Jens M. Kittner

Adding pegylated interferon to a current nucleos(t)ide therapy leads to HBsAg seroconversion in a subgroup of patients with chronic hepatitis B

BACKGROUND Nucleos(t)ides effectively halt disease progression in hepatitis B but require long-term medication. OBJECTIVES To determine whether add-on of peg-IFN to an ongoing nucleos(t)ide therapy accelerates decline of HBsAg and induces seroconversion. STUDY DESIGN We observed HBsAg kinetics in 12 patients on a stable oral therapy with undetectable HBV-DNA who additionally received peg-IFN-alfa 2a as an individualized therapy. 3 patients were HBeAg positive. Mean baseline HBsAg was 4695 (range 16-15,120)IU/ml. RESULTS A continuous decline of HBsAg was observed in 2 patients. The slope, respectively, became detectable at week 8 or 16. HBsAg had dropped by 2.90log(10) or 4.25log(10) fold at week 48, and anti-HBs appeared at week 40 or 32. Patient A - HBe-positive, genotype A, F3 fibrosis - had been HBV-DNA negative for 10 months receiving entecavir plus tenofovir. Previous therapy with peg-IFN had been unsuccessful, but now the patient experienced HBeAg seroconversion at week 24. Patient B - HBeAg negative, genotype D, cirrhosis - had a low initial HBsAg level of 16U/l. Receiving entecavir, his HBV-DNA had previously been non-detectable for 27 months. In the remaining 10 patients HBsAg declined only by a mean of 0.09log(10) (range 0.01-0.25log(10)) after 8-24 (mean 16.4) weeks, and therefore, peg-IFN was stopped. No unexpected side effects were observed. DISCUSSION We observed that the add-on of peg-IFN induced HBsAg seroconversion in 2 out of 12 patients. Response rates may have been higher with prolongation of therapy. The add-on concept merits to be evaluated in a clinical trial.

Early changes in dynamic biomarkers of liver fibrosis in hepatitis C virus-infected patients treated with sofosbuvir

BACKGROUND Chronic hepatitis C is a major cause of liver-associated mortality caused by decompensated cirrhosis and hepatocellular carcinoma. With the approval of sofosbuvir, therapeutic efficacy has markedly increased. Early changes in non-invasive biomarkers of liver fibrosis under effective antiviral therapy are widely unknown. AIM To evaluate early changes of fibrosis markers determined by enhanced liver fibrosis (ELF) scores and liver stiffness measurement (FibroScan(®)) in patients treated with sofosbuvir. METHODS A total of 32 hepatitis C patients treated prospectively with sofosbuvir were included. The ELF-panel and FibroScan measurements were performed at baseline, week 4, end-of-treatment and 12 weeks thereafter. RESULTS Antiviral therapy resulted in a biochemical and virological response within 4 weeks. Sustained virological response rate at 12-week follow-up (SVR12) was 93.8%; there was a significantly decrease from baseline to 12-week post-treatment follow-up in ELF (10.00 vs. 9.37; p=0.007) and FibroScan (8.0 vs. 6.8 kPa; p=0.016) measurements, indicating improvement of the dynamics of liver fibrosis. CONCLUSION We observed a rapid decrease in non-invasive fibrosis markers measured by ELF-scores and FibroScan in hepatitis C-infected patients receiving sofosbuvir treatment. These initial results need to be histologically confirmed by liver biopsy in the future.

Hepatitis B virus-specific T-cell responses during IFN administration in a small cohort of chronic hepatitis B patients under nucleos(t)ide analogue treatment.

The effect of pegylated interferon‐α (IFN) add‐on therapy on HBV‐specific T‐cell responses was evaluated in 12 patients with stable, undetectable hepatitis B virus (HBV) load under nucleos(t)ide analogue therapy. Peripheral blood mononuclear cells were isolated at week 0, 4, 8, 12, 24 and 48 of IFN add‐on therapy. Quantity and quality of circulating HBV S‐ and core‐specific CD4 and CD8 T cells were analysed ex vivo by flow cytometry. HBV S‐ and core‐specific CD4 T‐cell numbers modestly increased within 8 weeks of IFN administration (P = 0.0391 and P = 0.0195), whereas HBV‐specific CD8 T cells in general showed only minor changes under IFN add‐on therapy. Functionality of HBV‐specific CD4 but not CD8 T cells positively correlated with serum transaminase activity. In addition, we observed an increase in CD4 T cells producing tumour necrosis factor‐α (TNFα) without antigen restimulation (P = 0.0039), which correlated with elevated transaminases. During IFN add‐on therapy, two patients developed an anti‐HBs seroconversion, only one of whom showed a relevant increase in HBV‐specific T cells. In conclusion, IFN add‐on therapy of chronic hepatitis B increased HBV‐specific T‐cell responses and affected a previously unrecognized TNFα‐monofunctional CD4 T‐cell population. Although the observed T‐cell responses did not correlate with HBsAg seroconversion, we expect additional insights into the immunopathogenesis of hepatitis B, following the characterization of the newly identified TNF α‐monofunctional T‐cell population.

The Impact of Liver Cell Injury on Health-Related Quality of Life in Patients with Chronic Liver Disease

Background Patients with chronic liver disease often suffer from unspecific symptoms and report severe impairment in the quality of life. The underlying mechanisms are multifactorial and include disease-specific but also liver related causes. The current analysis evaluated the association of hepatocellular apoptosis in non-viral chronic liver disease and health-related quality of life (HRQL). Furthermore we examined factors, which influence patients physical and mental well-being. Methods A total of 150 patients with non-infectious chronic liver disease were included between January 2014 and June 2015. The German version of the Chronic Liver Disease Questionnaire (CLDQ-D), a liver disease specific instrument to assess HRQL, was employed. Hepatocellular apoptosis was determined by measuring Cytokeratin 18 (CK18, M30 Apoptosense ELISA). Results Female gender (5.24 vs. 5.54, p = 0.04), diabetes mellitus type II (4.75 vs. 5.46, p<0.001) and daily drug intake (5.24 vs. 6.01, p = 0.003) were associated with a significant impairment in HRQL. HRQL was not significantly different between the examined liver diseases. Levels of CK18 were the highest in patients with NASH compared to all other disease entities (p<0.001). Interestingly, CK18 exhibited significant correlations with obesity (p<0.001) and hyperlipidemia (p<0.001). In patients with cirrhosis levels of CK18 correlated with the MELD score (r = 0.18, p = 0.03) and were significantly higher compared to patients without existing cirrhosis (265.5 U/l vs. 186.9U/l, p = 0.047). Additionally, CK18 showed a significant correlation with the presence and the degree of hepatic fibrosis (p = 0.003) and inflammation (p<0.001) in liver histology. Finally, there was a small negative association between CLDQ and CK18 (r = -0.16, p = 0.048). Conclusion Different parameters are influencing HRQL and CK18 levels in chronic non-viral liver disease and the amount of hepatocellular apoptosis correlates with the impairment in HRQL in chronic non-viral liver diseases. These findings support the role of liver-protective therapies for the improvement of the quality of life in chronic liver disease.

No beneficial effect of all-trans retinoic acid in previous non-responder patients with chronic hepatitis C: The ATRACTION study, a phase II randomised trial

BACKGROUND Preclinical data suggested all-trans retinoic acid (tretinoin) as a potential antiviral agent against chronic hepatitis C infection. AIMS To assess efficacy, safety, and tolerability of tretinoin in combination with peg-interferon and ribavirin in genotype-1 infected patients with prior non-response. METHOD We performed an open-label multicentre clinical trial. Patients were randomised to either receive additional tretinoin (45mg/m(2)/day) for 12 weeks (arm A), or peg-interferon and ribavirin alone (arm B). Primary endpoint was the slope of the third phase of viral decline (Mδ) as determined in an established kinetic model known to correlate with treatment outcome. Secondary endpoints were additional kinetic parameters, viral response rates, safety, and tolerability. RESULTS 27 patients in arm A and 30 patients in arm B were treated per protocol until week 12. Viral kinetic parameters did not differ. Rates of early virological response (>2log10 drop at week 12) were similar (10/27 versus 11/30 patients). In arm A, patients experienced a higher rate and intensity of adverse events, most commonly skin and mucosal dryness, and headache. CONCLUSION Addition of tretinoin was safe and acceptably well tolerated. However, it did not influence viral kinetics and thus cannot be further considered as a treatment option.

Coagulation factor 9-deficient mice are protected against dextran sulfate sodium-induced colitis

ABSTRACT Patients with inflammatory bowel disease (IBD) are susceptible to thromboembolism. Interestingly, IBD occurs less frequently in patients with inherited bleeding disorders. Therefore, we analyzed whether F9-deficiency is protective against the onset of acute colitis in a genetic hemophilia B mouse model. In the 3.5% dextran sulfate sodium (DSS)-induced colitis model, F9-deficient mice were protected from body-weight loss and had a reduced disease activity score. We detected decreased colonic myeloperoxidase activity and decreased CXCL1 levels in DSS-treated F9-deficient mice compared with wild-type (WT) littermate controls, indicating decreased neutrophil infiltration. Remarkably, we identified expression of coagulation factor IX (FIX) protein in small intestinal epithelial cells (MODE-K). In epithelial cell cultures, cellular FIX protein expression was increased following stimulation with the bacterial Toll-like receptor agonists lipopolysaccharide, macrophage-activating lipopeptide-2 and Pam3CSK4. Thus, we revealed a protective role of F9-deficiency in DSS-induced colitis and identified the intestinal epithelium as a site of ectopic FIX. This article has an associated First Person interview with the first author of the paper. Summary: Since IBD incidence is less frequent in patients with inherited bleeding disorders, we explored and demonstrated that F9-deficiency is protective against DSS-induced acute colitis in a hemophilia B mouse model.

Prospective Randomized Open-label Trial Protocol Investigating the Addition of Pegylated Interferon-alpha to an Ongoing Nucleos(t)ide Treatment Regimen of HBeAg Negative Chronic Hepatitis B Patients (PADD-ON)

Background: Hepatitis B surface antigen (HBsAg) clearance marks the prime event of HBV elimination in chronic hepatitis B and is associated with better overall outcome. Despite reliable viral suppression under standard treatment with nucleos(t)ide analogues (NUCs) the goal of HBsAg clearance is rarely achieved. Also synchronous combination of NUCs with pegylated interferon-α-2a (peg-IFNα) has not been superior compared to peg-IFNα monotherapy in prospective randomized trials. However, sequential addition of peg-IFNα to an ongoing NUC regimen has provided higher HBsAg clearance rates in uncontrolled pilot studies. Methods/Design: In this protocol we investigate the sequential addition of open-label peg-IFNα for 48 weeks to an ongoing NUC regimen following patients written informed consent. Included are patients with HBeAg negative chronic hepatitis B and a suppressed HBV DNA (<20 IU/mL) for a minimum of 12 months under NUCs prior to trial enrollment. Patients are randomized (2:1 ratio) to peg-IFNα add-on/ NUC treatment or a control group receiving continuous NUCs only. Patients are followed regularly during the trial intervention including a per protocol follow-up for 24 weeks after end of treatment. The primary endpoint is the objective response after 48 weeks of combination therapy, defined by a confirmed reduction of HBsAg by ≥ 1log10 IU/mL compared to baseline. Secondary endpoints are the HBsAg seroconversion rate, safety and tolerability of the IFN add-on therapy regimen. The trial was approved by the local ethic committees of all participating study sites. Trial registration: The trial was registered on the 10th of June 2011 at EudraCT (ID number 2011-002812-10).

Combination therapy with Adefovir and Entecavir is well tolerated and effective in Lamivudine-resistant chronic Hepatitis B

Methods: 26 patients (pts) (23 male/3 female, age 49.3 (27.7–72.2yrs) with chronic hepatitis B (13 pts HBeAg pos) who were pretreated with and resistant to lamivudine received combination therapy with entecavir 1mg and adefovir 10mg daily. 9 pts (33%) had cirrhosis, none of them decompensated (MELD score 9, (6–13)); The mean duration of lamivudine pretreatment was 23 months (2–122 mo). In 10 pts lamivudine had been stopped or changed to another treatment more than 24 wks before the start of this study. 8 (30%) were switched directly from lamivudine monotherapy (5 pts) or combination therapy with lamivudine and adefovir (3 pts) to combination therapy with entecavir and adefovir. Lamivudine resistance was determined by virological or biochemical non-response or break-through during lamivudine treatment. In addition, mutational analysis was performed; lamivudine resistance mutations were found in all patients and were an inclusion criterion. No adefovir resistance mutations were detectable. Results: At the start of combination therapy ALT was normal in 12 pts (43%), 10 had elevated ALT (3 pts not tested). ALT levels ranged between 0.36–10.3 *ULN (mean 1.9 * ULN). HBV-DNA was 87–6.4 * 108 copies/ml (mean 5.2 * 107 copies/ml; TaqMan PCR). Follow-up data (HBV DNA, week 12–24) was available of 19 pts. After 12 to 24 wks 43% of patients had normal ALT values (range 0.38–4.78, mean 1.4 * ULN). In 6 pts HBV-DNA was below detection level (70 copies/ml, TaqMan PCR), in 7 pts viral load was detectable but reduced by at least 2 log, 3 pts showed no virological response. 1 patient was switched to another therapeutic regimen because of biochemical non-response (ALT >2*ULN after 24 wks), 1 patient was switched because of a viral load >103 after 24 wks. No major side effects were observed due to combination therapy with entecavir and adefovir for up to 1 year. None of the patients showed signs of progression or complications due to chronic liver disease or cirrhosis. Conclusion: This study suggests that combination therapy with entecavir and adefovir is well tolerated and effective in lamivudine-resistant chronic hepatitis B and should thus be considered as a treatment option for those patients.