870. Higher Levels of HBV-DNA in Genotypes B and C Compared to Genotypes A and D
H. Krarup; P. Madsen; A. Bentzen-Petersen; J. M. Møller;
Hepatitis B viral factors such as viral load and HBV
genotype have been suggested to influence progression of chronic hepatitis B.
To explore relations between 1)
genotype and viral load, 2) gender and viral load, 3) gender and genotype and
4) genotype and country of origin.
Material: Samples from 802 consecutive HBV-DNA positive patients in Denmark were genotyped if
possible. In house real-time PCR based methods were used.
HBV-DNA levels were in the range of 10(2) –
10(10) IU/mL. Genotypes were determined using genotype specific primer pairs
selected from the pre-S region of the genome.
Male/female ratio 427 to 375, age given as median (25;75 percentiles) was for males 37 (27;46) and females 30
(24;38) years. In total 195 samples could not be genotyped; 106 due to lack of
sufficient amount of material and 89 due to various reasons, mostly too low
viral load. Of 607 samples 11.2% were genotype A, 14.3% B, 19.4% C, 50.3% D,
2.3% E, 0.5% F and 1.5% genotype G, 0.8% had more than one genotype.
1) A significant difference was observed in viral load
in genotype A compared to B and C (p values <0.008) and genotype D compared
to B and C (p values <0.007), but no difference was observed in viral load
between A and D or B and C. The viral loads in genotypes A to D were 1.2 x
10(5) (4.4 x 10(3); 3.8 x 10(7)) IU/mL, 1.4 x 10(7) (2.9 x 10(4); 1.4 x 10(8))
IU/mL, 1.4 x 10(7) (8.5 x 10(4); 1.4 x 10(8)) IU/mL and 1.0 x 10(5) (4.0 x
10(3); 5.9 x 10(7)) IU/mL respectively.
2) No difference in viral load among gender was
observed either overall or in different genotypes.
3) A significant difference in distribution of gender
over the 4 dominant genotypes was observed: more women had genotypes B or C
while more men had genotypes A or D (p values <0.001). Women were
significantly younger than men, 30 years versus 41 years (p value <0.001)
and 30 years versus 35 years (p value <0.004) in genotypes B and D
respectively, whereas no significant age difference was observed in genotypes A
or C, men 32 years versus 35 years and 29 years versus 31 years respectively.
4) More than 65% of patients with genotype A originated
from Africa.73% and 95% of patients with genotypes B and C originated from
South East Asia, while 75% of patients with genotype D originated from the
Middle East, Afghanistan or India.
We found the median of serum HBV-DNA levels 100 times higher
in genotypes B and C compared to genotypes A and D. More women, than men, had
genotypes B or C, as opposed to genotypes A or D. The distribution of genotypes
was as expected from ethnic origin of the patients.
Treatment – Adefovir
of Adefovir Dipivoxil-Induced HBeAg Loss Following Long-term Additional Therapy
in Patients with YMDD Mutants of Hepatitis B Virus
S. Kim; Y. Chung; J. A. Kim; Y. Lee; D.
Lee; S. Lee; D. Seo; J. Shin; N. Park; K. Kim; H. Lee; Y. Lee; D. Suh
Adefovir dipivoxil (ADV) has been widely used in
patients with YMDD mutants as well as in those with wild type of hepatitis B
virus (HBV). However, the optimal duration of ADV administration remains to
be determined due to frequent relapse after cessation of the therapy,
especially in endemic areas of HBV. In this study we intended to examine the
durability of ADV-induced HBeAg loss following
long-term additional therapy in patients with YMDD mutants of HBV.
Among 318 chronic hepatitis B (CHB) patients with YMDD
mutants of HBV who had been treated with ADV at a dose of 10 mg once
daily for a median 27 months (range: 9-59), 100 patients (31%) lost their serum
HBeAg as well as HBV-DNA (by real-time PCR) at a median 18 months
(range: 1-53) after initiation of ADV therapy. Out of them, 35
patients whose serum HBeAg and HBV-DNA had been negative
persistently for 24 months discontinued ADV administration and
followed for a median 9 months (range: 2-31). The median duration of ADV therapy in these patients
was 31 months (range: 25-47). During the treatment and follow-up periods, serum
ALT, HBV-DNA levels and HBeAg/anti-HBe
were monitored at every visit per 1 to 3 months. Genotypes of HBV were
determined by restriction fragment length polymorphism (RFLP) following PCR.
All the 318 patients [Median age: 45 years (range:
15-81); male: 266 (84%)] enrolled in this study had HBV of genotype C. YIDD
variants of HBV were determined in 196 (62%); YVDD in 103 (32%) and both in 19
(6%). In 13 (37%) and 14 (40%) out of 35 patients whose serum HBeAg and HBV-DNA had been negative
persistently for 24 months, serum HBeAg reappeared at 6 and 12 months after
stopping ADV therapy, respectively; serum HBV-DNA became detectable by
real-time PCR again in 20 (57%) and 20 (60%),
respectively. At 6 and 12 months after cessation of ADV therapy, the cumulative
rates of serum HBeAg reversion were 49% and 56%; those of ALT re-elevation were 65% and
73%, respectively. Between relapsers and sustained responders, there was no
difference in age, gender, initial serum ALT, HBV-DNA level, the presence of
anti-HBe, the proportion of YMDD variants and the association of liver
Our data suggest that serum HBeAg loss induced by ADV therapy may not be
durable even following long-term additional administration of ADV for 24 months.
952. HBeAg Seroconversion Induced by Nucleos(t)ide Analogues in Chronic Hepatitis B Is Not
Durable in a Majority of Cases
M. Perquin; J. G. Reijnders; N. Zhang;
H. L. Janssen
Background and Aim:
Seroconversion of HBeAg indicates the probable
attainment of sustained response in chronic hepatitis B (CHB) patients, currently
justifying discontinuation of antiviral therapy after a consolidation period.
Yet, long-term durability of HBeAg seroconversion achieved under treatment with
nucleos(t)ide analogues (NA) is unclear.
In this single center cohort study, all HBeAg positive
CHB patients who received more than six months of treatment with
any NA were included. Measurement of virologic parameters was done every 3 to 6
months. Seroconversion was defined as loss of HBeAg with appearance of
anti-HBe. Relapse of seroconversion was defined as either reappearance of HBeAg
or loss of anti-HBe.
In this study 131 patients were included (69 treated
with Lamivudine(LAM), 35 Adefovir(ADV), 18 Entecavir(ETV), 6 Tenofovir(TDF), 1 ADV+LAM, 2 TDF+LAM). Baseline
characteristics: mean age 35±18 years; m/f 97/34; mean ALT 4.8±6.4 xULN ; mean HBV DNA 8.1±1.6log10
copies/mL. During a median follow up of 98 (24-507) weeks HBeAg seroconversion
was observed in 44 (34%) patients (27 induced by LAM, 12 ADV, 3 ETV, 2
TDF). In 4 cases there was no follow-up after HBeAg seroconversion and,
therefore, these subjects were excluded from further analysis. Median duration
of therapy until HBeAg seroconversion was 28 (7-211) weeks. In multivariate
analysis, independent baseline predictors of HBeAg seroconversion were high ALT (OR 1.25, CI 1.11-1.41,
P<0.001) and low HBV DNA (OR 0.62, CI 0.45-0.85,
P=0.003). Relapse after HBeAg seroconversion occurred in 26 (65%) patients (LAM
19/26 (73%), ADV 6/10 (60%), ETV 1/2 (50%), TDF 0/2 (0%)).
Twenty-three (88%) HBeAg relapses occurred during therapy under which
seroconversion was achieved. Fifteen (58%) patients experienced relapse more
than 6 months after HBeAg seroconversion, 8 (31%) more than 1 year after HBeAg
seroconversion. Relapse was associated with antiviral drug resistance in 11
(42%) cases. Of 9 patients who stopped therapy after a consolidation therapy of
at least 6 months (median duration 67 (25-198) weeks), 3 (33%) experienced
off-therapy relapse, 2 (22%) restarted with NA therapy (due to increasing viral
load) and 4 (45%) remained HBeAg-negative, anti-HBe positive in absence of
NA induced HBeAg seroconversion was followed by
relapse in a majority of cases, often during treatment. Consolidation treatment
of more than 6 months did not induce remission of disease in the majority of
cases. Therefore, long-term continuation of treatment with NA after HBeAg
seroconversion appears necessary, irrespective of the occurrence of HBeAg
Treatment – Antiviral Resistance
897. High Risk of
Renal Impairment and Arterial Hypertension During Long-term
Adefovir and Lamivudine Combination Therapy in Patients with
Lamivudine-resistant Chronic Hepatitis B
M. Viganò; P. Lampertico; M. Iavarone;
G. Tontini; F. Facchetti; M. Colombo
Background and Aim:
“Add-on” treatment with adefovir (ADV) is recommended for
lamivudine (LMV)-resistant patients with chronic hepatitis B, but the long-term
safety of this approach is unknown.
Material and Methods:
271 LMV-resistant patients with chronic hepatitis B
treated with ADV+LMV (213 males, 55 yr, 184
Child-Pugh score A/B cirrhotics, median creatinine 0.8 mg/dL, median creatinine
clearance 87 mL/min), with normal renal function at baseline and more than 6
month treatment were followed for 7-77 months (median 32). Patients were
followed every three months with laboratory, clinical exams and arterial blood
pressure measurement. Renal impairment was the increase of serum creatinine of
≥ 0.5 mg/dL compared to baseline and led to ADV dose reduction from 10 mg
daily to 10 mg on the other day. Arterial hypertension was diagnosed according
to the current guidelines. Results. 31 (11%) patients
showed renal impairment after a median of 23 months (range: 7-60), requiring ADV dose reduction. Six
months (range 1-30) after dose adjustment, serum creatinine significantly
declined from 1.6±0.3 to 1.3±0.2, (p<0.001), no patient had further renal
One patient had >1 log10 rebound of viremia but no
rtN236T or rtA181T/V mutations were identified, whereas all the others
maintained either undetectable or stable serum HBV DNA levels. Twenty-five of
221 patients (11%) without arterial hypertension at baseline developed
mild-moderate hypertension (≥ 140-90 mmHg) after a median of 15 (range:3-47) months of treatment, requiring specific treatment.
Five patients had both adverse events with arterial hypertension preceeding in
all cases renal impairment occurrence. The 4-year cumulative rates
of renal impairment and arterial hypertension development was 18% for
Patients on long-term treatment with ADV+LMV should be carefully
monitored for the development of renal impairment and arterial hypertension.
Treatment – Entecavir
969. Entecavir Induced HBV DNA Suppression at 12 Weeks in Treatment-Navie Patients
with Chronic Hepatitis B is a Good Predictive Factor for Virological Response
at 48 Weeks
H. Lee; H. Kim; M. Kim; K. Kim; J. Lee;
H. Sul; S. Chung; S. Hwang; C. Choi; J. Kim; J. Do; J. Kim; S. Chang; S. Park
Entecavir (ETV) is a potent, selective
inhibitor of HBV DNA polymerase. ETV had superior virological
and biochemical efficacy to lamivudine in treatment-naïve patients with chronic
hepatitis B (CHB). The aims of our study are to
evaluate the efficacy of ETV and to explore useful
predictors for efficacy of ETV treatment in
treatment-naïve patients with CHB.
A total of 112 treatment-naïve patients with CHB, who visited Chung-Ang University Hospital and Ilsan Paik Hospital in Korea between January 2007 and
October 2007, were enrolled in this study (79 males and 66 HBeAg positive).
Mean age, baseline serum ALT level and serum HBV DNA level were 46 years
(range, 23-69), 190.2 IU/L (range, 43-724) and 7.3 log10 copies/ml (range,
5.4-9.9), respectively. They were treated with ETV 0.5 mg/d. The mean
duration of treatment was 11 months (range, 6-15). All patients were assessed
for virological response (HBV DNA<140 copies/mL),
biochemical response (ALT<40IU/mL), and HBeAg
seroconversion. Serum HBV DNA was quantified using the
real time PCR assay (Artus HBV LC PCR Kit, Roche Diagnositcs,
lower limit of quantification, 140 copies/mL). The
definition of good response was undetectable HBV-DNA and normalization of
serum ALT at 48 weeks.
The rates of virological response were 48.2% (53/110)
and 66.1% (39/59) at week 24 and 48. The rates of biochemical response were
76.4% (84/110) and 84.7% (50/59) at week 24 and 48. In addition, the rates of
composite virological and biochemical response were 38.2% (42/110) and 61.0%
(36/59) at week 24 and 48. Mean reduction of baseline HBV DNA was -5.7,
and -6.5 log10 copies/mL at 24 and 48 weeks. Through 48 weeks, HBeAg
seroconversion occurred in 5.7% (3/53). There was no virologic breakthrough,
primary non-response, and other adverse event. In multivariate analysis, the
rapid decline in HBV DNA (≥5 log10 copies/mL) at week
12 was clinically important predictive factors for good response at week 48
(odds ratio [OR], 6.659; 95% confidence interval [CI], 1.444-30.705; P =
In patients with treatment-naïve CHB, ETV provides potent viral
load reduction, and ALT normalization free from adverse
event. In addition, the rapid decline in HBV DNA (≥5 log10
copies/mL) at week 12 may be used as a good predictor of long-term outcome.
Treatment – Clevudine
911. Clevudine Was Superior to Lamivudine in the Patients
with HBeAg(+) Chronic Hepatitis B
G. K. Lau; N. Leung; C. K. Hui; A. Kwok;
A. Wong; R. Chan; H. W. Yoo
Clevudine is a pyrimidine analogue with potent
anti-HBV activity in vitro. In the pivotal phase III clinical trials,
clevudine 30 mg for 24 weeks showed profound viral suppression with
normalization of serum ALT levels.
The aim of this study is to compare the efficacy and
safety of clevudine versus lamivudine for 48 weeks in chronic hepatitis B (CHB) patients in a randomized
and blinded way. The study is ongoing in Hong Kong. Eligible patients were
treatment-naïve HBeAg(+) CHB patients with HBV DNA levels≥3,000,000
copies/mL and 1.0 ≤ALT<10 times of the upper
limit of the normal range. HBV DNA was quantified by
Amplicor PCR assay with a lower limit of
detection (LOD) of 300 copies/mL.
Preliminary results from the 55 patients (29 in the clevudine group and 26 in
the lamivudine group) who have completed 48-week dosing period are presented
here. After completion of 48-week treatment period, an optional 48 weeks
extension treatment period are planned. During the 48 weeks optional extension
phase, open-labelled clevudine treatment was provided to eligible subjects with
their consents. The interim data of 21 patients who continue the extension
study is also presented here.
The clevudine group demonstrated greater viral
suppression at Week 48 when compared with the lamivudine group [median
reduction (range) 4.7 (3.3-6.2) vs. 3.2 (-0.2~5.7) log copies/ml at Week 48,
respectively, p < 0.01]. Serum HBV DNA level was below 300
copies/mL in 59% and 32% at week 32 and in 72% (N=29) and 46% (N=26) at week 48
in the clevudine and lamivudine groups, respectively. HBeAg seroconversion
occurred in 17% of patients in the clevudine group while as 8% of patients in
the lamivudine group at week 48. Lamivudine-resistant mutations were detected
in 9 patients in the lamivudine group, who showed viral rebound during
lamivudine therapy but no mutation was found in clevudine group during 48-week
At week 72, 82% of patients (N=11) in the clevudine
group had HBV DNA below LOD. At week 24 after
switching to clevudine from lamivudine (at week 72), viral level in the
previous lamivudine group was more decreased (viral decrease from baseline : 4.2 log copies/ml) and 80% of patients had HBV DNA below LOD after switching to
clevudine from lamivudine.
A 48-week dosing with clevudine 30mg showed superior
viral suppression to lamivudine 100mg without the emergence of viral
breakthrough in HBeAg(+) CHB patients, while 31% of
patients in the lamivudine group showed lamivudine-related resistance during 48
weeks. The extension study with clevudine demonstrated that clevudine is a
promising drug for the long-term treatment.
Treatment – Antiviral Resistance
A. D. Ludwig; T. Goebel; O. Adams; N.
Baumann; K. Hauck; H. Fey; H. Hengel; D. Haussinger; A. Erhardt
Little is known about the frequency of primary
resistance mutations in treatment naive patients with acute or chronic
hepatitis B infection. The occurence of primary resistance mutations and the
association of these mutations with viral genotypes was
Direct sequencing of the HBV polymerase gene and
overlapping S-gene was performed with an ABI 310 system and data of
288 patients with treatment naïve hepatitis B virus infection. Sequence
alignments and phylogenetic analysis together with detection of resistance
mutations were accomplished with the ABI program SeqScapev2.5.
Additionally, genotyping of viral strains and detection of resistance mutations
were performed with an open access strain matching system
Distribution of hepatitis B genotypes in the
investigated patients was as follows: 56.9% D, 28.8% A, 5.6% C, 2.7% B, 4.2% E
and 0,7% G. Primary resistance mutations were observed in 9.3% (exclusive
polymorphisms at nt 215 and 217; table) and in 34.7% of patients (inclusive
polymorphisms at nt 215 and 217) respectively. Primary resistance mutations (not
including polymorphisms at nt 215 and 217) were detected at a rate of 8.2% in
genotype A, 20.8 % in genotype B/C, 10.4 % in genotype D and 0% in genotype E.
Polymorphisms at nt 217 were highly associated with genotype A, and
polymorphisms at nt 215 with genotype D. Patients with primary resistance
mutations were less frequent HBeAg-positive (25%) compared to patients without
primary resistance mutations (44%; p<0.008) but did not differ in ALT-levels and viral load.
In the present investigation, which is among the first
to study the prevalence resistance mutations in naïve patients, about 10% of
all patients were diagnosed with primary resistance mutations against
lamivudine, telbivudine, adefovir and possibly entecavir and tenofovir. Since these
findings have an impact on therapeutic decisions, newly diagnosed patients with
hepatitis B infection should receive a primary resistance testing. The clinical
significance of polymorphisms at nt 215 and 217
warrants further study.
Treatment – Antiviral Resistance
Lamivudine-resistant Mutation Among Treatment-naive
Hepatitis B Patients Is Common and May Be Associated with Treatment Failure
S. K. Fung; T. Mazzulli; M. El-Kashab;
M. Sherman; V. Popovic; E. Sablon
Pre-existing hepatitis B (HBV) antiviral resistance
mutations (AVR) to lamivudine (LAM) among
treatment-naïve HBV patients have been reported to occur at low frequency, but
the clinical significance with regard to antiviral therapy remains unclear.
To document the prevalence of antiviral resistance (AVR) mutations among
untreated HBV patients using a sensitive line probe assay and to determine
whether AVR mutations are associated with
reduced efficacy to antiviral therapy.
Patients and Methods:
Consecutive untreated adult patients with chronic
hepatitis B attending the liver clinics of University Health Network and Mount Sinai Hospital (Toronto, Canada) from 11/06 – 03/08 were
tested for AVR. Patients were deemed to be
treatment-naïve after a careful treatment history corroborated by a family
member, where possible. HBV DNA was quantified by PCR (Roche TaqMan, LLQ 6
IU/ml). HBV genotype and AVR mutations were detected
using INNO-LiPA HBV DRv2 and DRv3 (InnoGenetics, Gent, Belgium). Statistical analysis
was performed using SPSS v13 (Chicago, IL).
209 treatment-naïve adult patients were tested for AVR: 69% male, 15% cirrhotic,
mean age 38±17 years, 85% Asian, 51% HBeAg positive. Mean HBV DNA was 5.7±2.3 log10 IU/ml
and HBV genotypes A, B, C and D were found in 8%, 32%, 47% and 10% patients,
respectively. The prevalence of AVR mutations was: rtL180M,
10%; rtM204V/I, 12%; rtL80V/I, 9%; rtV173L, 3%; rtA181V/T, 0%, rtN236T, 0%.
Patients with high viral load and male gender were more likely to harbor AVR mutants. Among 21
patients with LAM-resistance at baseline, 12 did not meet treatment criteria
(immune tolerant or inactive carriers), while the remainder is scheduled to
start or has already started therapy. 3 patients received lamivudine 100 mg daily
(mean duration 11 months); 1 had primary nonresponse, while 2 had virologic
breakthrough. However, in 3 patients treated with adefovir 10 mg daily or
tenofovir 300 mg daily (mean duration 7 months), all had undetectable HBV DNA at last follow-up.
Mutations associated with the rt180/204 nucleoside
resistance pathway were common (10% patients), whereas those associated with
the rt236 nucleotide pathway were not found in any patient in this study. Among
patients with pre-existing LAM-resistance, lamivudine resulted in treatment
failure requiring salvage therapy, whereas adefovir or tenofovir showed no
reduced efficacy. Our data suggest AVR testing among
treatment-naïve patients is important, in order to tailor antiviral therapy and
optimize treatment response. However, further studies are required to determine
the role of AVR testing in routine clinical