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Blackard JT, Sherman KE. Hepatitis B virus (HBV) reactivation-The potential role of direct-acting agents for hepatitis C virus (HCV). Rev Med Virol 2018; 28:e1984. [PMID: 29761585 PMCID: PMC6233878 DOI: 10.1002/rmv.1984] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 12/16/2022]
Abstract
Hepatitis C virus (HCV) is known to inhibit hepatitis B virus (HBV) replication in patients with HBV/HCV coinfection. Reactivation of HBV in patients treated for HCV with direct-acting agents (DAAs) has emerged recently as an important clinical consideration. A growing number of case reports and case series support the association between new HCV treatments and HBV reactivation. Yet, very little is known about the specific viral characteristics that facilitate reactivation as functional characterization of the reactivated HBV has been conducted only rarely. This review provides the most recent data on HBV reactivation in the context of DAA initiation and highlights the existing viral genomic data from reactivating viruses. Current functional studies of HBV reactivation are largely limited by the retrospective identification of cases, no standardization of genomic regions that are studied with respect to HBV reactivation, and the lack of inclusion of nonreactivating controls to establish specific viral mutations that are associated with HBV reactivation. Importantly, none of these sequencing studies included cases of HBV reactivation after initiation of DAAs. While new HCV treatments have revolutionized care for HCV infected patients, HBV reactivation will likely increase in frequency, as DAAs are more commonly prescribed. Pretreatment determination of HBV status and thoughtful management of HBV coinfections will be necessary and lead to improved patient safety and yield optimal treatment results.
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Affiliation(s)
- Jason T Blackard
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kenneth E Sherman
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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2
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Chen J, Liu Y, Zhao J, Xu Z, Chen R, Si L, Lu S, Li X, Wang S, Zhang K, Li J, Han J, Xu D. Characterization of Novel Hepatitis B Virus PreS/S-Gene Mutations in a Patient with Occult Hepatitis B Virus Infection. PLoS One 2016; 11:e0155654. [PMID: 27182775 PMCID: PMC4868315 DOI: 10.1371/journal.pone.0155654] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 05/02/2016] [Indexed: 12/19/2022] Open
Abstract
Objective The impact of hepatitis B virus (HBV) preS/S-gene mutations on occult HBV infection (OBI) is not fully understood. This study characterized multiple novel HBV preS/S-gene mutants obtained from an OBI patient. Methods PreS/S-gene mutants were analyzed by clonal sequencing. Viral replication and expression were analyzed by transfecting HBV genomic recombinants into HepG2 cells. Results Twenty-one preS/S-gene mutants were cloned from four sequential serum samples, including 13 mutants that were not previously documented: (1) sI/T126V+sG145R; (2) preS1 nt 3014−3198 deletion; (3) preS1 nt 3046−3177 deletion; (4) preS1 nt 3046−3177 deletion+s115−116 “INGTST” insertion; (5) preS1 nt 3046−3177 deletion+s115−116 “INGTST” insertion+sG145R; (6) preS1 nt 3115−3123 deletion+sQ129N; (7) preS1 nt 3115−3123 deletion+s126−127 “RPCMNCTI” insertion; (8) s115−116 “INGTST” insertion; (9) s115−116 “INGTST” insertion+sG145R; (10) s126−127 “RPCMNCTI” insertion; (11) preS1 nt 2848−2862 deletion+preS2 initiation codon M→I; (12) s122−123 “KSTGLCK” insertion+sQ129N; and (13) preS2 initiation codon M→I+s131−133TSM→NST. The proportion of preS1 nt 3046−3177 deletion and preS2 initiation codon M→I+s131−133TSM→NST mutants increased in the viral pool with prolonged disease. The 13 novel OBI-related mutants showed a 51.2−99.9% decrease in HBsAg levels compared with that of the wild type. Additional N-glycosylation-associated mutations, sQ129N and s131−133TSM→NST, but not s126−127 “RPCMNCTI,” greatly attenuated anti-HBs binding to HBsAg. Compared with the wild type, replication and surface antigen promoter II activity of the preS1 nt 3046−3177 deletion mutant decreased by 43.3% and 97.0%, respectively. Conclusion PreS/S-gene mutations may play coordinated roles in the presentation of OBI and might be associated with disease progression. This has implications for HBV diagnosis and vaccine improvement.
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Affiliation(s)
- Jianhong Chen
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Yan Liu
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Jun Zhao
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Zhihui Xu
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Rongjuan Chen
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Lanlan Si
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Shanshan Lu
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Xiaodong Li
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Shuai Wang
- Department of liver disease, General Hospital of Beijing Military Region, Beijing 100700, China
| | - Kai Zhang
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Jin Li
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Juqiang Han
- Department of liver disease, General Hospital of Beijing Military Region, Beijing 100700, China
- * E-mail: (DX); (JH)
| | - Dongping Xu
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
- * E-mail: (DX); (JH)
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Zhang ZH, Wu CC, Chen XW, Li X, Li J, Lu MJ. Genetic variation of hepatitis B virus and its significance for pathogenesis. World J Gastroenterol 2016; 22:126-144. [PMID: 26755865 PMCID: PMC4698480 DOI: 10.3748/wjg.v22.i1.126] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 11/13/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B virus (HBV) has a worldwide distribution and is endemic in many populations. Due to its unique life cycle which requires an error-prone reverse transcriptase for replication, it constantly evolves, resulting in tremendous genetic variation in the form of genotypes, sub-genotypes, and mutations. In recent years, there has been considerable research on the relationship between HBV genetic variation and HBV-related pathogenesis, which has profound implications in the natural history of HBV infection, viral detection, immune prevention, drug treatment and prognosis. In this review, we attempted to provide a brief account of the influence of HBV genotype on the pathogenesis of HBV infection and summarize our current knowledge on the effects of HBV mutations in different regions on HBV-associated pathogenesis, with an emphasis on mutations in the preS/S proteins in immune evasion, occult HBV infection and hepatocellular carcinoma (HCC), mutations in polymerase in relation to drug resistance, mutations in HBV core and e antigen in immune evasion, chronicalization of infection and hepatitis B-related acute-on-chronic liver failure, and finally mutations in HBV x proteins in HCC.
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Tsutsumi Y, Yamamoto Y, Ito S, Ohigashi H, Shiratori S, Naruse H, Teshima T. Hepatitis B virus reactivation with a rituximab-containing regimen. World J Hepatol 2015; 7:2344-2351. [PMID: 26413224 PMCID: PMC4577642 DOI: 10.4254/wjh.v7.i21.2344] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/27/2015] [Accepted: 09/08/2015] [Indexed: 02/06/2023] Open
Abstract
Rituximab is currently used not only in the treatment of B-cell lymphoma but also for various other diseases, including autoimmune diseases, post-transplant graft vs host disease, and rejection following kidney transplants. Due to rituximab’s widespread use, great progress has been made regarding research into complications that arise from its use, one of the most serious being the reactivation of hepatitis B virus (HBV), and efforts continue to establish guidelines for preventive treatment against this occurrence. This report discusses preventive measures against rituximab-induced HBV reactivation and future objectives.
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Civan J, Hann HW. Giving rituximab in patients with occult or resolved hepatitis B virus infection: are the current guidelines good enough? Expert Opin Drug Saf 2015; 14:865-75. [PMID: 25826452 DOI: 10.1517/14740338.2015.1032243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Hepatitis B virus (HBV) reactivation after 'resolved' infection can occur in the setting of immunosuppression, including iatrogenically induced by anti-CD20 antibodies. The presence of antibodies against the HBV core antigen (anti-HBc) is a marker of risk for this phenomenon. The risk of this occurring in patients with circulating HBV surface antigen (HBsAg) is well characterized, but is less well characterized in patients who are HBsAg negative. AREAS COVERED This article reviews the literature regarding HBV reactivation in the context of rituximab therapy. We have limited our review to HBsAg-negative patients, and clinical outcomes following HBV reactivation. EXPERT OPINION We have recommended prophylactic anti-viral therapy for all HBsAg-negative/anti-HBc-positive patients undergoing rituximab therapy in combination with other immunosuppressive therapy.
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Affiliation(s)
- Jesse Civan
- Thomas Jefferson University, Division of Gastoenterology and Hepatology, Department of Medicine , Philadelphia, PA 19107 , USA
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Gutiérrez García ML, Alonso Lopez S, Martín Rios MD, Sanmartin Fenollera P, Agudo Fernandez S, Fernández Rodriguez CM. Reactivación del virus de la hepatitis B en pacientes tratados con rituximab: incidencia y factores de riesgo. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:1-6. [DOI: 10.1016/j.gastrohep.2014.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 05/16/2014] [Accepted: 05/24/2014] [Indexed: 12/13/2022]
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Powell EA, Gededzha MP, Rentz M, Rakgole NJ, Selabe SG, Seleise TA, Mphahlele MJ, Blackard JT. Mutations associated with occult hepatitis B in HIV-positive South Africans. J Med Virol 2014; 87:388-400. [PMID: 25164924 DOI: 10.1002/jmv.24057] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2014] [Indexed: 12/16/2022]
Abstract
Occult hepatitis B is characterized by the absence of hepatitis B surface antigen (HBsAg) but the presence of HBV DNA. Because diagnosis of hepatitis B virus (HBV) typically includes HBsAg detection, occult HBV remains largely undiagnosed. Occult HBV is associated with increased risk of hepatocellular carcinoma, reactivation to chronic HBV during immune suppression, and transmission during blood transfusion and liver transplant. The mechanisms leading to occult HBV infection are unclear, although viral mutations are likely a significant factor. In this study, sera from 394 HIV-positive South Africans were tested for HBV DNA and HBsAg. For patients with detectable HBV DNA, the overlapping surface and polymerase open reading frames (ORFs) were sequenced. Occult-associated mutations-those mutations found exclusively in individuals with occult HBV infection but not in individuals with chronic HBV infection from the same cohort or GenBank references-were identified. Ninety patients (22.8%) had detectable HBV DNA. Of these, 37 had detectable HBsAg, while 53 lacked detectable surface antigen. The surface and polymerase ORFs were cloned successfully for 19 patients with chronic HBV and 30 patients with occult HBV. In total, 235 occult-associated mutations were identified. Ten occult-associated mutations were identified in more than one patient. Additionally, 15 amino acid positions had two distinct occult-associated mutations at the same residue. Occult-associated mutations were common and present in all regions of the surface and polymerase ORFs. Further study is underway to determine the effects of these mutations on viral replication and surface antigen expression in vitro.
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Affiliation(s)
- Eleanor A Powell
- Division of Digestive Disease, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Viganò M, Mangia G, Lampertico P. Management of patients with overt or resolved hepatitis B virus infection undergoing rituximab therapy. Expert Opin Biol Ther 2014; 14:1019-31. [DOI: 10.1517/14712598.2014.912273] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Tsutsumi Y, Yamamoto Y, Shimono J, Ohhigashi H, Teshima T. Hepatitis B virus reactivation with rituximab-containing regimen. World J Hepatol 2013; 5:612-620. [PMID: 24303089 PMCID: PMC3847944 DOI: 10.4254/wjh.v5.i11.612] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
Rituximab is recognized as a useful drug for the treatment of B-cell non-Hodgkin’s lymphoma and its use has been extended to such diseases as idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, chronic rheumatoid arthritis and ANCA-associated vasculitides. One serious complication associated with its use is the reactivation of hepatitis B virus and the search for methods to prevent this occurrence has resulted in the rapid accumulation of knowledge. In this review, we discuss case analyses from our department and other groups and outline the current knowledge on the topic and the remaining issues.
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Feeney SA, McCaughey C, Watt AP, Agnaf MRE, McDougall N, Wend UC, Gerlich WH, Coyle PV. Reactivation of occult hepatitis B virus infection following cytotoxic lymphoma therapy in an anti-HBc negative patient. J Med Virol 2013; 85:597-601. [DOI: 10.1002/jmv.23513] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2012] [Indexed: 12/18/2022]
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Martin CM, Welge JA, Rouster SD, Shata MT, Sherman KE, Blackard JT. Mutations associated with occult hepatitis B virus infection result in decreased surface antigen expression in vitro. J Viral Hepat 2012; 19:716-23. [PMID: 22967103 PMCID: PMC3442934 DOI: 10.1111/j.1365-2893.2012.01595.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Occult hepatitis B virus (HBV) infection is characterized by the absence of detectable hepatitis B surface antigen (HBsAg) in the serum, despite detectable HBV DNA. Investigations of the mechanisms underlying the development of occult HBV infection are lacking in the current literature, although viral mutations in the surface region, resulting in decreased HBsAg expression or secretion, represent one potential mechanism. Wild-type HBsAg expression vectors were constructed from genotype-matched chronic HBV sequences. Site-directed mutagenesis was then utilized to introduce three genotype A mutations - M103I, K122R and G145A - associated with occult HBV infection in vivo, alone and in combination, into the wild-type HBsAg vectors. Transfection of Huh7 and HepG2 cell lines was performed, and cell culture supernatants and cell lysates were collected over 7 days to assess the effects of these mutations on extracellular and intracellular HBsAg levels. The G145A mutation resulted in significantly decreased extracellular and intracellular HBsAg expression in vitro. The most pronounced reduction in HBsAg expression was observed when all three mutations were present. The mutations evaluated in vitro in the current study resulted in decreased HBsAg expression and potentially increased hepatic retention and/or decreased hepatic secretion of synthesized HBsAg, which could explain the lack of HBsAg detection that is characteristic of occult HBV infection in vivo.
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Affiliation(s)
- Christina M. Martin
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH 45267
| | - Jeffrey A. Welge
- Departments of Psychiatry and Environmental Health, University of Cincinnati College of Medicine, Cincinnati, OH 45267
| | - Susan D. Rouster
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH 45267
| | - Mohamed Tarek Shata
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH 45267
| | - Kenneth E. Sherman
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH 45267
| | - Jason T. Blackard
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH 45267, Address requests for reprints to: Jason Blackard, PhD Division of Digestive Diseases University of Cincinnati College of Medicine ML 0595, 231 Albert Sabin Way Cincinnati, OH 45267 Phone: (513) 558-4389 Fax: (513) 558-1744
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12
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Yong-Lin Y, Qiang F, Ming-Shun Z, Jie C, Gui-Ming M, Zu-Hu H, Xu-Bing C. Hepatitis B surface antigen variants in voluntary blood donors in Nanjing, China. Virol J 2012; 9:82. [PMID: 22500577 PMCID: PMC3342217 DOI: 10.1186/1743-422x-9-82] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 04/14/2012] [Indexed: 02/06/2023] Open
Abstract
Background Hepatitis B virus (HBV) is still one of the serious infectious risks for the blood transfusion safety in China. One plausible reason is the emergence of the variants in the major antigenic alpha determinant within the major hydrophilic region (MHR) of hepatitis B surface antigen (HBsAg), which have been assumed to evade the immune surveillance and pose a challenge to the disease diagnosis. It is well documented that some commercial ELISA kits could detect the wild-type but not the mutant viruses. The high prevalence of HBV in China also impaired the application of nucleic acid testing (NAT) in the improvement of blood security. Molecular epidemiological study of HBsAg variations in China is still limited. This study was designed to identify the prevalence of mutations in the HBsAg in voluntary blood donors in Nanjing, China. Methods A total of 20,326 blood units were enrolled in this study, 39 donors were positive for HBV S gene in the nested-PCR. Mutations in the major hydrophilic region (MHR; aa 99-169) were identified by direct sequencing of S region. Results Among of 20,326 blood units in the Red Cross Transfusion Center of Nanjing from October 2008 to April 2009, 296 samples (1.46%, 296/20,326) were HBsAg positive in the 2 successive rounds of the ELISA test. In these HBsAg positive units, HBV S gene could be successfully amplified from 39 donors (13.18%, 39/296) in the nested-PCR. Sequence analysis revealed that 32 strains (82.1%, 32/39) belong to genotype B, 7 strains (17.9%, 7/39) to genotype C. Besides well known G145R, widely dispersed variations in the MHR of S region, were observed in 20 samples of all the strains sequenced. Conclusions HBV/B and HBV/C are dominant in Nanjing, China. The mutations in the MHR of HBsAg associated with disease diagnosis are common.
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Pei SN, Ma MC, Wang MC, Kuo CY, Rau KM, Su CY, Chen CH. Analysis of hepatitis B surface antibody titers in B cell lymphoma patients after rituximab therapy. Ann Hematol 2012; 91:1007-12. [PMID: 22273839 DOI: 10.1007/s00277-012-1405-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 01/03/2012] [Indexed: 12/14/2022]
Abstract
Hepatitis B virus (HBV) reactivation is a well-known complication after rituximab therapy in patients with B cell lymphoma. Traditionally, hepatitis B surface antibody (anti-HBs) is a protective antibody, but the effect of rituximab on these antibodies has not been well studied. In 29 B cell lymphoma patients who were positive for anti-HBs before rituximab therapy, anti-HBs serologies before and after rituximab therapy were compared. Anti-HBs titers after rituximab treatment were significantly lower (P < 0.001) than those before treatment. None of the ten cases with pre-treatment anti-HBs titers above 100 mIU/mL became negative for anti-HBs after rituximab therapy. In contrast, 8 of the 19 patients with pre-treatment anti-HBs titers below 100 mIU/mL lost their anti-HBs (P = 0.027). Of these, one patient developed HBsAg seroreversion and HBV reactivation after rituximab therapy. Regarding patients with loss of anti-HBs or not, there was no significant difference in pre- and post-treatment immunoglobulin G levels between both groups. The rate of anti-HBs loss increased with advanced lymphoma stage and international prognostic index (P = 0.002 and <0.001, respectively). Multiple logistic regression analysis showed that pre-treatment anti-HBs titer is the only independent factor influencing the loss of anti-HBs (per one log mIU/mL, odds ratio, 0.003; 95% confidence interval, 0.000-0.302; P = 0.014). In conclusion, we found that anti-HBs titers decreased significantly (P < 0.001) after rituximab treatment. B cell lymphoma patients with low pre-treatment anti-HBs titers (<100 mIU/mL) were more likely to lose anti-HBs antibodies and were at risk of HBV reactivation after rituximab immunochemotherapy.
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Affiliation(s)
- Sung-Nan Pei
- Division of Hema-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Tsutsumi Y, Yamamoto Y, Tanaka J, Asaka M, Imamura M, Masauzi N. Prevention of hepatitis B virus reactivation under rituximab therapy. Immunotherapy 2011; 1:1053-61. [PMID: 20635919 DOI: 10.2217/imt.09.59] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rituximab is a useful drug for the treatment of B-cell non-Hodgkin's lymphoma, and its use has been extended to other diseases such as idiopathic thrombocytopenic purpura and chronic rheumatoid arthritis. One serious complication associated with rituximab use is reactivation of hepatitis B virus, and the search for methods to prevent this occurrence has resulted in a rapid accumulation of knowledge in recent years. In this review, we will discuss case studies from our group, as well as other groups, and outline current knowledge on the topic together with issues that remain to be resolved.
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Affiliation(s)
- Yutaka Tsutsumi
- Department of Internal Medicine, Hakodate Municipal Hospital 1-10-1, Minato-cho, Hakodate 041-8680, Japan.
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15
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Rituximab administration and reactivation of HBV. HEPATITIS RESEARCH AND TREATMENT 2010; 2010:182067. [PMID: 21188195 PMCID: PMC3003947 DOI: 10.1155/2010/182067] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 09/03/2010] [Accepted: 09/29/2010] [Indexed: 12/11/2022]
Abstract
Rituximab is a drug used for the treatment of B-cell non-Hodgkin's lymphoma, and its range of use has expanded to the treatment of collagen diseases such as idiopathic thrombocytopenic purpura and rheumatoid arthritis. One serious complication of rituximab use is the reactivation of dormant hepatitis B virus, and prevention of this phenomenon has become an urgent issue. This paper provides a general outline of the problem through an analysis of patient cases that we and other groups have experienced to date.
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Evens AM, Jovanovic BD, Su YC, Raisch DW, Ganger D, Belknap SM, Dai MS, Chiu BCC, Fintel B, Cheng Y, Chuang SS, Lee MY, Chen TY, Lin SF, Kuo CY. Rituximab-associated hepatitis B virus (HBV) reactivation in lymphoproliferative diseases: meta-analysis and examination of FDA safety reports. Ann Oncol 2010; 22:1170-1180. [PMID: 21115603 DOI: 10.1093/annonc/mdq583] [Citation(s) in RCA: 254] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Rituximab has been associated with hepatitis B virus reactivation (HBV-R). However, the characteristics and scope of this association remain largely undefined. METHODS We completed a comprehensive literature search of all published rituximab-associated HBV-R cases and from the Food and Drug Administration (FDA) Adverse Event Reporting System (AERS) MedWatch database. Literature and FDA cases were compared for completeness, and a meta-analysis was completed. RESULTS One hundred and eighty-three unique cases of rituximab-associated HBV-R were identified from the literature (n = 27 case reports, n = 156 case series). The time from last rituximab to reactivation was 3 months (range 0-12), although 29% occurred >6 months after last rituximab. Within FDA data (n = 118 cases), there was a strong signal for rituximab-associated HBV-R [proportional reporting ratio = 28.5, 95% confidence interval (CI) 23.9-34.1; Empiric Bayes Geometric Mean = 26.4, 95% CI 21.4-31.1]. However, the completeness of data in FDA reports was significantly inferior compared with literature cases (P < 0.0001). Among HBV core antibody (HBcAb(+)) series, the pooled effect of rituximab-based therapy showed a significantly increased risk of HBV-R compared with nonrituximab-treated patients (odds ratio 5.73, 95% CI 2.01-16.33; Z = 3.33, P = 0.0009) without heterogeneity (χ(2) = 2.12, P = 0.5473). CONCLUSIONS The FDA AERS provided strong HBV-R safety signals; however, literature-based cases provided a significantly more complete description. Furthermore, meta-analysis of HBcAb(+) series identified a more than fivefold increased rate of rituximab-associated HBV-R.
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Affiliation(s)
- A M Evens
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA; Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University.
| | - B D Jovanovic
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA; Department of Preventive Medicine
| | - Y-C Su
- Division of Oncology, Dalin Tzu-Chi General Hospital, Chiayi, Taiwan
| | - D W Raisch
- Veterans Administration Cooperative Studies Program College of Pharmacy, University of New Mexico, Albuquerque, USA
| | - D Ganger
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA; Division of Hepatology
| | - S M Belknap
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA; Department of Internal Medicine
| | - M-S Dai
- Division of Hematology/Oncology, Tri-Service General Hospital, Taipei, Taiwan
| | - B-C C Chiu
- Department of Health Studies, Division of Epidemiology, The University of Chicago, Chicago, USA
| | - B Fintel
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA; Department of Internal Medicine
| | - Y Cheng
- Veterans Administration Cooperative Studies Program College of Pharmacy, University of New Mexico, Albuquerque, USA
| | - S-S Chuang
- Department of Pathology, Chi-Mei Medical Center, Tainan and Taipei Medical University, Taipei
| | - M-Y Lee
- Division of Oncology, Chia-Yi Christian Hospital, Chiayi
| | - T-Y Chen
- Division of Oncology, National Cheng Kung University Hospital, Tainan
| | - S-F Lin
- Faculty of Medicine and Division of Hematology & Oncology, Kaohsiung Medical University and Hospital, Kaohsiung
| | - C-Y Kuo
- Division of Hematology/Oncology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Variable influence of mutational patterns in reverse-transcriptase domain on replication capacity of hepatitis B virus isolates from antiviral-experienced patients. Clin Chim Acta 2010; 412:305-13. [PMID: 21056552 DOI: 10.1016/j.cca.2010.10.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 10/10/2010] [Accepted: 10/29/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND Various mutations in reverse-transcriptase domain (RT) of hepatitis B virus (HBV) polymerase may develop during antiviral therapy. The influence of these mutational patterns on HBV replication capacity remains to be fully clarified. METHODS Nine clones containing complete HBV genomes were isolated from 5 patients with chronic hepatitis B who had received antiviral treatment. Viral replication capacity was measured by quantitation of HBV replicative intermediates using vector-free transfer of paired mutant and wild-type HBV genomes into human hepatoma cell lines HepG2 and Huh7. HBV pgRNA was quantitated by real-time PCR and Southern blot analysis. RESULTS A real-time PCR assay with high sensitivity and small variation was developed for quantitation of HBV replicative intermediates. Compared to wild-type counterpart, mutant rtL217P produced 1.98-fold higher replicative intermediate level, and mutant rtM204I+rtL217P increased the replicative intermediate level to 1.20 fold. Other mutational patterns (rtV173M, rtA181S/V, rtM204I, rtQ215H, rtL229M, rtN238H, rtV84M+rtA181S+rtM204I, rtV84M+rtM204I, rtA181S+rtM204I, rtA181V+rtL229M, rtQ215H+rtN238H) reduced viral replication capacity to different extents. CONCLUSIONS The study offers a practical measurement assay and novel information for replication features of mutant strains; especially, rtL217P substitution likely represents an energetic replication-compensatory mutation.
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Cheung WI, Chan HLY, Leung VKS, Tse CH, Fung K, Lin SY, Wong A, Wong VWS, Chau TN. Reactivation of hepatitis B virus infection with persistently negative HBsAg on three HBsAg assays in a lymphoma patient undergoing chemotherapy. J Clin Virol 2009; 47:193-5. [PMID: 20031483 DOI: 10.1016/j.jcv.2009.11.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 10/04/2009] [Accepted: 11/24/2009] [Indexed: 10/20/2022]
Abstract
In patients with occult hepatitis B virus (HBV) infection, acute exacerbation may occur when they become immunocompromised. Usually, these patients develop hepatitis B surface antigen (HBsAg) seroreversion during the flare. Here we report on a patient with occult HBV infection, who developed HBV exacerbation after chemotherapy for diffuse large B-cell lymphoma. The resurgence of HBV DNA preceded the elevation of liver enzymes for 20 weeks. Atypically, despite high viraemia, serological tests showed persistently negative HBsAg using three different sensitive HBsAg assays (i.e., Architect, Murex and AxSYM). On comparing the amino acid sequence of the index patient with the consensus sequence, five mutations were found at pre-S1, five at pre-S2 and twenty-three mutations at the S region. Six amino acid mutations were located in the 'a' determinant, including P120T, K122R, M133T, F134L, D144A and G145A. The mutants K122R, F134L and G145A in our patient have not been tested for their sensitivity to Architect and Murex assays by the previous investigators and might represent the escape mutants to these assays.
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Affiliation(s)
- Wing-I Cheung
- Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong
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Ram R, Ben-Bassat I, Shpilberg O, Polliack A, Raanani P. The late adverse events of rituximab therapy--rare but there! Leuk Lymphoma 2009; 50:1083-95. [PMID: 19399690 DOI: 10.1080/10428190902934944] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Rituximab, an anti CD20 monoclonal antibody, has now become a cornerstone in the treatment of many CD20 positive hematological malignancies and a variety of autoimmune disorders. In contrast to the acute allergic and cytokine associated reactions, late adverse events of rituximab are indeed uncommon but at the same time probably under-reported. In this review, we detail late adverse events reported since its use in hemato-oncological neoplasias and other disorders. These adverse events include the development of late-onset neutropenia, defects of immune reconstitution with associated immune compromise, infections, progressive multifocal leukoencephalopathy, reactivation of hepatitis, intestinal perforation and interstitial pneumonitis. Possible mechanisms involved in rituximab-associated complications and the pathogenesis of these adverse effects are reviewed and discussed. Evidence based graded recommendations for the management of these adverse effects are proposed.
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Affiliation(s)
- Ron Ram
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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