Sustained Virological Responders Research Articles

Outcome of Treatment With Pegylated Interferon and Ribavirin in Heart Transplant Recipients With Chronic Hepatitis C

Background/aim The combination of pegylated interferon (PEG-IFN) and ribavirin (RBV) is the current treatment for chronic hepatitis C (CHC). The treatment is thought to suppress viral replication and induce viral clearance via immunomodulatory effects. For this reason, concern exists for the use of this treatment in recipients of a solid organ transplantation. We sought to evaluate the safety and efficacy of PEG-IFN/RBV in heart transplant recipients with CHC. Methods From June 2005 to September 2009, we treated three CHC patients with heart transplantation. PEG-IFN alpha2b and RBV doses and treatment duration were set according to the hepatitis C virus (HCV) genotype and body weight as per current recommendations. Dose reductions were dictated by individual patient tolerability. Cardiac safety was monitored by clinical examinations, echocardiography, and measurement of troponin I and B-type natriuretic peptide, as well as endomyocardial biopsies. Results All three patients, displayed HCV genotype 1b infection, viral loads of >5 logs, and a Scheuer fibrosis score ≥ 2. Two of them completed the prescribed treatment course becoming sustained virological responders. The other patient had an initial complete virological response, but subsequently experienced a viral breakthrough after reduction of PEG-IFN and withdrawal of RBV due to severe anemia. We observed no cardiovascular adverse events nor rejection episodes. Posttreatment clinical history and examination, electrocardiography, and echocardiography did not show any sign of graft dysfunction. Conclusions Treatment with PEG-IFN/RBV may be safely offered to stable heart transplant recipients with CHC and signs of liver disease progression. Close monitoring of treatment safety is mandatory.

Mutations around interferon sensitivity-determining region: A pilot resistance report of hepatitis C virus 1b in a Hong Kong population

To explore mutations around the interferon sensitivity-determining region (ISDR) which are associated with the resistance of hepatitis C virus 1b (HCV-1b) to interferon-α treatment. Thirty-seven HCV-1b samples were obtained from Hong Kong patients who had completed the combined interferon-α/ribavirin treatment for more than one year with available response data. Nineteen of them were sustained virological responders, while 18 were non-responders. The amino acid sequences of the extended ISDR (eISDR) covering 64 amino acids upstream and 67 amino acids downstream from the previously reported ISDR were analyzed. One amino acid variation (I2268V, P = 0.023) was significantly correlated with treatment outcome in this pilot study with a limited number of patients, while two amino acid variations (R2260H, P = 0.05 and S2278T, P = 0.05) were weakly associated with treatment outcome. The extent of amino acid variations within the ISDR or eISDR was not correlated with treatment outcome as previously reported. Three amino acid mutations near but outside of ISDR may associate with interferon treatment resistance of HCV-1b patients in Hong Kong.

Durability of antiviral therapy for chronic hepatitis C after achieving sustained virological response

See Article on Page 183 Hepatitis C virus (HCV) causes various liver diseases including acute hepatitis, chronic hepatitis, health-holders, liver cirrhosis and hepatocellular carcinoma.1 Acute hepatitis C progresses to chronic hepatitis from 75 to 85% and cirrhosis after 20-25 years later. In patients with HCV-positive cirrhosis, the annual incidence of hepatocellular carcinoma has been reported as 5% approximately.1 The current standard antiviral treatment with peginterferon and ribavirin combination therapy is effective in about 50% of patients with chronic hepatitis C. It is assumed that achievement of sustained virological response (SVR) after the combination therapy, confirmed by means of commercial HCV RNA detection assays is regarded as a cure for chronic hepatitis C (Table 1). It is associated with histological improvement, reduced the risk of hepatocellular carcinoma and liver related mortality, and improved quality of life. Table 1 Commercially available HCV RNA detection assays For the respect of the durability of SVR, several studies have been reported. Marcellin et al2 reported that an SVR after antiviral therapy was associated with long-term biochemical and virological responses as well as histologic improvement. Eighty-patients who had SVR after interferon-alpha monotherapy, mean follow-up of 4 years showed that 96% had undetectable serum HCV RNA. In a large-scale clinical trials, 7 (2%) among 400 sustained virological responder had detectable hepatic HCV RNA during follow-up; 5 have been followed and 2 (0.5%) were reappearance of serum HCV RNA at 12 months after therapy.3 Many other reports including the study of Choi et al4 confirmed that late relapse is rare after achievement of an SVR with completion of interferon without or with ribavirin therapy (Table 2).5-13 On the other hand, earlier reports showed higher rate of late relapse.14-16 These discrepancies may be resulted from use of HCV polymerase chain reaction (PCR) assays with varying degrees of sensitivity and a range of patient populations. As a result, the true durability of the response remains unclear, and the optimal follow-up for patients who have achieved an SVR is unknown. Table 2 Reappearance rates of serum HCV RNA after achieving SVR Even then achievement of an SVR, there are many evidences that HCV can persist and replicate in peripheral blood mononuclear cells, hepatic tissue and other organs including kidney, heart, pancreas, intestine, adrenal gland, lymph node and gallbladder in spite of still undetectable serum HCV RNA.3,17-21 It is so called HCV, which can be reservoir of reappearance HCV RNA in serum3,21 and thus play a role in the persistence and reactivation of infection. Highly sensitive reverse transcription and nested PCR assays detected residual HCV RNA in case of occult HCV. However, these assays are not currently standard diagnostic procedures and whether these findings actually represent a replication-competent virus or have any clinical significance is not clear. The immunologic mechanism of HCV recurrence after SVR is also not well investigated. Quiroga et at22 reported HCV-specific cellular immune responses are stronger in occult HCV infection than in chronic hepatitis C and it would be the cause of the rare incidence of late relapse. For the factors affecting the durability of SVR, no distinct pattern of baseline characteristics could be identified. Several studies with small number of patients reported the transfusion, injection drug use or dose reduction as a risk factor. However, it was unknown whether these cases reflect relapse or re-infection because of the paucity of paired samples. Although there is reappearance of serum HCV RNA in approximate 1% of patients with an SVR, individuals who have achieved an SVR should have a single additional follow-up HCV RNA measurement performed to ensure that the negative HCV RNA result at 6 months posttreatment was not a false negative possibly due to faulty sample collection. If the second posttreatment HCV RNA measurement is negative, the SVR appears to be durable and a reliable sign of cure after antiviral therapy in chronic hepatitis C. However, it is recommended to follow up serum HCV RNA for a long time after an SVR for those individuals who show intermittent viral breakthrough during treatment or who may be considered at risk for reinfection or late relapse.

Durability of a sustained virologic response in patients with chronic hepatitis C treated with peginterferon and ribavirin

A Sustained virologic response is durable in patients with chronic hepatitis C with peginterferon alfa-2a and ribavirin. Swain MG, Lai MY, Shiffman ML, Cooksley WG, Zeuzem S, Dieterich DT, Abergel A, Pessoa MG, Lin A, Tietz A, Connell EV, Diago M. Gastroenterology 2010;139(5):1593-1601. The current standard therapy for chronic hepatitis C virus (HCV) infection is the combination of pegylated interferon and ribavirin. The ultimate goal of treatment in patients with chronic HCV infection is to completely eradicate HCV in infected hosts, and prevent liver-related morbidity and mortality. However, these goals are difficult to measure and it takes long time to assess the achievement of these goals. A sustained virologic response (SVR) has been used as a surrogate marker of these ultimate goals in treatment of chronic hepatitis C. An SVR is defined as undetectable serum HCV RNA at 24 weeks after the end of treatment. To be a useful surrogate marker, achievement of SVR should result in the reduction of liver-related morbidity and mortality, complete eradication of HCV in infected hosts, and no late virologic relapse. Achievement of SVR has been associated with improvement in liver histology and health-related quality of life, as well as a reduced risk of hepatocellular carcinoma and liver-related mortality.1-3 The survival of patients who achieved SVR was reported to be comparable to that of general population, matched for age and sex.4 However, the development of hepatocellular carcinoma was reported despite achievement of SVR in patients with chronic hepatitis C and advance fibrosis.5 There is some debate as to whether achievement of SVR results in complete eradication of HCV. In a study of 2089 patients with chronic hepatitis C from 3 clinical trials, hepatic HCV RNA was found to correlate with serum HCV RNA in all cases, and 98% of sustained virologic responders had undetectable hepatic HCV RNA.6 Several small studies have described patients who achieved SVR but have residual HCV RNA detected in peripheral blood mononuclear cells with highly sensitive reverse transcription and nested polymerase chain reaction assays.7,8 Whether these findings represent a replication-competent virus or have any clinical significance is unclear. Several small studies reported SVR achieved with conventional interferon alone or in combination with ribavirin was durable. In these reports, serum HCV RNA remained undetectable in 92-100% of patients who achieved SVR with 2 to 13 years of follow-up.4,5,9-12 However, there are limited data on the durability of SVR achieved with peginterferon in patients with chronic hepatitis C. Swain et al. studied the durability of SVR achieved with peginterferon in 1343 patients.13 They analyzed the durability of SVR in large cohort of patients who were enrolled in one of 9 randomized controlled clinical trials,14-22 which evaluated the efficacy of peginteferon alfa-2a alone or in combination with ribavirin. Total 1343 treatment-naive patients who achieved SVR and had at least one post-baseline HCV RNA evaluation were assessed. One thousand three hundred thirty one of 1343 patients (99.1%) remained HCV RNA undetectable in serum at mean of 3.9 years after completion of treatment. The durability of SVR in this study was independent of patient characteristics such as HCV mono-infection, HCV-HIV co-infection, or ALT level. The durability of SVR also appeared to be unaffected by the type of treatment. HCV RNA was detected in the serum of 12 patients who obtained SVR in their original studies at mean of 666 days after completing treatment. Among the 12 patients with reappearance of HCV RNA, there were no baseline or treatment factors associated with reappearance of HCV RNA including HCV genotype, sex, age, race, risk factor for infection, or baseline viral load. It was unknown whether these cases reflect relapse or re-infection because of the paucity of paired samples. The findings of this study were comparable with those reported from smaller studies with conventional interferon. There was one domestic report on the durability of interferon-based therapy in patients with chronic hepatitis C.23 In this study, 73 patients who achieved SVR with conventional interferon or peginterferon in combination with ribavirin were included. HCV RNA reappeared in 8 of 73 (11%), but persistent viremia remained only in one patient (1.4%). Transient positive tests probably represent false-positive test, and the durability of SVR in Korean patients with chronic hepatitis C appears to be similar with those reported in other studies. In conclusion, this study showed SVR achieved with peginterferon alfa-2a alone or in combination with ribavirin is durable in 99% of patients for at least 4 years after completion of therapy and is independent of patient or treatment characteristics.

Human cytomegalovirus infection inhibits response of chronic hepatitis‐C‐virus‐infected patients to interferon‐based therapy

Cytomegalovirus (CMV) is a ubiquitous pathogen that infects the majority of humans. Co-infection of CMV and hepatitis C virus (HCV) may deteriorate the prognosis of HCV-infected patients. This study was conducted to examine the role of CMV reactivation in determining the response rate to treatment with interferon and ribavirin therapy in chronic HCV patients. Viral loads and genotyping were assessed using reverse transcription polymerase chain reaction and Innolipa systems, respectively. Reactivation of CMV in HCV patients who were all positive for CMV immunoglobulin G antibodies was tested by amplification of the gB1 gene using the end-point dilution quantitative-nested polymerase chain reaction method. CMV DNA was detected in 89.7% of non-responders and in 34.6% of sustained virological responders. Patients with reactivated CMV had significantly higher fibrosis scores (72.7%) than those with undetectable CMV DNA (23.8%, P=0.002). Patients with positive CMV had higher rates of non-response and relapse (79.5%) than those with negative CMV DNA (19%). Chronic HCV patients with latent CMV had higher rates of response (81%) to treatment than those with reactivated CMV (20.5%, P<0.001). Therefore, HCV patients with reactivated CMV and advanced fibrosis were least likely to achieve a sustained virological response following interferon therapy. This possibility is reduced to 50% of its original value in patients with reactivated CMV without fibrosis. Besides the staging of liver fibrosis, CMV co-infection should be considered as an extremely important factor when designing predictive models for HCV response to interferon treatment.

Effect of pegylated interferon therapy on intrahepatic recurrence after curative treatment of hepatitis C virus-related hepatocellular carcinoma

We wished to determine whether pegylated interferon (PEG-IFN) therapy after curative treatment of hepatocellular carcinoma (HCC) prevents a recurrence of HCC. Thirty-seven HCC patients with hepatitis C virus (HCV) infection who were treated with PEG-IFN after curative treatment (PEG-IFN group) and 145 controls without IFN therapy (non-IFN group) were enrolled. The overall survival and recurrence-free survival rates were compared between the groups, and the predisposing factors for recurrence and survival were analyzed. The rates were also examined by propensity score (PS) matched analysis that could minimize selection biases. The median follow-up period was 3.7 years. The 5-year survival rate in the PEG-IFN group (91%) was significantly higher than that in the non-IFN group (56%; P < 0.01). The rate of the second recurrence but not that of the first recurrence of HCC in the sustained virological responder (SVR) group was lower than that in the non-IFN group (P = 0.03). Improvement of survival by PEG-IFN and low rate of second recurrence in the SVR group were also observed in PS matched analysis. Multivariate analysis revealed that PEG-IFN therapy and high serum albumin were good prognostic factors for survival. Although low serum albumin and large and multiple tumors were risk factors for the first recurrence, non-SVR and low serum albumin were risk factors for the second recurrence. PEG-IFN-therapy after curative treatment of HCC improved the rate of survival, and SVR was found to be closely correlated with the prevention of recurrence.

Outcome in partial early virologic responders to combination therapy with peginterferon and ribavirin in patients infected with hepatitis C virus genotype 1b

The course and outcome in patients infected with hepatitis C virus (HCV) genotype 1b with partial early virologic response during combination therapy with peginterferon and ribavirin, in whom serum HCV RNA is detectable but has decreased by more than 2 log(10) 12 weeks after the start of the therapy, has not been elucidated sufficiently. The outcome in this group of patients was investigated. Serum HCV RNA levels was measured every 4 weeks in 149 patients with HCV genotype 1b infection who underwent combination therapy for 48 weeks. In patients with partial early virologic response, the time point when serum HCV RNA became undetectable as well as the final virologic response to treatment was determined. Sixty-three patients (42.3%) had partial early virologic response. The time when serum HCV RNA became undetectable ranged from 16 to 48 weeks after the start of therapy. Serum HCV RNA remained detectable in 17 patients. The rates of sustained virologic response decreased with the delay of the time when serum HCV RNA became undetectable; sustained virologic responder was not found in patients in whom HCV RNA was still detectable at 24 weeks after the start of treatment. The degree of decrease in serum HCV RNA levels at 12 weeks corresponded to the rate of sustained virologic response in partial early virologic responders. The outcome of partial early virologic responders varied greatly, and close monitoring of serum HCV RNA is required for predicting the outcome of treatment in these patients.

Hepatitis C virus‐specific CD8+ T cell frequencies are associated with the responses of pegylated interferon‐α and ribavirin combination therapy in patients with chronic hepatitis C virus infection

Hepatitis C virus (HCV)-specific cytotoxic T lymphocytes (CTLs) play critical roles in elimination of the HCV-infected hepatocytes. However, the mechanism of HCV elimination by pegylated interferon-α (peg-IFNα) plus ribavirin is not fully understood. We examined HCV-specific CTL responses during this combination therapy. CD8+ T cells were isolated from 16 HCV infected patients treated by this combination therapy and were subjected to IFN-γ enzyme-linked immunospot (ELISPOT) assay. The numbers of IFN-γ spots against HCV Core or NS3 protein-derived peptides in HCV patients before treatment were similar to those in healthy donors, and those in HCV patients significantly increased 4 weeks after the initiation of combination therapy. All HCV Core or NS3 proteins-derived peptides specific CD8+ T cells responses in pre-treated patients were not associated with ALT levels and HCV viral loads of HCV patients before treatment. And those in pre-treated patients were similar between sustained virologic responder (SVR) patients and non-SVR patients. Significant increase of HCV Core or NS3 proteins-derived peptides specific CD8+ T cells responses between before and 4 weeks after this combination therapy were observed in SVR patients, but not in non-SVR patients. These results demonstrated that significant increase of HCV-specific CD8+ T cells at 4 weeks after the initiation of IFN treatment might be associated with the elimination of HCV. Our findings suggest that the reactivity against HCV Core and NS3 proteins-derived peptides might be useful in predicting the clinical outcome of the combination therapy of peg-IFNα and ribavirin.

Identification of Treatment Efficacy-Related Host Factors in Chronic Hepatitis C by ProteinChip Serum Analysis

Recent development of proteomic array technology, including protein profiling coupling ProteinChip array with surface-enhanced laser desorption ionization time-of-flight mass spectrometry (SELDI-TOF/MS), provides a potentially powerful tool for discovery of new biomarkers by comparison of its profiles according to patient phenotypes. We used this approach to identify the host factors associated with treatment response in patients with chronic hepatitis C (CHC) receiving a 48-wk course of pegylated interferon (PEG-IFN) alpha 2b plus ribavirin (RBV). Protein profiles of pretreatment serum samples from 32 patients with genotype 1b and high viral load were conducted by SELDI-TOF/MS by using the three different ProteinChip arrays (CM10, Q10, IMAC30). Proteins showed significantly different peak intensities between sustained virological responders (SVRs), and non-SVRs were identified by chromatography, SDS-PAGE, TOF/MS and tandem mass spectrometry (MS/MS) assay. Eleven peak intensities were significantly different between SVRs and non-SVRs. The three SVR-increased peaks could be identified as two apolipoprotein (Apo) fragments and albumin and, among the eight non-SVR-increased proteins, four peaks identified as two iron-related and two fibrogenesis-related protein fragments, respectively. Multivariate analysis showed that the serum ferritin and three peak intensity values (Apo A1, hemopexin and transferrin) were independent variables associated with SVRs, and the area under the receiver operating characteristic (ROC) curves for SVR prediction by using the Apo A1/hemopexin and hemopexin/transferrin were 0.964 and 0.936. In conclusion, pretreatment serum protein profiling by SELDI-TOF/MS is variable for identification of response-related host factors, which are useful for treatment efficacy prediction in CHC receiving PEG-IFN plus RBV. Our data also may help us understand the mechanism for treatment resistance and development of more effective antiviral therapy targeted toward the modulation of lipogenesis or iron homeostasis in CHC patients.

Hepatitis C virus: Up to the minute

Key Points 1. Hepatitis C virus reinfection is almost universal in patients who are polymerase chain reaction–positive at the time of transplantation, and it significantly impairs patient and graft survival. 2. The virus infects the graft a few hours after transplantation and leads within weeks to a viral load higher than the pretransplant levels; this is associated with an accelerated progression to cirrhosis, graft loss, and death. 3. Multiple host, donor, and viral factors are associated with rapid fibrosis progression: high pretransplant and posttransplant viral loads, severe early histological recurrence, more potent immunosuppression and treatment of rejection episodes, cytomegalovirus or human immunodeficiency virus coinfections, and increasing donor age. 4. Annual protocol biopsy, noninvasive fibrosis evaluation, or both are recommended to evaluate fibrosis progression and determine the time for antiviral therapy. 5. Pretransplant antiviral therapy may reduce or eliminate the risk of recurrent infection. However, this approach is limited because of side effects and a risk of complications in decompensated patients. 6. Preemptive therapy early after transplantation is less effective because of the high level of immunosuppression and is limited by low applicability and poor tolerance. 7. The treatment of established graft lesions with a therapy combining pegylated interferon and ribavirin yielded promising results, and a sustained virological response was achieved in approximately 30% of the patients. Sustained virological responders experienced long-term beneficial effects with respect to fibrosis progression and graft and patient survival. Variables associated with a sustained virological response include the following: non-1 genotype, absence of previous antiviral therapy, early virological response, adherence to therapy, and low pretreatment viral load. However, antiviral therapy is limited by the frequent need for dose reductions or discontinuation and a low risk of acute or chronic rejection and autoimmune-like hepatitis. 8. Patients infected with hepatitis C virus before and after transplantation are those who will benefit the most from new classes of direct antiviral agents. Liver Transpl 16:S26-S35, 2010. © 2010 AASLD.

Angiogenic Cytokines in Patients Undergoing Antiviral Treatment for Chronic Hepatitis C Virus Infection

During chronic liver disease (CLD), angiogenesis participates in the fibrogenic process. Herein, we aimed at verifying the on-treatment kinetics of serum vascular endothelial growth factor (VEGF) and angiopoietin-2 (Ang-2) in hepatitis C virus (HCV) patients undergoing antiviral therapy. Forty-three HCV patients treated with pegylated-interferon/ribavirin and 26 controls were studied. Serum VEGF and Ang-2 were determined before treatment, at different time points during treatment, and at follow-up after treatment. Thirty and 13 patients were sustained virological responder (SVR) and No-SVR, respectively. Patients showed increased Ang-2 levels [504 (368-720) versus 449 (389-483) pg/mL, P < 0.05], and equivalent VEGF levels [271 (193-377) versus 274 (199-324) pg/mL, P = 0.6], with respect to controls. By univariate analysis, stage of fibrosis was associated with Ang-2 levels (odds ratio 4.25, P < 0.05). In SVR patients VEGF levels showed a progressive reduction (P < 0.05) but returned to pretherapy levels at follow-up, and Ang-2 levels showed an opposite progressive increase, being significantly reduced at follow-up (P < 0.01). No significant modifications in VEGF and Ang-2 levels were observed in No-SVR. We conclude that, in patients with HCV-CLD, Ang-2 serum levels are associated with fibrosis and reduced at follow-up in SVR patients. On-treatment, VEGF and Ang-2 serum levels undergo different-sided modifications only in SVR patients, possibly expressing the vascular remodeling occurring early after viral clearance.

Tumor Necrosis Factor Receptor 1 Expression Is Upregulated in Dendritic Cells in Patients with Chronic HCV Who Respond to Therapy

The present studies assessed the level of tumor necrosis factor receptor (TNFR) expression in peripheral blood mononuclear cells (PBMCs) subsets from patients with chronic HCV undergoing interferon α/ribavirin-based therapy (Ifn/R). Methods. TNFR family member mRNA expression was determined using quantitative real-time PCR assays (RTPCRs) in PBMC from 39 HCV+ patients and 21 control HCV− patients. Further subset analysis of HCV + patients (untreated (U), sustained virological responders (SVR), and nonresponders (NR)/relapsers (Rel)) PBMC was performed via staining with anti-CD123, anti-CD33, anti-TNFR1 or via RTPCR for TNFR1 mRNA. Results. A similar level of TNFR1 mRNA in PBMC from untreated HCV+ genotype 1 patients and controls was noted. TNFR1 and TNFR2 mRNA levels in PBMC from HCV+ patients with SVR were statistically different than levels in HCV(−) patients. A significant difference was noted between the peak values of TNFR1 of the CD123+ PBMC isolated from SVR and the NR/Rel. Conclusion. Upregulation of TNFR1 expression, occurring in a specific subset of CD123+ dendritic cells, appeared in HCV+ patients with SVR.

Fibrosis Progression and the Pros and Cons of Antiviral Therapy for Hepatitis C Virus Recurrence After Liver Transplantation: A Review

The progression of fibrosis due to hepatitis C virus (HCV) recurrence after liver transplantation (OLT) is faster than in the pretransplant setting, leading to histologically documented cirrhosis within 5 years in 25% to 30% of cases. Whether it is associated with biliary complications or previous alcohol abuse, recurrent HCV is the main cause of graft failure and death after OLT. The most important donor risk factor for HCV recurrence is advanced donor age. The disease's course is even more aggressive if it is associated with anti-HCV positivity or graft steatosis. The type of calcineurin inhibitor does not seem to influence HCV recurrence. Avoiding or slowly tapering steroids has been associated with less disease recurrence, while steroid pulses to treat acute rejection episodes have been associated with a worse progression of fibrosis. Antiviral therapy (AT) is not always recommended in OLT patients, but is of some benefit. Fibrosis has been shown to ameliorate in sustained virological responders to AT and to progress significantly more in nonresponders. Using long-term maintenance, AT has recently been shown to increase the probability of biochemical and histological responses, regardless of the timing of the HCV recurrence. In conclusion, the donor- recipient match should be assessed to limit HCV recurrences and their severity; AT is recommended to reduce or reverse the progression of fibrosis.

Does chemotherapy prevent HCV-related hepatocellular carcinoma? Cons

The accuracy and the reliability of well-recognized clinical, virologic, histologic, and molecular risk factors for hepatocellular carcinoma (HCC) are still insufficient. Thus, accurate risk prediction of cancer development in individual patients with the aim of selecting high risk cohorts of patients for HCC chemoprevention programs remains an elusive goal. Future directions in chemoprevention of HCC will be in the development of molecular risk models and of new chemopreventive agents. Studies examining multiple genes and proteins (genomics and proteomics) in the same HCCs will be required to evaluate this possibility thoroughly. A strategy aiming at preventing chronic liver disease of any etiology (HCV and HBV infection, alcohol, obesity, others) may be required to prevent HCC in low and intermediate incidence areas, and hence, worldwide. In the setting of secondary chemoprevention, literature data pooling suggests a slight preventive effect of interferon (IFN) on HCC development in patients with HCV-related cirrhosis. The magnitude of this effect is low, and the observed benefit might be due to spurious associations. The preventive effect is limited to sustained virological responders to IFN. So, there is no sound evidence to support a recommendation for widespread use of IFN to prevent HCC in HCV-related cirrhosis. In the setting of tertiary chemoprevention, the risk of recurrence of HCC may be reduced by IFN treatment in selected patient populations. Further large-scale multicenter randomized controlled trials may prove useful to evaluate the benefit on overall survival.

Effect of IFN therapy and amino acid substitutions in the hepatitis C virus (HCV) core region on hepatocarcinogenesis in HCV-related cirrhotic patients.

4009 Background: Although some reports have shown that interferon (IFN) can reduce the hepatocarcinogenesis in HCV-related noncirrhotic and cirrhotic patients through reduction or complete remission of inflammatory activity, the effect of IFN therapy without anti-inflammation has not been clear. In patients with HCV genotype 1b(HCV-1b), amino acid (aa) substitutions in hepatitis C virus core region (HCVCR) are negative predictors of virologic response to pegylated interferon plus ribavirin and they may be one of the important predictors of hepatocarcinogenesis. Then, the purpose of this study is to evaluate the effect of IFN therapy and aa substitutions in HCVCR on the carcinogenesis in HCV-related cirrhotic patients. Methods: The hepatocellular carcinogenesis rate was analyzed statistically in 1,015 patients with cirrhosis C: 268 with IFN therapy and 747 without IFN therapy. HCV genotyping was performed in 818 patients. As for HCV-1b, aa substitution was measured using the PCR Method with mutation-specific primer as an alternative to the direct sequencing method. Results: Hepatocarcinogenesis rates in sustained virological responder (SVR), biochemical responder (BR), non responder (NR) and untreated groups were 29%, 38%, 54% and 57% at the end of the tenth year. The carcinogenesis rate in SVR/BR is lower than that in untreated group. As for male patients with Child-Pugh A, the carcinogenesis rate in NR group is lower than that in untreated group (p = 0.058). The carcinogenesis rate in NR patients who received IFN therapy for 3 years or longer was lower than that in NR patients who received shorter IFN therapy (p = 0.030). Multivariate analysis showed that the risk of carcinogenesis was decreased to 0.52 (p = 0.003) and 0.53 (p = 0.012) in SVR/BR and in NR with 3 years or longer IFN therapy, respectively. In patients with HCV-1b, the hazard ratio of non-double wild aa in core region was 2.01 (p < 0.0001). Conclusions: IFN therapy should be continued in HCV-related cirrhotic patients as long as possible, because IFN therapy of 3 years or longer can suppress the hepatocarcinogenesis even when either HCV RNA clearance or ALT normalization cannot be observed. No significant financial relationships to disclose.

Outcome of Sustained Virological Responders With Histologically Advanced Chronic Hepatitis C†,‡,§,¶

Retrospective studies suggest that subjects with chronic hepatitis C and advanced fibrosis who achieve a sustained virological response (SVR) have a lower risk of hepatic decompensation and hepatocellular carcinoma (HCC). In this prospective analysis, we compared the rate of death from any cause or liver transplantation, and of liver-related morbidity and mortality, after antiviral therapy among patients who achieved SVR, virologic nonresponders (NR), and those with initial viral clearance but subsequent breakthrough or relapse (BT/R) in the HALT-C (Hepatitis C Antiviral Long-Term Treatment Against Cirrhosis) Trial. Laboratory and/or clinical outcome data were available for 140 of the 180 patients who achieved SVR. Patients with nonresponse (NR; n = 309) or who experienced breakthrough or relapse (BT/R; n = 77) were evaluated every 3 months for 3.5 years and then every 6 months thereafter. Outcomes included death, liver-related death, liver transplantation, decompensated liver disease, and HCC. Median follow-up for the SVR, BT/R, and NR groups of patients was 86, 85, and 79 months, respectively. At 7.5 years, the adjusted cumulative rate of death/liver transplantation and of liver-related morbidity/mortality in the SVR group (2.2% and 2.7%, respectively) was significantly lower than that of the NR group (21.3% and 27.2%, P < 0.001 for both) but not the BT/R group (4.4% and 8.7%). The adjusted hazard ratio (HR) for time to death/liver transplantation (HR = 0.17, 95% confidence interval [CI] = 0.06-0.46) or development of liver-related morbidity/mortality (HR = 0.15, 95% CI = 0.06-0.38) or HCC (HR = 0.19, 95% CI = 0.04-0.80) was significant for SVR compared to NR. Laboratory tests related to liver disease severity improved following SVR. Patients with advanced chronic hepatitis C who achieved SVR had a marked reduction in death/liver transplantation, and in liver-related morbidity/mortality, although they remain at risk for HCC.

Impairment of TLR7-Dependent Signaling in Dendritic Cells from Chronic Hepatitis C Virus (HCV)-Infected Non-responders to Interferon/Ribavirin Therapy

Dendritic cell (DC) dysfunction has been suggested to play a role in the weak antiviral T-cell responsiveness observed during the course of chronic hepatitis C virus (HCV) infection. This study was undertaken to evaluate whether changes in DC functions might be related to a different therapeutic outcome in HCV-infected patients. Peripheral blood DCs (PBDCs) or monocyte-derived DCs (MoDCs) were obtained from chronic HCV-infected patients, sustained virologic responders (SVR) or non-responders (NR) to interferon/ribavirin therapy, and from healthy controls (HC). The frequency of BDCA-1+, BDCA-3+ or CD16+ myeloid DCs (mDCs) and BDCA-2+ plasmacytoid DCs (pDCs), as well as the expression of the costimulatory molecule CD86 in each PBDC subset, were evaluated by flow cytometry. MoDCs from single individuals were stimulated with TLR2, TLR3, TLR4, and TLR7 ligands and analyzed for CD86, CD83, CD40, CD80, and CD209 expression. Finally, mitogen-activated protein kinase (MAPK) phosphorylation of TLR7-triggered MoDCs was assessed by Western blotting. NR exhibited a reduced percentage of BDCA-1+ mDCs, as well as lower levels of CD86+ cells, in both BDCA-1+ mDCs and pDCs as compared to SVR and HC. Furthermore, MoDCs from NR displayed a defective CD86 and CD83 increase and ERK1/2 or p38-MAPK phosphorylation upon TLR7-cell triggering. Our data suggest that a TLR7-dependent impairment of costimulatory molecule expression caused by HCV persistence may affect DC activity in NR patients.

Prevalence and impact of occult hepatitis B infection in chronic hepatitis C patients treated with pegylated interferon and ribavirin

The prevalence of occult hepatitis B, defined by absence of HBsAg and HBV DNA, ranges widely in patients with hepatitis C. This may influence the treatment of hepatitis C and the severity of liver disease. Sensitive and specific real-time PCR techniques are available commercially and can detect more reliably low HBV DNA levels. The aim of this study was to determine the prevalence of occult hepatitis B virus infection using the COBAS Taqman assay (Roche Diagnostics, Meylan, France) in the serum and liver of HBsAg negative patients with chronic hepatitis C and to evaluate its clinical consequences on liver pathology and its impact on the response to treatment with peg-IFNalpha and Ribavirin. HBV DNA detection was assessed retrospectively on 140 sera and 113 liver biopsies of HCV positive/HBsAg negative patients before treatment. A 4.4% (5/113) prevalence of occult hepatitis B was recorded in liver samples and in none of the sera. Anti-HBc was not detected in one, three of whom were sustained virological responders to treatment, one was relapsed responder and one was non-responder. Furthermore, in this cohort composed of 12% anti-HBs negative/anti-HBc positive and 20% anti-HBs positive/anti-HBc positive patients, anti-HBc was not associated with pre-therapeutic viral load, ALT serum levels, and histological activity or fibrosis. Using a commercial real-time PCR assay, we observed a low prevalence of occult B hepatitis. This, just as anti-HBC status, had no clinical impact in a large cohort of hepatitis C patients. It therefore does not appear useful to screen for occult hepatitis B in these patients with this test before beginning HCV treatment.

Genetic diversity of NS5A protein from hepatitis C virus genotype 3a and its relationship to therapy response

BackgroundThe quasispecies nature of HCV may have important implications for viral persistence, pathogenicity and resistance to antiviral agents. The variability of one of the viral proteins, NS5A, is believed to be related to the response to IFN therapy, the standard treatment for infection. In this study we analyzed the quasispecies composition of NS5A protein in patients infected with HCV genotype 3a, before IFN therapy.MethodsViral RNA was isolated from samples of 12 patients: four sustained virological responders (SVR), four non-responders (NR), and four end-of-treatment responders (ETR). cDNA was synthesized, the NS5A region was amplified and the fragments obtained were cloned. Fifteen clones from each patient were sequenced with eight primers, generating 179 contigs.ResultsHigher values for substitution (either synonymous or non-synonymous) and for distance were found in the SVR group. However, the NR group showed relatively more non-synonymous mutations than the other groups, owing to the higher values of dN/dS in complete NS5A and most specific regions. Overall, NS5A protein is undergoing purifying selection, since all dN/dS ratios values are below 0.5.ConclusionsOur study provides an overview of the genetic variability of complete NS5A protein in HCV genotype 3a.

Natural killer cell receptor and HLA-C gene polymorphisms among patients with hepatitis C: a comparison between sustained virological responders and non-responders

Killer cell immunoglobulin-like receptors (KIR) are involved in the activation/inhibition of NK cells through an interaction with HLA class I molecules on target cells. Our study aimed to evaluate the association between KIR gene polymorphisms and the response of patients with CHC to antiviral therapy. We compared the frequency of KIR genes, as well as that of compound KIR/HLA-C genotypes, between groups of patients with CHC who presented a sustained virological response (n=66) and who were non-responders to a combination of pegylated or standard interferon and ribavirin (n=101). KIR and HLA-C genotyping were performed using commercial kits. We detected a greater frequency of the KIR2DL5 gene among non-responders to antiviral therapy compared with sustained virological responders (68.3 vs. 40.9%) (P<0.001). We used multiple logistic regression analysis to determine the association between therapy response and the presence of KIR2DL5, after a control for potentially confounding variables (genotype, alcohol, fibrosis, gender, age, ethnic background and route of HCV infection). The results confirmed the strong association between the presence of KIR2DL5 and the non-response to antiviral treatment (P=0.001). Host genetic factors may be associated with a non-response to antiviral therapy. KIR2DL5 is a candidate gene involved in immunomodulation associated with non-response to antiviral therapy.