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
HHéépatocyte infectpatocyte infect éé
HBVHBV
CTLCTL
FasFas perforineperforine
HHéépatocyte patocyte non infectnon infect éé
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
HHéépatocyte infectpatocyte infect éé
HBs AgHBs Ag
HHéépatocyte patocyte non infectnon infect éé
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
Months After Exposure
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
Seeger, Zoulim, Mason, Fields Virology 2007
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
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
Seeger, Zoulim, Mason, Fields Virology 2007
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
Seeger, Zoulim, Mason, Fields Virology 2007
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
Lamivir cohort, Zoulim et al, J Viral Hepatitis 2006
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
Lamivir cohort, Zoulim et al, J Viral Hepatitis 2006
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
LL((--))--SddCSddC --TPTP
LL((--))--SddCSddC --TPTP
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)
Virological Response
Q2
(n=38)
Virological Response
Q3
(n=38)
Virological Response
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
• cccDNA in the liver:
– Is propagated during the normal replication cycle of HBV
– Can serve as a template for the production of new virus
• It is believed that viral variants with antiviral resistance may be archived in this way
Archiving of viral variants
Viral quasispecies
cccDNA variants
Blood circulation
Liver
Majority population
Minority variants
Resistant variants
Zhou et al, AAC 1999; Zoulim F. Antivir Res. 2004. Zoulim F & Perillo R. J Hepatol. 2008
• cccDNA in the liver:
– Is propagated during the normal replication cycle of HBV
– Can serve as a template for the production of new virus
• It is believed that viral variants with antiviral resistance may be archived in this way
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
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)
Patient #7 (30 months)
Patient #2 (23 months)
Patient #3 (37 months)
Patient #10 (7 months)
Patient #5 (44 months)
Patient #4 (31 months)
Patient #6 (36 months)
Patient #9 (19 months)
Patient #8 (47 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 !!!!!!
Top Related