HCV Clearance Research Articles

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The cover image, by F. Marcellin et al., is based on the Letter to the Editor Impaired patient-reported outcomes persist in HIV-HCV co-infected patients and in cirrhotic patients despite HCV clearance, DOI 10.1111/jvh.12811. Supported by the French National Agency for Research on HIV/AIDS and viral hepatitis (ANRS).

Primary biliary cholangitis triggered by DAAs-induced HCV clearance: a biological proof of concept.

Primary biliary cholangitis triggered by DAAs-induced HCV clearance: a biological proof of concept.

HCV clearance and pro-thrombotic shift in advanced liver disease

HCV clearance and pro-thrombotic shift in advanced liver disease

The course of oesophagogastric varices in patients with cirrhosis after DAA-induced HCV clearance

The course of oesophagogastric varices in patients with cirrhosis after DAA-induced HCV clearance

A Biomolecular Network Driven Proteinic Interaction in HCV Clearance.

Hepatitis C virus infection causes chronic liver disease that leads to cancer-related mortality. Presently around 30% of the HCV (infected) affected population get rid of the infection through spontaneous disease clearance. This phenomenon is conducted by a set of reported immune candidate genes. Hence, this study focuses only on these immune-response related genes with aid of network approach, where the idea is to disseminate the network for better understanding of key functional genes and their transcription control activity. Based on the network analysis the IFNG, TNF, IFNB1, STAT1, NFKB1, STAT3, SOCS1, and MYD88 genes are prioritized as hub genes along with their common transcription factors (TFs), IRF9, NFKB1, and STAT1. The dinucleotide frequency of TF binding elements indicated GG-rich motifs in these regulatory elements. On the other hand, gene enrichment report suggests the regulation of response to interferon gamma signaling pathway, which plays central role in the spontaneous HCV clearance. Therefore, our study tends to prioritize the genes, TFs, and their regulatory pathway towards HCV clearance. Even so, the resultant hub genes and their TFs and TF binding elements could be crucial in underscoring the clearance activity in specific populations.

Rapid reversal of innate immune dysregulation in blood of patients and livers of humanized mice with HCV following DAA therapy.

Chronic hepatitis C virus (HCV) infection results in sustained immune activation in both the periphery and hepatic tissue. HCV infection induces innate immune signaling that is responsible for recognition of dsRNA, leading to activation of transcription factors and production of Type I and III IFNs, as well as pro-inflammatory cytokines and chemokines. Continued activation of host-immune mediated inflammation is thought to contribute to pathologic changes that result in progressive hepatic fibrosis. The current standard treatment for chronic HCV infection is directly-acting antivirals (DAAs), which have provided the unique opportunity to determine whether successful, rapid treatment-induced eradication of viral RNA normalizes the dysregulated antiviral innate immune response in patients chronically infected with HCV.ResultsFirst, in patients receiving two different combinations of DAAs, we found that DAAs induced not only rapid viral clearance, but also a re-setting of antiviral immune responses in the peripheral blood. Specifically, we see a rapid decline in the expression of genes associated with chronic IFN stimulation (IFIT3, USP18, IFIT1) as well as a rapid decline in genes associated with inflammation (IL1β, CXCL10, CXCL11) in the peripheral blood that precedes the complete removal of virus from the blood. Interestingly, this rapid reversal of innate immune activation was not seen in patients who successfully clear chronic HCV infection using IFN-based therapy. Next, using a novel humanized mouse model (Fah-/-RAG2-/-IL2rgnull—FRG), we assessed the changes that occur in the hepatic tissue following DAA treatment. DAA-mediated rapid HCV clearance resulted in blunting of the expression of proinflammatory responses while functionally restoring the RIG-I/MAVS axis in the liver of humanized mice.ConclusionsCollectively, our data demonstrate that the rapid viral clearance following treatment with DAAs results in the rebalancing of innate antiviral response in both the peripheral blood and the liver as well as enhanced antiviral signaling within previously infected hepatocytes.

Hepatitis B Reactivation: The Catch-22 of DAA Therapy in Hepatitis C Treatment

Hepatitis C is a leading cause of cirrhosis in the US, and co-infection or prior infection with Hepatitis B is common. Direct anti-viral agents have revolutionized the treatment of HCV, and new treatment dilemmas emerge in those who have achieved SVR. This case highlights an example of HBV reactivation after successful HCV treatment in a patient with a history of liver transplantation. The patient is a 68-year-old African American man with cirrhosis secondary to HCV (Genotype Ia) and alcohol abuse, who underwent an orthotopic liver transplant in 2011 (HCV positive) after developing hepatocellular carcinoma. In December 2015, he received direct-acting antiviral therapy for HCV, finishing a 12-week course of ledipasvir and sofosbuvir. Post-treatment labs revealed SVR12 in March 2016. In September 2016, he was hospitalized for pancreatitis. Labs drawn at the time of admission showed a non-reactive HBsAg, < 3.10 HBsAb, and isolated reactive HBV core antibody. Repeat labs during hospitalization, which were incidentally drawn one week later, showed reactive HBsAg, HBcAb IgM, and an HBV DNA viral load of >170,000,000. Repeat confirmatory serologies showed similar results, and HBeAg and HBeAb were also positive. No genotype was reported and Hepatitis D antibody was negative. Hepatitis B treatment was initiated with entecavir. In March 2017, he was found to have a malignant neoplasm of the pancreatic head, and he passed away one month later from catheter-associated bacteremia. This case focuses on a new treatment hurdle in direct-acting antiviral therapy for HCV, and one that is more common compared to prior interferon-based therapy. The exact mechanism of HBV reactivation is unknown, but thought to be secondary to HCV-HBV viral interference or by rapid clearance of HCV leading to immune reconstitution, favoring HBV reactivation. Thus, it is vital to monitor patients' HBV status before and after treatment, as per new FDA guidelines. This case proves unique as our patient is an African American male; most cases involve Caucasian or Asian patients, with a greater percentage of women reactivating than men. Additionally, prior to reactivation our patient was isolated HBcAb positive, HBsAg negative. Almost all cases in the literature show reactivation exclusively with patients who are HBsAg positive. This case highlights the importance of monitoring Hepatitis B serologies in patients receiving DAA therapy, including those whose serology show HBcAb positive and HBsAg negative.

Effect of Chronic Kidney Disease Stage 3-5 on Hepatitis Therapy Outcome

Introduction: Use of HCV DAA agents have resulted in significant improvement in the treatment outcomes in patients with chronic HCV. Certain patient subgroups such as patients with chronic kidney disease remain a challenge with SVR rates that are lower than the general HCV population. Limited data exists on factors that may effect treatment outcomes adversely in this population. The aim of this study was to describe the effect of CKD stage on HCV therapy outcome. Methods: Charts of a retrospective cohort of all patients with stage 3-5 CKD were reviewed. Data collected included demographics, HCV RNA, creatinine clearance, HCV genotype, liver fibrosis stage and co-morbidities. Results: A total of 15 patients were identified with an age range of 37 - 77 years. There were 13 males and 2 females with 10 Blacks, 2 Hispanics and 3 White patients. All patients were genotype 1 with liver fibrosis of stage 1-2 in 8 patients and stage 3-4 in 7 patients. CKD was stage 3 in 10 patients, stage 4 in 1 patient, stage 5 in 3 patients on hemodialysis and one stage 3 post kidney transplant patient. HCV therapy prescribed was elbasvir/grazoprevir in 6 patients, dasabuvir/ombitasvir/paritaprevir/ritonavir in 4 patients, ledipasvir/sofosbuvir in 3 patients, valpatasvir/sofosbuvir in 1 patient and simeprevir/sofosbuvir in 1 patient. All patients were HCV RNA not detected at week 4 and none relapsed during treatment. Treatment was discontinued between weeks 4-10 due to worsening kidney function in 4 patients which resulted in treatment failure. CKD in these treatment failure patients was stage 3 in 2 patients, stage 4 in 1 patient and 1 post kidney transplant patient. Overall the SVR rate was 80%; 67% in stage 3-4 CKD and 100% in Stage 5 CKD. Conclusion: Use of HCV DAA agents has resulted in a significant improvement in SVR rates in this difficult-to-treat population. Patients on hemodialysis are more likely to have better treatment outcomes as they are more stable medically and are easier to manage. Patients with CKD stage 3-4 are the most challenging during HCV therapy due to several factors including worsening of kidney function, poorly controlled blood pressure and diabetes resulting in premature discontinuation of therapy. Close monitoring of these patients is warranted and further studies are needed in order to identify CKD stage 3-4 patients that are likely to have improvement in their kidney function and in their quality of life as a result of HCV clearance.

Rapid changes in peripheral lymphocyte concentrations during interferon-free treatment of chronic hepatitis C virus infection.

Treatment of chronic hepatitis C virus (HCV) infection with direct‐acting antivirals results in a rapid decline in viral load and markers of hepatic inflammation, including serum chemokine (C‐X‐C motif) ligand 10 (CXCL10) concentration, which is followed in most cases by a sustained virologic response. Whether parallel changes of significance occur in the cellular composition of peripheral blood is relatively unknown. We hypothesized that longitudinal characterization of peripheral blood during treatment would provide insight into cellular migration and immune activation, which would have implications for understanding host immunity both before and after HCV treatment and may relate to HCV clearance. We analyzed longitudinal peripheral innate and adaptive immune cell populations by flow cytometry from 95 subjects enrolled in two direct‐acting antiviral clinical trials and examined chemokine receptor expression on T lymphocytes in 43 patients. Within 1‐2 weeks of initiating treatment, significant increases were observed in the concentration of peripheral cluster of differentiation 4–positive (CD4+) and CD8+ T lymphocytes but not monocyte or natural killer cells. In tandem with these changes, the percent of both CD4+ and CD8+ T lymphocytes with an activated phenotype (human leukocyte antigen [HLA] DR+ and CD38+) decreased, and T‐lymphocyte surface expression of chemokine (C‐X‐C motif) receptor 3, the chemokine receptor for CXCL10, increased. Conclusion: Rapid changes in peripheral cellular populations occur during direct‐acting antiviral treatment of HCV infection, which could potentially relate to hepatic efflux of tissue lymphocytes due to altered inflammation and chemokine receptor signaling, providing critical insight into the relationship between host immunity and viral clearance during HCV infection. (Hepatology Communications 2017;1:586–594)

Immune Reconstitution After HCV Clearance With Direct Antiviral Agents: Potential Consequences for Patients With HCC?

Recent introduction of all-oral direct-acting antiviral (DAA) treatment has revolutionized care of patients with chronic hepatitis C virus infection. Because patients with different liver disease stages have been treated with great success including those awaiting liver transplantation, therapy has been extended to patients with hepatocellular carcinoma as well. From observational studies among compensated cirrhotic hepatitis C patients treated with interferon-containing regimens, it would have been expected that the rate of hepatocellular carcinoma occurrence is markedly decreased after a sustained virological response. However, recently 2 studies have been published reporting markedly increased rates of tumor recurrence and occurrence after viral clearance with DAA agents. Over the last decades, it has been established that chronic antigen stimulation during persistent infection with hepatitis C virus is associated with continuous activation and impaired function of several immune cell populations, such as natural killer cells and virus-specific T cells. This review therefore focuses on recent studies evaluating the restoration of adaptive and innate immune cell populations after DAA therapy in patients with chronic hepatitis C virus infection in the context of the immune responses in hepatocarcinogenesis.

Polymorphisms of chemokine receptor genes and clearance of hepatitis C virus infection in Chinese population

BackgroundChemokine genes play an essential role in both spontaneous clearance in acute infection and therapy of HCV. We investigated whether several CXC family-related genes associated with HCV spontaneous clearance and response to treatment. MethodsThe current study genotyped four SNPs, respectively are CXCR6 rs2234358, CXCL12 rs1801157, CXCL9 rs10336, rs3733236 to assess their associations with HCV spontaneous clearance and response to treatment in a two stage study (668 chronic and 400 resolvers in discovery group, meanwhile 333 chronic and 199 resolver in replication group), and a treatment cohort of HCV with 282 patients. ResultsWe found that the CXCR6 rs2234358 was associated with HCV spontaneous clearance in Chinese Han population (dominant model: adjusted OR=1.62, 95%CI: 1.30–2.01; additive model: adjusted OR=1.43, 95%CI: 1.20–1.70). Patients carrying GT/TT genotypes had increased sustained virological response compared with patients carrying the GG genotype (dominant model: adjusted OR=2.23, 95%CI: 1.26–3.95). ConclusionThese results suggest that CXCR6 rs2234358 is associated with spontaneous clearance of HCV and response to IFN-α/RBV therapy, which may be identified as a predictive marker in Chinese Han population of HCV.

Association of Genotype and Haplotype of IL-28B Gene with Hepatitis C Infection Outcome in Iran: Spontaneous Clearance Versus Chronic Infection

Background: Spontaneous viral clearance occurs in 10% to 40% of individuals after hepatitis C virus infection. Some polymorphisms in IL-28B gene may influence the outcome of HCV infection. The present study aimed at investigating the genotype and allele frequency of IL-28B rs12979860 and rs8099917 SNPs in HCV infected patients in addition to determining their association with disease outcome. Methods: A total of 302 patients with chronic hepatic C infection and 36 individuals whose infection was spontaneously cleared were included in this case-control study. The presences of chronic or spontaneously cleared infection in participants were determined by serologic and molecular methods. Genomic DNA of the participants was extracted using salting out method. IL-28B/IFN-λ3 gene polymorphisms were conducted using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Results: The frequency of CC genotype (P = 0.001) and C allele (P = 0.0007) of IL-28B gene at rs12979860 SNP was significantly higher in participants with spontaneously cleared HCV infection compared to that of those who were chronically infected. In the case of rs8099917 SNP of IL-28B, no correlation was found between frequency of genotype (P = 0.17) or allele (P = 0.12) and HCV infection outcome. The results of haplotype analysis showed the association of CT (P = 0.012) and TT (P = 0.013) haplotypes with spontaneous clearance and chronic infection, respectively. Conclusions: The findings implied that individuals with CC or CT genotype at rs12979860 SNP but rs8099917 SNP was not in association with spontaneous clearance of HCV in an Iranian population with HCV infection.

HCV clearance after direct-acting antivirals in patients with cirrhosis by stages of liver impairment: The ITAL-C network study

BackgroundSustained virological response (SVR12) rates at 12 weeks after treatment for HCV-infected patients with decompensated cirrhosis are used when referring to those with moderate functional impairment, while few data are available for those with more severe impairment. The use of the cirrhosis staging system proposed by D’Amico might provide new insights on timing for antiviral therapy. MethodsWe investigated efficacy (SVR12), safety, and post-treatment variations in clinical and laboratory parameters in 2612 patients with advanced fibrosis (n=575) or cirrhosis (n=2037). Cirrhosis was in the compensated phase (without/with varices) or had previously been in the decompensated stage. Different direct-acting antiviral (DAA) regimens were administered in accordance with scientific guidelines. ResultsThe SVR12 rate was 97.6% in patients with advanced fibrosis. For patients with cirrhosis, the rate was 96.5% in stage 1, 95.1% in stage 2, 100% in stage 3, 95.7% in stage 4, and 93.6% in stage 5. These rates were independent of gender, age, HCV genotype, and treatment schedule. Positive changes in biochemical parameters and CPT classes following therapy were evident in compensated and previously decompensated patients. ConclusionOur findings support the use of DAAs in patients with advanced cirrhosis (stages 3–5) who are at greatest risk and have the most to gain from therapy.

Interferon Lambda 4 Gene (IFNL4) Linked to Hepatitis C Virus Clearance, Treatment

Background: AdesignatedIFNL4 gene, encoding the interferon-λ4 protein (IFNL4), which is moderately similar to IFNL3, is more strongly associated with HCV clearance in individuals of African ancestry, whereas it provides comparable information in Europeans and Asians. Aim of the work: The study was attempted for the identification of interferon Lambda 4 (IFNL4) gene expression in the liver biopsy and the recombinant IFNL4 protein in the serum of CHCV patients. Patients and methods: Eighty five patients with chronic hepatitis C virus infection (CHCV), whose age ranged between 19 and 57 years, were selected from the National Hepatology and Tropical Medicine Research Institute were included in this study, before chronic HCV therapy, during the preparation of patients, and ten healthy individuals were included to serve as controls. All the patients and controls were subjected to the following: history, clinical examination, abdominal ultrasonography and collection of blood samples for routine laboratory investigations, CBCs. Liver biopsy was done to all patients and controls. Patients revealed mild fibrosis (Metavir fibrosis from F1 to F3). Using freshly frozen liver biopsies to identify gene (IFNL4) by real time-PCR and the detection of its serum protein levels by ELISA. Results: Patientswith CHCVhave higher hepatic expression of IFNL4 before treatment and also recombinant IFNL4 protein expression was detectable in serum with high levels. Conclusion: An inducible human protein-coding gene IFNL4, which is related to, known IFNs have been identified in genotype 4 CHCV patients. Recommendations: Thetherapeutic inhibition of IFNL4 might represent a novel biological target for the treatment of HCV and HBV infection and possibly other diseases.

Mo1382 - Risk of HCC in HCV Related Cirrhosis After HCV Clearance with Direct Acting Antivirals: A Systematic Review and Meta-Analysis

Mo1382 - Risk of HCC in HCV Related Cirrhosis After HCV Clearance with Direct Acting Antivirals: A Systematic Review and Meta-Analysis

The dynamics of HCV-specific antibody responses in HIV/HCV patients on long-term antiretroviral therapy

Antibody responses have not been fully characterised in chronically HIV/HCV patients receiving antiretroviral therapy (ART). Seventeen HIV/HCV patients receiving ART were followed for a median (range) interval of 597 (186–766) weeks. Prior to ART, HIV/HCV patients had lower levels of antibodies reactive with HCV core and JFH-1, and lower genotype cross-reactive neutralising antibodies (nAb) titres, than HCV patients. Levels of JFH-1 reactive antibody increased on ART, irrespective of CD4+ T-cell counts or changes in serum ALT levels. The appearance of nAb coincided with control of HCV viral replication in five HIV/HCV patients. In other patients, HCV viral loads remained elevated despite nAb responses. Sustained virological responses following HCV therapy were associated with reduced antibody responses to JFH-1 and core but elevated responses to non-structural proteins. We conclude that nAb responses alone may fail to clear HCV, but contribute to control of viral replication in some HIV/HCV patients responding to ART.

Genetic variants in interferon-\u03bb 4 influences HCV clearance in Chinese Han population

Recent many studies indicated a novel dinucleotide variant in ss469415590 (TT vs. ΔG) of interferon-λ 4 (IFNL4) gene strongly associated with hepatitis C virus clearance. To evaluate the impact and clinical usefulness of IFNL4 ss469415590 genotype on predicting both spontaneous HCV clearance and response to therapy in Chinese population, we genotyped 795 chronic HCV carriers, 460 subjects with HCV natural clearance and 362 patients with pegylated interferon-α and ribavirin (PEG IFN-α/RBV) treatment. IFNL4 ss469415590 variant genotypes significantly decreased host HCV clearance, both spontaneous (dominant model: OR = 0.50, 95% CI = 0.36–0.71) and IFN-α induced (dominant model: OR = 0.32, 95% CI = 0.18–0.56). Multivariate stepwise analysis indicated that ss469415590, rs12979860, the level of baseline HCV RNA and platelet were as independent predictors for sustained virological response (SVR). But the area under the ROC curve (AUC) was only 0.58 for ss469415590, and it was elevated to 0.71 by adding rs12979860, baseline HCV RNA and platelet in the prediction model of SVR. Therefore, these findings underscore that although genetic factors of host and pathogen were commonly important during HCV clearance, ss469415590 may be also a strongly predictive marker in the Chinese population.

Spontaneous Clearance of Hepatitis C Virus after Liver Transplantation, A Report of Two Cases

1.1.Background: End-stage liver cirrhosis due to HCV is the main indication for liver transplantation worldwide. Recurrence and rapid replication of HCV after liver transplantation is universal and leads to decreased graft and patient survival. Among patients exposed to HCV, spontaneous clearance of the virus is rare. Here we report two patients with spontaneous clearance after liver transplantation. 1.2.Case Reports:We report two female patients, with HCV cirrhosis, received liver transplantation (one DDLT and one LDLT), they cleared HCV on average of 20 days post liver transplant, one remained negative throughout while the other patient showed relapse on re-testing 2 years later. 1.3.Conclusion:Spontaneous clearance of HCV is rare when the patient is immunosuppressed. Here, we reported two patients with spontaneous clearance of HCV after liver transplantation. One has relapsed which highlights the need for serial testing in these patients

Longterm Evaluation of Hemoglobin A1c Following Hepatitis C Therapy in Patients with and without HIV Co-infection

BackgroundHistorically, eradication of HCV with interferon-based treatments was linked with decreased incidence of diabetes. While viral clearance with direct acting agents (DAAs) may be associated with acute decreases in fasting glucose levels and hemoglobin A1c (HbA1c), there remains a need for larger prospective studies to address the longterm impact of sustained viral response (SVR) achieved with DAAs on glucose metabolism.MethodsProspective longitudinal cohort study of 251 subjects with chronic HCV (100% genotype 1a/b, 31% HIV+, 17% diabetes) evaluated pre- and post-DAA therapy with median follow-up of 28 mos. Change in HbA1c, glucose, lipid and transaminase levels were compared based on SVR, HIV, diabetes status and fibrosis stage.ResultsThere was no difference in change in HbA1c between subjects who achieved SVR (n = 241) compared with those who did not. Mean change in HbA1c did not differ from zero (−0.022 ± 0.53%) for those with SVR. Further, when subjects were grouped based on HIV, diabetes or fibrosis stage, there were no significant differences in changes in HbA1c or glucose following SVR. Subjects with HIV had smaller reductions in transaminase values (change ALT −33.3 ± 51 IU/L HIV+ vs. −47.8 ± 45 IU/L HIV-, P = 0.0007). Following SVR, total and LDL cholesterol increased (P = 0.0002 and P = 0.0003, respectively) whereas triglyceride levels decreased (P = 0.008). A greater proportion of subjects (7%) started or increased medication therapy for diabetes following SVR compared with the percentage who decreased diabetes therapy (3%). There was a statistically significant positive correlation between change in BMI and change in HbA1c (r=0.17, P = 0.006).ConclusionThe current study failed to identify sustained benefits in glucose or HbA1c in HCV treated patients, irrespective of HIV, diabetes or fibrosis stage. HIV infection blunted improvements in transaminase levels related to SVR. While HbA1c did not improve with HCV clearance, alterations in lipids were identified that warrant further investigation.Disclosures C. Gross, Merck: stock holder, Own stock; Pfizer: stock holder, Own stock; JohnsonandJohnson: stock holder, Own stock

Circulating Interferon-λ3, Responsiveness to HBV Vaccination, and HBV/HCV Infections in Haemodialysis Patients

The IFN-λ3 gene (IFNL3) plays a role in HCV clearance. We investigated circulating IFN-λ3 and IFNL3 SNPs in haemodialysis patients who differed in their response to HBV vaccination and their HBV/HCV infection status. In 201 patients, plasma IFN-λ3 was determined using ELISA. IFNL3 SNPs (rs12979860, rs8099917) were genotyped using HRM analysis. Differences in IFN-λ3 levels were shown between responders and nonresponders to HBV vaccination and between HBsAg-positive patients and those who developed anti-HBs after infection and became HBsAg negative. HBV vaccine responders without HCV resolution revealed lower IFN-λ3 than noninfected responders. HBsAg/HCV RNA-positive subjects showed lower IFN-λ3 than patients positive only for HCV RNA or subjects who resolved both infections. Circulating IFN-λ3 correlated positively with anti-HBs and negatively with positive HCV RNA testing in the adjusted regression analyses. HBV vaccine nonresponders, HBsAg-positive patients, and subjects with replicating HCV composed a group with unfavourable outcomes. Responders to HBV vaccination, subjects who became HBsAg negative, and those who cleared HCV were analysed as having favourable outcomes. The latter showed higher IFN-λ3 but did not differ in distribution of IFNL3 SNPs compared with subjects with unfavourable outcomes. Higher IFN-λ3 concentrations are associated with response to HBV vaccination, self-limited HBV infection, and HCV resolution.