Zoulim Hbv EpidéMio Marqueurs

HHéépatite Bpatite B

Fabien ZoulimFabien Zoulim

DDéépartement dpartement d’’ hhéépatologie patologie

& & INSERM UINSERM U871871, , LyonLyon

VHBVHB HCAHCA cirrhose cirrhose CHCCHC

VaccinVaccin ANTIVIRAUXANTIVIRAUX IFNIFN

AntivirauxAntiviraux //IFNIFN?? Niederau Niederau N Engl J Med N Engl J Med 19961996 & & Liaw Liaw N Engl J Med N Engl J Med 20042004

RESISTANCE VIRALERESISTANCE VIRALE

3030--5050 ans ans GuGuéérison rison

LeeLee, , N Engl J Med N Engl J Med 19971997; ; LokLok, , Hepatology Hepatology 20012001

EPIDEMIOLOGIE DE LEPIDEMIOLOGIE DE L ’’ HHÉÉPATITE BPATITE B

EPIDEMIOLOGIE DE LEPIDEMIOLOGIE DE L''INFECTION A VHBINFECTION A VHB

•• HHéépatites aigues patites aigues

–– VHA VHA : : 40%40%

–– VHB VHB : : 30%30%

–– VHC VHC : : 20%20%

•• incidence incidence : : 300300 000000 infections infections àà VHB VHB / / anan

•• 3030 000000 nouveaux porteurs chroniques nouveaux porteurs chroniques / / anan

•• 33 000000 d dééccèès s / / anan

AUX USAAUX USA

MODES DE TRANSMISSION DU VHBMODES DE TRANSMISSION DU VHB

•• 11081108 habitants de San Francisco habitants de San Francisco •• 159159 ( (14%14%) ) antianti--HBc HBc ++ •• positivitpositivitéé des anti des anti--HBc associHBc associéée avece avec

–– âgeâge –– ééthniethnie –– degrdegréé d d''ééducationducation –– toxicomanie IVtoxicomanie IV –– prostitutionprostitution –– nombre de partenaires sexuelsnombre de partenaires sexuels

–– homosexualithomosexualitéé

–– HIV HIV / / HSV HSV 22 / / syphilissyphilis

MODES DE TRANSMISSION DU VIRUS DE LMODES DE TRANSMISSION DU VIRUS DE L ''HHÉÉPATITE B EN EUROPEPATITE B EN EUROPE

sexuellesexuelle 34%34%

hhééttééroro 23%23%

homohomo 11%11%

drogue IVdrogue IV 26%26%

inconnueinconnue 31%31%

hhéémodialysmodialys ééss 8%8%

transfusionstransfusions 2%2%

personnels de santpersonnels de sant éé 2%2%

contact aveccontact avec porteur du VHBporteur du VHB

4%4%

AsieAsie Transmission verticaleTransmission verticale

Déclaration obligatoire de l’hépatite B en France :

résultats des 12 premiers mois de notification

Denise Antona, E Delarocque-Astagneau, D Lévy-Bruhl département des maladies infectieuses

Incidence of acute hepatitis B in France Sentinel networks 1991-1996 et Lyon (COURLY) 1983-1997

Circuit de l’information

Biologiste

InVS

MISP de DDASS du département

d’exercice

Médecin prescripteur

Fiche de notification autocopiante à 4 feuillets Partie 1 : code d’anonymat irréversible, caractéristiques du patient Partie 2 : information biologique Parties 3-4-5 : information clinique et épidémiologique Parties 6-7 : identification du médecin prescripteur et du biologiste déclarants

Feuillet 1 : parties 1-2 et 6-7 renseignées

Feuillets 2 et 3 à compléter

Feuillet 2 : parties 3-4-5 complétées

Feuillets 1 et 2 complétés et validés

Relance

Results

158158 acute hepatitis cases acute hepatitis cases

•• Hospital doctor in Hospital doctor in 64%64% cases cases

•• Sex ratio MSex ratio M//F F : : 2,952,95 ( (118/40118/40))

•• Median ageMedian age: : 3737 yrs for males yrs for males, , 3636yrs for females yrs for females

•• Jaundice Jaundice : : 69%69%

•• Hospitalisation Hospitalisation : : 46%46%

•• Fulminant hepatitis Fulminant hepatitis : : 33 ( (22 death death))

Age distribution: comparison of the different periods 1991-94 versus 03/2003 - 02/2004

years 1991- 94 n= 151

March 03- February 04 n= 158

Risk exposure within 6 months preceding the acute case Source : obligatory declaration 2003-04

•• SourceSource: : obligatory declaration march obligatory declaration march 0303-- february february 20042004 N N==145145

–– SexualSexual 5959 40,6%40,6% No factorNo factor 4343 29,6%29,6%

–– IVDUIVDU 99 6,2%6,2% >>11 factor factor 3838 26,3%26,3%

–– Invasive treatment Invasive treatment 1515 10,3%10,3%

–– TatooTatoo, , piercing piercing 55 3,4%3,4%

–– FamilialFamilial 1414 9,7%9,7%

–– Perinatal Perinatal 22 1,4%1,4%

–– Live in instiution Live in instiution 1111 7,6%7,6%

–– Travel in endemic Travel in endemic 2121 14,5%14,5%

areas areas 91/14591/145 patients patients ((6363 %) %) had a vaccine indication had a vaccine indication ((22 vaccinated vaccinated ≥≥≥≥≥≥≥≥ 33 doses doses) )

•• Sentinel networks Sentinel networks 9191--9696 NN==195195 –– sexualsexual 35%35% –– IVDUIVDU 19%19%

–– «« percutaneouspercutaneous »» 15%15%

–– No factor No factor 35%35%

Hépatites virales B: épidémiologie

- Vaccin mais 400 millions de porteurs chroniques dans le monde

- 280 000 porteurs chroniques en France (INVS)

- 45% ignorent leur statut

- 1 300 décès par an en France

- 60 000 avec hépatite chronique active

- Seulement 13 000 patients traités

VIROLOGIEVIROLOGIE

• FAMILLE : Hepadnaviridae, seul représentant humain •VIRUS RESISTANT : - 7 jours dans l’environnement - pendant 5 mn à 100°C, 10 h à 60°C - à la congélation.

LE VIRUS DE L ’HEPATITE B

LE GLE GÉÉNOME DU VIRUS DE LNOME DU VIRUS DE L’’HHÉÉPATITE BPATITE B

ddééterminant aterminant a vaccinvaccin //IgHBsIgHBs

GGèène pol ne pol antivirauxantiviraux

Mt preMt pre --corecore RRééponse antiponse anti --HBeHBe ??

Mt du coreMt du core RRééponse CTLponse CTL

88 g géénotypesnotypes A to HA to H

Tiollais Nature Tiollais Nature 19851985 GGüünther Adv Virus Res nther Adv Virus Res 19991999 Norder J Gen Virol Norder J Gen Virol 20032003

Ganem Ganem & & PrincePrince, , NEJM NEJM 20042004

ARN pg

ss DNA

RC DNA

cccDNA

intégration

virion

virion 10%

90%

ds DNA

cccDNA illégitime

noyau

Réplication du génome viral. Implication pour la persistance virale et l’intégration du génome viral

Membrane cellulaire

VHB HUMAINVHB HUMAIN

MARMOTTE MARMOTTE ((WHVWHV )) CANARD CANARD ((DHBVDHBV ))

ModModèèles Animauxles Animaux

Souris TransgSouris Transgééniquesniques Souris SCID uPaSouris SCID uPa

ChimpanzChimpanzéé

TupaiaTupaia

Summers PNAS Summers PNAS 19781978, , Mason J Virol Mason J Virol 19811981, , Chisari Science Chisari Science 19851985, , Petersen PNAS Petersen PNAS 19981998

•• Polymerase viralePolymerase virale

–– DHBV DHBV : : lysat rlysat rééticulocytaireticulocytaire

–– HBV HBV : : baculovirusbaculovirus

ModModèèles les in vitroin vitro

UU

Polymerase VHBPolymerase VHB

DNADNA((--))

ELONGATIONELONGATION

CCC CCC --

RC RC -- L L --

SS SS --

•• Culture cellulaireCulture cellulaire

–– Transfection Transfection : : lignlignéées des d’’ hhéépatomepatome

–– Infection Infection : : hhéépatocytes primairespatocytes primaires, , HepaRGHepaRG

–– Baculovirus ou adenovirus recombinant Baculovirus ou adenovirus recombinant

Sells PNAS Sells PNAS 19871987, , Wang Cell Wang Cell 19921992, , Zoulim J Virol Zoulim J Virol 19941994, , Lanford J Virol Lanford J Virol 19951995, , Gripon PNAS Gripon PNAS 20022002, , Sprinzl J Virol Sprinzl J Virol 20012001

Cycle de réplication du VHB

Zoulim & Locarnini, Gastroenterology 2009

Comparative dynamics among three viruses Comparative dynamics among three viruses

HIV (Ritonav ir)

HCV (IFN- )

HBV (Lamivu dine)

Plasma virus

Half-life 5.8 h 2.7 - 7.2 h 24 h Mea n viral genera tion time

2.7 d 3.8 - 7.3 d 24.7 d

Daily t urnover 95% 94% - 99.8% 50% Daily produ ction (plasm a)

1010 (1.1 - 12.7 )*1011

1011

Tot al load 1.2*1 0 9 (3.8 - 5.6)*1010 2*10 11 Infecte d cells

Half-life 1.6 d 2.4 - 4.9 d 10 - 100 d Mea n lifespan 2.3 d 3.5 - 7.1 d 23.3 d Daily t urnover 38% 13% - 25% 1% - 7%

(Tsiang et al. Hepatology 1999)

Infection Infection àà VHB et risque de CHC VHB et risque de CHC

•• Etude de Beasley Etude de Beasley àà Taiwan Taiwan

–– risque relatif risque relatif = = 100100 chez les porteurs de l chez les porteurs de l''AgHBsAgHBs

•• Etude de TsukumaEtude de Tsukuma

–– risque cumumatif de CHC risque cumumatif de CHC àà 33 ans ans •• 12,5%12,5% chez chez 240240 patients avec cirrhose patients avec cirrhose

•• 3,8%3,8% chez chez 677677 patients avec h patients avec héépatite chroniquepatite chronique

–– risque x risque x 77 si AgHBs si AgHBs ++

–– risque X risque X 44 si anti si anti--HCV HCV ++

•• Facteurs associFacteurs associéés s : : alcoolalcool, , tabactabac, , aflatoxineaflatoxine

•• Diminution incidence avec la vaccination de masse Diminution incidence avec la vaccination de masse ((ChenChen, ,

NEJM NEJM 19951995))

CARCINOME HEPATOCELLULAIRE ET VIRUS CARCINOME HEPATOCELLULAIRE ET VIRUS DE LDE L''HEPATITE B HEPATITE B

•• CoCo--incidence de rincidence de réépartition gpartition gééographique ographique

VHB VHB / / CHCCHC

•• Porteurs AgHBs Porteurs AgHBs : : RR x RR x 100100 pour le CHC pour le CHC

•• CHC dans les modCHC dans les modèèles animaux de lles animaux de l''hhéépatite B patite B ::

–– marmottemarmotte

–– éécureuilcureuil

•• PrPréésence dsence d''ADN viral intADN viral intéégrgréé dans les tumeurs dans les tumeurs

HBV replication and its role in HCC development

Wands, NEJM 2004

PATHOGENIE DU CARCINOME PATHOGENIE DU CARCINOME HEPATOCELLULAIREHEPATOCELLULAIRE

VHBVHB ALCOOLALCOOL

VHCVHC

LESIONS HEPATIQUES CHRONIQUESLESIONS HEPATIQUES CHRONIQUES

ACTIVATION FACTEURS ACTIVATION FACTEURS DE CROISSANCEDE CROISSANCE

REGENERATIONREGENERATION

ALTERATIONS GENETIQUESALTERATIONS GENETIQUES

CARCINOME HEPATOCELLULAIRECARCINOME HEPATOCELLULAIRE

DESORDRES DESORDRES METABOLIQUESMETABOLIQUES

FACTEURSFACTEURS ENVIRONNEMENTAUXENVIRONNEMENTAUX

Role du VHB dans l’oncog énèse h épatique

VHB

INFECTION CHRONIQUE

CARCINOGENES

CO-FACTEURS

REACTION INFLAMMATOIRE CHRONIQUE

REGENERATION HEPATIQUE

MUTAGENESE INSERTIONNELE

TRANSACTIVATION DE GENES CELLULAIRES

INTERACTIONS PROTEIQUES

INACTIVATION DE GENES SUPPRESSEURS DE TUMEUR

CHC

PHYSIOPATHOLOGIE PHYSIOPATHOLOGIE / / IMMUNOPATHOLOGIEIMMUNOPATHOLOGIE

Ganem and PrinceGanem and Prince, , NEJM NEJM 20042004

HHÉÉPATOCYTE INFECTPATOCYTE INFECT ÉÉ

VHBVHB

CTLCTL

FasFas perforineperforine

HHÉÉPATOCYTEPATOCYTE NON INFECTNON INFECT ÉÉ

IMMUNOPATHOGIMMUNOPATHOG ÉÉNIE NIE DES HDES HÉÉPATITES B CHRONIQUESPATITES B CHRONIQUES

AgHBcAgHBc//ee

HLAIHLAI

cytokinescytokines

RRÉÉPONSE IMMUNITAIREPONSE IMMUNITAIRE CYTOKINESCYTOKINES

ANTIVIRAUXANTIVIRAUX

ANTICORPS NEUTRALISANTSANTICORPS NEUTRALISANTS

IMMUNOPATHOLOGY OF HBV INFECTIONIMMUNOPATHOLOGY OF HBV INFECTION

Immune toleranceImmune tolerance

Clairance phaseClairance phase Chronic hepatitisChronic hepatitis

SeroconversionSeroconversion Remission Remission

CDCD8+8+

HBVHBV

CDCD8+8+ HBVHBV

CDCD8+8+ HBVHBV

Immunopathology

Fulminant hepatitisFulminant hepatitis

CDCD8+8+

HBVHBV

Non cytolytic processesNon cytolytic processes THTH 11 cytokines with direct antiviral cytokines with direct antiviral

effecteffect

TurnTurn --over of infected cellsover of infected cells Immune mediated lysis of infected cellsImmune mediated lysis of infected cells

DucksDucks WoodchucksWoodchucks ((Guo J Virol Guo J Virol 19991999

Summers PNAS Summers PNAS 20032003&&20042004))

Transgenic miceTransgenic mice ChimpanzeesChimpanzees

((Guidotti Science Guidotti Science 19991999, , Thimme J Virol Thimme J Virol 20032003))

AntiviralsAntivirals Inhibition of viral DNA synthesisInhibition of viral DNA synthesis --> > inhibition of intracellular recycling of cccDNAinhibition of intracellular recycling of cccDNA ((Werle Gastroenterology Werle Gastroenterology 20042004))

Restoration of antiRestoration of anti--HBV immune responseHBV immune response ((Boni Hepatology Boni Hepatology 20002000))

MECHANISMS OF VIRAL CLEARANCEMECHANISMS OF VIRAL CLEARANCE

Non cytolytic clearance of acute Non cytolytic clearance of acute HBV infection in chimpanzeeHBV infection in chimpanzee

Wieland S et al, PNAS 2004

Hepatocyte turnHepatocyte turn--over is required for clearance of over is required for clearance of viral infection in acute infectionviral infection in acute infection

Summers et alSummers et al, , PNAS PNAS 20032003 & & 20042004

HHéépatocyte infectpatocyte infect éé

HBVHBV

HHéépatocyte patocyte non infectnon infect éé

Phase de tolPhase de tol éérance immunitairerance immunitaire

MarqueursMarqueurs AgHBe AgHBe ++ HBV DNA HBV DNA ++++++ ALAT ALAT = = NN Foie Foie = = NN

HBcHBc //e Age Ag


HBVHBV

CTLCTL

FasFas perforineperforine


Phase de clairance immunePhase de clairance immune ((hhéépatite chroniquepatite chronique ))

MarqueursMarqueurs AgHBeAgHBe ++ HBV DNA HBV DNA ++ ALAT ALAT ++++++ FoieFoie : : HHéépatite patite chroniquechronique

HBcHBc //e Age Ag

HLAIHLAI

cytokinescytokines


HBs AgHBs Ag


MarqueursMarqueurs AgHBeAgHBe -- antianti --HBe HBe ++ HBV DNA HBV DNA < < 101044 / /mLmL ALAT ALAT = = NN Foie Foie = = rréémissionmission

Phase de rPhase de r éémissionmission portage inactif de lportage inactif de l ’’AgHBs AgHBs

RRééactivationactivation Virus sauvage Virus sauvage ou mt preou mt pre--corecore OncogOncogéénnèèsese

HHéépatocytes infectpatocytes infect ééss

HHéépatocytes patocytes non infectnon infect ééss

MarqueursMarqueurs HBsAg HBsAg --

antianti --HBc HBc ++ AntiAnti --HBs HBs +/+/--

HBV DNA HBV DNA -- mais PCR mais PCR ++

Clairance de lClairance de l ’’AgHBsAgHBs

Mutants dMutants d’é’échappementchappementInfections occultesInfections occultes

OncogOncogéénnèèsese

cccD

NA

cc

cDN

A ((

copi

esco

pies

// cel

lce

ll ))

Tot

al H

BV

DN

A

Tot

al H

BV

DN

A

(( cop

ies

copi

es// c

ell

cell )

)

cccDNA levels in the different phases of cccDNA levels in the different phases of chronic HBV infectionchronic HBV infection

•• HBeAgHBeAg+ + patients had significantly higher cccDNA patients had significantly higher cccDNA ((9090--foldfold) ) and total HBV and total HBV DNA DNA ((147147-- foldfold) ) levels compared to HBeAglevels compared to HBeAg-- patientspatients. (. (pp<<00..001001, , Wilcoxon Wilcoxon teststests))

10 -3

10 -2

10 -1

100

101

102

103

104

10 -3

10 -2

10 -1

100

101

102

103

HBeAg

HBeAg+ (+ (6363))

InactInact . . C

arriers

Carriers

((1010))

HBSAg

HBSAg-- ( (77))

HBeAg

HBeAg-- ( (1818))

HBeAg

HBeAg+ (+ (6363))

InactInact . . C

arriers

Carriers

((1010))

HBSAg

HBSAg-- ( (77)

HBeAg

HBeAg-- ( (1818))

Werle et al, Gastroenterology 2004

HISTOIRE NATURELLE ET VIROLOGIE CLINIQUE

Histoire Naturelle de lHistoire Naturelle de l’’ hhéépatite Bpatite B Infection aigueInfection aigue

Infection chroniqueInfection chronique

TolTol éérance immunitairerance immunitaire

HHéépatite chroniquepatite chronique

Portage inactifPortage inactif

GuGuéérisonrison 5%5% nx nx --nnééss 90%90% adultes adultes

Virus sauvage Virus sauvage ((HBeAgHBeAg +) +) Mutant preMutant pre --core core ((HBeAgHBeAg --))

Cirrhose Cirrhose

Carcinome hCarcinome h éépatocellulairepatocellulaire

RRééactivation activation

3030--5050 ans ans

Seeger, Zoulim, Mason; Fields Virology; 2007

MARQUEURS SEROLOGIQUESMARQUEURS SEROLOGIQUES

•• SystSystèème AgHBe me AgHBe //antianti--HBeHBe

–– distinction virus sauvage distinction virus sauvage / / virus mutvirus mutéé AgHBe AgHBe

nnéégatifgatif

•• VirVir éémiemie

–– d déétection quantitative de ltection quantitative de l''ADN viralADN viral

HEPATITE B AIGUE

•• Incubation Incubation 11 àà 66 mois mois •• Le plus souvent asymptomatiqueLe plus souvent asymptomatique

–– ÉÉvolution plus frvolution plus fr ééquente vers la chronicitquente vers la chronicitéé

•• ProdromesProdromes:: –– Maladie sMaladie séérique rique : : arthralgiesarthralgies, , urticaireurticaire , ,

acrodermatite etcacrodermatite etc. ... ..

•• Formes ictFormes ictéériques riques : + : + graves que VHA et VHCgraves que VHA et VHC –– DurDur éée de le de l’’ ictictèère re : : jusqujusqu’à’à 44 mois mois

•• Evolution Evolution : : chronicitchronicit éé 55 àà 10%10% •• HHéépatites fulminantespatites fulminantes

Laboratory Diagnosis of Acute Hepatitis B

0100200300400500600700800900

1000

0 1 2 3 4 5 6 12 24 36 48 60

ALT

HBsAg

HBeAg

HBV DNA

Normal

Months After Exposure

AL

T a

nd

HB

V D

NA

IU/L

an

d m

illio

n c

op

ies/

ml

Symptoms

Anti-HBs Ab

Anti-HBe Ab

IgM anti-HBc

Total anti-HBc

Seeger, Zoulim, Mason, Fields Virology 2007

HEPATITE B PROLONGEE

•• DDééfinitionfinition –– Persistance rPersistance rééplication virale plication virale àà la la 88èème me

semaine dsemaine d’é’évolution volution :: –– AgHBe AgHBe + + ou ADNou ADN--VHB VHB ++

•• EvolutionEvolution –– ChronicitChronicit éé : : 88 cas cas / / 1010

•• Traitement Traitement : : IFN IFN –– GuGuéérison rison : : 77 àà 88 cas cas / / 1010

INFECTIONS CHRONIQUES A VHBINFECTIONS CHRONIQUES A VHB FORMES CLINIQUESFORMES CLINIQUES

•• virus sauvagevirus sauvage –– toltoléérance immunitairerance immunitaire

–– rupture de tolrupture de toléérance rance --> > lléésions hsions héépatocytaires patocytaires : : HCAHCA

–– ssééroconversion antiroconversion anti--HBe spontanHBe spontanéée e ((portage inactifportage inactif) : ) : 55--1010% /% /anan

–– > > diminution significative rdiminution significative r ééplication viraleplication virale

–– > > amaméélioration signes histologiqueslioration signes histologiques

•• virus mutvirus mutéé pr préé--C C ((--)) –– sséélection au moment de la slection au moment de la sééroconversion antiroconversion anti--HBeHBe

–– ddéépend du gpend du géénotype viralnotype viral –– immunopathologie immunopathologie ??

–– sséévvééritrit éé de l de l'' hhéépatopathie patopathie : : controverscontroversééee

–– association au CHCassociation au CHC

0

100

200

300

400

500

600

700

800

0 1 2 3 4 5 6 12 24 36 48 60

ALT

HBsAg

HBeAg

HBV DNA

Normal


AL

T a

nd

HB

V D

NA

I U/L

or

mi ll

ion

co

pie

s/m

l

Laboratory Diagnosis of Chronic Hepatitis B associated with wild type virus infection


ALT

`` HBsAg

HBeAg

HBV DNA

Normal


AL

T a

nd

HB

V D

NA

IU/L

an

d m

illio

n c

op

ies/

ml

Anti-HBe

Laboratory Diagnosis of Transition of Chronic Hepatitis B to The inactive Carrier State

0

100

200

300

400

500

600

700

800

0 1 2 3 4 5 6 12 24 36 48 60 72 80 92 104


0

50

100

150

200

250

300

350

400

450

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48

ALT

HBsAg

HBV DNA

Normal ALT levels

Months

AL

T a

nd

HB

V D

NA

IU/L

an

d m

illio

n c

op

ies/

ml Anti-HBe HBeAg

Laboratory Diagnosis of HBeAg negative Chronic Hepatitis B


0,001

0,01

0,1

1

10

100

1000 ALAT

ADN- VHB

AgHBe AgHBe ++ antianti --HBe HBe ++ UIUI//mlml pgpg //mlml

AgHBsAgHBs

Tolérance hép chronique p. inactif mt pré-core VHB occulte

hybridationhybridation

PCRPCR

9 log

8 log

7 log

6 log

5 log

4 log

3 log

2 log

1 log

Dynamic ranges of quantification of HBV DNA assays

Amplicor HBV Monitor v2.0 (Roche)

HBV Hybrid-Capture II (Digene)

Ultra-sensitive HBV Hybrid-Capture II

Versant HBV DNA 3.0 (bDNA, Siemens)

Cobas Taqman HBV (Roche)

Abbot Real-time HBV (Abbott)

Versant HBV DNA 1.0 (kPCR, Siemens)*

*in development

1010 101022 101033 101044 101055 101066 101077 101088 101099

RealArt HBV LC PCR (Artus Biotech)

Formes cliniques

MANIFESTATIONS MANIFESTATIONS EXTRAHEPATIQUES DU VHBEXTRAHEPATIQUES DU VHB

•• PANPAN –– Complexes immuns circulants HBsComplexes immuns circulants HBs//antianti--HBsHBs

–– DDéépots artpots artèères moyens et petit calibreres moyens et petit calibre –– Traitement Traitement : : plasmaphplasmaphééresesreses, , corticoidescorticoides, , antiviraux antiviraux

((vidarabine vidarabine / / IFN IFN / / famciclovir famciclovir / / lamivudinelamivudine))

•• GlomGloméérulonrulon ééphritesphrites •• CryoglobulinCryoglobulin éémiesmies •• GuillainGuillain --BarrBarr éé •• MyocarditeMyocardite

TRANSMISSION VERTICALE DU VHBTRANSMISSION VERTICALE DU VHB

•• mmèère AgHBe re AgHBe ++

–– transmission transmission : : 90%90%

•• mmèère antire anti--HBe HBe ++

–– transmission transmission : : 1010--20%20%

–– VHB mutVHB mut éé pr préé--C C ((--) : ) : hhéépatites fulminantespatites fulminantes

•• chronicitchronicit éé chez l chez l’’ enfant enfant : : 9090%%

PRESENTATION CLINIQUEPRESENTATION CLINIQUE •• INFECTION PERIINFECTION PERI --NATALENATALE

–– ALT normales ou subnormalesALT normales ou subnormales

–– ADNADN--VHB VHB > > 10001000 pg pg//mlml

–– histologie histologie : : lléésions minimessions minimes

•• INFECTION POSTINFECTION POST --NATALENATALE

–– ALT ALT éélevlevééeses

–– ADNADN--VHB VHB < < 10001000 pg pg//mlml

–– histologie histologie : : hhéépatite modpatite modéérr éée e àà s séévvèèrere

•• CARCINOME HEPATOCELLULAIRE CARCINOME HEPATOCELLULAIRE : : 30 30 ANSANS

Histoire naturelle de l’infection chronique par le virus de l’hépatite B

en Alaska •• McMahon BJMcMahon BJ, , Ann Intern Med Ann Intern Med 20012001;;135135((99):):759759--6868 •• 15361536 natifs d natifs d’’ Alaska Alaska : : 641641 AgHBe AgHBe++, , 8383 anti anti--HBeHBe++ •• ProbabilitProbabilit éé d d’é’éliminer lliminer l ’’ Ag HBe Ag HBe àà 1010 ans ans : : 72,572,5 %. %. •• Elimination de lElimination de l ’’ Ag HBs chez Ag HBs chez 106106 porteurs porteurs

chroniques du VHB chroniques du VHB ((77 %) %) •• Incidence des Incidence des éévvéénements cliniquesnements cliniques: : 2,3/10002,3/1000

porteursporteurs//annannéée e •• Incidence du CHCIncidence du CHC: : 1,9/10001,9/1000 porteurs porteurs//annannéée e ((2,32,3 chez chez

ll ’’ hommehomme; ; 1,21,2 chez la femme chez la femme). ).

Pathophysiologic Cascade of Chronic HBV Infection

HBV Replication (Measured by

Serum HBV DNA)

HBV ReplicationHBV Replication ((Measured by Measured by

Serum HBV DNASerum HBV DNA ))

Liver Inflammation

Liver Liver InflammationInflammation

Worsening Histology • Necroinflammation • Fibrosis • Cirrhosis

Worsening HistologyWorsening Histology •• Necroinflammation Necroinflammation •• Fibrosis Fibrosis •• Cirrhosis Cirrhosis

Disease Progression • Liver Failure • Liver Cancer • Transplant • Death

Disease ProgressionDisease Progression •• Liver Failure Liver Failure •• Liver Cancer Liver Cancer •• Transplant Transplant •• Death Death

Adapted from: Lavanchy D. Journal of Viral Hepatiti s, 2004, 11, 97–107. Chen JC, et al. JAMA. 2006;29 5:65-73. Iloeje U. H, et al. Gastroenterology. 2006;130:678-86.

ALT Elevation

ALT ALT ElevationElevation

Normal Aminotransferase Levels and Risk of Mortality from Liver Diseases

Kim HC et alKim HC et al . . BMJBMJ 20042004; ; 328:983328:983

0 10 20 30 40 50 60 70 80 90

Risk ratio (95% CI)

<20

20-29

30-39

40-49

50-99

>100

ALT

1.01.0

2.92.9

9.59.5

19.219.2

30.030.0

59.059.0

NormalNormal

ElevatedElevated

• Korea Medical Insurance Corporation

– 94,533 men; 47,522 women

– 35-59 yrs old

– Relative risk for liver mortality compared with AST and ALT <20 IU/l

AgHBeAg et risque de CHC

Yang et al. N Engl J Med. 2002;347:168-174.

Cum

ulat

ive

inci

denc

e (%

)

Year

HBsAg+ HBeAg+

HBsAg+, HBeAg -

HBsAg -, HBeAg -

6 2 10

0

4

6

8

12

10

2

0 4 8

• 11,893 Taiwanese men; 92,359 person-years follow-up

Charge virale et incidence de la cirrhose

R.E.V.E.A.L. – HBV Study

Année de suivi

Incidence cumulative de cirrhose

.2

.1

0 1 2 3 4 5 6 7 8 9 10 11 12 13

0

.4

.3

P <0.001

n=3774

1.0 x 106 n=627

1.0-9.9x105 n=344

1.0-9.9x104 n=649

300-9.9x103 n=1210

<300 n=944

5.2%

6.3%

10.0%

23.0%

37.1%

Iloeje UH et al. Gastroenterology 2006; 130: 678-68 6

Survie chez les patients au stade cirrhose

1. Weissberg et al. Ann Intern Med. 1984;101:613. 2. De Jongh et al. Gastroenterology. 1992;103:1630.

1 3 2 4 5 0

20

40

60

100

80

Cirrhosis 1

(n = 130)

Decompensated cirrhosis 2

(n = 21) 14%

55%

Pat

ient

s S

urvi

ving

, %

Years

0

Charge virale et incidence du CHC

Chen et al; JAMA 2006

REVEAL-Incidence of HCC Increases with Increasing HBV DNA

Baseline Viral Level

Chen JC, et al. JAMA. 2006;295:65-73.

14.9%

12.2%

3.6%

1.4% 1.3%

0%

5%

10%

15%

20%

<300 >300 - 103

Baseline HBV DNA (copies/mL)

% c

umul

ativ

e in

cide

nce

of H

CC

> 103 - 104 >104 - 106 ≥106

High Baseline Serum HBV DNA Levels are Associated with Increased Risk of HCC Mortality

in HBsAg-Positive Patients

80%

84%

88%

92%

96%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12

Survival time (Years)

HBV DNA Negative

HBV DNA LowHBV DNA Low

< < 101055 copies copies //mL mL RR RR = = 1.71.7 ( (0.50.5--5.75.7))

HBV DNA HighHBV DNA High ≥≥ 101055 copies copies //mL mL

RR RR = = 11.211.2 ( (3.63.6--35.035.0)) p < 0.001 across viral categories

http://www.fccc.edu/docs/sci_report/Evans.pdf#searc h=%22haimen . Accessed 1/23/07. Chen G, et al. J Hepatology 2005; 42 (suppl 2):477A . Chen G, et al. Hepatology 2005; 40 (suppl 1):594A.

Relationship Between Persistent Viremia and HCC: Argument For Antiviral Therapy

• Persistent replication associated with greater risk of HCC

• Decreased risk when viral replication declines

Chen, et al. JAMA 2006

Baseline HBV DNA, (copies/mL) < 104 ≥≥≥≥105 ≥≥≥≥105 ≥≥≥≥105

Follow-up HBVDNA, copies/mL --- < 104 104 to <105 ≥≥≥≥105

Adjusted RR (95% CI)

1.0 (ref)

3.6 (1.7-7.6)

6.9 (3.4-13.8)

9.1 (5.8-14.1)

P Value -- < 0.001 < 0.001 < .001

HC

C In

cide

nce

Rat

e P

er 1

00,0

00

0

1473

5882

8730 10,108

2.0x103

4.0x103

6.0x103 8.0x103 1.0x104

1.2x104

Impact Clinique de la Variabilité du Génome Viral

VARIABILITE GENETIQUE DU VHBVARIABILITE GENETIQUE DU VHB

•• Multiplication viraleMultiplication virale

»» taux dtaux d'' erreur de la transcriptase inverseerreur de la transcriptase inverse

•• Pression de sPression de séélectionlection

»» rr ééponse immunitaire cellulaire ponse immunitaire cellulaire / / humoralehumorale

»» antivirauxantiviraux

--> > possibilitpossibilitéé de variants d de variants d'' ééchappementchappement

•• ConsConsééquences cliniquesquences cliniques

»» diagnostic sdiagnostic séérologiquerologique

»» traitements antivirauxtraitements antiviraux

•• SOUSSOUS--TYPES TYPES : : acides aminacides aminéés et ds et dééterminants HBsterminants HBs

–– boucle boucle 139139--147147 --> > det adet a

–– 122122 --> > det d ou ydet d ou y

–– 127127 --> > det wdet w11--44

–– 160 160 --> > det w ou rdet w ou r

•• GENOTYPES GENOTYPES : : variabilitvariabilit éé de s de sééquence gquence géénomique nomique

–– du gdu géénome complet nome complet : : 8%8%

–– du gdu gèène S ne S : : 4%4%

–– 88 g géénotypes A notypes A àà H H

•• MUTANTS DU VHBMUTANTS DU VHB

–– mutations ponctuelles mutations ponctuelles / / ddéélléétions tions / / insertionsinsertions

VARIABILITE GENETIQUE DU VHBVARIABILITE GENETIQUE DU VHB

8 genotypes, numerous sub-genotypes, and recombinant forms

World J Gastroenterol 2007; 13: 14-21

B6

D1

GGéénotypes VHB chez les patients atteints notypes VHB chez les patients atteints dd’’hhéépatite chronique en Francepatite chronique en France

Num

ber of su

bje

cts

Num

ber of su

bje

cts

FF GG AA BB CC DD EE

00

1010

2020

3030

4040

5050

6060

7070

8080

9090

100100

30.2%30.2%

7.9%7.9%

12.5%12.5%

37.4%37.4%

11.3%11.3%

0.40.4 % % 1.1%1.1%

Zoulim et al J Viral Hepatitis 2006

Impact du génotype sur la séroconversion

1 Janssen, Lancet 2005; 2 Flink, Am J Gastro 2006

PEG-IFN a-2b

HBeAg Loss 1

0

10

20

30

40

50

A n=90

28%

47%

44%

25%

B n=23

C n=39

D n=103

Per

cent

age

of p

atie

nts

(%)

HBV genotype

0

3

6

9

12

15

A n=90

5%

8%

0%

B n=23

C n=39

D n=103

18 15%

Per

cent

age

of p

atie

nts

(%) 21

HBV genotype

PEG-IFN a-2b

HBsAg Loss 2

LES MUTANTS DU GLES MUTANTS DU GÉÉNOME DU VHBNOME DU VHB

ddééterminant aterminant a vaccinvaccin //HBIgHBIg

polympolym ééraserase antivirauxantiviraux

Mt prMt pr éé--corecore RRééponse antiponse anti --ee ??

Mt coreMt core RRééponse CTLponse CTL

ROLE DE LA RROLE DE LA R ÉÉGION PRGION PRÉÉ--C ET DE LC ET DE L ’’ AgHBeAgHBe

•• Non nNon néécessaire cessaire àà la r la rééplication du VHBplication du VHB –– Culture cellulaireCulture cellulaire

–– ModModèèles in vivo les in vivo •• MarmotteMarmotte

•• CanardCanard

•• Modulation de la rModulation de la rééponse immuneponse immune –– TolToléérogrogèène ne : : souris transgsouris transgééniquesniques

–– Cible de la rCible de la rééponse antiponse anti--capsidecapside

Chang et alChang et al, , JJ. . Virol Virol 19871987; ; Schlicht et al JSchlicht et al J. . Virol Virol 19871987; ; Chen JChen J. . Virol Virol 19921992; ; Millich et al PNASMillich et al PNAS

LES MUTANTS PRLES MUTANTS PRÉÉ--C C ((--))

•• codon stop codon stop / / rr éégion prgion préé--CC

TGG TGG --> > TTAAG en posG en pos. . 18961896

–– ggéénotypes B notypes B àà E E ((A A : : exceptionnelexceptionnel))

–– arrêt traduction protarrêt traduction prot ééine prine préé--CC//C C

–– AgHBe nAgHBe néégatifgatif

•• mutation dans promoteur prmutation dans promoteur préé--CC

TTAAAGG TTAAAGG --> > TTAATTAA TTGGAA en pos en pos. . 1762 1762 //17641764

–– ggéénotypes A notypes A àà E E

–– transcrits prtranscrits pr éé--CC//C C ::

–– synthsynthèèse dse d''AgHBe AgHBe ::

Carman et al Lancet Carman et al Lancet 19891989, , Okamoto et al J Virol Okamoto et al J Virol 1990/19941990/1994, , Tong et al Virology Tong et al Virology 19901990

HBeAg and Precore Mutation

1814 1901

Precore Core region region

HBcAg

HBeAg

G 1896A = stop codon, TAG

ATG ATG

Virion

Serum

Core gene

HBeAg and Precore Mutation

1814 1901

Precore Core region region

HBcAg

HBeAg

ATG ATG

Virion

Serum

Core gene

VARIANTS NVARIANTS N ÉÉGATIFS POUR LGATIFS POUR L ’’ AgHBeAgHBe

mRNAmRNA

ProtProtééineine prpr éé--CC//CC

PREPRE--CC C C PROMOTEURPROMOTEUR

TAGTAG ** ** **

17621762--17641764 18961896

arrêt des syntharrêt des synthèèses protses protééiquesiques

Diminution de lDiminution de l ’’ expression de lexpression de l ’’ AgHBeAgHBe

Main pre-c/core promoter mutations observed in vivo

GGGGGAGGAGATTAGGTTAAAGGTCTTTGTATTAGGAGGCTGTAGGCATAAATT

PrePre--C mRNAC mRNA

Basic core promoter

17621762 6464

TTGGAA

LEF

HNF1 GGTTAATNATTA

HNF4 AGGTCA

TTTTAA

6666 6868

Deletion 63-70 Insertion (RGTTAATYATTA) at 74/75

Mutation AGG to TCA and insertion TA at 65/66

WTRTTKRY

Insertion (TTG) at 66/67

TTTTGG

HNF3

SSéélection des mutants prlection des mutants préé--core au cours de core au cours de ll ’’ histoire naturelle de lhistoire naturelle de l’’ hhéépatite B chroniquepatite B chronique

0500

1000150020002500

temps

ALATALAT

ADNADN--VHBVHB

AgHBeAgHBe AntiAnti --HBeHBe

0

20

40

60

80

100

temps

sauvagesauvage

Mt prMt pr éé--CC

Outcome of Chronic Anti-HBe Positive Hepatitis B

0

100

200

300

400

0

100

200

300

400

0

100

200

300

400

Biochemical patterns in Biochemical patterns in 164164 untreated patients untreated patients after after 2323 months months ((range range 1212--3636) ) monthly monitoringmonthly monitoring

00 1212 2424 monthsmonths

With flares and normalizationWith flares and normalization

Without flaresWithout flares

With flares and without normalizationWith flares and without normalization

7373 pts pts ( ( 44.5%44.5% ) )

5959 pts pts ( ( 36.0%36.0% ) )

3232 pts pts ( ( 19.5%19.5% ) )

Asymptomatic Asymptomatic flareflare --upup : :

90%90% of cases of cases

AA LL TT FlareFlare --up yearlyup yearly

frequencyfrequency :: once once 57.1%57.1% twice twice 20%20%

< < once once 22.8%22.8%

Brunetto MR et alBrunetto MR et al , , J Hepatol J Hepatol 20022002

Augmentation de prévalence des hépatites chroniques avec AgHBe négatif en France

HBeAg(+)HBeAg(-)

48% N=119

62% N=164

Zoulim et al, J Viral Hepatitis 2006

No preNo pre--core mutationcore mutation

( (n n = = 4242; ; 14.8%14.8%)) Both mutationsBoth mutations

( (n n = = 9595; ; 33.6%33.6%))

Promoter mutation Promoter mutation

( (n n = = 9999; ; 27.9%27.9%))

Stop codon mutation Stop codon mutation

( (n n = = 5555; ; 19.4%19.4%))

Data unavailableData unavailable

( (n n = = 1212; ; 4.2%4.2%))

PrePre--core mutationscore mutations

Lamivir cohort, Zoulim et al, J Viral Hepatitis 2006

HBe serotype and preHBe serotype and pre--core mutationscore mutations

00

1010

2020

3030

4040

5050

6060

7070

8080

9090

No preNo pre--corecore

mutationmutation Stop codonStop codon

mutationmutation Promoter Promoter

mutationmutation BothBoth

mutationsmutations

Num

ber of su

bje

cts

Num

ber of su

bje

cts

HBeHBe--positivepositive

HBeHBe--negativenegative


MUTANTS PRMUTANTS PRÉÉ--C ET SC ET SÉÉVVÉÉRITRIT ÉÉ HISTOLOGIQUE HISTOLOGIQUE LA CONTROVERSELA CONTROVERSE

•• ItalieItalie –– Cirrhose plus frCirrhose plus frééquentequente

•• Bonino Gastroenterology Bonino Gastroenterology 19861986, , Fattovich Hepatology Fattovich Hepatology 19881988

•• FranceFrance –– ActivitActivit éé idem idem / / cirrhose plus frcirrhose plus frééquentequente

•• Zarski et alZarski et al, , J Hepatol J Hepatol 19931993 •• Grandjacques et alGrandjacques et al, , J Hepatol J Hepatol 20002000 •• Zoulim et alZoulim et al, , J Viral Hepatitis J Viral Hepatitis 20062006

•• AsieAsie –– Mt promoteur Mt promoteur : : activitactivit éé histologique et fibrose plus importante histologique et fibrose plus importante –– Mt prMt pr éé--C C : : activitactivit éé histologique moins importante histologique moins importante

•• Lindh et alLindh et al, , J Infect Dis J Infect Dis 19991999

–– RRéémission histologiquemission histologique •• Chan et alChan et al, , Hepatology Hepatology 19991999

•• AfriqueAfrique –– Mt promoteur Mt promoteur : : plus frplus frééquents dans le CHCquents dans le CHC

•• Baptista et alBaptista et al, , Hepatology Hepatology 19991999

HBe serotype and liver pathologyHBe serotype and liver pathology

00--44 55--99 1010--1414 1515--2222

00

1010

2020

3030

4040

5050

6060

7070

Knodell scoreKnodell score

Num

ber of su

bje

cts

Num

ber of su

bje

cts

Metavir scoreMetavir score

≤≤ FF22 FF33 FF44 00

1010

2020

3030

4040

5050

6060

7070

HBeHBe--positivepositive

HBeHBe--negativenegative


HHÉÉPATITES FULMINANTES ET MUTANTS PREPATITES FULMINANTES ET MUTANTS PRE --CC

•• Lien de causalitLien de causalitéé ::

–– ÉÉpidpidéémies hmies héépatites fulminantespatites fulminantes

–– Transmission souche mutTransmission souche mutéée pre préé--C C ((--))

–– Rôle immunomodulateur de lRôle immunomodulateur de l ’’ AgHBeAgHBe

•• Pas de lien de causalitPas de lien de causalitéé

–– SSééquenquenççage gage géénome completnome complet

–– Pas de profil commun de mutationPas de profil commun de mutation

•• SSéélection des mutants par la rlection des mutants par la rééponse immunitaire cytotoxique ponse immunitaire cytotoxique

dirigdirig éée contre la souche e contre la souche àà l l ’’ origine de lorigine de l ’’ HFHF

Stuyver et alStuyver et al, , Hepatology Hepatology 19991999, , Sternbeck et al Hepatology Sternbeck et al Hepatology 19961996, , Liang et alLiang et al, , NEJM NEJM 19911991

DIAGNOSTICS DIFFICILESDIAGNOSTICS DIFFICILES

II . . Porteur inactifPorteur inactif IIII . . ExacerbationExacerbation

Diagnosis of inactive carrier versus Diagnosis of inactive carrier versus HBeAg negative chronic hepatitisHBeAg negative chronic hepatitis

•• Inactive CarrierInactive Carrier –– Persistently normal ALT levelsPersistently normal ALT levels

–– Persistently low levels of serum HBV DNAPersistently low levels of serum HBV DNA •• Threshold Threshold :: 2 2,,000 000 IUIU / / mL mL ??

•• HBeAg negative chronic hepatitisHBeAg negative chronic hepatitis –– Fluctuation Fluctuation / / exacerbation of ALTexacerbation of ALT

–– Fluctuations of HBV DNA levels usually belowFluctuations of HBV DNA levels usually below 6 6 log IUlog IU/ / mLmL

–– Presence of prePresence of pre--core core / / core promoter mutationscore promoter mutations

DIAGNOSTIC DDIAGNOSTIC D ''UNE EXACERBATION AIGUE UNE EXACERBATION AIGUE SUR HEPATITE B CHRONIQUESUR HEPATITE B CHRONIQUE

•• DDééfinition finition : : pousspousséée cytolytiquee cytolytique ≠≠ r rééactivation viraleactivation virale •• Ag HBe Ag HBe + + initialementinitialement

–– rupture de tolrupture de toléérance immunitairerance immunitaire

–– ssééroconversion antiroconversion anti--HBeHBe

–– trtr èès frs frééquent chez patients asiatiquesquent chez patients asiatiques

•• AntiAnti --HBe HBe + + initialementinitialement –– rr ééactivation virus sauvage activation virus sauvage : : --> > AgHBe AgHBe ++

–– rr ééactivation virus mutactivation virus mutéé pr préé--C C ((--)) –– corticothcorticothéérapierapie

–– surinfection delta surinfection delta / / VHCVHC

0

5

10

15

20

25

0 1 2 5 9 12 13 16months

1

10

100

1000

10000

100000

1000000

10000000

100000000

1000000000

10000000000

ALT

pre-S1

bDNA

PCR

casecase#6#6 Genotype AGenotype A

prepre--C promoterC promoter WTWT MTMT prepre--C regionC region WTWT MM 22 MM 44 MM 2+2+MM 44

-- ++

-- ++

++ ++

++ --

-- ++

++ --

++ -- -- --

++ -- -- --

++ -- -- --

++ -- -- --

++ -- -- --

++ -- -- --

HBeAgHBeAg AntiAnti --HBe AbHBe Ab

-- ++

++ ++

++ --

-- ++

-- ++

++ --

-- ++

-- ++

interferoninterferon

Pichoud et al, J hepatol 2000

COOH

137 149

107

99 NH2

S - S

S - S S - S

S- S

S-S

138

139 147

Tiollais P. et al., Nature 1985. Torresi J., J. Clin Virol 2002; Dryden KA. et al., Mol Cell 2006

« a » determinant

HBs Ag

« a » determinant induces the synthesis of

anti-HBs neutralizing antibodies

sG145R

sP120T

sD144H/A/E

PreS1 PreS2

S Pol

Pré-C

C

Brin(+) 2,4kb

Brin(-) 3,2kb

X

TATAA U5-like

DR1

DR2

Enh1 Enh2

GRE 0/3221

SHBs (S) MHBs (preS2+S)

LHBs (preS2+preS2+S)

Variants de lVariants de l ''Ag HBsAg HBs

•• ééchappement chappement àà la r la r ééponse humorale antiponse humorale anti --HBsHBs

–– naturellenaturelle

–– vaccination vaccination ((transmission mtransmission m èèrere--enfantenfant ))

–– immunoprophylaxie immunoprophylaxie ((transplantation htransplantation h éépatiquepatique ))

•• infection active malgrinfection active malgr éé Ac anti Ac anti --HBsHBs

•• sséérologie AgHBs faussement nrologie AgHBs faussement n éégativegative

áá Risques Risques : : transmission virale transmission virale + + infections occultesinfections occultes

VARIANTS DE LVARIANTS DE L ''AgHBsAgHBs

•• Mutations ponctuelles dans le dMutations ponctuelles dans le d ééterminant a de terminant a de

ll ''AgHBs AgHBs ((124124--147147))

–– aa aa 145145 : : Gly Gly --> > Arg Arg

–– aa aa 126 126 : : Ile Ile --> > Ser Ser / / Thr Thr --> > AsnAsn

•• transmission mtransmission m èèrere--enfant malgrenfant malgr éé la serovaccination la serovaccination

((3%3%))

•• infection du greffon hinfection du greffon h éépatique malgrpatique malgr éé

Immunoglobulines antiImmunoglobulines anti --HBsHBs

•• hhéépatites chroniques avec antipatites chroniques avec anti --HBc et antiHBc et anti --HBs HBs ++

Presence of HBV DNA in the liver ( ±±±± serum ) of

individuals testing HBsAg negative by currently

available assays

Occult HBV Infection (OBI)

Raimondo et al, J Hepatol 2008

How to Detect Occult HBV Infection

Currently there is no standardized

diagnostic assay for occult HBV infection

Reported Prevalence of Occult HBV Infection in HIV Positive Patients

Study

Country

N° of

patients

Occult HBV

N° (%)

Methods

Hofer, 1998

Switzerland

57

51 (89%)

“nested” PCR (serial evaluation)

Torres-Baranda, 2006

Mexico

35 7 (20%) “nested” PCR

Filippini, 2006

Italy

86

17 (20%)

single step PCR

Mphahlele, 2006

South Africa

140 31 (22.%) “nested” PCR

Pogany, 2005

Netherlands

93

4 (4%)

single step PCR

Neau, 2005

France

160

1 (0.6%)

Santos, 2003

Brazil

101

16 (16%)

single step PCR

Wagner, 2004 France 30 11 (37%) “nested” PCR

Goncales, 2003 Brazil 159 8 (5%) “nested” PCR

Nunez, 2002

Spain

85

0

Cobas Amplicor HBV Monitor (Roche)

Piroth, 2000

France 37

13 (35%) single step PCR

Raffa, 2007

Italy

“nested” PCR (liver)

Cobas Amplicor HBV Monitor (Roche)

101 42 (41%)

Raimondo et al, J Hepaol 2007, modified

OBI

Cause(s) for the failure of HBsAg detection

Suppression of HBV replication and

gene expression

Infection by S gene Variants

“false ” OBI

Occult HBV infection

HBV cccDNA Integrated HBV DNA

HBV mutants Epigenetic control

HBV replication

Immune surveillance Viral co-infections

OBI

Seropositive Seropositive Seronegative Seronegative

HBsAg lost during CH

HBsAg lost during CH

HBsAg lost after AH

HBsAg lost after AH

Progressive antibody disappearence

Progressive antibody disappearence

Primary occult Primary occult

Schematic representation of HBV serum marker profil e in OBI and “false” OBI

„false“ OBI

S gene escape mutants

S gene escape mutants

HBV DNA levels comparable to overt infection

HBV DNA levels < 200 UI/ml

Occult hepatitis B

Torbenson M. & Thomas D.L., Lancet Inf Dis, 2002

High

prevalence

ROLE in

HCC

Diagnostic

Tools ?

Worsen HCV infection ?

Co-infections ? Therapy?

To be improved

Specific treatments ?

Not fully understood ?

Occult HBV infections: unresolved issues

AntivirauxAntiviraux Persistance viralePersistance virale

Resistance aux antivirauxResistance aux antiviraux Monitoring des traitementsMonitoring des traitements

HBeAg(+) HBeAg(-) / anti-HBe(+)

ALAT

HBV DNA

Minimal CH Moderate to severe CH Moderate to severe CH Remission

Cirrhosis

Immunotolerant phase

Immuno-active phase

Inactive phase Low replication

Reactivation phase

Cirrhosis

109-1012 IU/mL >2000-<109 IU/mL <2000 IU/mL >2000 IU/mL

Inactive cirrhosis

Adapted from Fattovich G. Sem Liver Dis. 2003

Treatment indicated Treatment indicated

HBsAg Occult infection

Endpoints of therapy

Persistence of high viral load is associated with a significant risk of progression of the liver disease and of HCC

Aim of antiviral therapy:

HBV DNA < 10-15 IU/mL by real-time PCR assays

No replication =

No resistance

Viral suppression

Histological and clinical improvement

Chen CJ, et al. JAMA 2006. Iloeje UH, et al. Gastroenterology 2006. Chen C, et al. Am J Gastroenterol 2006. Zoulim & Perrillo J Hepatol 2008. Zoulim & Locarnini Gastroenterology 2009

Antivirals approved for hepatitis B

*Currently approved for HIV **development on hold

Drug Type Approved Phase 3 Phase 2

Nucleoside analogs • Lamivudine* • Entecavir • Telbivudine

• Emtricitabine* • Clevudine**

• Elvucitabine

• Valtorcitabine

• Amdoxovir • Racivir • LB80380

Nucleotide analogs • Adefovir dipivoxil • Tenofovir*

• Alamifovir • Pradefovir

Cytokines • Interferon alfa

• Pegylated Interferon alfa-2a

Treatment failure

Primary non response Partial response

Secondary treatment failure Antiviral drug resistance

Host factors Drug metabolism Patient’s compliance Drug factors Antiviral potency

Drug factors Barrier to resistance Viral factors Resistant mutants

Zoulim & Perrillo J Hepatol 2008; EASL CPG J Hepatol 2009

Clinical definition of resistance

• Virologic Breakthrough: Rebound in serum HBV DNA levels (e.g. 1 log10 above nadir)

• Genotypic Resistance: Detection of mutations known to confer resistance while on therapy

• Virologic Breakthrough with Genotypic Resistance: Viral rebound associated with a mutation(s) known to cause resistance.

• Primary non response: <1log10 decrease of viral load after 3 months

• Partial response: detectable HBV DNA levels during therapy

Zoulim & Perrillo, J Hepatol 2008; EASL CPG, J Hepatol 2009

Laboratory Definition of HBV Resistance to Antivirals

Laboratory Investigations • Phenotypic Resistance: Decreased susceptibility (in vitro testing) to

inhibition by anti-viral drugs associated with genotypic resistance. • Cross Resistance: Mutants selected by one agent that also confer

resistance to other antiviral agents

Zoulim et al; Future Virology 2006

Si Ahmed et al. Hepatology. 2000; Yuen et al Hepatology 2001; Locarnini et al Antiviral Therapy 2004; Villet et al Gastroenterology 2006 J Hepatol 2007 & 2008; Pallier et al J Virol 2007; Yim et al Hepatology 2006.

Kinetics of emergence of HBV drug resistant mutants

Lamivudine Resistance Accelerates Progression of Liver Disease

0

5

10

15

20

25

0 6 12 18 24 30 36

Time after randomization (Months)

Placebo (N=215)

YMDDm (N=209) (49%)

Wild Type (N=221)

YMDDm

WT

Placebo

5%

13%

21%

Liaw YF et al. N Engl J Med. 2004;351:1521-1531

Biochemical and Histologic Correlates of HBV Resistance

• Rise in ALT levels – Mild ALT elevations in most cases – ALT flares with acute exacerbations and liver failure:

especially patients with liver cirrhosis and/or pre-core mutant infection

• Progression of liver disease

– Progressive worsening of liver histology – Clinical deterioration, liver decompensation, HCC

development Lai et al Clin Infect Dis 2003; 36: 687-696; Dienst ag et al Gastroenterology 2003;124:105-117 ; Lok et al Gastroenterology 2003; 125 : 1714-1722; Hadziyannis et al Hepatology 2000;32:847-851; Si Ahmed et al Hepatology 2000; Z oulim et al J Viral Hepatitis 2006;13:278-288 ; Fung et al J Hepatol 2005;43:937-943; Liaw et a l NEJM 2004;351:1521-1531.

ALT flares in patients with lamivudine resistance over time

Lok et al Gastroenterology 2003; 125 : 1714-1722

Drug and patient population

Resistance at year of therapy expressed as percenta ge of patients

1 2 3 4 5 6

Lamivudine 23 46 55 71 80 -

Telbivudine HBeAg-Pos 4.4 21 - - - -

Telbivudine HBeAg-Neg 2.7 8.6 - - - -

Adefovir HBeAg-Neg 0 3 6 18 29 -

Adefovir (LAM-resistant) Up to 20% - - - - -

Tenofovir 0 0 0 - - -

Entecavir (naïve) 0.2 0.5 1.2 1.2 1.2 1.2

Entecavir (LAM resistant) 6 15 36 46 51 57

Incidence of drug resistance over time

CL Lai Clin Infect Dis 2003; CL Lai NEJM 2007; Hadzyiannis Gastroenterology 2006; Marcellin NEJM 2008; CL Lai & Chang NEJM 2006; Zoulim & Locarnini Gastroenterology 2009

Zoulim & Locarnini, Gastroenterology, 2009

viral persistence

viral persistence

cccDNA long half-life

infected cells long half-life

defective immune response

HBV HBV hepatocytes hepatocytes

viral polymerase spontaneous error rate

HBV HBV

viral quasi-species

viral quasi-species

wild type mutant

mutant archiving

Zoulim et al., Gastroenterology 2009

selection of escape mutants selection of

escape mutants

replication fitness replication space

Virus spread in the liver

host host

selective pressure antivirals or others

treatment failure treatment failure

immune response drug pharmacodynamics

Disease progression / HCC development

+

LL((--))--SddCSddC , , 33TCTC LamivudineLamivudine LL((--))--SddCSddC

mitochondriamitochondria

nucleusnucleus

LL((--))--SddCSddC --TPTP

HBV DNAHBV DNA

Nuclear DNANuclear DNA

Mt DNAMt DNA



cytoplasmcytoplasm

kinasekinase

LL((--))--SddUSddU

deaminasedeaminase

Bridges; Progress in Liver Disease 1995

interaction

Virion

Nucleus

Hepatocyte

translation

encapsidation reverse transcription

pgRNA DNA (-)

cccDNA amplification

transcription

mRNA

pgRNA AAA AAA

AAA AAA

cccDNAcccDNA

cccDNA formation

RC DNA

entry

polymerase

DNA (+)

(+) strand synthesis

virion secretion

ER

HBeAg

HBsAg

receptor ?

ER

viral proteins secretion

The HBV life cycle

Zoulim et al Future Virology 2006

Nucleoside analogs

uncoating CCC DNA

removal of protein primer removal of RNA primer completion of viral (+) strand DNA ligation of DNA strands extremities

supercoiled DNA minichromosome

viral polymerase? DNA repair protein? other cellular enzymes?

topoisomerase? Acetyl transferase ? Histones

Formation of the recalcitrant cccDNAFormation of the recalcitrant cccDNA : : a difficult a difficult target for antiviral therapytarget for antiviral therapy

Tuttleman et al Cell 1986 Le Guerhier et al AAC 2000 Delmas et al AAC 2002 Kock et al Hepatology 2003

Antivirals ?

Can we prevent cccDNA formation ? Nucleoside analogs in monotherapy or combination therapy cannot prevent the de novo formation of cccDNA in hepatocyte culture and in vivo in animal experiments (Delmas et al AAC 2000; Seigneres et al AAC 2002)

Can we clear cccDNA from a chronically infected cell ? The decrease of intrahepatic cccDNA during nucleoside analog requires hepatocyte turn over in animal experiments (Zhu et al J Virol 2001; Litwin et al J Clin Virol 2005)

Kinetics of Viral Loss During Antiviral Therapy with LKinetics of Viral Loss During Antiviral Therapy with L--FMAU FMAU ((clevudineclevudine) ) in the woodchuck modelin the woodchuck model

Zhu et al, J Virol 2001

ADV Associated Serum HBsAg Reductions are Similar in Magnitude to cccDNA Reductions

-6

-5

-4

-3

-2

-1

0

Cha

nges

in H

BV

Mar

kers

from

Bas

elin

e(lo

g10

copi

es/c

ell(m

l))Serum HBV DNA

Total Intracellular

DNA cccDNA Serum

HBsAg

� 4848 weeks of ADV resulted in significant reductions in weeks of ADV resulted in significant reductions in : : serum HBV DNA serum HBV DNA > > total intrahepatic HBV DNA total intrahepatic HBV DNA > > cccDNA cccDNA �� Changes in HBsAg levels correlated with cccDNA cha nges Changes in HBsAg levels correlated with cccDNA cha nges --> > 14 14 years of therapy to clear completely viral cccDNAyears of therapy to clear completely viral cccDNA

Werle et al, Gastroenterology 2004

• 0.8 log10 (84%) decline in cccDNA, not paralleled by a similar decline in the number of HBcAg+ cells

•• Suggests cccDNA depleted primarily by nonSuggests cccDNA depleted primarily by non--cytopathic mechanisms or that cell turncytopathic mechanisms or that cell turn--over over occurred but was associated with infection of new cells during occurred but was associated with infection of new cells during therapytherapy

Immunohistochemical Staining of Patient Biopsies at Immunohistochemical Staining of Patient Biopsies at Baseline and After Baseline and After 48 48 Weeks ADV TherapyWeeks ADV Therapy

BaselineBaseline Week Week 4848

Maynard et alMaynard et al, , J Hepatol J Hepatol 20052005

Persistence of cccDNA after HBs seroconversionPersistence of cccDNA after HBs seroconversion

Clearance of viral infection versus selection of Clearance of viral infection versus selection of escape mutantsescape mutants

The most important factors to considerThe most important factors to consider: :

§§ The rate of immune killing of infected hepatocytesThe rate of immune killing of infected hepatocytes

§§ The rate of replication and spread of mutant virus in the The rate of replication and spread of mutant virus in the

chronically infected liver chronically infected liver ((II ..ee. . fitness of the virusfitness of the virus: : the rate of the rate of

spread to uninfected hepatocytesspread to uninfected hepatocytes))

§§ Small changes in these factors may have profound effect on Small changes in these factors may have profound effect on

whether treatment response is durable or subject to rapid whether treatment response is durable or subject to rapid

rebound rebound ((Litwin et al J Clin Virol Litwin et al J Clin Virol 20052005))

§§ These factors may be subject to therapeutic interventionThese factors may be subject to therapeutic intervention

LamivudineLamivudine

II IIII IIIIII IVIV

wtwt mtmt

nini

INHIBITION OF WILD TYPE VIRUS REPLICATIONINHIBITION OF WILD TYPE VIRUS REPLICATION DELAYED EMERGENCE OF DELAYED EMERGENCE OF DRUG RESISTANT VIRUSDRUG RESISTANT VIRUS

XX

XX

XX

XX

XX

XX

XX

Zhou et al AAC 1999

Kinetics of emergence of drug resistant virus Kinetics of emergence of drug resistant virus during antiviral therapyduring antiviral therapy

• Free liver space • Mutant fitness

Kinetics of HBV drug resistance emergence

Si Ahmed et al. Hepatology. 2000; Yuen et al Hepato logy 2001; Locarnini et al Antiviral Therapy 2004; Villet et al Gastroenterology 2006 J Hepatol 2007 & 2008; Pallier et al J Virol 2 007; Yim et al Hepatology 2006.

Treatment begins

Drug-resistant variant

Drug-susceptible virus Naturally—occurring viral variants

Time

HB

V r

eplic

atio

n

Primary resistance mutations

Secondary resistance mutations / compensatory resistance mutations

Partial response to adefovir dipivoxil is not due to the selection of DR mutants

• The top 25% patients (quartile 1): > 4.91 log10 reduction in serum HBV DNA at week 48. • In Q2: 3.52 to 4.90 log10 reduction of viral load. • In Q3: 2.22 to 3.51 log10 reduction in viral load. • The bottom 25% of patients (Q4):< 2.22 log10 reduction in HBV DNA levels at week

48.

• Phenotypic analysis of viral strains: Q4 as sensitive to ADV as Q1 strains • Documented Drug Compliance (% of days without taking ADV)

• Wilcoxon rank sum test, P=0.01

Durantel et al, Antiviral Therapy, 2008

Virological Response

Q1 (best response)

(n=38)


Q2

(n=38)


Q3

(n=38)


Q4 (worse response)

(n=38)

Median

99%

99%

99%

97% a

range

86-100%

41*-100%

91-100%

70-100%

M204V reduces pocket size

Steric clash between lamivudine and V204

Wild-type M204/L180

L180

M204

LVD-TP

LVDr M204V/L180M

L180M

M204V

LVD-TP

LVDr M204V/L180M

L180M

M204V

ETV-TP

Langley DR, et al. J Virol. 2007;81:3992-4001.

Amino acid substitutions result in conformation changes of the polymerase catalytic site

Minimal steric clash between entecavir and V204

Polymerase gene mutations may result in decreased inhibitory activity of antivirals

Jacquard et al, Antimicrob Agents Chemother 2006

wt polymerase 3TC-R polymerase PMEA-R polymerase 3TC+PMEA-R polymerase

Drug IC50 (µM) P IC50 (µM) P IC50 (µM) P IC50 (µM) P

Elongation

FLG-TP 4 ± 0.9 5.43 ± 0.6 7.8 ± 1.9 6.33 ± 1.3

3TC-TP 10.75 ± 4.8 <0.05 >100 <0.05 14 ± 5.7 <0.05 >100 <0.05

PMEA-DP 2.8 ± 0.3 >0.05 0.9 ± 0.1 <0.05 49.5 ± 3.4 <0.05 16.5 ± 7.2 <0.05

Definition of fitness

• A parameter that quantifies the adaptation of an organism or a virus to a given environment

• For a virus, ability to produce infectious progeny relative to a reference viral clone, in a defined environment

Esteban Domingo, In Fields Virology 2007

Polymerase gene mutations Surface gene mutations wt none none

mutant #1 T128I; V173L; L180M; A181V; N236T F20S; P120S; E164D; L173F

mutant #2 T128I; V173L; L180M; A181V; M204V R79H; P120S; E164D; L173F; I195M; Y206F

mutant #3 ∆111-120; T128I; V173L; L180M; A181V F20S; ∆102-111; P120S; E164D; L173F

mutant #4 T128I; V173L; L180M; A181V; M204V; L220I; N236T P120S; E164D; L173F; I195M

Polymerase clonal genetic analysis

lamivudine

adefovir

HBIg

wt

Mutant #1 Mutant #2 Mutant #3 Mutant #4

Villet et al, Gastroenterology 2006

Villet, Billioud et al, Gastroenterology 2008

0

50

100

150

200

250

300

350

400

wt #1 #2 #3 #4 Mutant

Mut

ant r

eplic

atio

n ca

paci

ty /

wt (

%)

Viral replication capacity in the presence of both antivirals (LAM + ADV)

Mutant

wt #1 #2 #3 #4

1,7 kb

A

B

wt #1 #2 #3 #4 Mutant

Mut

ant i

nfec

tivity

/ w

t (%

)

0

20

40

60

80

100

120

Villet, Billioud et al, Gastroenterology 2008

Infectivity of the mutants in HepaRG cells Impact of mutations in the overlapping S gene

HDV hybrids with HBV mutant envelopes HDV replication in HepaRG cells as a reporter of infection

• cccDNA in the liver:

– Is propagated during the normal replication cycle of HBV

– Can serve as a template for the production of new virus

Archiving of viral variants

Viral quasispecies

cccDNA variants

Liver

Majority population

Minority variants

Resistant variants

Blood circulation

Zhou et al, AAC 1999; Zoulim F. Antivir Res. 2004. Zoulim F & Perillo R. J Hepatol. 2008




• It is believed that viral variants with antiviral resistance may be archived in this way


Viral quasispecies

cccDNA variants

Blood circulation

Liver

Majority population

Minority variants

Resistant variants





• It is believed that viral variants with antiviral resistance may be archived in this way


Viral quasispecies

cccDNA variants

Liver

Majority population

Minority variants

Resistant variants

Blood circulation


Phenotyping of HBV clinical isolates

1. Durantel D, et al., Hepatology, 2004;40:855-64. 2. Yang H, et al., Antiv Ther, 2005;10:625-33.

Lab S

train

Clone

A

Clone

A

Clone

C

Clone

D

Clone

E

Southern blot analysis

Patient serum

PCR cloning

Whole genome HBV clones

Transfection

HepG2 Huh7

IC50 reference strain

IC50 mutant Fold resistance =

Wild-type virus

Increasing antiviral concentration

Cell culture plate

Patient’s virus

SS -

RC -

lamivudine adefovir

Cross-resistance data for the main mutants and the commercially available drugs

Pathway Amino acid substitutions in the rt domain

Lamivudine Telbivudine Entecavir Adefovir Tenofovir

Wild type S S S S S

L-nucleoside M204I R R I S S

L-nucleoside L180M+M204V R R I S S

Alkyl phosphonate

N236T S S S R I

Shared A181T/V I/R I/R S R I D-Cyclopentane

(ETV) L180M+M204V/I

±I169T±V173L±M250V

R R R S S

D-Cyclopentane (ETV)

L180M+M204V/I±T184G±S202I/G

R R R S S

MDR V173L+L180M+A181V+N36T

R R S R S

Zoulim & Locarnini Gastroenterology 2009

ADV rtN236T +/or rtA181V

Wild-type virus

ADV-resistant virus

LAM-resistant virus LAM

rtM204V/I ± rtL180M

ETV-resistant virus

rtT184 or rtS202 or rtM250 ETV

rtM204V/I rtL180M +/-

TDF

TDF: what can

we expect?

rtM204V/I +/- rtL180M

LAM then ETV

rtT184 or rtS202 or rtM250

LAM + TDF – what

do we see?

Maximising the barrier to resistance

Can we detect low frequency mutants prior to or during therapy ?

Use of pyrosequencing to detect low frequency mutants

•May detect mutants representing as low as 0.1% of the viral population •The clinical significance for treatment choice or adaptation needs to be determined by prospective studies

Important factors involved in selection of MDR mutants

• Use of inadequate sequential monotherapies and inadequate treatment

adaptation

• Incomplete viral suppression

– > Persistent replication in the presence of antiviral pressure

• Use of drugs sharing cross-resistance characteristics

– One mutation may confer resistance to several drugs

– > Persistent replication

• Accumulation of mutations

• Wide replication space (liver transplantation)

?

Multiple drug resistant mutants with complex pattern of mutations

+ one mutation

+ one mutation

Drug A

Drug B

Risk of selection of MDR mutants by sequential therapy - drugs sharing cross-resistance characteristics - incomplete viral suppression - liver transplantation

The problem of sequential therapy with nucleoside analogues

Zoulim F, et al. J Hepatol. 2008;48:S2-19. Yim et al, Hepatology 2006; Villet et al Gastroenterology 2006 & 2009

103

104

105

106

107

108

109

0 20 40 60 80 100 120 Treatment (months)

HB

V D

NA

(co

pies

/ml)

entecavir

IFN adefovir

lamivudine Genotype H

lamivudine

Drugs sharing cross-resistance characteristics: Switching strategy á emergence of MDR mutant

L180M+S202G+M204V

L180M+M204V

Villet et al, J Hepatol 2007

Tre

atm

ent (

mon

ths)

lam

ivud

ine

ente

cavi

r

0 20 40 60 80 100

1

L180M+M204V M204V wt

V173L+L180M+M204V

L180M+M204V V173L+L180M+M204V

L180M+S202G+M204V I169L+L180M+S202G+M204V V173L+P177S+L180M+S202G+M204V

V173L+P177S+L180M+S202G+M204V L180M+A181G+S202G+M204V

L180M+S202G+M204V

L180M+A181G+S202G+M204V

wt

% clones in the quasi-species

27/0

0

11

34

36

- Lamivudine therapy: Selection of a main population harboring the V173L+L180M+M204V mutations = primary resistance mutations - Entecavir therapy: Selection of three populations, all harboring the L180M+S202G+M204V mutations = secondary resistance mutations

Genotypic analysis of the viral quasi-species during lamivudine and entecavir therapy

Lamivudine rebound

Entecavir rebound

Villet et al, J Hepatol 2007

Role of cross-resistance, inefficacy of viral load suppression, and replication space, in MDR mutant selection

Villet et al Gastroenterology 2006

Genotype E

102

103

104

105

106

107

108

0 500 1000 1500 2000 2500 3000 3500

days of treatment

HB

V D

NA

(M

eq/m

l)

lamivudine

adefovir

HBIg tenofovir

V173L+L180M+A181V+N236T L180M+M204V

Liver transplantation

0 10 20 30 40 50 60 70 80 90 100

1

Lam

ivud

ine+

adef

ovir

trea

tmen

t (m

onth

s)

1

8

24

34

38

40

42 to 50

Viral rebound

0

16

26

30

32

34 to 42

Tim

e post-transplantation (months)

% of variants in the viral quasi-species

Accumulation of mutations and selection of a compl ex mutant

YMDDYMDD Terminal Protein

spacer Pol/RT RNaseH

V173L L180M A181V

N236T

Pre-S/S gene

P120S

dominant HBV mutant

L180M+M204I

wt

V173L+L180M+A181V+M204V

M204I

V173L+L180M+A181V V173L+L180M+A181V+M204V+N236T

V173L+L180M+A181V+N236T

V173L+L180M+A181V+N236T

V173L+L180M+A181V+N236T

V173L+L180M+A181V+M204V+N236T

V173L+L180M+A181V+M204V

V173L+L180M+A181V+M204V

V173L+L180M+A181V+M204V

V173L+L180M+A181V+M204V

L180M+M204I

V173L+L180M+A181V+M204I

I169V+L180M+T184I+M204V

V173L+L180M+A181V+N236T

A single a.a. substitution at position rt181 may be responsible for multidrug resistance

Villet S, et al. J Hepatol. 2008;48:747-55.

wt

A181V

A181T

A181V + N236T

A181T + N236T

N236T

N236T + N238T

M204V

M204I

L80V

L80V + M204I

LVD

LVD+TDF LVD+ADV+TDF

Patient #1 (67 months)










LVD+ADV ADV

Potential risk of transmission of HBV DR mutants

Clements et al, Bull WHO 2009

Management algorithm

Antiviral treatment

Treatment failure

Viral load asssessment

Add-on therapy based on cross-resistance data

Check compliance Primary non response

Switch to more potent drug

Zoulim and Perrillo, J Hepatol, 2008; EASL CPG J Hepatol 2009

Viral genome sequence analysis

Wild type virus HBV drug resistant mutant

Check compliance

Management algorithm

Antiviral treatment

Treatment response

Viral load asssessment

Zoulim and Perrillo, J Hepatol, 2008; EASL CPG J Hepatol 2009

Check for HBe/HBs seroconversion on a regular basis (6 monthly)

Virologic Consequences of Persistent Viremia

� Infection of new hepatocytes á slower kinetics of clearance infected cells and cccDNA � Increases the risk of occurrence and subsequent selection

of HBV mutations responsible for drug resistance � On-treatment prediction of HBV drug resistance

Le Guerhier et al Antimicrob Agents Chemoter 2000;4 4:111-122; Delmas et al Antimicrob Agents Chemother 2002; 46:425-433; Kock et al Hepatology20 03; 38:1410-1418; Richman Hepatology 2000;32:866-867

Viral Load at Week 24 is a Predictor of Resistance at Week 104 of Therapy (Telbivudine vs. Lamivudine trial)

4%

25%29%

30%

9%

24%

41%45%

0%

20%

40%

60%

80%

100%

< QL,n=203,146

QL - 3,n=57,63

3 to 4,n=83,79

> 4,n=115,175

% o

f pat

ient

s w

ith r

esis

tanc

e

2%

12%

20%

60%

5% 6%

50%56%

0%

20%

40%

60%

80%

100%

< QL,n=178,157

QL - 3,n=18,20

3 to 4,n=16,24

> 4,n=10,23

% o

f pat

ient

s w

ith r

esis

tanc

e

Telbivudine

Lamivudine

HBeAg PositiveHBeAg Positive , , nn==921921 HBeAg NegativeHBeAg Negative , , nn==446446

Lai et al , NEJM, 2007

HBeAg Seroconversion at 2 Years vs. Antiviral Effect at Week 24

Percent HBeAg

Seroconversion

Serum HBV DNA Level at Week 24

HBeAg Positive PatientsHBeAg Positive Patients, , Combined Treatment GroupsCombined Treatment Groups

39% 46%

19%

6%

0%

20%

40%

60%

Below QL QL to 3 log 3 to 4 log > 4 log

Lai et al , NEJM, 2007

Comment adapter le traitement ?

Zoulim Antivir Res 2004; 64: 1-15. Villeneuve et al J Hepatol 2003. Lampertico et al Gastroenterology 2007

Wild type

LAM-R

ADV-R

ADV

+ LAM

ADV

LAM

Months

ADV mono

Pa t

ient

s w

ith v

irolo

gica

l bre

akth

rou g

h

273 268 256 225 201 158 61

30%

6%

P<0.001

ADV+LAM

255 238 223 213 200 177 103 P

a tie

nts

with

AD

V-R

229 225 217 194 179 146 57

16%

0%

P<0.001

ADV mono

ADV+LAM

242 227 214 205 200 174 92

3-yr cumulative probability

* > 1 log rebound of HBV DNA compared to on-treatment nadir ** N236T or A181T-V in patients with a virological breakthrough

Patients still at risk

Virologic breakthrough* Virologic breakthrough* and ADV resistance**

Lampertico P for the AISF ADV Study Group, 57th AASLD Meeting, October 27-31, 2006, Boston, USA. Oral presentation LB5. Hepatology. 2006;44(4, suppl 1):229A-30 (Abstract 110).

0

20

40

60

80

100

0 3 6 9 12 15 18 21 24 27 30 33 36 0

20

40

60

80

100

0 3 6 9 12 15 18 21 24 27 30 33 36

Patients with lamivudine resistance: adefovir add-on strategy

� HBV DNA ∆ ALT

The problem of sequential therapy and switching strategy

Villeneuve et al, J Hepatol 2003

N236T

Ser

um H

BV

DN

A

(Log

10 c

opie

s/m

L)

ALT

(IU/L)

300

250

200

150

100

50

L180M+M204V

LAM

ADV

Reverted to wild type

2

3

4

5

6

7

8

9

10

janv-98 janv-99 janv-00 janv-01 janv-02 janv-03

janv-04 janv-05

LAM

M

0

M6

M12

M18

M24

M30

M36

ALT0

2

4

6

8

ALT HBV DNA

Month of therapy

Rescue therapy in patients with clinical breakthrough

Drug A

Drug B

Ser

um H

BV

DN

A (

Log1

0 co

pies

/mL)

an

d A

L T (

x U

LN)

M0

M6

M12

M18

M24

M30

M36

ALT0

2

4

6

8

ALTHBV DNA

Month of therapy

Rescue therapy in patients at the time of virologic breakthrough

Drug A

Drug B

Ser

um H

BV

DN

A (

Log1

0 co

pies

/mL)

an

d A

L T (

x U

LN)

M0

M6

M12

M18

M24

M30

M36

ALT0

2

4

6

8

ALTHBV DNA

Month of therapy Month of therapy

Early add-on therapy to prevent drug resistance

Drug A

Drug B

Ser

um H

BV

DN

A (

Log1

0 co

pies

/mL)

an

d A

L T (

x U

LN)

Very Early Add-on Therapy to Keep Viral Load as Low as Possible

2

3

4

5

6

7

8

M0 M3 M6 M9 M12 M15 M18 M21 M24

Ser

um H

BV

DN

A (

Log1

0 co

pies

/mL)

Drug ADrug A Drug ADrug A

++ Drug BDrug B

Month of therapy

1. Start with a drug having a high genetic barrier for resistance 2. Add a drug with a different cross-resistance profile

outgrowth of drug resistant mutant ?

MDR ?

Rationale for de novo Combination Therapy

Drug A

Drug B

Wild type

Drug B resistant mutant

Drug A resistant mutant

áá Combination of drugs without crossCombination of drugs without cross --resistanceresistance

wt

Low risk of Low risk of selection of MDRselection of MDR

Clavel et al NEJM 2004;350:1023-35 ; Zoulim Antivir al Res 2004;64: 1-15

M0

M6

M12

M18

M24

M30

M36

ALT0

2

4

6

8

ALTHBV DNA

Month of therapy Month of therapy

De novo combination therapy to prevent drug resistance

Drug A

Drug B

Ser

um H

BV

DN

A (

Log1

0 co

pies

/mL)

an

d A

L T (

x U

LN)

Preventing L-Nucleosides Resistance with de novo Combination Therapy

1 Marcellin et al. N Engl J Med 2004; 351: 1206-17 2 Lau et al. Hepatology 2004;40:171A

3 Lai et al. Hepatology 2003;38:262A 4 Sung et al. J Hepatol 2003 ;38 (suppl 2):25-26 5 Lau et al. Hepatology 2004:40:666A

* After 1- year therapy

20% 18%

34%

21%

2% 1%

11% 12% 5%

0

20

40

60

80

100

Sung 4

Marcellin 1

Lau 2

Lai 3

LAM LAM LAM LAM LAM

+ADV

LAM

+Peg

LAM

+Peg

LAM

+LdT

Inci

denc

e of

res

ista

nce*

(%

)

LdT FTC FTC

+ADV

0% 0%

Lau 5

Perspectives / Prevention of drug resistance

• First line therapy – Use of antivirals with high antiviral potency and high barrier to

resistance

– Combination therapy with complementary drugs to increase the barrier to resistance

• Second line treatment – Add-on strategies with complementary drugs preferred to

sequential monotherapies

– Early treatment adaptation to prevent accumulation of mutations

– Choice always based on cross-resistance data

Perspectives beyond the guidelines

• Early treatment intervention to prevent disease progression ? � screening program

� non invasive evaluation of liver disease / biomarkers

• Can we prevent prevent HCC development ? �decreased risk of HCC if HBsg clearance <50 yrs (Yuen et al, Gastroenterology 2008)

• Can we clear cccDNA and/or HBsAg ? � new treatment strategies

� new treatment targets

HBsAg clearance

Werle-Lapostolle B et al., Gastroenterology 2004;126: 1750-58.

Infected hepatocytes

Infected liver

CD8

NKT

CD4

B

cccDNA

Antivirals

Clearance of HBsAg?

Blood circulation viral load

Lamivudine 100 mg/day

Clinical example of HbsAg clearance

HBs Ag Positivity cut off: 0.05

Viral load Detection treshold

Viral load Log Copies/ml

HBs Ag IU/ml

* *

* : Anti- HBs antibody Negativation of HBe Ag May 1987 HBe Seroconversion between June 87 and November 1996?

Borgniet O et al., J Med Virol , 2009;81:1336-42.

New targets

Immune system

Conclusions 1

•• Maladie frMaladie fr ééquente et gravequente et grave –– 300300 000000 porteurs chroniques en france porteurs chroniques en france

–– 11èère cause de cancer du foie dans le mondere cause de cancer du foie dans le monde

–– 13001300 d dééccèès par an en Frances par an en France

•• Maladie mMaladie mééconnueconnue –– Souvent asymptomatiqueSouvent asymptomatique, , ou symptomes non spou symptomes non spéécifiquescifiques

–– Seulement Seulement 6060 000000 personnes connaissent leur maladie personnes connaissent leur maladie

–– 1313 000000 sont trait sont traitééeses

•• Persistance viralePersistance virale –– Pas dPas d’é’éradication du gradication du géénome viralnome viral

–– Surveillance prolongSurveillance prolongééee, , possibilitpossibilitéé de r de rééactivationsactivations

Conclusions 2

•• DiffDiff éérentes formes drentes formes d’’ hhéépatites en fonction de patites en fonction de ll ’’ interaction virus interaction virus / / rr ééponse immunitaireponse immunitaire –– Portage asymptomatique Portage asymptomatique / / hhéépatite chronique patite chronique / / cirrhose cirrhose / /

cancer du foiecancer du foie

•• Impact de la variabilitImpact de la variabilit éé du g du géénome viralnome viral -- Role dans la persistance virale et la rRole dans la persistance virale et la réésistance aux antivirauxsistance aux antiviraux

-- Echappement diagnostiqueEchappement diagnostique

•• NNéécessitcessitéé d d’’ un dun déépistage et traitement prpistage et traitement préécoce des coce des formes chroniquesformes chroniques

•• PrPréévention par la vaccination vention par la vaccination !!!!!!

Zoulim Hbv EpidéMio Marqueurs

Health & Medicine

Transcript of Zoulim Hbv EpidéMio Marqueurs