The role of hepatitis B core-related antigen in predicting hepatitis B virus recurrence after liver transplantation

HBV Recurrence Detected by HBV-Related Serum Markers and Immune Escape Mutations in Chronic Hepatitis B Patients Following Liver Transplantation

The posttransplantation recurrence rate of hepatitis B virus (HBV) infection in patients with chronic hepatitis B (CHB) is underestimated and linked with unfavorable outcomes. We investigated HBV recurrence by serum assays in patients with CHB following liver transplantation. We enrolled patients with CHB who underwent liver transplantation between March 2001 and July 2021 to participate in cross-sectional testing for HBV-related serum markers, including biochemical analysis for HBsAg and hepatitis B core-related antigen (HBcrAg) and real-time RT-PCR/PCR for HBV RNA and HBV DNA, in 2022. HBV recurrence in this study was defined as positive results of at least one posttransplantation HBV-related serum markers. Next-generation sequencing was performed for those with posttransplantation virological breakthroughs. Ninety-six patients with CHB who underwent liver transplantation were enrolled. Among 84 patients who received grafts negative for HBsAg, 41 (48.8%) exhibited HBV recurrence, and they tested positive for either HBsAg or HBcrAg, or both. High-risk patients, identified using a risk stratification model, had a higher likelihood of recurrence than low-risk patients (odds ratio: 2.59, 95% confidence interval: 1.06-6.35, p = 0.038). In 51 patients who tested negative for HBsAg after receiving HBsAg-negative grafts, 8 (15.7%) had positive HBcrAg, indicating occult HBV infection (OBI). We identified immune escape mutations and altered N-glycosylation patterns on the surface protein in patients experiencing virological breakthroughs following lamivudine resistance. HBsAg plus HBcrAg levels can be used to detect posttransplantation HBV recurrence. The OBI prevalence was higher in patients transplanted with HBsAg-negative liver grafts compared to blood donors, vaccinated young population, and community-based populations reported in literatures, possibly because of immune escape mutations or altered N-glycosylation patterns of surface proteins.

Role of hepatitis B core-related antigen in predicting the occurrence and recurrence of hepatocellular carcinoma in patients with chronic hepatitis B: A systemic review and meta-analysis

BACKGROUND AND AIM

The purpose of the current study was to investigate the predictive value of hepatitis B core-related antigen (HBcrAg) on the occurrence and recurrence of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB).

METHODS

We searched PubMed, Embase, Scopus, and Web of Science from database inception to April 6, 2023. Pooled hazard ratio (HR) or odds ratio (OR) with 95% confidence interval (CI) was calculated for the occurrence and recurrence of HCC.

RESULTS

Of the 464 articles considered, 18 articles recruiting 10 320 patients were included. The pooled results showed that high serum HBcrAg level was an independent risk factor for the occurrence of HCC in CHB patients (adjusted HR = 3.12, 95% CI: 2.40-4.06, P < 0.001, I2 = 43.2%, P = 0.043; OR = 5.65, 95% CI: 3.44-5.82, P < 0.001, I2 = 0.00%, P = 0.42). Further subgroup analysis demonstrated that the predictive ability of HBcrAg for the occurrence of HCC is not influenced by the hepatitis B e antigen (HBeAg) status or the use of nucleoside/nucleotide analogs (NAs). In addition, our meta-analysis also suggests that HBcrAg is a predictor of HCC recurrence (adjusted HR = 1.71, 95% CI: 1.26-2.32, P < 0.001, I2 = 7.89%, P = 0.031).

CONCLUSIONS

For patients with CHB, serum HBcrAg may be a potential predictive factor for the occurrence of HCC, regardless of HBeAg status or NA treatment. It may also serve as a novel prognostic biomarker for the recurrence of HCC. More studies are needed to confirm our conclusions.

Effects of 3-HAA on HCC by Regulating the Heterogeneous Macrophages-A scRNA-Seq Analysis

Kynurenine derivative 3-hydroxyanthranilic acid (3-HAA) is known to regulate the immune system and exhibit anti-inflammatory activity by inhibiting T-cell cytokine secretion and influencing macrophage activity. However, the definite role of 3-HAA in the immunomodulation of hepatocellular carcinoma (HCC) is largely unexplored. An orthotopic HCC model and treated with 3-HAA by intraperitoneal injection is developed. Furthermore, cytometry by time-of-flight (CyTOF) and single-cell RNA sequencing (scRNA-seq) analyses are carried out to define the immune landscape of HCC. It is found that 3-HAA treatment can significantly suppress tumor growth in the HCC model and alter the level of various cytokines in plasma. CyTOF data shows that 3-HAA significantly increases the percentage of F4/80hi CX3CR1lo Ki67lo MHCIIhi macrophages and decreases the percentage of F4/80lo CD64+ PD-L1lo macrophages. scRNA-seq analyses demonstrate that 3-HAA treatment is proved to regulate the function of M1 macrophages, M2 macrophages, and proliferating macrophages. Notably, 3-HAA inhibits the proinflammatory factors TNF and IL-6 in multiple cell subsets, including resident macrophages, proliferating macrophages, and pDCs. This study reveals the landscape of immune cell subsets in HCC in response to 3-HAA, indicating that 3-HAA may be a promising therapeutic target for HCC.

Impact of cirrhosis-related complications on posttransplant survival in patients with acute-on-chronic liver failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a life-threatening syndrome defined as acute decompensation in patients with chronic liver disease. Liver transplantation (LT) is the most effective treatment. We aimed to assess the impact of cirrhosis-related complications pre-LT on the posttransplant prognosis of patients with ACLF.

METHODS

This was an observational cohort study conducted between January 2018 and December 2020. Clinical characteristics, cirrhosis-related complications at LT and patient survival post-LT were collected. All liver recipients with ACLF were followed for 1 year post-LT.

RESULTS

A total of 212 LT recipients with ACLF were enrolled, including 75 (35.4%) patients with ACLF-1, 64 (30.2%) with ACLF-2, and 73 (34.4%) with ACLF-3. The median waiting time for LT was 11 (4-24) days. The most prevalent cirrhosis-related complication was ascites (78.8%), followed by hepatic encephalopathy (57.1%), bacterial infections (48.1%), hepatorenal syndrome (22.2%) and gastrointestinal bleeding (11.3%). Survival analyses showed that patients with complications at LT had a significantly lower survival probability at both 3 months and 1 year after LT than those without complications (all P < 0.05). A simplified model was developed by assigning one point to each complication: transplantation for ACLF with cirrhosis-related complication (TACC) model. Risk stratification of TACC model identified 3 strata (≥ 4, = 3, and ≤ 2) with high, median and low risk of death after LT (P < 0.001). Moreover, the TACC model showed a comparable ability for predicting the outcome post-LT to the other four prognostic models (chronic liver failure-consortium ACLF score, Chinese Group on the Study of Severe Hepatitis B-ACLF score, model for end-stage liver disease score and Child-Turcotte-Pugh score).

CONCLUSIONS

The presence of cirrhosis-related complications pre-LT increases the risk of death post-LT in patients with ACLF. The TACC model based on the number of cirrhosis-related complications pre-LT could stratify posttransplant survival, which might help to determine transplant timing for ACLF.

Identification of effective diagnostic biomarker and immune cell infiltration characteristics in acute liver failure by integrating bioinformatics analysis and machine-learning strategies

Background: To determine effective biomarkers for the diagnosis of acute liver failure (ALF) and explore the characteristics of the immune cell infiltration of ALF.

Methods: We analyzed the differentially expressed genes (DEGs) between ALF and control samples in GSE38941, GSE62029, GSE96851, GSE120652, and merged datasets. Co-expressed DEGs (co-DEGs) identified from the five datasets were analyzed for enrichment analysis. We further constructed a PPI network of co-DEGs using the STRING database. Then, we integrated the two kinds of machine-learning strategies to identify diagnostic biomarkers of top hub genes screened based on MCC and Degree methods. And the potential diagnostic performance of the biomarkers for ALF was estimated using the AUC values. Data from GSE14668, GSE74000, and GSE96851 databases was performed as external verification sets to validate the expression level of potential diagnostic biomarkers. Furthermore, we analyzed the difference in the protein level of diagnostic biomarkers between normal and ALF mice models. Finally, we used CIBERSORT to estimate relative infiltration levels of 22 immune cell subsets in ALF samples and further analyzed the relationships between the diagnostic biomarkers and infiltrated immune cells.

Results: A total of 200 co-DEGs were screened. Enrichment analyses depicted that they are highly enriched in metabolism and matrix collagen production-associated processes. The top 28 hub genes were obtained by integrating MCC and Degree methods. Then, the collagen type IV alpha 2 chain (COL4A2) was regarded as the diagnostic biomarker and showed excellent specificity and sensitivity. COL4A2 also showed a statistically significant difference and excellent diagnostic effectiveness in the verification set. In addition, there was a significant upregulation in the COL4A2 protein level in ALF mice models compared with the normal group. CIBERSORT analysis showed that activated CD4 T cells, plasma cells, macrophages, and monocytes may be implicated in the progress of ALF. In addition, COL4A2 showed different degrees of correlation with immune cells.

Conclusion: In conclusion, COL4A2 may be a diagnostic biomarker for ALF, and immune cell infiltration may have important implications for the occurrence and progression of ALF.

1,5-Anhydroglucitol Predicts Mortality in Patients with HBV-Related Acute-on-chronic Liver Failure

BACKGROUND AND AIMS

1,5-Anhydroglucitol (1,5AG) activity has been reported in chronic liver disease. Hepatitis B virus (HBV)-related acute-on-chronic liver failure (HBV-ACLF) patients have a high mortality. We aimed to discover the relationship between serum 1,5AG and the prognosis of HBV-ACLF.

METHODS

Serum 1,5AG levels were determined in 333 patients with HBV-ACLF, 300 without diabetes were allocated to derivation (n=206) and validation cohorts (n=94), and 33 were recruited to evaluate 1,5AG in those with diabetes. Forty patients with chronic hepatitis B, 40 with liver cirrhosis, and 40 healthy people were controls in the validation cohort.

RESULTS

In the derivation and validation cohorts, serum 1,5AG levels were significantly lower in nonsurvivors than in survivors. The AUC of 1,5AG for 28-day mortality was 0.811. In patients with diabetes, serum 1,5AG levels were also significantly lower in nonsurvivors than in survivors. In multivariate Cox regression analysis, serum 1,5AG levels were independently associated with 28-day mortality. A novel predictive model (ACTIG) based on 1,5AG, age, TB, cholesterol, and INR was derived to predict mortality. In ACTIG, the AUC for 28-day mortality was 0.914, which was superior to some prognostic score models. ACTIG was also comparable to those prognostic score models in predicting 6-month mortality. In mice with D-galactosamine/lipopolysaccharide-induced liver failure, 1,5AG levels were significantly reduced in serum and significantly increased in urine and liver tissue.

CONCLUSIONS

Serum 1,5AG levels are a promising predictor of short-term mortality in HBV-ACLF patients. The 1,5AG distribution changed in mice with D-galactosamine/ lipopolysaccharide-induced liver failure.

Impact of hepatitis B surface antigen positive grafts on liver transplantation in patients with benign and malignant liver disease

Hepatitis B surface antigen (HBsAg) persists after liver transplantation in almost all patients receiving HBsAg-positive grafts. Chronic hepatitis B virus (HBV) infection is one of the main causes of hepatocellular carcinoma (HCC). We aimed to investigate possible interactions between HBsAg-positive donors, HCC, HBV-related transplant indication, and long-term outcomes. This retrospective study enrolled 1176 patients from two centers between January 2015 and May 2019, of which 135 (11.5%) were HBsAg-positive and 1041 (88.5%) were HBsAg-negative donors. Cox regression models were fitted to study the association between variables and patient and graft survival. In univariate and multivariate analyses, the donor HBsAg status was not significantly associated with patient and graft survival in the entire cohort, but there was a significant interaction between HBsAg-positive donors and HCC, independent of HBV-related transplant indication. The cumulative incidence of patient and graft survival was significantly lower in the subgroup of HCC recipients receiving HBsAg-positive grafts, but no significant difference was found in recipients with benign liver disease. In a subgroup analysis of HCC recipients, HBsAg-positive donors were significantly associated with an increased risk of HCC recurrence (hazard ratio: 1.73; 95% confidence interval: 1.20-2.48; p = 0.003) and similar results were obtained after propensity score matching analysis. We showed excellent outcomes of using HBsAg-positive grafts in patients with benign liver disease, regardless of HBV-related transplant indications. However, positive grafts should be used with caution in recipients with HCC, which are associated with an increased risk of HCC recurrence.

Peripheral Immune Cells Exhaustion and Functional Impairment in Patients With Chronic Hepatitis B

After infection of hepatitis B virus (HBV), the virus induces a variety of immune disorders in the host, leading to immune escape and, finally, the chronicity of the disease. This study investigated immune cell defects and functional impairment in patients with chronic hepatitis B (CHB). We analyzed the percentage, function, and phenotypes of various immune cell subpopulations in the peripheral blood along with the concentrations of cytokines in the plasma. We compared the results between patients with CHB and healthy individuals. It was found that in patients with CHB, the cell function was impaired and, there was increased expression of inhibitory receptors, such as NKG2A and PD-1 in both NK and T cells. The impairment of function was mainly in cytokine secretion, and the cytotoxicity was not significantly diminished. We also found that the proportion of dendritic cells (DC) decreased and regulatory B cells (Breg) increased in CHB. In addition, the Breg cells were negatively correlated with T cell cytokine and positively correlated with ALT and HBV viral load. Taken together, various disorders and functional impairments were found in the immune cells of peripheral blood in CHB patients, especially NK and T cells. These cells showed exhaustion and the increase of regulatory B cells may be one of the reasons for this phenomenon.

How to interpret viral markers in the management of chronic hepatitis B infection

BACKGROUND

Hepatitis B virus (HBV) infection is a global public health issue with several unsolved clinical challenges. As multiple new drugs are under development, HBV markers are gaining importance for both diagnostic and prognostic purposes.

OBJECTIVES

This review summarizes the most important data on the usefulness of HBV markers in the natural history of this infection, and in predicting clinical and treatment outcomes.

SOURCES

Selected peer-reviewed publications on HBV markers published between January 2009 and July 2021.

CONTENT

In addition to the classical markers (e.g. HBV-DNA), newer ones, such as quantitative HBsAg, HBcrAg, HBV-RNA and quantitative anti-HBc, have proven useful for predicting events within the natural history of HBV infection, the development of complications (e.g. hepatocellular carcinoma) and the response to antiviral therapy. Most data regarding the response to treatment have been related to nucleos(t)ide analogues, whereas evidence on new therapeutic agents, such as capsid assembly modulators or small interference RNAs, is promising, but still scarce.

IMPLICATIONS

Knowledge on the use of viral markers is a key factor for optimizing the clinical appraisal of HBV infection. The new markers have an enhanced ability to predict clinical outcomes. Further studies should expand the current evidence on the use of markers in relation to antiviral agents currently under evaluation. Wide availability of these markers in regions with a high incidence of HBV infection is of paramount importance.

C-Reactive Protein Is an Independent Predictor of 30-Day Bacterial Infection Post-Liver Transplantation

The relationship between aseptic systemic inflammation and postoperative bacterial infection is unclear. We investigated the correlation of systemic inflammation biomarkers with 30-day clinically significant bacterial infections (CSI) after liver transplantation (LT). This retrospective study enrolled 940 patients who received LT and were followed for 30 days. The primary end point was 30-day CSI events. The cohort was divided into exploratory (n = 508) and validation (n = 432) sets according to different centers. Area under the receiver operated characteristic (AUROC) and Cox regression models were fitted to study the association between baseline systemic inflammation levels and CSI after LT. A total of 255 bacterial infectious events in 209 recipients occurred. Among systemic inflammation parameters, baseline C-reactive protein (CRP) was independently associated with 30-day CSI in the exploratory group. The combination of CRP and organ failure number showed a good discrimination for 30-day CSI (AUROC = 0.80, 95% CI, 0.76-0.84) and the results were confirmed in an external verification group. Additionally, CRP levels were correlated with bacterial product lipopolysaccharide. In conclusion, our study suggests that pre-transplantation CRP is independent of other prognostic factors for 30-day CSI post-LT, and can be integrated into tools for assessing the risk of bacterial infection post-LT or as a component of prognostic models.

Viral Biomarkers for Hepatitis B Virus-Related Hepatocellular Carcinoma Occurrence and Recurrence

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and the fourth leading cause of cancer-related death. The most common risk factor for developing HCC is chronic infection with hepatitis B virus (HBV). Early stages of HBV-related HCC (HBV-HCC) are generally asymptomatic. Moreover, while serum alpha-fetoprotein (AFP) and abdominal ultrasound are widely used to screen for HCC, they have poor sensitivity. Thus, HBV-HCC is frequently diagnosed at an advanced stage, in which there are limited treatment options and high mortality rates. Serum biomarkers with high sensitivity and specificity are crucial for earlier diagnosis of HCC and improving survival rates. As viral-host interactions are key determinants of pathogenesis, viral biomarkers may add greater diagnostic power for HCC than host biomarkers alone. In this review, we summarize recent research on using virus-derived biomarkers for predicting HCC occurrence and recurrence; including circulating viral DNA, RNA transcripts, and viral proteins. Combining these viral biomarkers with AFP and abdominal ultrasound could improve sensitivity and specificity of early diagnosis, increasing the survival of patients with HBV-HCC. In the future, as the mechanisms that drive HBV-HCC to become clearer, new biomarkers may be identified which can further improve early diagnosis of HBV-HCC.

Hepatitis B Core-Related Antigen: From Virology to Clinical Application

Hepatitis B core-related antigen (HBcrAg) is a composite measure of the serum levels of hepatitis B e antigen, hepatitis B core antigen, and a 22-kDa precore protein. It has been shown to reflect the level and transcriptional activity of covalently closed circular DNA in the liver. Longitudinal cohort studies have improved our understanding of the role of this novel viral marker in the natural history of chronic hepatitis B. HBcrAg kinetics reflect the response to peginterferon, and its role in defining guidelines for stopping peginterferon therapy has been evaluated. HBcrAg is a marker of intrahepatic viral activity, which may influence the risk of hepatocellular carcinoma. In this article, we review the virology and role of HBcrAg in defining phases of chronic hepatitis B. Furthermore, the function of HBcrAg in predicting treatment outcomes and its role in monitoring response to novel antiviral agents will be discussed.

Review article: preventing hepatitis B graft infection in hepatitis B patients after liver transplantation: immunoglobulin vs anti-virals

BACKGROUND

A critical aspect of liver transplantation in hepatitis B patients is to prevent graft reinfection with hepatitis B virus. The use of hepatitis B immune globulin after transplant was a significant milestone, which allowed prolonged graft and patient survival by controlling hepatitis B reinfection in liver grafts. The development of anti-viral treatments with oral nucleos(t)ide analogues, led to a further reduction in graft reinfection and improvement in patient survival. The combination of the aforementioned two therapies has been widely used in hepatitis B-associated liver transplants.

AIMS

To address the post-transplant management of hepatitis B and provide updates on preventing graft reinfection.

METHODS

We performed a literature search on Ovid and PubMed for randomised controlled trials or cohort studies in English, which investigated the effectiveness of hepatitis B immune globulin and anti-viral therapy on hepatitis B-associated transplants (1/2000-1/2020). Studies that met pre-established criteria were reviewed.

RESULTS

Based on currently available evidence, an algorithm for post-transplant management with anti-viral therapy is proposed. Also, the management of recipients who received grafts from hepatitis B core antibody-positive donors is discussed.

CONCLUSIONS

The development of hepatitis B immune globulin and anti-viral treatments led to substantial improvement in graft and patient survival. The prevention of hepatitis B graft reinfection is complex and involves a broad interdisciplinary team.