Do the therapeutic vaccines hold hope for the treatment of hepatitis B?

Background and AimsThe therapeutic effect of tenofovir alafenamide fumarate (TAF), tenofovir disoproxil fumarate (TDF) and entecavir (ETV) on chronic hepatitis B (CHB) patients remains inconsistent. The aim of this study was to explore the differences in virological responses to TAF, TDF and ETV in patients with CHB.MethodsLiterature searches were conducted of the PubMed, EMBASE, and the Cochrane Library databases to identify randomized controlled trials and observational studies published up to July 21, 2020. Statistical comparisons of virological response between TDF, ETV, and TAF were carried out with pooled odds ratio (OR) values.ResultsThe virological response in TDF-treated CHB patients was notably superior to that of the ETV-treated CHB patients after 12-weeks [OR=1.12, 95% confidence interval (CI): 0.89–1.41], 24-weeks (OR=1.33, 95% CI: 1.11–1.61), 48-weeks (OR=1.62, 95% CI: 1.16–2.25), 72-weeks (OR=1.43, 95% CI: 0.78–2.62), and 96-weeks (OR=1.56, 95% CI: 0.87–2.81) treatment. No significant difference was observed for the virological responses in CHB patients after 48-weeks treatment with TAF or TDF. The virological response in TDF+ETV-treated CHB patients was superior to that of TDF-treated CHB patients after 24-weeks, 48-weeks (OR=1.54, 95% CI: 1.17–2.02), 96-weeks, and 144-weeks.ConclusionsThe virological response in TDF-treated CHB patients was superior to that in ETV-treated CHB patients, but there was no significant difference between TAF and TDF. In addition, the therapeutic effect of TDF+ETV was superior to TDF alone.

Objective To observe the dynamic characteristics of hepatitis B core antibody (anti-HBc) titers in chronic hepatitis B (CHB) patients treated with interferon and to explore the predictive value of anti-HBc for response to interferon. Methods The clinical information of the patients diagnosed with CHB in Department of Infectious Diseases, the First Affiliated Hospital of Xi′an Jiaotong University from October 2011 to October 2014 were collected. HBV DNA, liver function and HBV serological markers of CHB patients were tested dynamically during and after interferon treatment. The dynamic characteristics of anti-HBc titers in patients with different virological responses were analyzed. The predictive values of anti-HBc titer for the efficacy of interferon treatment of CHB patients were analyzed by binary logistic regression. Results Of the 42 CHB patients aging(30.8±10.1) years old, 34 patients were hepatitis B e antigen (HBeAg) positive and 8 were negative. All patients completed 48-week interferon treatment and 24-week follow-up after the end of treatment. Among them, 28.6% (12/42), 26.2% (11/42) and 45.2% (19/42) of patients achieved sustained virological response (SVR), virological relapse (VR) and non-response (NR), respectively. Patients with different virological response presented various characteristics of anti-HBc titers. Compared with NR group, the anti-HBc titers at baseline and week 12 were significantly higher in SVR group (at baseline: [4.93 ± 0.30] vs [4.70 ± 0.33] lg IU/mL, t=2.147, P=0.013; at week 12: [4.83 ± 0.23] vs [4.44 ± 0.41] lg IU/mL, t=3.032, P=0.007). The anti-HBc titers in SVR group at week 12 and week 24 were significantly higher than those in VR group (at week 12: [4.83 ± 0.23] vs [4.67 ± 0.51] lg IU/mL, t=2.400, P=0.039; at week 24: [4.73 ± 0.21] vs [4.55 ± 0.50] lg IU/mL, t=2.542, P=0.039). By multivariate logistic regression analysis, the anti-HBc titer at baseline was the independent predictive factor for SVR in CHB patients treated with interferon (OR=6.000, 95%CI: 1.118 - 20.486, P=0.037). The area under receiver operating characteristics curve was 0.753 and the optimal cutoff value of anti-HBc titer for the response to interferons in CHB patients was 5.03 lg IU/mL, with positive predictive value of 64.3% and negative predictive value of 89.3%. Conclusions Dynamic pattern of anti-HBc titers is correlated with different virological responses in CHB patients treated with interferon, and the baseline anti-HBc titer is the independent predictive factor for SVR. Key words: Interferon; Hepatitis B, chronic; Anti-HBc titer

BackgroundThe association between hepatic steatosis (HS) and chronic hepatitis B (CHB) remains controversial. We performed a systematic review and meta-analysis to investigate the latest concurrence rate and impact of HS on CHB patients.MethodsRelevant studies were identified by searching PubMed, EMBASE, and the Cochrane Library from January 1, 2000 to December 2, 2020. We calculated the pooled prevalence of HS in CHB patients using a random effects model. A subgroup analysis was performed to explore the impact of HS on CHB patients. This study is registered with PROSPERO (No. CRD42021242584).ResultsA total of 98 studies with a population of 48,472 patients were included. The global prevalence of HS in CHB patients was 34.93% [95% confidence interval (CI): 32.01–37.90%]. Overweight status, hypertension, diabetes, hyperlipidemia, and metabolic syndrome showed a higher risk for developing HS in CHB patients, while positive hepatitis B e antigen (HBeAg) status was negatively associated with the presence of HS [odds ratio (OR) =0.81, 95% CI: 0.70–0.93]. The pooled analysis showed no significant association between HS and fibrosis progression (OR =0.68, 95% CI: 0.44–1.05). However, the coexistence of HS was negatively associated with the antiviral therapy response in CHB patients, including virological response (OR =0.69, 95% CI: 0.48–0.99) and alanine aminotransferase (ALT) normalization (OR =0.44, 95% CI: 0.28–0.69).DiscussionThe global prevalence of HS in CHB patients is higher than previously estimated. The concurrence of HS could impact the replication of HBV and the effectiveness of antiviral therapy in CHB patients. However, coexistence with HS did not show a higher risk of developing advanced fibrosis in CHB patients.

Reply to: “Is transient elastography inaccurate in chronic hepatitis B and non-alcoholic fatty liver disease?”

To evaluate the inhibition of CD4+ CD25+ regulatory T cells (Treg) in the chronic hepatitis B patients. Peripheral blood samples were collected from 22 patients with chronic hepatitis B (CHB) and 18 healthy blood donors to isolate the peripheral blood mononuclear cells (PBMCs). Flow cytometry was used to analyze the proportion of CD4+ CD127(lo)CD25(hi-int) Tregs in the CD4+ T cells so as to calculate the proportion of CD4+ CD25+ Tregs in the CD4+ T cells. BrdU incorporation method was used to evaluate the immune inhibition of the CD4+ CD25+ Tregs. CD4+ CD25- cells were isolated by magnetic bead sorting technique. The CD4- T cells and CD4+ CD25- T cells ere mixed and stimulated by HBVcore 18-27 peptide. The PBMCs of the CHB patients with the Treg depleted and Treg not depleted underwent detection of HBVcore18-27 specific cytotoxic T lymphocytes (CTLs). The IFN-gamma secretion of the CTLs in the PBMCs of CHB patients with Treg depleted and Treg not depleted was detected by HLA-pentamer and enzyme-linked immunospot assay (Elispot). The proportion of CD4+ CD127(lo)CD25(hi-int) Treg in the CD4+ T cells used to reflect the percentage of CD4+CD25+ Tregs in the CD4+ T cells of the CHB patients was 4.3% +/- 2.4%, significantly higher than that of the healthy controls (2.1% +/- 1.3%, t = 3.74, P <0.01). There was no significant difference in the inhibition of CD4+ CD25- T cells by autogenous CD4+ CD25+ T cells between the CHB patients and healthy controls. The frequency of CTLs induced by HBV core 18-27 of the CHB patients with their CD4+ CD25+ cells in circulation depleted was 0.74% +/- 0.31%, significantly higher than that of the patients whose CD4+ CD25+ cells in circulation were not depleted (0.17% +/- 0.08%, t = 4.75, P <0.01). The frequency of IFN-gamma secreting spots of HBVcore18-27-specific CD8+ T cells of the CHB patients with their CD4+ CD25+ cells depleted was (112 +/- 33), significantly higher than that of the CHB patients whose CD4+ CD25+ cells in circulation were not depleted [(23 +/- 14), t =7.828, P<0.01)]. The proportion of CD4+ CD25+ Treg in CHB patients is increased compared to the healthy blood donor. The proliferative capacity of CD4+ CD25- T cells is inhibited by the presence of CD4+ CD25+ Treg dose-dependently, and the inhibition of CD4+ CD25+ Tregs in the CHB patients is similar to the inhibition of CD4+ CD25+ Tregs in healthy donors. The elimination of Treg cells followed by stimulation with HBVcore18-27 peptide significantly improves the antivirus CTL responses in CHB patients.

The changing epidemiology of liver diseases in Asia.

Circulating CD4+ CD25+ regulatory T cells (Tregs) have been demonstrated to maintain immunotolerance and suppress the antigen-specific or antigen-non-specific T-cell responses, but their role in chronic hepatitis B (CHB) infection in humans has not been well characterized. In this study, we analysed the frequency and phenotypic characteristics of CD4+ CD25+ Tregs in patients of different hepatitis B virus (HBV) infection status, and investigated the effect of Tregs on antiviral immune responses in CHB patients, and the mechanism of this effect. A total of 137 subjects, including 79 CHB patients, 26 asymptomatic HBV carriers (ASCs), 12 acute hepatitis B (AHB) patients and 20 healthy controls, were enrolled in the study. We found that the frequency of CD4+ CD25(high) Tregs in AHB patients was comparable to that in healthy controls, while it was significantly increased in CHB patients. CD4+ CD25+ Tregs produced interleukin (IL)-10 but little or no interferon (IFN)-gamma under anti-CD3 stimulation. In CHB patients, the frequency of CD4+ CD25(high) Tregs positively correlated with serum viral load, and the Tregs were capable of suppressing the proliferation and IFN-gamma production of autologous peripheral blood mononuclear cells (PBMC) mediated by HBV antigen stimulation in vitro. However, combined administration of anti-programmed death-1 (PD-1) and anti-cytotoxic lymphocyte antigen-4 (CTLA-4) monoclonal antibody slightly enhanced the cellular proliferation and significantly increased the IFN-gamma production of PBMC cocultured with Tregs at a ratio of 2:1. Thus, the frequency of circulating CD4+ CD25+ Tregs is increased in patients with CHB, and this may play an important role in viral persistence by modulating virus-specific immune responses.

T-helper (Th) 17 cells have been shown to have an important role in host defense against viral infection. However, little is known about the regulation of Th17 cells in hepatitis B virus (HBV) infections. Peripheral blood mononuclear cells (PBMCs) isolated from patients with chronic hepatitis B (CHB) were stimulated with anti-interleukin (IL)-10 antibody or recombinant IL-10. The frequency of hepatitis B core antigen (HBcAg)-specific Th17 cells was characterized and produced cytokines were determined by flow cytometry. A low frequency of Th17 cells and a high frequency of Th1 cells were detected in CHB patients. HBcAg stimulation promoted IL-17A, IL-22, IL-23, IL-6, transforming growth factor (TGF)-β and IL-10 production by PBMCs from CHB patients, but not from healthy controls. Furthermore, endogenous IL-10 inhibited HBcAg-stimulated production of IL-17A, IL-22, IL-6 and IL-23, but not TGF-β. Treatment with IL-10 inhibited the HBcAg-stimulated activation of Th17 cells, whereas anti-IL-10 antibody significantly increased the frequency of Th17 and Th1 cells, but not that of CD4(+)CD25(+) regulatory T cells, associated with upregulating RORγt expression in CD4(+) T cells. HBcAg stimulated the production of IL-10, which negatively regulated HBcAg-specific Th17 cell responses in CHB patients. Our findings may represent one evasion strategy for HBV to subvert specific antiviral responses in humans.

The molecular basis of the failed immune response in chronic HBV: Therapeutic implications

Type I interferon receptor (IFNAR) has been involved in the progression of chronic hepatitis B (CHB). Oxidative stress is also associated with hepatitis B virus (HBV) infection and might contribute to the structure and function of protein synthesis including the IFNAR family. This study was aimed to determine the possible associations between oxidative stress and peripheral IFNAR expression in chronic HBV infection. Fifty-four CHB patients and 31 liver cirrhosis (LC) patients were consecutively collected, as well as 11 healthy subjects as controls. Expression levels of IFNAR1 and IFNAR2 in peripheral blood lymphocytes and monocytes were measured by flow cytometry. IFNAR1 and IFNAR2c mRNA were detected by real-time reverse transcription-polymerase chain reaction. Levels of plasma-soluble IFNAR and oxidative stress parameters, including xanthine oxidase (XOD), malondialdehyde (MDA), glutathione (GSH), glutathione S-transferase (GST), and glutathione peroxidase (GSH-Px) were detected by enzyme linked immunosorbent assay (ELISA). The frequencies of IFNAR1 and IFNAR2 in lymphocytes and monocytes were significantly increased in CHB and LC patients than in healthy controls. Expression levels of IFNAR1 and IFNAR2c mRNA and plasma-soluble IFNAR level in CHB and LC patients were upregulated compared with healthy controls. Mean fluorescence intensity (MFI) of IFNAR2 in monocytes of CHB patients was higher than that in LC patients. Levels of plasma XOD, MDA, and GST were significantly increased in CHB and LC patients compared with healthy controls. Meanwhile, GSH and GSH-Px in CHB and LC patients were decreased than that in healthy controls. Furthermore, plasma MDA, GSH, and GST levels in CHB patients were higher than that in LC patients. In CHB patients, plasma GST level was negatively correlated with MFI of IFNAR2 in lymphocytes. Our results suggested that oxidative stress play an important role in the regulation of IFNAR in chronic HBV infection.

Hepatitis B virus (HBV) infection and nonalcoholic fatty liver disease (NAFLD) are two major causes of chronic liver disease (CLD) that can cause liver cirrhosis and hepatocellular carcinoma (HCC). It is a trend to superimpose NAFLD on chronic HBV infection in Asia. This review presents the epidemiology of concurrent NAFLD in chronic hepatitis B (CHB) patients and focuses on the impact of concurrent NAFLD on the outcome of CHB patients in Asia. Although CHB patients tend to have a lower prevalence and incidence of NAFLD than the general population, concurrent NAFLD among CHB patients is still common and has an upward trend over time. Concurrent NAFLD can promote hepatitis B surface antigen (HBsAg) seroclearance and might inhibit HBV replication but exacerbate liver fibrosis. The impacts of concurrent NAFLD on HCC risk, all-cause mortality and antiviral treatment response in CHB patients remain controversial.

The impact of concurrent fatty liver (FL) on response to antiviral therapy in chronic hepatitis B (CHB) patients has not been well characterized. We aimed to systematically review and analyse antiviral treatment response in CHB patients with and without FL. We searched PubMed, Embase, Web of Science and the Cochrane Library databases from inception to 31 May 2023 for relevant studies. Biochemical response (BR), complete viral suppression (CVS) and hepatitis B e antigen (HBeAg) seroconversion in CHB patients with FL (CHB-FL) and without FL (non-FL CHB) were compared. In an initial pool of 2101 citations, a total of 10 studies involving 2108 patients were included. After 12 weeks of treatment, CHB-FL patients as compared with non-FL CHB patients had lower BR rate (48.37% [108/227] vs. 72.98% [126/174], p = .04) but similar trend for CVS (36.86% [80/227] vs. 68.81% [114/174], p = .05) and similar rates of HBeAg seroconversion (6.59% [7/103] vs. 7.40% [7/110], p = .89). However, at week 48, there were no statistically significant differences between CHB-FL and non-FL CHB patients in any of the outcomes, including BR (60.03% [213/471] vs. 69.37% [314/717], p = .67), CVS (65.63% [459/746] vs. 73.81% [743/1132], p = .27) and HBeAg seroconversion (10.01% [30/275] vs. 14.06% [65/453], p = .58) with similar findings for week 96. BR rate was lower in CHB-FL patients after 12 weeks of antiviral treatment. However, after a longer follow-up of either 48 or 96 weeks, no statistically significant differences were observed in BR, CVS or HBeAg seroconversion rates between CHB patients with and without FL.

The natural course of chronic hepatitis B (CHB) infection and treatment response are determined mainly by the genomic characteristics of the individual. We investigated liver gene expression profiles to reveal the molecular basis associated with chronic hepatitis B and IFN-alpha (IFNα) treatment response in CHB patients. Expression profiles were compared between seven paired liver biopsy samples taken before and 6 months after successful IFNα treatment or between pretreatment biopsy samples of 11 IFNα responders and 11 non-responders. A total of 132 differentially up-regulated and 39 down-regulated genes were identified in the pretreated livers of CHB patients. The up-regulated genes were mainly related to cell proliferation and immune response, with IFNγ and B cell signatures significantly enriched. Lower intrahepatic HBV pregenomic RNA levels and 25 predictive genes were identified in IFNα responders. The predictive gene set in responders significantly overlapped with the up-regulated genes associated with the pretreated livers of CHB patients. The mechanisms responsible for IFNα treatment responses are different between HBV and HCV patients. HBV infection evokes significant immune responses even in chronic infection. The up-regulated genes are predictive of responsiveness to IFNα therapy, as are lower intrahepatic levels of HBV pregenomic RNA and pre-activated host immune responses.

Antibodies in response to antigens are related to the immune repertoire of T- and B-cell receptors. However, some patients with chronic hepatitis B (CHB) have coexisting HBsAg and anti-HBsAg antibodies (anti-HBs) that cannot neutralize HBV. We attempted to investigate the repertoires that produce this response in CHB patients. The T-cell receptor β chain (TRB) and B-cell receptor (BCR) repertoires of peripheral blood genomic DNA were analyzed using MiXCR. T-cell receptor (TCR) cluster analysis was carried out by clusTCR, and motifs prediction was selected by Multiple Em for Motif Elicitation (MEME). A total of 76 subjects were enrolled, including 26 HBsAg and anti-HBs coexisting patients with CHB (DP group), 25 anti-HBs single-positive healthy people (SP group), and 25 CHB patients (CHB group). The clone length of BCR in 39, 90 was significantly different among these groups (p = 0.005, 0.036). The motif “CASSLG” in the DP group was significantly higher than SP and CHB groups and may relate to coexistence, and the motif “GAGPLT” was only shown in the SP group and may relate to anti-HB expression. These provide important insights into vaccine development and CHB treatment.

Objectives: The aim of this study was to evaluate histopathological improvement and virological, biological and serological response rates in patients receiving long-term entecavir therapy who were followed with the diagnosis of chronic hepatitis B (CHB).Materials and Methods: Ninety-eight nucleoside(t)e-naive CHB patients who were receiving 0.5 mg/day entecavir (ETV) were included in the study. Virological, serological and biochemical test results were assessed baseline and every 12-week intervals. Liver biopsy specimens were assessed according to the modified Ishak scoring.Results: Forty-six CHB patients receiving ETV treatment underwent liver biopsy. The mean age of the patients was 44 ± 12.9, 26.1% of them were female. The mean duration of follow-up was 44.9 ± 10.8 months. All patients had hepatitis B virus (HBV) genotype D infection. Of 21 patients who were HBeAg positive at baseline, HBeAg loss occurred in 9 and seroconversion occurred in 5. HBsAg loss occurred in none of the patients. Serum HBV DNA levels became undetectable in 93.5% patients. Of the patients, 50% achieved ≥ 2 point improvement in HAI scores and 30.4% achieved ≥ 1 point improvement in fibrosis scores with treatment. The mean improvement in HAI and fibrosis score were 1.94 ± 1.93 and 0.11 ± 0.9 points, respectively.Conclusion: ETV is an effective treatment in histological improvement and virological response in CHB patients. Large-scale, long-term studies are still warranted to evaluate the long-term outcomes of entecavir therapy.