Hannelore Tenckhoff

A Polymorphism Near IL28B Is Associated With Spontaneous Clearance of Acute Hepatitis C Virus and Jaundice

BACKGROUND & AIMS A single nucleotide polymorphism (SNP) upstream of the IL28B gene has been associated with response of patients with chronic hepatitis C to therapy with pegylated interferon and ribavirin and also with spontaneous clearance of acute hepatitis C in a heterogeneous population. We analyzed the association between IL28B and the clinical presentation of acute hepatitis C virus (HCV) infection in a homogeneous population. METHODS We analyzed the SNP rs12979860 in 190 women from the German anti-D cohort (infected with HCV genotype 1b via contaminated rhesus prophylaxis) and its association with spontaneous clearance. Clinical data were available in 136 women with acute infection who were also evaluated for IL28B genotype. Based on results of a TaqMan polymerase chain reaction assay, the rs12979860 SNP genotypes studied were C/C, C/T, or T/T. RESULTS Spontaneous clearance was more common in patients with the C/C genotype (43/67; 64%) compared with C/T (22/90; 24%) or T/T (2/33; 6%) (P < .001). Jaundice during acute infection was more common among patients with C/C genotype (32.7%) than non-C/C patients (with C/T or T/T) (16.1%; P = .032). In C/C patients, jaundice during acute infection was not associated with an increased chance of spontaneous clearance (56.3%) compared with those without jaundice (60.6%). In contrast, in non-C/C patients, jaundice was associated with a higher likelihood of spontaneous clearance (42.9%) compared with those without jaundice (13.7%). CONCLUSIONS The SNP rs12979860 upstream of IL28B is associated with spontaneous clearance of HCV. Women with the C/T or T/T genotype who did not develop jaundice had a lower chance of spontaneous clearance of HCV infection.

Non-Invasive Assessment of Hepatic Steatosis in Patients with NAFLD Using Controlled Attenuation Parameter and 1H-MR Spectroscopy

Introduction Non-invasive assessment of steatosis and fibrosis is of growing relevance in non-alcoholic fatty liver disease (NAFLD). 1H-Magnetic resonance spectroscopy (1H-MRS) and the ultrasound-based controlled attenuation parameter (CAP) correlate with biopsy proven steatosis, but have not been correlated with each other so far. We therefore performed a head-to-head comparison between both methods. Methods Fifty patients with biopsy-proven NAFLD and 15 healthy volunteers were evaluated with 1H-MRS and transient elastography (TE) including CAP. Steatosis was defined according to the percentage of affected hepatocytes: S1 5-33%, S2 34–66%, S3 ≥67%. Results Steatosis grade in patients with NAFLD was S1 36%, S2 40% and S3 24%. CAP and 1H-MRS significantly correlated with histopathology and showed comparable accuracy for the detection of hepatic steatosis: areas under the receiver-operating characteristics curves were 0.93 vs. 0.88 for steatosis ≥S1 and 0.94 vs. 0.88 for ≥S2, respectively. Boot-strapping analysis revealed a CAP cut-off of 300 dB/m for detection of S2-3 steatosis, while retaining the lower cut-off of 215 dB/m for the definition of healthy individuals. Direct comparison between CAP and 1H-MRS revealed only modest correlation (total cohort: r = 0.63 [0.44, 0.76]; NAFLD cases: r = 0.56 [0.32, 0.74]). For detection of F2–4 fibrosis TE had sensitivity and specificity of 100% and 98.1% at a cut-off value of 8.85 kPa. Conclusion Our data suggest a comparable diagnostic value of CAP and 1H-MRS for hepatic steatosis quantification. Combined with the simultaneous TE fibrosis assessment, CAP represents an efficient method for non-invasive characterization of NAFLD. Limited correlation between CAP and 1H-MRS may be explained by different technical aspects, anthropometry, and presence of advanced liver fibrosis.

Evaluation of liver disease progression in the German hepatitis C virus (1b)‐contaminated anti‐D cohort at 35 years after infection

The natural course of HCV infection remains controversial. The German HCV (1b)‐contaminated anti‐D cohort provides an ideal population to investigate the natural course of HCV infection in a large, homogenous cohort of young women from the date of HCV inoculation. Our previous follow‐up studies at 20 and 25 years after infection suggested slow fibrosis progression rates in this unique cohort. The aim of our prospective, community‐based, multicenter study was to reevaluate the liver disease progression in 718 patients of the original anti‐D cohort at 35 years after infection. Patients with self‐limited HCV infection (n = 189) were compared to those who failed to eliminate the virus spontaneously (n = 529), comprising patients who were treatment naïve (n = 197) or achieved a sustained virological response (SVR; n = 149), respectively, failed to clear the virus (non‐SVR; n = 183) after antiviral therapy. In the overall cohort, 9.3% of patients showed clinical signs of liver cirrhosis at 35 years after infection. Liver disease progression largely depended on HCV infection status. The highest proportion of patients with clinical signs of end‐stage liver disease was observed in the non‐SVR group (15.3%), whereas decreased cirrhosis rates were detected in the SVR group (6%) and in patients with self‐limited HCV infection (1.1%; P = 6.2 × 10−6). Overall survival was significantly enhanced after SVR, compared to treatment‐naïve patients or non‐SVR (P = 0.027). Conclusion: The present study provides further evidence for a mild, but significant, disease progression at 35 years after infection in the German HCV (1b)‐contaminated anti‐D cohort. Patients with self‐limited HCV infection or SVR after antiviral treatment were protected from progressive liver disease and showed the best clinical long‐term outcome. (Hepatology 2014;58:49–57)

CD8+ T-Cell Response Promotes Evolution of Hepatitis C Virus Nonstructural Proteins

BACKGROUND & AIMS Hepatitis C virus (HCV) acquires mutations that allow it to escape the CD8+ T-cell response, although the extent to which this process contributes to viral evolution at the population level is not clear. We studied viral adaptation using data from a large outbreak of HCV genotype 1b infection that occurred among women immunized with contaminated immunoglobulin from 1977 to 1978. METHODS The HCV nonstructural protein coding regions NS3-NS5B were sequenced from 78 patients, and mutations were mapped according to their location inside or outside previously described CD8+ T-cell epitopes. A statistical approach was developed to identify sites/regions under reproducible selection pressure associated with HLA class I. RESULTS The frequency of nonsynonymous mutations was significantly higher inside previously described CD8+ T-cell epitopes than outside-particularly in NS3/4A and NS5B. We identified new regions that are under selection pressure, indicating that not all CD8+ T-cell epitopes have been identified; 6 new epitopes that interact with CD8+ T cells were identified and confirmed in vitro. In some CD8+ T-cell epitopes mutations were reproducibly identified in patients that shared the relevant HLA allele, indicating immune pressure at the population level. There was statistical support for selection of mutations in 18 individual epitopes. Interestingly, 14 of these were restricted by HLA-B allele. CONCLUSIONS HLA class I-associated selection pressure on the nonstructural proteins and here predominantly on NS3/4A and NS5B promotes evolution of HCV. HLA-B alleles have a dominant effect in this selection process. Adaptation of HCV to the CD8+ T-cell response at the population level creates challenges for vaccine design.

Prevalence of elevated ALT values, HBsAg, and anti-HCV in the primary care setting and evaluation of guideline defined hepatitis risk scenarios.

BACKGROUND & AIMS Prevalence data for hepatitis B and C and an evaluation of a guideline based screening in the primary care setting are not yet available. We therefore implemented a hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus (HCV) screening and developed guideline based screening strategies. METHODS HBsAg, anti-HCV, and alanine aminotransferase (ALT) were included in a routine check-up together with a questionnaire covering 16 guideline adapted risk scenarios. Significant risk factors were identified by stepwise logistic regression. RESULTS 51 private practices screened 21,008 patients. The HBsAg, anti-HCV, and HCV-RNA prevalence was 0.52%, 0.95%, and 0.43%, respectively. Infections were previously unknown in 85% and 65% of HBsAg and anti-HCV positive individuals, respectively. Sexual risk factors were under-reported, while the following scenarios were significantly associated with viral infections (Odds ratio [95% confidence interval]). HBV: Immigration (4.4 [2.9, 6.7]), infection in household (2.5 [1.2, 4.5]), male gender (1.6 [1.1, 2.4]). Male immigrants had a 2.1% HBsAg prevalence and 80% were unaware of the infection. HCV: IV drug use (384 [233, 644]), blood transfusion before 1992 (5.3 [3.5, 7.9]), immigration (2.4 [1.5, 3.6]). Presence of either one of the HBV related guideline defined risk scenarios or elevated ALT identified 82% of previously undiagnosed patients. Presence of one of the three significant HCV risk factors or elevated ALT levels diagnosed 83% of unknown HCV-RNA positive cases by screening only 26% of the population. CONCLUSIONS Undiagnosed hepatitis B and C infections frequently exist in the primary care setting. Easy to apply guideline defined risk scenarios help to diagnose previously unknown infections.

The predictive value of IL28B gene polymorphism for spontaneous clearance in a single source outbreak cohort is limited in patients carrying the CCR5Δ32 mutation

BACKGROUND & AIMS The CCR5Δ32 mutation has been suspected to adversely affect outcomes of HCV infection, although reports have remained controversial. Here, we investigated the relative genetic contributions of the CCR5Δ32 deletion and the IL28B rs12979860 polymorphisms to spontaneous clearance of hepatitis C in a single-source outbreak. METHODS We retrieved 396 Caucasian women (119 women with spontaneous HCV clearance) who had been infected with HCV genotype 1-contaminated anti-D immunoglobulin in 1978, and determined their IL28B and CCR5 alleles. RESULTS IL28B CC, CT, and TT genotypes were found in 35.4%, 50%, and 14.6% of patients and corresponded to spontaneous clearance rates of 50%, 21.2%, and 12.1% (Chi(2)=38.7, p=5.0×10(-10)), respectively. CCR5 WT/WT, WT/Δ32, and Δ32/Δ32 genotypes were observed in 76%, 22.7%, and 1.3% of patients and corresponded to clearance rates of 33.2%, 21.2%, and 0% (Chi(2)=6.9, p=0.009), respectively. In a stepwise forward-conditional multivariate regression model both CCR5 (OR 2.1, p=0.01 for WT/WT) and IL28B genetic variants (OR 4.3, p=4.6×10(-10) for the C/C genotype) were identified as independent predictors of spontaneous HCV clearance. Importantly, favorable response rates were associated with the IL28B CC genotype only in CCR5 wild-type homozygous women, while HCV clearance in CCR5Δ32 carriers remained poor even in patients with the rs12979860 CC genotype. CONCLUSIONS Both IL28B rs1297860 and CCR5Δ32 allelic variants are independent genetic determinants of spontaneous HCV clearance. The variable relative distribution between IL28B rs1297860 and CCR5Δ32 allelic variants in different populations may have masked the role of the CCR5Δ32 mutation in some studies.

Non-invasive evaluation of hepatic manifestation in Wilson disease with transient elastography, ARFI, and different fibrosis scores

Abstract Objective. Noninvasive investigation of liver fibrosis with ultrasound-based elastography and laboratory-based fibrosis indices have been established in various chronic liver diseases within the last years. We aimed to evaluate feasibility and diagnostic value of transient elastography (TE), acoustic radiation force impulse imaging (ARFI), and different serologic fibrosis indices in Wilsons disease (WD). Materials and methods. TE and ARFI were performed in 50 Wilson patients. In addition, AST/Platelet Ratio Index (APRI), FIB-4, and Forns score were calculated. Hepatic fibrosis was classified by a clinical score. Results. Of the 50 Wilson patients 41 had hepatic manifestation of WD. TE results were significantly increased in advanced hepatic fibrosis (7.0 ± 2.2 kPa; p < 0.05) and cirrhosis (10.1 ± 6.73 kPa; p < 0.05) compared to individuals without hepatic manifestation (5.0 ± 1.4 kPa). Right liver lobe ARFI (R-ARFI) values were only increased in cirrhotic patients (1.43 ± 0.28 vs. 1.19 ± 0.14 m/s; p < 0.05). The cutoff values to best discriminate cirrhosis were 6.1 kPa for TE and 1.29 m/s for R-ARFI. Left lobe ARFI failed to provide additional diagnostic benefit. Elastography methods displayed a significant correlation with APRI, FIB-4, and Forns indices (Pearsons rho > 0.33; p < 0.03). Conclusions. TE displayed a gradual increase between different stages of hepatic manifestation in WD and could significantly discriminate cirrhosis. The TE cutoff for cirrhosis may be clinically more relevant than the R-ARFI value.

P1272 IDENTIFICATION OF HBV AND HCV INFECTIONS IN THE PRIMARY CARE SETTING: PRE-DEFINED RISK SCENARIOS ARE A BETTER SCREENING STRATEGY THAN ELEVATED ALT VALUES

508 IDENTIFICATION OF HBV AND HCV INFECTIONS IN THE PRIMARY CARE SETTING: PRE-DEFINED RISK SCENARIOS ARE A BETTER SCREENING STRATEGY THAN ELEVATED ALT VALUES J. Wiegand, O. Batz, I. Wolffram, J. Kramer, K. Jedrysiak, H. Tenckhoff, T. Berg, German “Check-Up 35” Study Group. Clinic of Gastroenterology and Rheumatology, Section of Hepatology, University of Leipzig, Leipzig, LADR GmbH Medizinisches Versorgungszentrum Dr. Kramer und Kollegen, Geesthacht, Sudstadtpraxis Paderborn, Paderborn, Germany E-mail: johannes.wiegand@medizin.uni-leipzig.de

1345 INTERACTION BETWEEN IL28B CCR5Δ32, AND HCV PERSISTENCE WITH GBV-C VIREMIA AND SYMPTOMS DURING ACUTE INFECTION

20 G2) were included. SVR was defined as undetectable HCVRNA at 24 weeks of follow up. The SNP analysis of rs12979860 variant was determined in 50ng of DNA by RT-PCR using specific oligonucleotide primers and probes to amplify the sequence target in DNA (Tib MoLBIOL GmbH, Berlin Germany). All HCV patients were genotyped as CC, CT or TT. Results: CT and TT variants were present in 45 and 18 subjects (56% and 23%, respectively) of the studied population. CC polymorphism had the lowest frequency in our cohort (21%, CI 95%: 12.89–31.83%) and it was strongly associated with response to standard treatment (OR 2.95); 76% of CC carriers achieved SVR compared with 55.5% and 44.4% of SVR in patients with CT and TT variants.