared with patients without a CD4 cell increase (12 months: 25.5 versus 15.8%; P 1⁄4 0.03; OR 1.8, 95% CI 1.03–3.23; 24 months: 30.9 versus 13.9%; P 1⁄4 0.006; OR 3.22, 95% CI 1.4– 7.9). Moreover, after 12 months of treatment, ALT levels were significantly correlated with the HIV viral load (P 1⁄4 0.018; OR 0.627, 95% CI 0.425–0.924) [2].

Ombitasvir/Paritaprevir/Ritonavir and Dasabuvir Combination Treatment in Patients with HIV/HCV Co-Infection: Results of an Italian Compassionate Use Program.

Patients co-infected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are at high risk of liver disease progression. We report a favorable safety profile and SVR12 rates of 96.7% among HIV/HCV co-infected patients participating in an Italian compassionate-use program of ombitasvir/paritaprevir/ritonavir + dasabuvir (OBV/PTV/r + DSV) ± ribavirin (RBV).

Development of hepatotoxicity in HIV patients switching at least one protease inhibitor

In order to evaluate the occurrence of hepatotoxicity in patients treated with antiretroviral therapy (ART) who switch protease inhibitor (PI), and the role of viral hepatitis in its development, we performed a retrospective study on 182 HIV patients treated with ART for 24 months. The presence of hepatitis viruses and alanine transaminase levels were evaluated. Hepatotoxicity developed in a low number of subjects without co-infection, but was significantly higher in co-infected patients (14/51 versus 62/131, P = 0.01). Ritonavir was associated with higher rates of severe hepatotoxicity in the co-infected group. Patients presenting any problems related to ART, including the development of hepatotoxicity, continued therapy by switching PI. The occurrence of hepatotoxicity with second/third choice PIs, including ritonavir, remained stable. Our results suggest that switching PI does not increase the occurrence of drug-related liver toxicity.

Improvement of ALT decay kinetics by all-oral HCV treatment: Role of NS5A inhibitors and differences with IFN-based regimens

Background Intracellular HCV-RNA reduction is a proposed mechanism of action of direct-acting antivirals (DAAs), alternative to hepatocytes elimination by pegylated-interferon plus ribavirin (PR). We modeled ALT and HCV-RNA kinetics in cirrhotic patients treated with currently-used all-DAA combinations to evaluate their mode of action and cytotoxicity compared with telaprevir (TVR)+PR. Study design Mathematical modeling of ALT and HCV-RNA kinetics was performed in 111 HCV-1 cirrhotic patients, 81 treated with all-DAA regimens and 30 with TVR+PR. Kinetic-models and Cox-analysis were used to assess determinants of ALT-decay and normalization. Results HCV-RNA kinetics was biphasic, reflecting a mean effectiveness in blocking viral production >99.8%. The first-phase of viral-decline was faster in patients receiving NS5A-inhibitors compared to TVR+PR or sofosbuvir+simeprevir (p<0.001), reflecting higher efficacy in blocking assembly/secretion. The second-phase, noted δ and attributed to infected-cell loss, was faster in patients receiving TVR+PR or sofosbuvir+simeprevir compared to NS5A-inhibitors (0.27 vs 0.21 d-1, respectively, p = 0.0012). In contrast the rate of ALT-normalization, noted λ, was slower in patients receiving TVR+PR or sofosbuvir+simeprevir compared to NS5A-inhibitors (0.17 vs 0.27 d-1, respectively, p<0.001). There was no significant association between the second-phase of viral-decline and ALT normalization rate and, for a given level of viral reduction, ALT-normalization was more profound in patients receiving DAA, and NS5A in particular, than TVR+PR. Conclusions Our data support a process of HCV-clearance by all-DAA regimens potentiated by NS5A-inhibitor, and less relying upon hepatocyte death than IFN-containing regimens. This may underline a process of “cell-cure” by DAAs, leading to a fast improvement of liver homeostasis.

Novel HBsAg mutations correlate with hepatocellular carcinoma, hamper HBsAg secretion and promote cell proliferation in vitro

Background An impaired HBsAg-secretion can increase HBV oncogenic-properties. Here, we investigate genetic-determinants in HBsAg correlated with HBV-induced hepatocellular carcinoma (HCC), and their impact on HBsAg-secretion and cell-proliferation. Methods This study included 128 chronically HBV-infected patients: 23 with HCC (73.9% D; 26.1% A HBV-genotype), and 105 without cirrhosis/HCC (72.4% D, 27.6% A) as reference-group. The impact of mutations on HBsAg-secretion was assessed by measuring the ratio [secreted/intracellular HBsAg] until day 5 post-transfection. The impact of mutations on cell-cycle advancement was assessed by flow-cytometry. Results Two HBsAg mutations significantly correlated with HCC: P203Q (17.4% [4/23] in HCC vs 1.0% [1/105] in non-HCC, P=0.004); S210R (34.8% [8/23] in HCC vs 3.8% [4/105] in non-HCC, P <0.001); P203Q+S210R (17.4% [4/23] in HCC vs 0% [0/110] in non-HCC, P=0.001). Both mutations reside in trans-membrane C-terminal domain critical for HBsAg-secretion. In in-vitro experiments, P203Q, S210R and P203Q+S210R significantly reduced the ratio [secreted/intracellular HBsAg] compared to wt at each time-point analysed (P <0.05), supporting an impaired HBsAg-secretion. Furthermore, P203Q and P203Q+S210R increased the percentage of cells in S-phase compared to wt, indicating cell-cycle progression (P203Q:26±13%; P203Q+S210R:29±14%; wt:18%±9, P <0.01. Additionally, S210R increased the percentage of cells in G2/M-phase (26±8% for wt versus 33±6% for S210R, P <0.001). Conclusions Specific mutations in HBsAg C-terminus significantly correlate with HBV-induced HCC. They hamper HBsAg-secretion and are associated with increased cellular proliferation, supporting their involvement in HCC-development. The identification of viral genetic markers associated with HCC is critical to identify patients at higher HCC-risk that may deserve intensive liver monitoring, and/or early anti-HBV therapy.

Frequent NS5A and multiclass resistance in almost all HCV genotypes at DAA failures: what are the chances for second-line regimens?

Velia Chiara Di Maio, Valeria Cento, Marianna Aragri, Stefania Paolucci, Teresa Pollicino, Nicola Coppola, Bianca Bruzzone, Valeria Ghisetti, Maurizio Zazzi, Maurizia Brunetto, Ada Bertoli, Silvia Barbaliscia, Silvia Galli, William Gennari, Fausto Baldanti, Giovanni Raimondo, Carlo Federico Perno, Francesca Ceccherini-Silberstein, on behalf of treatment team of the HCV Virology Italian Resistance Network (VIRONET-C),