#671. Clearance of HBeAg Is Linked with Emergence of Mutations within Pre-core and Core Regions of Hepatitis B Virus in Pediatric Patients

I. Carey; A. Giannattasio; S. Bansal; P. Cheesman; J. A. Byrne; G. Mieli-Vergani; D. Vergani

 

Interaction between hepatitis B virus (HBV) and host’s immune system is crucial for the outcome of HBV infection. Changes in the balance between HBV-specific immune reactivity and viral replication influence the course of disease. Selective pressure of the immune system might be associated with the emergence of mutations within pre-core and core regions of HBV and affects successful control of viral replication.

 

Aim:

To investigate the presence of mutations within HBV pre-core and core gene in 5 different groups of pediatric patients (pts) and correlate them with HBeAg clearance and viral replication.

 

Patients:

Sixty-nine consecutive padiatric patients (median age 13.25, 44 males) were divided into 5 groups according to presence/absence of HBsAg, HBeAg and aminotransferases activity: group A (immunotolerant) - HBsAg+, HBeAg+, normal ALT – 33 pts; group B (immunoactive) – HBsAg+, HBeAg+, elevated ALT – 17 pts; group C (low replication) – HBsAg+, HBeAg-, normal ALT – 13 pts; group D (HBeAg negative chronic hepatitis B) – HBsAg+, HBeAg-, elevated ALT – 2 pts and group E (self-limited) - HBsAg-, HBeAg-, normal ALT – 4 pts.

 

Methods:

HBV DNA was isolated from serum samples. The presence of point mutations within of HBV pre-core and core promoter regions and amino acid substitutions within immunodominant epitopes of HBV core gene was analysed by direct sequencing (mutations/patient). HBV DNA viral load was quantified by real-time PCR (log10 copies/ml).

 

Results:

HBV DNA viral load was significantly higher in groups A, B, and D when compared to C and E (p=0.001). Total number of point mutations within HBV pre-core and core promoter regions and the number of amino acid substitutions within the immunodominant epitopes of HBV core gene were higher in HBeAg negative patients compared to HBeAg positive children (p=0.001 and 0.055). Results as mean ± SEM are presented in the table.

 

There was a strong inverse correlation between the number of mutations in pre-core and core regions and HBeAg presence (r=-0.628, p=0.001 and r=-0.341, p=0.005).

 

Conclusions:

Clearance of HBeAg is associated with a high number of mutations within pre-core and core regions of HBV, suggesting that the selective pressure of the immune system on hepatitis B virus is responsible for the emergence of mutations within HBV pre-core and core regions.

 

Group

HBV DNA

Pre-core region

Core region

A

7.89 ± 0.22

2.17 ± 0.23

4.82 ± 0.38

B

6.81 ± 0.52

2.27 ± 0.40

5.88 ± 0.75

C

3.94 ± 0.26

5.42 ± 0.33

6.54 ± 0.48

D

7.45 ± 1.23

6.5 ± 0.50

8.00 ± 0.00

E

0

ND

ND

 


#49. HBeAg Seroconversion Is Associated with HBV-specific T Cell Reactivity of Th1 Lymphocytes and the Emergence of Mutations within HBV Pre-core and Core Regions in Pediatric Patients

I. Carey; A. Giannattasio; S. Bansal; P. Cheesman; Y. Ma; M. S. Longhi; F. Meda; J. A. Byrne; G. Mieli-Vegani; D. Vergani

 

Infancy-acquired chronic hepatitis B (CH-B) is characterized by prolonged phase of immune tolerance. Hepatitis B virus (HBV) starts to be recognized by the immune system in adulthood with consequent HbeAg seroconversion. Mutations within HBV pre-core and core regions are usually present in HBeAg- CH-B patients (pts). Vigorous and broad HBV-specific immune reactivity is associated with successful control of viral replication. The selective pressure of immune system could be responsible for the development of mutations, which may interfere with efficient immune control of the virus.

 

Aim:

To investigate T helper 1 (Th1), Th2 and cytotoxic T lymphocytes HBV-specific immune reactivity in relation to point mutations within HBV pre-core and core promoter regions and amino acid substitutions in HBV core immunodominant epitopes in children with infancy-acquired CH-B.

 

Patients and Methods:

40 children (median age 11.8 years) with infancy-acquired CH-B (27 HBeAg+ and 13 HBeAg-) were studied. The number of HBV-specific CD4+ peripheral blood mononuclear cells (PBMC) producing IFN-γ and IL-4 upon stimulation with HBV recombinant antigens (HBcAg, HBeAg and HBsAg) was evaluated by Elispot. In 20 HLA-A2+ subjects, CD8+ reactivity was determined by INF-γ Elispot after incubation with HLA-A2 restricted HBV-core18-27 peptide. Point mutations within HBV pre-core and core promoter regions and amino acid substitutions in HBV-core gene immunodominant epitopes were analysed in HBV DNA extracted from serum by direct sequencing (mutations/pts).

 

Results:

Frequency of HBeAg-specific CD4+ cells producing IFN-γ was higher in HBeAg- than HBeAg+ pts (113.3vs.39.4 specific spot-forming cells [spSFC]/1 million PBMC, p=0.034). While Th1 CD4+ reactivity to HBcAg and HBsAg and CD8+ reactivity to HBV-core18-27 peptide were similar in two groups, the proportion of HBV-specific CD4+ cells producing IL-4 tended to be higher in HBeAg+ pts than in HBeAg- pts (for HBeAg: 4.2vs.0.4 spSFC/1 million PBMC, p=0.143). Point mutations within HBV pre-core and core promoter regions and amino acid substitutions in immunodominant epitopes of the HBV-core gene were more frequent in HBeAg- than HBeAg+ pts (pre-core: 4.8vs.2.5, p=0.001 and core: 6.6vs.5.2, p=0.029).

 

Conclusions:

Clearance of HBeAg in children is associated with HBV-specific Th1 immune reactivity and higher numbers of mutations, especially in HBV pre-core region. These findings suggest that HBV-specific T cell responses are involved in control of virus (HBeAg clearance), but paradoxically they are responsible for the emergence of mutations within HBV pre-core and core regions possibly as the result of their immunoselective pressure.


 

#779. Anti-HBs-trough-levels and Anti-HBs-half-lives Do Not Differ after Intravenous Versus Intramuscular Hepatitis B Immunoglobulin Administration Given for Long-term Hepatitis B Reinfection Prophylaxis after Liver Transplantation

J. Rosenau; N. Hooman; J. Hadem; G. Philipp3; J. Klempnauer2; H. L. Tillmann; C. P. Strassburg; M. P. Manns

 

Administration of hepatitis B immunoglobulin (HBIg) remains an essential component of standard reinfection prophylaxis after liver transplantation for HBV-related liver disease. However, long-term HBIg treatment is expensive and discussion about cost-reduction is ongoing. Previous studies showed that intramuscular (IM) as compared to intravenous (IV) HBIg administration may be cost-effective and dose-saving. As these studies were either small or difficult to interpret, we performed a cross-over study to compare anti-HBs-kinetics after IM versus IV administration of equal HBIg doses.

 

Methods:

Twenty-four patients receiving long-term prophylaxis with HBIg plus Lamivudine and/or Adefovir were enrolled. During study period 2000 IU HBIg were administered every 6 weeks, beginning at week 0. HBIg was started IV (Hepatect CP, Biotest) in 12 patients of group A and IM (Hepatitis B Immunoglobulin ZLB Behring) in 12 patients of group B. At week 24 HBIg was switched from IM to IV and vice versa (cross-over). Study was completed after week 48. Anti-HBs-levels were measured 2, 4 and 6 weeks after each HBIg administration, e.g. 4x3 values during IM- and 4x3 values during IV-administration period per patient. 22 patients (11 in each group) completed the study and were evaluated.

 

Mean anti-HBs-levels of individual patients measured 2, 4 and 6 weeks after IM versus IV HBIg administration did not differ significantly in multivariate analysis (p > 0.05). Mean values of individual patients’ mean levels were 480±166, 319±126, 221±106 after IV versus 457±166, 310±147, 218±112 IU/l after IM administration. Half-lives of anti-HBs-decline (IV 25.5±6.0 versus IM 24.7±6.2 days) and AUC values from week 2 - 6 of single patients (IV 9.4±3.6 versus IM 9.0±3.9 IU*d/ml) also showed no significant difference in multivariate analysis (p>0.05). Intra-individual variations of anti-HBs-levels at week 2, 4 and 6 (mean standard-deviations 113, 70 and 58 after IV versus 104, 62 and 43 IU/l after IM administration) were significantly lower (p<0.001) as compared to inter-individual variation (standard-deviations 166, 126, 106 versus 166, 147, 112 IU/l) without significant differences of IV- and IM-levels.

 

Conclusion:

In conclusion, intramuscular HBIg administration is not advantageous as compared to intravenous HBIg administration in respect of anti-HBs trough-levels, half-lives, AUC-values and intra- or inter-individual variability of anti-HBs-levels. HBIg dosing intervals should be individualized, whereas fixed intra-individual dosing intervals may be considered. IM instead of IV HBIg administration is only cost-effective, if price of IM HBIg is lower.


#782. Low Risk of HBV Recurrence Post-liver Transplantation (OLT) in Patients Maintained on Nucleoside(t)e Analogue (NA) Therapy after Withdrawal of Hepatitis B Immune Globulin (HBIG)

S. N. Wong; C. Chu; C. Wai; T. Howell; C. R. Moore2; R. J. Fontana; A. S. Lok

 

Background and Aims:

Recent studies have reported HBV recurrence rates of 0-10% in hepatitis B patients who underwent OLT and were maintained on NA after discontinuation of HBIG. However, follow-up in these studies was short (range 13-17 mos.). We aimed to determine the long-term risk of HBV recurrence in post-OLT patients who had discontinued HBIG and were maintained on NA.

 

Methods:

All HBV patients who received at least 7 doses of IV HBIG post-OLT with no HBV recurrence while on HBIG, and eventually discontinued HBIG and maintained on NA, were included. Primary endpoint was HBV recurrence (HBsAg+ve on >2 occasions at least 1 mo. apart). Secondary endpoint was the detection of serum HBV DNA >3 log10 copies/ml on >2 occasions in the absence of detectable serum HBsAg. HBV DNA was tested by PCR assay.

 

Results:

Between January 1994 and December 2005, 40 (4.5%) of 886 OLT at our center were performed on HBV patients and 21 met inclusion criteria. Mean age at OLT was 49 ± 10 yrs, 17 were men, 19 were Caucasians, 18:3 had cirrhosis:hepatocellular carcinoma. Immediate post-OLT prophylaxis consisted of combination HBIG and NA (lamivudine [LAM] =14; adefovir [ADV] = 1) in 15 patients while the remaining 6 patients received HBIG monotherapy for a median of 82 (62-109) mos. post-OLT before LAM was added. HBIG was discontinued a median of 26.4 (0.2-121) mos. post-OLT, 4 patients discontinued HBIG during year 1 (all had low or undetectable HBV DNA at OLT), 4 in years 2-3, and 13 after year 3. All patients were negative for HBsAg and HBV DNA when HBIG was discontinued. Median post-HBIG follow-up was 40.2 (4.5-51.1) mos. Only 1 patient had HBV recurrence, this patient discontinued HBIG 12 mos. post-OLT and was lost to follow-up until mo. 46 post-OLT when he presented with fatigue and tested positive for HBsAg with ALT 164 and HBV DNA 7.9 log10 copies/ml. Another patient had HBV DNA of 3.3 log10 copies/ml but with negative HBsAg 47 and 48 mos. post-HBIG. Emergent LAM-resistant mutations were detected in both patients. Cumulative probability of HBV recurrence was 0% and 9% while probability of meeting the combined study endpoints was 0% and 22% at 2 and 4 yrs post-HBIG. Four patients had 1-3 episodes of transiently detectable HBV DNA (maximum 3.8 log10 copies/ml) but with negative HBsAg. All 4 patients had been HBV DNA and HBsAg negative on repeat tests over a period of 1-34 months.

 

Conclusions:

HBIG discontinuation after 3 yrs post-OLT and maintenance on NA is associated with very low risk of HBV recurrence in compliant HBV patients. Persistent detection of low levels of serum HBV DNA may be an early sign of HBV recurrence.

 


#786. Presence of Intrahepatic (Total and ccc) HBV DNA Is Not Predictive of HBV Recurrence after Liver Transplant (OLT)

M. Hussain; C. Soldevila-Pico; S. Emre; V. Luketic; A. S. Lok

 

Background:

Previous studies reported that HBV DNA can be detected in liver biopsies from patients (pts) who had OLT for hepatitis B despite the absence of serological markers of HBV recurrence. However, quantification of HBV DNA was not performed in most studies and presence of covalently closed circular (ccc) DNA was not analyzed.

 

Aim:

To quantify intrahepatic (total and ccc) HBV DNA in explant and post-OLT liver and correlate it with HBV recurrence post-OLT.

 

Patients and Methods:

Explant liver from 8 pts and post-OLT biopsies from 26 pts were analyzed. Total and ccc HBV DNA were quantified using real time PCR. Serum HBV DNA was quantified by the COBAS Amplicor assay.

 

Results:

Among the 8 patients (pts) with explant liver, 7 were HBeAg+ve, 8 had detectable serum HBV DNA, and 0 were receiving antiviral therapy prior to OLT. Total HBV DNA was detected in 7 and ccc DNA in 6 pts. HBeAg+ve patients had higher concentrations of ccc DNA (-.87 vs -3.27 log0copies/cell, p=0.037) and higher ratio of ccc/total HBV DNA: .7% vs. 3.% (p=0.04) than HBeAg-ve pts.

After a median follow-up of 8 months (range 5-35), 2(%) pts had HBV recurrence. Mean serum HBV DNA level at OLT in these 2 patients was higher than in pts without recurrence (8.79 vs 5.2 log0 copies/mL, p=0.046). Concentrations of total and ccc HBV DNA were also higher in these 2 pts but the difference was not significant.

 

Five biopsies from 26 patients collected between 7 days to 48 months post-OLT were studied. 8 pts had detectable total (6/6) and ccc (2/6) HBV DNA in their biopsies, of these 2 had HBV recurrence. 4 pts had detectable total (27/30 biopsies) but not ccc (0/30 biopsies) HBV DNA, of these  had HBV recurrence. 4 pts had undetectable total and ccc HBV DNA in all their biopsies (0/5), none of which had HBV recurrence. The concentrations of total and ccc DNA in post-OLT biopsies were 2.7 and .2 log lower than explant livers. All 3 pts with HBV recurrence were HBeAg+ve pre-OLT compared to only 3/20 pts without recurrence (p=0.00). All 3 pts with HBV recurrence had detectable total HBV DNA in their post-OLT biopsies compared to 9/23 pts without HBV recurrence. 2 of the 3 pts with HBV recurrence had detectable ccc DNA in their post-OLT biopsies compared to 6/23 without HBV recurrence (p=0.25).

 

Conclusions:

Total and ccc HBV DNA could be detected in the explant livers of most pts with hepatitis B including those who had undetectable HBV DNA in serum. Total but not ccc HBV DNA could be detected in post-OLT liver biopsies of most pts despite undetectable serum HBV DNA and HBsAg. Detection of HBV DNA in explant liver or post-OLT biopsies does not predict HBV recurrence post-OLT.

 


1297. Monitoring Interferon And Lamivudine Treatment By Quantitative Measurement Of Hbsag And Hdv-Rna Serum Levels In Hbeag-Negative Patients With Chronic Hepatitis Delta. 

E. K. Manesis; M. Schina; E. Gault; O. Agelopoulou; C. Papaioannou; K. Kalligeros; V. Arseniou; S. Manolakolpoulos; E. S. Hadziyannis; F. Le Gal; J. Koskinas; G. Papatheodoridis; A. J. Archimandritis.

 

Background:

Treatment of chronic hepatitis delta virus (HDV) infection is difficult, lengthy and response is usually based on normalization of serum alanine aminotransferase (ALT) and undetectable serum HDV-RNA by qualitative PCR. Quantitative determination of serum HBsAg and HDV-RNA appears to be a more logical approach for monitoring treatment in such patients.

 

Methods:

53 HBeAg-negative patients, chronically co-infected with HDV (CHDe-), followed in 3 Hepatology Centers in Athens between 1998-2005 (age 40±14 years; 60% males; 64% compensated cirrhotics; no hepatocellular carcinoma) were retrospectively analysed. 21 of them had received 28 courses of 3-5 MU IFN-a2b thrice weekly for 12.7 median months (IQR 7.6-34.1), 5 had received 8 courses of 100mg LAM daily for 23.6 (8.4-61.5) months and 27 were untreated. Controls were 54 untreated HBeAg-negative chronic hepatitis B patients without delta infection (CHBe-) randomly selected from a large CHBe- serum database. Measurements were performed in sera stored at -300C and thawed once, collected at baseline in all cases, as well as during and at the end-of-follow up (EFU) (or the last on-treatment) in CHDe- cases. HBsAg was quantitated by ADVIA Centaur™ (Bayer Diagnostics; sensitivity 0.066 IU/mL) and HDV-RNA by a real-time reverse transcription-PCR (sensitivity 100 copies/mL; J Med Microbiol 2005;43:2363-9). Serum HBV-DNA by real-time PCR and ALT were also analysed.

 

Results:

At baseline, untreated CHDe- patients had significantly higher median HBsAg (5873 vs 3501 IU/mL; P=0.045) and lower HBV-DNA (2.467 vs 6.459 log10 copies/mL; P<0.001) levels compared to CHBe- controls. Baseline HDV-RNA of 6.447 log10 copies/mL (4.857-7.100) was not different between untreated, IFN- or LAM-treated patients. IFN, but not LAM treatment, was associated with significantly lower HBsAg (6102 vs 6480 IU/mL; P=0.016) and HDV-RNA (4.164 vs 6.447 log10 copies/mL; P=0.009) at EFU. HDV-RNA became negative in LAM-treated and in 4 IFN-treated patients (2 HBsAg negative too) within 24 and 30 months. In IFN-treated patients, HDV-RNA became undetectable within 31 (17-60.5) months, followed by a slower decrease of HBsAg.

 

Conclusions:

In CHDe- patients, suppression of HBV-DNA replication is associated with significantly increased HBsAg serum levels. Despite HBV-DNA suppression, LAM treatment has no effect on HBsAg and HDV-RNA serum levels, in contrast to IFN which steadily suppresses both. Long IFN treatment (1.5-5.0 years) appears necessary for undetectable serum HDV-RNA and further treatment is required for HBsAg loss. These findings emphasize the importance of monitoring HBsAg and HDV-RNA serum levels in treated CHDe- patients.

 


1304. HBV Vaccine Non-Responsiveness Could be Due to Enhanced Cellular Surface Expression of CD150. 

N. T. Pati; S. Baweja; H. Syed; K. Aggrawal; R. Rani; S. K. Sarin.

 

Background:

Non- responsiveness to HBV vaccine is a major concern. Mechanisms of non-responsiveness could be genetic, immune dysfunctional cellular response or both. CD150 is signaling lymphocyte activation molecule and may have the suppressive activity after activation. We assessed the mechanisms of non- responsiveness by cellular proliferation response and expression of CD150 in HBV vaccinated individuals.

 

Methods:

After standard HBV vaccination (0, 1, 6 mo.), and at mo. 7, subjects were categorized as responder (anti-HBs >10 IU/ml) or non-responder (< 1 IU/ml). PBMCs and CD4+ T cells were stimulated with either plate bound anti-CD3, anti-CD 28, anti-CD3 combined with soluble anti-CD28 (1µg/ml each), Phytohemoaglutinin (PHA) (8 μg/ml), Phorbol 12-Myristate 13-Acetate (PMA) (20ng/ml), HBsAg (3 μg/ml) and HBcAg (8μg/ml) for 72 hrs. Cell proliferation performed by thymidine uptake assay and proliferation index (PI) was measured. PI After 72hr of stimulation, cells were stained with CD150- PE FACs antibody and control isotypes. FACs analysis was performed on FACs caliber and data was analysed by Win-MDi software.

 

Results:

The non-responders (n=10) had significantly lower proliferation indices than responders (n=18) (Table 1). Lack of cellular proliferation was associated with CD150 cell surface expression. In non-responders the surface expression of CD150 was significantly increased on PBMCs and CD4+T after stimulations with anti-CD28 (p=0.002), PHA (p=0.01), HBsAg and HBcAg (p=0.001). Non-responders’ PBMCs had15.9, 14.3 and 405 times greater CD150 expression than responders’ PBMCs after stimulations with anti-CD28, HBcAg and HBsAg. However, expression of CD150 on CD4+T cells of non responders was 13.5, 72.7, and 258, 72 and 39 times greater after stimulations with anti-CD3 + anti-CD28, anti-CD28, PHA, HBsAg and HBcAg.

 

Conclusions:

Our results suggest that the differences in proliferative response of PBMCs and CD4+T cells in non-responders is associated with increased CD150 expression, which may be used as a predictive marker for non-responsiveness to HBV vaccination.

 

Comparison of PI in PBMCs and CD4+ T cells of Responders and Non-responders

 

Stimulators

PBMCs

CD4+T cells

Res. N=18

Non-res. N=10

Resp. Vs. Non-Resp

Res. N=18

Non-res. N=10

Resp. Vs. Non-Resp

Mean±SE

P

Mean±SE

P

Anti-CD3

10.5±2.1

2.3±0.45

0.001

12.2±2.6

1.6±0.4

0.001

Anti-CD3,CD28

12.8±2.3

2.3±0.8

0.001

17.9±3.7

1.7±0.6

0.001

Anti-CD 28

3.8±0.9

1.2±0.4

0.03

3.2±0.6

0.7±0.1

0.003

PHA

14.7±3.1

6.9±3.5

0.02

16±3.64

3±1.74

0.0

PMA

2.9±0.9

1.5±0.7

NS

3.4±0.7

1.2±0.3

0.04

HBsAg

4.6±1.0

1.3±0.45

0.006

6.0±1.2

0.8±0.2

0.0

HBcAg

5.6±0.8

1.2±0.37

0.02

4.2±0.7

1.1±0.21

NS

 


1305. High Prevalence of Liver Injury in Patients With Chronic Hepatitis B Virus (HBV) Infection in HBeAg positive subjects with normal ALT. 

M. Kumar; H. Syed; C. Pande; S. K. Sarin.

 

Background

Management of chronic HBV infected patients in immunotolerant phase is unsatisfactory. Current guidelines recommend monitoring without treatment when ALT<2XULN. Reasons for deferring therapy include low prevalence of significant histologic disease and low therapeutic response. There is paucity of histological data in these subjects. Aims Correlate HBVDNA levels and liver histology in HBeAg+subjects with chronic HBV infection with persistently normal ALT and compare with patients with intermittently normal ALT.

 

Patients and methods

HBeAg + patients who had at least 1 year follow-up and had either persistently normal ALT (at least 3 ALT values in 1yr prior to liver biopsy) or intermittently normal ALT (at least 3 ALT values and at least one <40 IU/L in 1yr prior to biopsy). Biopsy specimens were scored by Knodel index.

 

Results

190 HBeAg+ patients were classified as:Gr1:persistently normal ALT[n=73,age:27.7±15.3yr, 70%M]&Gr. 2:intermittently normal ALT[n=117,age:30.8±16.1yr,87%M]. Distribution of genotypes[A/B/D/A+D] was 8.0/0/84.0/8.0% in Gr1&25.8/2.2/67.7/4.3% in Gr2[p=0.03]. Mean±SD[median(range)] baseline DNA was 5.871±2.083[5.228(2.406-9.274)]logcopies/mL in Gr1 & 6.508±1.764[5.933(2.824-9.399)]logcopies/mL in Gr2[p=0.025]. 44(60.3%)patients in Gr1 & 96(82.1%) in Gr2 had baseline DNA >5logcopies/mL [p=0.001]. 145(76.3%)patients had HAI >3 & 169(88.9%) had ≥1 fibrosis score. Mean±SD [median(range)] HAI was 5.0±2.5[5(1-11] in Gr1 & 6.3±2.8[6(1-14)] in Gr2[p=0.003]. 46(63.0%)patients in Gr1 & 99(84.6%) in Gr2 had HAI >3[p=0.001]. Mean±SD[median(range)] of fibrosis scores were 1.4±0.9[1(0-4)] in Gr1 & 2.0±0.9[2(0-4)]in Gr2[p=<0.001]. Distribution of fibrosis stages[0/1/2/3/4] were17.8/42.5/26.0/11.0/2.7% in Gr1 & 6.8/17.9/49.6/18.8/6.8% in Gr2[p=<0.001]. 60(82.2%)patients in Gr1 & 109(95.6%) in Gr2 had ≥1 fibrosis[p=0.004]. There was no correlation between fibrosis stage & ALT(r=-0.090,p=0.223), HBVDNA(r=0.026,p=0.722) or genotype (r=0.121,p=0.192). Similarly there was no correlation between HAI & ALT(r=-0.017,p=0.820), DNA (r=0.066,p=0.367) or genotype(r=0.157,p=0.089).

 

Conclusions

(i) HBeAg+ patients with persistently normal or intermittently normal ALT have significant (stage ≥2) fibrosis (39.7% and 75.2% respectively) (ii) 60% with persistently normal and 82.1% with intermittently normal ALT have HBV DNA >5 logcopies/mL. (iii) Serum ALT & DNA correlate poorly with histology. Newer therapeutic options need to be developed to treat these groups of patients.

 


1309. Occult HBV infection of transfusion blood products in Korea. 

S. Hwang; H. Song; C. Kwon; S. Hong; H. Cho; L. Phyun ; K. Ko; S. Hong ; P. Park; K. Rim.

 

Background/Aims:

Occult Hepatitis B Virus (HBV)infection is defined as the presence of HBV DNA in blood or tissues without detectable hepatitis B surface antigen (HBsAg). With the improvement in sensitivity of polymerase chain reaction (PCR) method, there was the recognizable advances in the the research of occult HBV infection. In Korea, blood donors are screened only for ongoing infections by HBsAg or ongoing hepatitis activity by serum alanine aminotransferase (ALT) levels, but not for past infections by HBcAb. Like Korea, where HBV infection is endemic, we can assume that occult HBV infection is high and the transmission of occult HBV infection is possible. Therefore, we investigated the occult HBV infection in transfusion blood products in Korea.

 

Materials/Methods:

In 2005, we collected 200 blood transfusion products which supplied from Gyeonggi Province Blood Center in Korea. All blood transfusion products were negative for serum HBsAg and had normal serum ALT level according to current screening policy for bleed products in Korea. Serum samples were seperated from blood products and kept at -70o C. We conducted HBV-DNA quantification assay with real-time polymerase chain reaction TaqMan method (PCR primers, forward primer HBV1F: 59 CCG TCT GTG CCT TCT CAT CTG; reverse primer HBV1R: 59 AGT CCA AGA GTY CTC TTA TGY AAG ACC TT and fluorescent probe HBV1TAQ: 59 CCG TGT GCA CTT CGC TTC ACC TCT GC) and Anti-HBc with enzyme immunoassay(EIA, RADIM diagnostics, Italia).

 

Results:

Out of 200 blood donors, the number of age from 21 to 30 was 116 (58%). 177 blood products conducted HBV-DNA quantification assay. The blood products which showed positive results were 33(18%) and all were below 500 copies/mL. 14(8%) blood products were between 100 and 500 copies/mL. 1 blood product was above 300 copies/mL. 150 blood products conducted anti-HBc assay and 19 blood products showed positive results. Only 128 blood products conducted both HBV-DNA quantification assay and anti-HBc assay. Out of 128 blood products, 20 blood products showed HBV-DNA positive results and 15 blood products showed anti-HBc positive results. Only 4 blood products showed both HBV-DNA positive and anti-HBc positive results.

 

Conclusions:

In Korea, blood transfusion products showed 18% HBV DNA positive results and 12% Anti-HBc positive results. Like Korea, where HBV infection is endemic and the incidence of occult HBV infection is high, we should investigate on the follow-up studies of transfusion recipients and the safety of blood transfusion products, with large scale research.

 


1316. Positive Impact of Hepatitis B(HB) Video on HB Vaccine Coverage in Homeless Children and Adolescents in Baltimore: Results of a Randomized Controlled Trial. 

K. B. Schwarz; B. Garrett; D. Thompson; J. Lee; T. Thiel; M. Alter; S. Strathdee.

 

The purpose of our study was to determine if a culturally appropriate HB video would be effective in increasing HB vaccine coverage in homeless children and adolescents, a population at increased risk for HB infection in whom we had previously described low vaccine coverage rates. (JPGN 2005:41:225-9)

 

Methods:

We performed a prospective clinical trial in which homeless subjects 2- 18 years of age were randomized to an 8 minute HB video (Respect Yourself/Protect Yourself by Hepatitis Foundation International) or a smoking prevention video (Bilal’s Dream, by the American Lung Association). HB vaccine attitudes and knowledge in both caregivers and adolescents were assessed before exposure to the video. In caregivers demographics and a depression screen were assessed, and HB vaccine #1 was offered to all children and adolescents who did not produce a vaccine record. Subjects were asked to return 1 and 3 months after visit one, HB vaccine was offered to all with incomplete vaccine coverage, and HB knowledge was reassessed.

 

Results:

Data are reported for all caregivers with at least 1 child needing vaccine. Thirty-seven caregivers with 53 children were randomized to the HB video vs 39 caregivers with 51 children randomized to the smoking video. There were no significant group differences in either sociodemographics or per cent who could produce a vaccine record. Comparing HB knowledge scores of caregivers at Visit #2 vs Visit 1, scores improved in the HB video group (p = 0.01) but not in the smoking group (p = 0.82). Similar results were observed for adolescents in the HB video group (p = <0.05) but not in the smoking group (p = 0.40). Vaccine acceptance was higher in the HB video group vs smoking group at Visit #2 (p = <0.05) and Visit #3 (p = 0.06). As shown in the Table below, the shelter based vaccine program was very effective in increasing HB coverage rates in the entire group of 328 children and adolescents enrolled in the study.

 

Conclusions:

Shelter-based HB vaccine programs can be highly effective in increasing vaccine coverage rates in older children and adolescents. A brief exposure to a culturally appropriate HB video not only improves HB knowledge but has a positive impact on increasing vaccine acceptance rates in this high risk population.

 

Homeless Subjects with Complete HB Vaccine Coverage

Age group

Visit 1

Visit 3

2-5 y

92/105
(88%)

100/105
(95%)

6-9 y

84/95
(88%)

90/95
(95%)

10-12 y

29/66
(44%)

48/66
(73%)

13-18 y

19/62
(31%)

42/62
(68%)

Total

224/328
(68%)

280/328
(85%)

 


1318. Characteristics, management and evolution of Hepatitis B in HIV infected patients: the prospective multicenter EPIB05 survey. 

L. Piroth; D. Sene; I. Goderel; P. Stanislas; K. Lacombe; D. Rey; V. Loustaud-Ratti; J. Bergmann; G. Pialoux; A. Gervais; C. Lascoux-Combe; F. Carrat; P. Cacoub.

 

Methods:

A questionnaire itemizing the characteristics of HBV infection, and their evolution over time according to the different HBV treatments taken, was sent to the participating French Internal Medicine, Infectious Diseases and Hepatology Departments in 89 hospitals (GERMIVIC). A total of 479 patients (pts) with past or present chronic HBV infection (Ag HBs+) and seen during the 4 week study period in October 2005 have been included.

 

Results:

Main characteristics : HIV co-infection was observed in 260 (55%) pts. HIV-HBV co-infected (HIV+) compared to HBV mono-infected patients (HIV-) were more frequently male (80 vs 68%, p=0.005), past or present IVDUs (10 vs 0.5%, p<10-3), alcoholics (11 vs 3 %, p=0.005), more often born in France (56 vs 23%) than in sub-saharian Africa (32% vs 36%) or Asia (1.2 vs 21%) (p<10-3). 62 (24%) pts developed AIDS defining event. 235 (94%) pts have been on antiretroviral treatment [mean final CD4 count 433 +/- 349 (25.8 +/- 29%) and HIV viral load 2.43 +/- 1.21 log10 copies/ml].

 

HBV infection:

Before HBV treatment, HBe Ag+ and anti-HBe Ab+ were found in 103 (58%) and 68 (39 %) HIV+ pts (vs. 28% and 72% HIV- pts, p<10-3). Clinical presentation of hepatitis B was similar.

Co-infections:

Compared to HIV- pts, HIV+ pts were more often HCV positive (13 vs. 3.8%, p<10-3), whereas HDV infection was less frequent (4.7 vs. 7.1%, p<10-3), even if less often investigated (79 vs 92%, p<10-3)

Liver histology: was assessed in 32 (12%) HIV+ pts before HBV treatment, with a median METAVIR score of A1-F2 (vs. A2F1 for HIV- pts, p=NS). Liver histology was assessed during follow up in 53 (20%) HIV+ pts (liver biopsy 46, biological tests 7).

 

HBV treatment was prescribed in 213 (82%) HIV+ pts (monotherapy 41.8%, combinations 58.2%) vs. 73 (34.1%) HIV- pts (monotherapy 57.5%, combinations 42.5%) (p<10-3). HIV+ pts received lamivudine (76%), tenofovir (64%), adefovir (10%), emtricitabine (7.5%), or pegylated interferon (1.4%).

 

Serological evolution: loss of HBe Ag and HBe seroconversion were less often observed in HIV+ than HIV- pts (8.6 vs. 11.6% and 6.9 vs 13.8%, p=0.05 and p=0.02). HBs Ag disappeared in 5 HIV+ pts (vs 3) and appeared in 4 (vs 0) (p=0.03).

 

Conclusions:

During chronic HBV infection in HIV infected patients,

1) Infection with pre-core HBV mutants is less frequent than in mono-infected

2) Specific management of HBV infection still needs to improve, even if liver histological evaluations and specific anti-HBV treatments are increasing

3) Anti-HBV combinations are more frequently used than in HIV- patients

4) Loss of HBe Ag or HBe seroconversion are still infrequent, underlying the need for new drugs/strategies.

 


1320. Elevated iron parameters and disease severity in hepatitis B: a more complex relationship than might be assumed. 

A. Jazwinski; J. J. Feld; D. E. Kleiner; M. G. Ghany; T. Liang; J. H. Hoofnagle; T. Heller.

 

Background:

Elevation of serum iron parameters is common in liver disease and is typically ignored. However iron parameters may not simply reflect hepatic inflammation. Aim: To determine serum iron parameters in patients with chronic hepatitis B (CHB). To investigate the relationship between iron indices and liver disease.

 

Materials and Methods:

Data from patients with CHB followed at the Clinical Center of the NIH were reviewed. Pretreatment liver biopsies and laboratory values taken within 6 months of biopsy were analyzed. Univariate and multivariate analyses were performed to investigate relationships between various parameters.

 

Results:

268 patients (80.5% male) were evaluated. Of the patients, 25% had elevated iron (Fe); 8.5% elevated iron saturation (Fe Sat), and 10% elevated ferritin. Elevations in Fe sat were significantly associated with elevations in ALT (P=0.0001), AST (P=0.0001), AFP (P=0.0001), and lower levels of haptoglobin (p=0.0011), and platelets (P=0.0007). Iron saturation was significantly higher in patients with severe inflammation on biopsy than patients with mild/moderate inflammation (P<0.05). Iron saturation was significantly higher in patients with advanced fibrosis (Ishak5/6) compared to patients with mild fibrosis (Ishak 1/2). By MV analysis, Fe saturation was independently associated with elevated AST (P<0.0001), increased fibrosis on biopsy (P=0.003), increased iron on biopsy (P=0.04), decreased ceruloplasmin (P=0.02), and transferrin (P=0.0004). Ferritin elevations were significantly associated with elevations in ALT (P<0.0001), AST (P=0.0002), AFP (P=0.002), and lower levels of haptoglobin (P=0.013). Ferritin was not associated with more inflammation or fibrosis on biopsy. Ferritin levels were significantly higher in patients with >1+ stainable Fe on biopsy than patients with 0 or trace iron (P<0.05). By MV analysis, ferritin was independently associated with AST (P<0.0001), increased iron on biopsy (P<0.0001), and lower transferrin (P=0.0007) and ALT (P=0.004). Stainable Fe did not correlate with inflammation or fibrosis on biopsy.

 

Conclusions:

Elevations in serum iron indices were seen in a significant proportion of patients with CHB. Increasing levels of serum Fe saturation suggest more severe liver disease, while increasing levels of ferritin are seen in patients with more iron on biopsy, which does not correlate with disease severity. This suggests that Fe saturation may relate to liver disease independent of iron stores. The role of ceruloplasmin is of particular interest as it relates to Fe saturation. Further understanding of the biology of these relationships may be valuable.


1319. Diagnostic accuracy of MP3, Fibrotest and Hepascore for evaluating liver fibrosis in chronic hepatitis B. 

M. Hilleret; C. Trocme; P. Faure; J. Renversez; A. Plages; N. Sturm ; F. Morel; J. Zarski; L. Vincent.

Several biological scores have recently been designed to estimate liver fibrosis in chronic hepatitis C. Their diagnostic accuracy is poorly documented in chronic hepatitis B.

 

The aim of this study was to evaluate in chronic HBs Ag carriers diagnostic performances of MP3, a score combining PIIINP and MMP1, Fibrotest (FT) and Hepascore (HS).

 

Methods:

260 chronic AgHBs antigen carriers (age 38 +/-18 years, 71% of male) seen in our center were included. Criteria for exclusion were HIV and HCV coinfection and ongoing antiviral treatment. Liver biopsy was performed in 184 patients who had ALT > N or HBV DNA > 5 log cop/ml. The METAVIR classification was used. 76 patients with ALT < N, HBV DNA < 5 log cop/ml, negative Hbe Ag and normal liver US scan were considered as inactive Hbs Ag carriers and did not undergo liver biopsy. MP3, HA and FT were dosed on frozen serums.

 

Results:

Characteristics of the 184 chronic hepatitis B patients were as follow : Hbe Ag 30%, METAVIR F0 n=37, F1 n=52, F2 n=44, F3 n=23 and F4 n=28. MP3 (r=0.47), HS (r=0.49) and FT (r=0.29) were significantly correlated to fibrosis stage (p<0.01). Diagnostic accuracy evaluated by AUROC for discriminating F0F1F2 vs F3F4 were HS : 0.83, MP3 : 0.81, FT : 0.74. MP3 score greater than 0.50 had a PPV for extensive fibrosis of 82%, while score lower than 0.30 had a NPV of 88%. When combining MP3 and HS, or MP3 and FT PPVs could increase up to 92% for F3F4. For each score, diagnostic performance was much less accurate for discriminating F0F1 vs F2F3F4 (ROC ranging from 0.62 to 0.70). This was especially true for discriminating F1 versus F2 and arises the question of histological features in HBV compared to HCV infection. In inactive carriers, scores had on average similar (MP3 and HS) or significant lower (FT) values than in F0F1 group. However, 6 patients (8%) had concomitant elevation of MP3, HA and FT similar to that observed in F3/F4 group, suggesting presence of inactive cirrhosis.

 

Conclusion:

Our results confirm that MP3, HA and FT have a good accuracy in HBV infection in predicting extensive fibrosis, especially when used in combination. By contrast, they do not seem appropriate to discriminate mild versus moderate fibrosis. They could be especially usefull in management of inactive carriers who might have cirrhosis.