Management of chronic hepatitis B infection: Current treatment guidelines, challenges, and new developments

Novel therapeutic approaches for the management of hepatitis infections

Hepatitis B virus (HBV) & hepatitis C virus (HCV) infection is a substantial reason for morbidity and mortality around the world. Chronic hepatitis B (CHB) infection is connected with an enhanced risk of liver cirrhosis, liver decompensation and hepatocellular carcinoma (HCC). Conventional therapy do face certain challenges, for example, poor tolerability and the growth of active resistance. Thus, novel treatment procedures are essential to accomplish the initiation of strong and stable antiviral immune reactions of the individuals. This review explores the current nanotechnology-based carriers for drug and vaccine delivery to treat HBV and HCV.

Structure-Activity Relationships and Discovery of (S)-6-Isopropyl-2-methoxy-3-(3-methoxypropoxy)-10-oxo-5,10-dihydro-6H-pyrido[1,2-h][1,7]naphthyridine-9-carboxylic Acid (AB-452), a Novel Orally Available HBV RNA Destabilizer

Approved therapies for hepatitis B virus (HBV) treatment include nucleos(t)ides and interferon alpha (IFN-α) which effectively suppress viral replication, but they rarely lead to cure. Expression of viral proteins, especially surface antigen of the hepatitis B virus (HBsAg) from covalently closed circular DNA (cccDNA) and the integrated genome, is believed to contribute to the persistence of HBV. This work focuses on therapies that target the expression of HBV proteins, in particular HBsAg, which differs from current treatments. Here we describe the identification of AB-452, a dihydroquinolizinone (DHQ) analogue. AB-452 is a potent HBV RNA destabilizer by inhibiting PAPD5/7 proteins in vitro with good in vivo efficacy in a chronic HBV mouse model. AB-452 showed acceptable tolerability in 28-day rat and dog toxicity studies, and a high degree of oral exposure in multiple species. Based on its in vitro and in vivo profiles, AB-452 was identified as a clinical development candidate.

Associations of hepatitis B and C in women aged 15-49 years with neonatal preterm birth in 66 high-income countries, 1990-2019

OBJECTIVE

To assess the associations between hepatitis B and C in women aged 15-49 years and neonatal preterm birth in high-income countries (HICs).

METHODS

This ecological study collected hepatitis B and C prevalence data in women aged 15-49 years and age-standardized incidence rates (ASIRs) of neonatal preterm birth in HICs in 1990-2019 from the Global Burden of Disease study. Estimated annual percentage changes (EAPCs) in hepatitis B and C prevalence and ASIRs of neonatal preterm birth were calculated to quantify their temporal trends. Pearson correlation tests and generalized additive mixed models were used to estimate the associations between hepatitis B and C prevalence and ASIR of neonatal preterm birth.

RESULTS

Among women aged 15-49 years in HICs, hepatitis B prevalence increased only in the Northern Mariana Islands (EAPC, 0.16 [95% confidence interval (CI), 0.05-0.27]) and the United Kingdom (EAPC, 0.08 [95% CI, 0.04-0.12]) and hepatitis C prevalence increased in more than 20% of HICs in 1990-2019, with the largest increase in Belgium (EAPC, 1.00 [95% CI, 0.65-1.35]). Nearly 80% of HICs showed an increasing trend in ASIR of neonatal preterm birth in 1990-2019, with the largest increase in Greece (EAPC, 3.91 [95% CI, 3.65-4.18]). A positive association between hepatitis C prevalence in women aged 15-49 years and ASIR of neonatal preterm birth was observed in Pearson correlation tests and generalized additive mixed models (P ≤ 0.01).

CONCLUSION

ASIR of neonatal preterm birth was associated with hepatitis C prevalence in women aged 15-49 years in HICs. Universal screening for hepatitis C virus is recommended at least once for women of reproductive age and during each pregnancy.

Trends and future projections of liver cancer incidence in Hong Kong: a population-based study

BACKGROUND

Liver cancer remains a significant burden in Hong Kong. We sought to examine trends in liver cancer incidence using 30 years of cancer registry data in Hong Kong. Additionally, we aimed to assess the impact of age, period and birth cohort on liver cancer incidence, provided projections for liver cancer incidence until 2030, and examined the drivers of liver cancer incidence.

METHODS

Data on liver cancer incidence were collected from the Hong Kong Cancer Registry (HKCaR). We assessed age, period, and birth cohort effects using age-period-cohort (APC) models. We employed Bayesian APC analysis with integrated nested Laplace approximations to project the future burden of liver cancer in Hong Kong. Furthermore, we attributed the changes in new liver cancer cases to population growth, population ageing, and epidemiological changes.

RESULTS

The study included a total of 51,333 individuals, of whom 39,287 (76.53%) were male. From 1991 to 2020, the age-standardized liver cancer incidence rate in Hong Kong continued declining, while the number of new cases increased significantly, especially among males. The net drift, representing the overall annual percentage change of the age-adjusted rate, was - 3.06% (95% confidence interval [CI]: -3.31% to -2.80%) for males and - 3.85% (95% CI: -4.61% to -3.09%) for females. Local drift, which estimates the annual percentage change over time specific to age group, decreased in all age groups for both sexes, with a more pronounced decrease in younger age groups. The period and cohort risk of developing liver cancer also showed decreasing trends for both sexes. The study projected a decline in liver cancer cases for males but an increase for females in Hong Kong, with an estimated 1,083 cases in males and 710 cases in females by 2030. Demographic decomposition analysis revealed that while population growth and ageing were the main drivers of increased liver cancer cases, epidemiologic shifts mostly offset these factors.

CONCLUSION

The period and cohort risk of developing liver cancer in Hong Kong declined due to epidemiological changes. Although the age-standardized incidence rates of liver cancer have also declined, demographic and epidemiological factors have led to lower case expectations in males but a likely increase in females. Further research and epidemiological assessment of the disease are needed.

Hepatitis B infection status among South Africans attending public health facilities over a five-year period: 2015 to 2019

Hepatitis B, a potentially life-threatening viral infection of the liver, remains a global public health concern despite the availability of effective vaccines for over three decades. The aim of our study was to provide national data on active hepatitis B infections in the public health sector of South Africa. We conducted retrospective analyses on national laboratory data over the period 2015 to 2019. We identified 176,530 cases who tested positive for HBsAg (active infection) with a test positivity rate of 9.02%. Of these active infections, 11,355 (6.43%) were found to be chronically infected. We linked 24,839 (14.07%) and 2,461 (21.67%) HBeAg positive results to all active HBV infections and identified chronic infections respectively. Clearance of HBsAg was observed in 5,569 cases, inclusive of clearance in 135 chronic cases. Active HBV infections were significantly higher in men than women over the five years (p < 0.0001). Among individuals who were vaccine-eligible as infants (0 to 19 years old), we observed 4,981 active HBV infections, including 1,131 infections under five years old, majority of which (65.78%) were under one year old. In the under five-year age group, the HBsAg population positivity rate was 0.02% and test positivity rate was 4.83%. Among all women with active HBV infections (78,935), 85.17% were of reproductive age and of these, 13.73% were HBeAg positive. Without a birth dose of the HBV vaccine, lack of routine HBsAg screening at antenatal care, and HBsAg and HBeAg prevalence among women of reproductive age, it is likely that the majority of cases under five years old were vertically infected. Optimal HBV vaccine coverage, inclusive of a birth dose, is key to eliminating horizontal and vertical transmission of HBV. Early identification of HBV chronicity through real time data analysis is fundamental in reducing the risk of liver cirrhosis and hepatocellular carcinoma.

Injectable controlled-release systems for the prevention and treatment of infectious diseases

Pharmaceutical drugs, including vaccines, pre- and post-exposure prophylactics, and chronic drug therapies, are crucial tools in the prevention and treatment of infectious diseases. These drugs have the ability to increase survival and improve patient quality of life; however, infectious diseases still accounted for more than 10.2 million deaths in 2019 before the COVID-19 pandemic. High mortality can be, in part, attributed to challenges in the availability of adequate drugs and vaccines, limited accessibility, poor drug bioavailability, the high cost of some treatments, and low patient adherence. A majority of these factors are logistical rather than technical challenges, providing an opportunity for existing drugs and vaccines to be improved through formulation. Injectable controlled-release drug delivery systems are one class of formulations that have the potential to overcome many of these limitations by releasing their contents in a sustained manner to reduce the need for frequent re-administration and improve clinical outcomes. This review provides an overview of injectable controlled drug delivery platforms, including microparticles, nanoparticles, and injectable gels, detailing recent developments using these systems for single-injection vaccination, long-acting prophylaxis, and sustained-release treatments for infectious disease.

Increased liver stiffness promotes hepatitis B progression by impairing innate immunity in CCl4-induced fibrotic HBV+ transgenic mice

Background

Hepatitis B virus (HBV) infection develops as an acute or chronic liver disease, which progresses from steatosis, hepatitis, and fibrosis to end-stage liver diseases such as cirrhosis and hepatocellular carcinoma (HCC). An increased stromal stiffness accompanies fibrosis in chronic liver diseases and is considered a strong predictor for disease progression. The goal of this study was to establish the mechanisms by which enhanced liver stiffness regulates HBV infectivity in the fibrotic liver tissue.

Methods

For in vitro studies, HBV-transfected HepG2.2.15 cells were cultured on polydimethylsiloxane gels coated by polyelectrolyte multilayer films of 2 kPa (soft) or 24 kPa (stiff) rigidity mimicking the stiffness of the healthy or fibrotic liver. For in vivo studies, hepatic fibrosis was induced in C57Bl/6 parental and HBV+ transgenic (HBVTg) mice by injecting CCl4 twice a week for 6 weeks.

Results

We found higher levels of HBV markers in stiff gel-attached hepatocytes accompanied by up-regulated OPN content in cell supernatants as well as suppression of anti-viral interferon-stimulated genes (ISGs). This indicates that pre-requisite "fibrotic" stiffness increases osteopontin (OPN) content and releases and suppresses anti-viral innate immunity, causing a subsequent rise in HBV markers expression in hepatocytes. In vitro results were corroborated by data from HBVTg mice administered CCl4 (HBVTg CCl4). These mice showed higher HBV RNA, DNA, HBV core antigen (HBcAg), and HBV surface antigen (HBsAg) levels after liver fibrosis induction as judged by a rise in Col1a1, SMA, MMPs, and TIMPs mRNAs and by increased liver stiffness. Importantly, CCl4-induced the pro-fibrotic activation of liver cells, and liver stiffness was higher in HBVTg mice compared with control mice. Elevation of HBV markers and OPN levels corresponded to decreased ISG activation in HBVTg CCl4 mice vs HBVTg control mice.

Conclusion

Based on our data, we conclude that liver stiffness enhances OPN levels to limit anti-viral ISG activation in hepatocytes and promote an increase in HBV infectivity, thereby contributing to end-stage liver disease progression.

Baseline and on-treatment HBcrAg levels as predictors of HBeAg seroconversion in chronic hepatitis B patients treated with antivirals

HBeAg seroconversion is an important treatment endpoint. We aimed to identify predictors of seroconversion using serum HBsAg and hepatitis B core-related antigen (HBcrAg) in HBeAg-positive patients treated with nucleos(t)ide analogs (NAs). Data and samples from 70 HBeAg-positive patients treated with entecavir or tenofovir between January 2007 and December 2017 were retrospectively analysed. The mean follow-up period was 11 years. The predictive power for HBeAg seroconversion of HBcrAg levels at baseline and 2 years after antiviral therapy was determined using receiver operating curve analysis. Twenty-one patients (30%) achieved HBeAg seroconversion at a mean of 28 (range, 12-84) months after antiviral treatment. The median baseline HBcrAg and HBsAg levels were 6.9(5.7-7.0) vs. 5.8(5.5-6.5) log₁₀ U/mL (p = .006), 4.9(4.5-5.1) vs. 4.5(4.1-5.0) log₁₀ IU/mL (p = .044) in the no seroconversion group and seroconversion group, respectively. In the multivariate analysis, the serum HBcrAg levels at baseline and 2 years after antiviral therapy were predictive factors for HBeAg seroconversion ([HR]; 0.326; [CI], 0.111-0.958; p = .042 and HR, 0.4555; CI, 0.211-0.984; p = .045). HBcrAg levels≤6.5log₁₀ U/mL at baseline and ≤5.3log₁₀ U/mL at 2 years after antiviral therapy had sensitivities of 53.1% and 69.8%, specificities of 95.2% and 70.6%, positive predictive values of 82.6% and 50.0%, and negative predictive values of 82.6% and 84.5%, respectively, with AUROCs of 0.712 (95%CI, 0.596-0.830) and 0.745 (95%CI, 0.599-0.891) for predicting HBeAg seroconversion. In chronic hepatitis B patients treated with NAs, HBcrAg levels≤6.5log₁₀ U/mL at baseline and ≤5.3log₁₀ U/mL at 2 years after antiviral therapy were useful predictive factors of HBeAg seroconversion.

Evaluation of the drug-drug interaction potential of the novel hepatitis B and D virus entry inhibitor bulevirtide at OATP1B in healthy volunteers

Introduction: Bulevirtide is a first-in-class antiviral drug to treat chronic hepatitis B/D. We investigated the drug-drug interaction potential and pharmacokinetics of high-dose subcutaneous bulevirtide (5 mg twice daily) with organic anion transporting polypeptide 1B1 (OATP1B1) and cytochrome P450 (CYP) 3A4. Methods: This was a single-center, open-label, fixed-sequence drug-drug interaction trial in 19 healthy volunteers. Before and at bulevirtide steady state, participants ingested a single 40 mg dose of pravastatin. A midazolam microdose was applied to quantify CYP3A4 activity. Results: At bulevirtide steady state, pravastatin area under the concentration-time curve (AUC_0-∞) increased 1.32-fold (90% CI 1.08-1.61). The 5 mg bulevirtide twice-daily treatment resulted in a mean AUC_0-12 of 1210 h*ng/ml (95% CI 1040-1408) and remained essentially unchanged under the influence of pravastatin. CYP3A4 activity did not change to a clinically relevant extent. As expected, total bile acids increased substantially (35-fold) compared to baseline during bulevirtide treatment. All study medication was well tolerated. Discussion: The study demonstrated that high-dose bulevirtide inhibited OATP1B-mediated hepatic uptake of the marker substrate pravastatin but the extent is considered clinically not relevant. Changes in CYP3A4 activity were also not clinically relevant. In conclusion, this study suggests that OATP1B substrate drugs as well as CYP3A4 substrates may safely be used without dose adjustment in patients treated with bulevirtide. However, in patients using high statin doses and where concomitant factors potentially further increase statin exposure, caution may be required when using bulevirtide.

Long-term and efficient inhibition of hepatitis B virus replication by AAV8-delivered artificial microRNAs

Chronic hepatitis B virus (HBV) infection remains a global health problem and current treatments are insufficient due to immune tolerance to hepatitis B surface antigen (HBsAg). RNA interference (RNAi) is a more promising approach for antiviral therapy. Here, 17 single artificial microRNAs (amiRNAs) targeting the highly conserved regions of HBV genome were screened to inhibit HBV replication. In addition, we compared three tandem amiRNAs, each containing 3 different amiRNAs, out of which amiRNA135 was selected to be studied in detail. In vitro data showed that amiRNA135 significantly inhibited the replication of different HBV genotypes (including resistant and mutant). In vivo study was carried out by adeno-associated virus 8-mediated gene delivery, we found that the anti-HBV effects of AAV8-amiRNA135 were time and dose-dependent. Serum HBsAg and HBeAg in high dose groups were significantly reduced at 7 days after a single intravenous vector injection, and maintained at low levels throughout a 15-month experiment. Immunohistochemical staining and HBV core particle DNA analysis confirmed that HBV replication in the liver was strongly inhibited by AAV8-amiRNA135. Taken together, our data suggest that AAV8-mediated trimeric amiRNA expression is a promising therapeutic approach for chronic HBV infection.

METTL3 inhibition ameliorates liver damage in mouse with hepatitis B virus-associated acute-on-chronic liver failure by regulating miR-146a-5p maturation

Hepatitis B virus (HBV)-associated acute-on-chronic liver failure (ACLF) is a clinical syndrome of severe liver damage. HBV infection is affected by N6-methyladenosine (m⁶A) RNA modification. Here, we investigated whether methyltransferase-like 3 (METTL3)-mediated m⁶A methylation can affect ACLF. Human hepatic cells (THLE-2) were treated with lipopolysaccharide (LPS) to induce cell damage. Proliferation, apoptosis and m⁶A modification were measured by MTT assay, flow cytometry and Dot blot assay. Our results showed that HBV infection significantly enhanced the levels of m⁶A modification and elevated the expression of METTL3 and mature-miR-146a-5p in THLE-2 cells, which was repressed by cycloleucine (m⁶A inhibitor). METTL3 overexpression enhanced m⁶A modification and promoted mature-miR-146a-5p expression. METTL3 overexpression promoted HBV replication and apoptosis, enhanced the levels of pro-inflammatory cytokines, hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg), and repressed cell proliferation in THLE-2 cells, which attributed to repress miR-146a-5p maturation. Moreover, a severe liver failure mouse model was established by HBV infection to verify the impact of METTL3 knockdown on liver damage in vivo. HBV-infection led to a severe liver damage and increase of apoptosis in hepatic tissues of mice, which was abolished by METTL3 knockdown. METTL3 knockdown reduced METTL3 expression and impeded miR-146a-5p maturation in HBV-infected mice. In conclusion, this work demonstrates that METTL3 inhibition ameliorates liver damage in mouse with HBV-associated ACLF, which contributes to repress miR-146a-5p maturation. Thus, this article suggests a novel therapeutic avenue to prevent and treat HBV-associated ACLF.

Phytomedicines to Target Hepatitis B Virus DNA Replication: Current Limitations and Future Approaches

Hepatitis B virus infection (HBV) is one of the most common causes of hepatitis, and may lead to cirrhosis or hepatocellular carcinoma. According to the World Health Organization (WHO), approximately 296 million people worldwide are carriers of the hepatitis B virus. Various nucleos(t)ide analogs, which specifically suppress viral replication, are the main treatment agents for HBV infection. However, the development of drug-resistant HBV strains due to viral genomic mutations in genes encoding the polymerase protein is a major obstacle to HBV treatment. In addition, adverse effects can occur in patients treated with nucleos(t)ide analogs. Thus, alternative anti-HBV drugs of plant origin are being investigated as they exhibit excellent safety profiles and have few or no side effects. In this study, phytomedicines/phytochemicals exerting significant inhibitory effects on HBV by interfering with its replication were reviewed based on different compound groups. In addition, the chemical structures of these compounds were developed. This will facilitate their commercial synthesis and further investigation of the molecular mechanisms underlying their effects. The limitations of compounds previously screened for their anti-HBV effect, as well as future approaches to anti-HBV research, have also been discussed.

Serum hepatitis B core-related antigen as a surrogate marker of hepatitis B e antigen seroconversion in chronic hepatitis B

BACKGROUND

Quantitative hepatitis B core-related antigen (qHBcrAg) has a better correlation with intrahepatic hepatitis B virus (HBV) covalently closed circular DNA (cccDNA) than HBV DNA or hepatitis B e antigen (HBeAg), but data are still lacking for its clinical application.

AIM

The aim was to investigate serum qHBcrAg levels in patients with chronic hepatitis B and assess the correlation of serum qHBcrAg with pregenomic RNA (pgRNA), cccDNA, and HBeAg seroconversion.

METHODS

This study was a secondary analysis of patients who underwent percutaneous liver biopsy between July 2014 and June 2019 in two multicenter randomized controlled clinical trials of peginterferon vs nucleos(t)ide analog (NUC)-based therapy (NCT03509688 and NCT03546530). Serum qHBcrAg, pgRNA, HBV DNA, hepatitis B core antigen, HBeAg, liver cccDNA, and HBV DNA were measured. The correlations of serum qHBcrAg with other biomarkers were analyzed.

RESULTS

A total of 139 patients were included. The mean qHBcrAg levels were 5.32 ± 1.18 log₁₀ U/mL at baseline and decreased during treatment (all P < 0.0001). Serum qHBcrAg levels were positively correlated with pgRNA (r = 0.597, P < 0.0001) and cccDNA (r = 0.527, P < 0.0001) levels. The correlation of serum qHBcrAg level and intrahepatic HBV DNA levels at baseline was weak but significant (r = 0.399, P < 0.0001). HBcrAg predicted HBeAg seroconversion, with areas under the receiver operating characteristics curve of 0.788 at 24 wk and 0.825 at 48 wk. Log HBcrAg at wk 24 and 48 was independently associated with HBeAg seroconversion [odds ratio (OR) = 2.402, 95% confidence interval (CI): 1.314-4.391, P = 0.004; OR = 3.587, 95%CI: 1.315-9.784, P = 0.013].

CONCLUSION

Serum HBcrAg levels were correlated with HBV virological markers and could be used to predict HBeAg seroconversion.

Development of pH-Sensitive Chitosan-g-poly(acrylamide-co-acrylic acid) Hydrogel for Controlled Drug Delivery of Tenofovir Disoproxil Fumarate

The present study aimed to develop a pH-sensitive chitosan-based hydrogel for controlled delivery of an anti-hepatitis B drug, tenofovir disoproxil fumarate (TDF). Free radical polymerization was utilized to graft acrylamide and acrylic acid using N,N-methylene bisacrylamide as the crosslinker. Physicochemical characterization confirmed the synthesis of thermally stable chitosan-g-poly(acrylamide-co-acrylic acid) hydrogels with well-defined pores within a fibrous surface. The prepared hydrogels exhibited pH and ionic strength sensitivity, with the swelling significantly lower under acidic and strong ionic strength conditions but higher in neutral and basic solutions. In addition, cytotoxicity studies on HeLa cell lines proved the cytocompatibility of the drug delivery material and its readiness for physiological applications. The encapsulation of TDF in the hydrogels was optimized and an encapsulation efficiency and a drug loading percentage of 96% and 10% were achieved, respectively. More interestingly, in vitro release studies demonstrated a pH-dependent release of TDF from hydrogels. The release at pH 7.4 was found to be up to five times higher than at pH 1.2 within 96 h. This further suggested that the newly developed hydrogel-loaded TDF could be proposed as a smart delivery system for oral delivery of anti-hepatitis B drugs.

Hepatocyte-derived exosome may be as a biomarker of liver regeneration and prognostic valuation in patients with acute-on-chronic liver failure

BACKGROUND

The assessment of liver regeneration is particularly critical for patients with acute-on-chronic liver failure (ACLF). Exosome has both the advantages of specificity of liver biopsy and noninvasion of peripheral blood, which may be the potential biomarker of liver disease.

METHODS

The patients with chronic hepatitis B (CHB) and ACLF were enrolled from outpatients and inpatients in Beijing Youan Hospital, Capital Medical University. The exosomes in plasma were extracted by ultracentrifuge using Optima XPN-100 Ultracentrifuge. Exosomes were dyed with fluorescent direct-labeled antibody and the expression profile was assayed using ImageStream® X MKII Imaging Flow Cytometer.

RESULTS

The percentage of exosomes with ALB and CD63 was significant higher in ACLF than that in CHB. The percentage of exosomes with ALB and CD63 and VEGF increased in CHB, but decreased in ACLF. The exosomes with ALB, CD63, and VEGF were significant more in survival group than that in dead group in patients with ACLF. The sensitivity and specificity of exosomes with CD63, ALB, and VEGF were significantly higher than the other markers of liver regeneration and prognostic valuation in patients with ACLF including AFP. The hepatocyte-derived exosomes expression profile had no difference in different stages and different AFP levels of patients with ACLF.

CONCLUSION

The exosomes profile with ALB and VEGF may be a more accurate and specific biomarker of liver regeneration and prognostic valuation than AFP in patients with ACLF. In addition, the exosomes profile with CD63 and ALB may be an early-warning marker in patients with ACLF.

A computational multi-targeting approach for drug repositioning for psoriasis treatment

Background

Psoriasis is an autoimmune inflammatory skin disease that affects 0.5–3% of the world’s population and current treatment options are posed with limitations. The reduced risk of failure in clinical trials for repositioned drug candidates and the time and cost-effectiveness has popularized drug reposition and computational methods in the drug research community.

Results

The current study attempts to reposition approved drugs for the treatment of psoriasis by docking about 2000 approved drug molecules against fifteen selected and validated anti-psoriatic targets. The docking results showed that a good number of the dataset interacted favorably with the targets as most of them had − 11.00 to − 10.00 kcal/mol binding free energies across the targets. The percentage of the dataset with binding affinity higher than the co-crystallized ligands ranged from 34.76% (JAK-3) to 0.73% (Rac-1). It was observed that 12 out of the 0.73% outperformed all the co-crystallized ligands across the 15 studied proteins. All the 12 drugs identified are currently indicated as either antiviral or anticancer drugs and are of purine and pyrimidine nuclei. This is not surprising given that there is similarity in the mechanism of the mentioned diseases.

Conclusion

This study, therefore, suggests that; antiviral and anticancer drugs could have anti-psoriatic effects, and molecules with purine and pyrimidine structural architecture are likely templates to consider in developing anti-psoriatic agents.

Noninvasive DW-MRI metrics for staging hepatic fibrosis and grading inflammatory activity in patients with chronic hepatitis B

PURPOSE

To assess the value of various diffusion parameters obtained from monoexponential, biexponential, and stretched-exponential diffusion-weighted imaging (DWI) models for staging hepatic fibrosis (HF) and grading inflammatory activity in patients with chronic hepatitis B (CHB).

METHODS

82 patients with CHB and 30 healthy volunteers underwent DWI with 13 b-values on a 3T MRI unit. The standard apparent diffusion coefficient (ADC_st) was calculated using a monoexponential model. The true diffusion coefficient (D_t), pseudo-diffusion coefficient (D_p), and perfusion fraction (f) were calculated using a biexponential model. The distributed diffusion coefficient (DDC) and water-molecule diffusion heterogeneity index (α) were calculated using a stretched-exponential model. Receiver operating characteristic (ROC) curves were performed for diffusion parameters to compare the diagnosis performance.

RESULTS

The distributions of hepatic fibrosis stages and the inflammatory activity grades (METAVIR scoring system) were as follows: F0, n = 1; F1, n = 16; F2, n = 31; F3, n = 19; and F4, n = 15. A0, n = 1; A1, n = 14; A2, n = 46; and A3, n = 21. ADC_st, D_t and DDC values showed negative correlation with the fibrosis stage (r = - 0.418, - 0.717 and - 0.630, all P < 0.001) and the inflammatory activity grade (r = - 0.514, - 0.626 and - 0.550, all P < 0.001). The area under the ROC curve (AUC) of D_t (AUC = 0.854, 0.881) and DDC (AUC = 0.794, 0.834) were significantly higher than that of ADC_st (AUC = 0.637, 0.717) in discriminating significant fibrosis (≥ F2) and advanced fibrosis (≥ F3) (all P < 0.05). Although D_t (AUC = 0.867, 0.836) and DDC (AUC = 0.810, 0.808) showed higher AUCs than ADC_st (AUC = 0.767, 0.803), there was no significant difference in their ability in detecting inflammatory activity grade ≥ A2/A3 (P > 0.05).

CONCLUSIONS

D_t and DDC are promising indicators and outperform ADC_st for staging HF. While both D_t and DDC have similar diagnostic performance compared with ADC_st for grading inflammatory activity.

Disease burden of chronic hepatitis B and complications in China from 2006 to 2050: an individual-based modeling study

Background

Chronic hepatitis B has become a major public health problem in China. An accurate depiction of the disease burden has not yet been thoroughly conducted. We aimed to project the disease burden of chronic hepatitis B virus (HBV) infection and related complications by modeling various scenarios.

Method

An individual-based Markov model was used to predict disease burden from 2006 through 2050. We simulated 5 scenarios with different annual incidences, diagnoses and nucleotide analog (NA) treatment rates as well as treatment eligibility, which included a natural history without diagnosis or NA therapy, a base case, a World Health Organization (WHO)-proposed target case and two ideal cases.

Result

The natural history scenario is projected to have the fewest HBsAg losses (27.59 million) and highest number of HBV-related deaths (27.19 million). With improved diagnosis and treatment rates of NA therapy, ideal cases have fewer HBV-related deaths (14.46–14.77 million) than do WHO-proposed cases (15.13 million) and base cases (16.89 million), but the proportion of HBsAg loss is similar among them. With a reduction in new infections, the prevalence of chronic HBV in 2050 is expected to be a minimum of 27.03–27.49 million under WHO and ideal cases.

Conclusion

Ideal scenarios 1 and 2 contribute to the lowest disease burden of HBV and its complications in the future, in which new infection control is more effective than increasing diagnosis, treatment rate and treatment eligibility. However, considering the large existing chronic HBV infected population and the low HBsAg loss rate of NA therapy, it is still difficult to avert the increasing trend of cumulative cirrhosis, DC, HCC, LT, and HBV-related death in all scenarios. If new high-potency drugs are not developed, the disease burden of chronic HBV will remain high in the future.

Assessment of risk factors, and racial and ethnic differences in hepatocellular carcinoma

Despite improved screening and surveillance guidelines, significant race/ethnicity‐specific disparities in hepatocellular carcinoma (HCC) continue to exist and disproportionately affect minority and disadvantaged populations. This trend indicates that social determinants, genetic, and environmental factors are driving the epidemic at the population level. Race and geography had independent associations with risk of mortality among patients with HCC. The present review discusses the risk factors and issues related to disparities in HCC. The underlying etiologies for these disparities are complex and multifactorial. Some of the risk factors for developing HCC include hepatitis B (HBV) and hepatitis C (HCV) viral infection, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, smoking and alcohol consumption. In addition, population genetics; socioeconomic and health care access; treatment and prevention differences; and genetic, behavioral, and biological influences can contribute to HCC. Acculturation of ethnic minorities, insurance status, and access to health care may further contribute to the observed disparities in HCC. By increasing awareness, better modalities for screening and surveillance, improving access to health care, and adapting targeted preventive and therapeutic interventions, disparities in HCC outcomes can be reduced or eliminated.

Liver Fibrosis: Mechanistic Concepts and Therapeutic Perspectives

Liver fibrosis due to viral or metabolic chronic liver diseases is a major challenge of global health. Correlating with liver disease progression, fibrosis is a key factor for liver disease outcome and risk of hepatocellular carcinoma (HCC). Despite different mechanism of primary liver injury and disease-specific cell responses, the progression of fibrotic liver disease follows shared patterns across the main liver disease etiologies. Scientific discoveries within the last decade have transformed the understanding of the mechanisms of liver fibrosis. Removal or elimination of the causative agent such as control or cure of viral infection has shown that liver fibrosis is reversible. However, reversal often occurs too slowly or too infrequent to avoid life-threatening complications particularly in advanced fibrosis. Thus, there is a huge unmet medical need for anti-fibrotic therapies to prevent liver disease progression and HCC development. However, while many anti-fibrotic candidate agents have shown robust effects in experimental animal models, their anti-fibrotic effects in clinical trials have been limited or absent. Thus, no approved therapy exists for liver fibrosis. In this review we summarize cellular drivers and molecular mechanisms of fibrogenesis in chronic liver diseases and discuss their impact for the development of urgently needed anti-fibrotic therapies.

PD-L1 is induced on the hepatocyte surface via CKLF-like MARVEL transmembrane domain-containing protein 6 up-regulation by the anti-HBV drug Entecavir

Chronic hepatitis B is now controllable when treated with nucleoside reverse transcriptase inhibitors (NRTIs), which inhibit hepatitis B virus (HBV) replication. However, once the NRTIs are discontinued, most patients relapse, necessitating lifelong NRTIs treatment. HBV infection relapse is assumed to be caused by the persistent existence of covalently closed circular DNA (cccDNA) in the nuclei of infected hepatocytes. The mechanism by which cccDNA-positive hepatocytes escape immune surveillance during NRTIs treatment remains elusive. Entecavir (ETV), a commonly used NRTI, post-transcriptionally up-regulates programmed cell death-ligand 1 (PD-L1), an immune checkpoint molecule, on the cell surface of hepatocytes regardless of HBV infection. Up-regulation by ETV depends on up-regulation of CKLF-like MARVEL transmembrane domain-containing 6, a newly identified potent regulator of PD-L1 expression on the cell surface. ETV-treated hepatic cells suppressed the activity of primary CD3 T cells and programmed cell death protein-1 (PD-1)-over-expressed Jurkat cells. Finally, ETV induces PD-L1 in primary hepatocytes infected by HBV. These results provide evidence that ETV considerably up-regulates PD-L1 on the cell surface of infected hepatocytes, which may be one of the mechanisms by which infected hepatocytes subvert immune surveillance.

Upregulation of microRNA-328-3p by hepatitis B virus contributes to THLE-2 cell injury by downregulating FOXO4

Background

Hepatitis B virus (HBV) remains a major cause of chronic hepatitis and hepatocellular carcinoma, and miRNAs play important roles in HBV pathogenesis. Our previous study has shown that miR-328-3p is upregulated in HBV-infected patients and serves as a potent predictor for the prognosis of HBV-related liver failure.

Methods

Here, the role of miR-328-3p in modulating cell injury in HBV-infected liver cells THLE-2 was investigated in detail. MiR-328-3p expression was examined using qRT-PCR. The levels of pro-inflammatory cytokines were measured using ELISA. HBV RNA and HBV DNA levels were quantified. The interactions between STAT3 and miR-328-3p promoter as well as miR-328-3p and FOXO4 were analyzed using chromatin immunoprecipitation (CHIP) assay and luciferase reporter assay, respectively. THLE-2 cell injury was evaluated by examining cell viability and apoptosis.

Results

HBV promoted expression of miR-328-3p through the STAT3 signal pathway and that increasingly expressed miR-328-3p downregulated its target FOXO4, leading to the promotion of cell injury in HBV-infected liver cells THLE-2.

Conclusion

These data demonstrate that HBV-STAT3-miR-328-3p-FOXO4 regulation pathway may play an important role in the pathogenesis of HBV infection.

The HLA-G 14-bp insertion/deletion polymorphism is associated with chronic hepatitis B in Southern Brazil: A case-control study

There is growing evidence that the non-classical HLA-G has a role in the process of the immune response against pathogens, including HBV and HIV. Previous studies demonstrated that a 14-bp insertion/deletion (indel) polymorphism at 3'-untranslated region of HLA-G gene interferes in the mRNA stability and expression. The present study aimed to evaluate the association of the 14-bp indel polymorphism (rs371194629) with HBV infection in chronic hepatitis B (CHB) mono-infected and HBV/HIV co-infected patients from Southern Brazil. A total of 817 individuals were analyzed, including 357 CHB patients, 134 HBV/HIV co-infected patients and 326 healthy controls. The 14-bp indel polymorphism was analyzed by DNA amplification using PCR. Logistic regression models were performed to compute adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs). To control for multiple comparisons, the Bonferroni correction was applied to the p-values. The 14-bp Ins allele was observed in 47.6% of the CHB mono-infected patients and in 41.6% of the controls (aOR = 1.33; 95% CI: 1.05-1.60; p = 0.02; p_corrected = 0.08). The results also showed that the 14-bp Ins/Ins genotype was present in 21.8% of the CHB mono-infected patients and in 12.9% of the controls (aOR = 1.91; 95% CI: 1.21-3.01; p < 0.01; p_corrected = 0.02). There was significant association between the 14-bp indel and CHB monoinfection, but not in HBV/HIV co-infection. In conclusion, the 14-bp indel polymorphism was associated with CHB in this specific population.

Impact of maternal HIV-HBV coinfection on pregnancy outcomes in an underdeveloped rural area of southwest China

OBJECTIVES

Our objective was to determine the impact of maternal HIV-hepatitis B virus (HBV) coinfection on pregnancy outcomes.

METHODS

The current study was conducted in a county of Yi Autonomous Prefecture in southwest China. Data were abstracted from hospitalisation records, including maternal and infant information. The seroprevalences of HIV and HBV infections and HIV-HBV coinfection were determined and the impact of maternal HIV-HBV coinfection on adverse pregnancy outcomes was assessed using logistic regression analysis. A treatment effects linear regression model was also applied to examine the effect of HBV, HIV or coinfection to quantify the absolute difference in birth weight from a reference of HBV-HIV negative participants.

RESULTS

A total of 13 198 pregnant women were included in our study, and among them, 99.1% were Yi people and 90.8% lived in rural area. The seroprevalences of HIV and HBV infections and HIV-HBV coinfection were 3.6% (95% CI: 3.2% to 3.9%), 3.2% (95% CI: 2.9% to 3.5%) and 0.2% (95% CI: 0.1% to 0.2%) among the pregnant women, respectively. Maternal HIV-HBV coinfection was a risk factor for low birth weight (adjusted OR (aOR)=5.52, 95% CI: 1.97 to 15.40). Compared with the HIV mono-infection group, the risk of low birth weight was significantly higher in the HIV-HBV coinfection group (aOR=3.62, 95% CI: 1.24 to 10.56). Maternal HIV infection was associated with an increased risk of low birth weight (aOR=1.90, 95% CI: 1.38 to 2.60) and preterm delivery (aOR=2.84, 95% CI: 1.81 to 4.47). Perinatal death was more common when mothers were infected with HBV (aOR=2.85, 95% CI: 1.54 to 5.26).

CONCLUSIONS

The prevalence of HIV infection was high among pregnant women of the Yi region. Both HIV and HBV infections might have adverse effects on pregnancy outcomes. Maternal HIV-HBV coinfection might be a risk factor for low birth weight in the Yi region, which needs to be confirmed.

Chronic hepatitis B: dynamic change in Traditional Chinese Medicine syndrome by dynamic network biomarkers

Background

In traditional Chinese medicine (TCM) clinical practice, TCM syndromes help to understand human homeostasis and guide individualized treatment. However, the TCM syndrome changes with disease progression, of which the scientific basis and mechanism remain unclear.

Methods

To demonstrate the underlying mechanism of dynamic changes in the TCM syndrome, we applied a dynamic network biomarker (DNB) algorithm to obtain the DNBs of changes in the TCM syndrome, based on the transcriptomic data of patients with chronic hepatitis B and typical TCM syndromes, including healthy controls and patients with liver-gallbladder dampness-heat syndrome (LGDHS), liver-depression spleen-deficiency syndrome (LDSDS), and liver-kidney yin-deficiency syndrome (LKYDS). The DNB model exploits collective fluctuations and correlations of the observed genes, then diagnoses the critical state.

Results

Our results showed that the DNBs of TCM syndromes were comprised of 52 genes and the tipping point occurred at the LDSDS stage. Meanwhile, there were numerous differentially expressed genes between LGDHS and LKYDS, which highlighted the drastic changes before and after the tipping point, implying the 52 DNBs could serve as early-warning signals of the upcoming change in the TCM syndrome. Next, we validated DNBs by cytokine profiling and isobaric tags for relative and absolute quantitation (iTRAQ). The results showed that PLG (plasminogen) and coagulation factor XII (F12) were significantly expressed during the progression of TCM syndrome from LGDHS to LKYDS.

Conclusions

This study provides a scientific understanding of changes in the TCM syndrome. During this process, the cytokine system was involved all the time. The DNBs PLG and F12 were confirmed to significantly change during TCM-syndrome progression and indicated a potential value of DNBs in auxiliary diagnosis of TCM syndrome in CHB.

Trial registration Identifier: NCT03189992. Registered on June 4, 2017. Retrospectively registered (http://www.clinicaltrials.gov)

Stigma among healthcare workers towards hepatitis B infection in Bangalore, India: a qualitative study

BACKGROUND

With about 50 million people infected with hepatitis B (HBV) in India the burden of disease is high. Stigma has been identified to have a major negative impact on screening, diagnosis and treatment of hepatitis B patients. The aim of this study was to assess the stigma in nurses and physicians in Bangalore, India; studies on stigma in HBV have only been published outside of India.

METHODS

Semi-structured in-depth-interviews were conducted in the period of March 20th and April 16th 2018 to study stigma and other problems in the care of hepatitis B patients. Stigma was pragmatically defined as a mark of disgrace associated with having a hepatitis B infection. Thirty physicians and nurses in different clinics and hospitals across the city of Bangalore were selected by purposeful sampling and snowball effect until theoretical saturation was reached.

RESULTS

The following themes were identified during the interviews: feelings when treating a patient; pregnancy and marriage; confidentiality; morality; improvement in care and the difference with HIV. The most stigma was discovered in the theme morality. The majority of our participants mentioned lack of awareness as biggest obstacle in health care of hepatitis B patients.

CONCLUSIONS

This is the first qualitative study in India exploring hepatitis B stigma among health care workers. Stigma was found in certain themes, such as morality. Though, no unwillingness to treat was found. There was a general lack of awareness amongst patients according to our participants and could jeopardize proper treatment. These results will further help in developing strategies to tackle hepatitis B in India.

Soluble mannose receptor as a predictor of prognosis of hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND

Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is a syndrome with a high short-term mortality rate, and it is crucial to identify those patients at a high mortality risk clinically.

AIM

To investigate the clinical value of soluble mannose receptor (sMR) in predicting the 90-day mortality of HBV-ACLF patients.

METHODS

A total of 43 patients were diagnosed with HBV-ACLF between October 2017 and October 2018 at the Second Hospital of Anhui Medical University, and all of them were enrolled in this retrospective study. Their serum sMR levels were determined using an enzyme-linked immunosorbent assay. Demographic and clinical data, including gender, age, albumin level, total bilirubin (TBIL) level, international normalized ratio, HBV-DNA level, HBV serological markers, procalcitonin level, interleukin-6 level, and model for end-stage liver disease (MELD) score were accessed at the time of diagnosis of HBV-ACLF. A multivariate logistic regression analysis was used to analyze the independent risk factors for mortality.

RESULTS

Serum sMR level was significantly increased in HBV-ACLF patients compared with chronic hepatitis B patients and healthy controls (P < 0.01). When compared with surviving patients, it was higher in those patients who succumbed to HBV-ACLF (P < 0.05). Serum sMR level was positively correlated with MELD score (r_s = 0.533, P = 0.001), HBV-DNA level (r_s = 0.497, P = 0.022), and TBIL level (r_s = 0.894, P < 0.001). Serum sMR level (odds ratio = 1.007, 95% confidence interval: 1.004–1.012, P = 0.001) was an independent risk factor for the 90-day mortality in the HBV-ACLF cases. The patients with HBV-ACLF were stratified into two groups in accordance with their serum sMR levels at the baseline (low risk: < 99.84 pg/mL and high risk: ≥ 99.84 pg/mL). The 90-day mortality rates were 27.3% in the low-risk group and 87.5% in the high-risk group. Furthermore, sMR level apparently improved the performance of MELD score for predicting the prognosis of patients with HBV-ACLF.

CONCLUSION

Serum sMR level may be a predictor of the prognosis of HBV-ACLF patients.

Effects of Moloney Leukemia Virus 10 Protein on Hepatitis B Virus Infection and Viral Replication

Moloney leukemia virus 10 (MOV10) is an RNA helicase that has been shown to affect the replication of several viruses. The effect of MOV10 on Hepatitis B virus (HBV) infection is not known and its role on the replication of this virus is poorly understood. We investigated the effect of MOV10 down-regulation and MOV10 over-expression on HBV in a variety of cell lines, as well as in an infection system using a replication competent virus. We report that MOV10 down-regulation, using siRNA, shRNA, and CRISPR/Cas9 gene editing technology, resulted in increased levels of HBV DNA, HBV pre-genomic RNA, and HBV core protein. In contrast, MOV10 over-expression reduced HBV DNA, HBV pre-genomic RNA, and HBV core protein. These effects were consistent in all tested cell lines, providing strong evidence for the involvement of MOV10 in the HBV life cycle. We demonstrated that MOV10 does not interact with HBV-core. However, MOV10 binds HBV pgRNA and this interaction does not affect HBV pgRNA decay rate. We conclude that the restriction of HBV by MOV10 is mediated through effects at the level of viral RNA.

Immune network for viral hepatitis B: Topological representation

The liver is a well-known immunotolerogenic environment, which provides the adequate setting for liver infectious pathogens persistence such as the hepatitis B virus (HBV). Consequently, HBV infection can derive in the development of chronic disease in a proportion of the patients. If this situation persists in time, chronic hepatitis B (CHB) would end in cirrhosis, hepatocellular carcinoma and eventually, the death of the patient. It is thought that this immunotolerogenic environment is the result of complex interactions between different elements of the immune system and the viral biology. Therefore, the purpose of this work is to unravel the mechanisms implied in the development of CHB and to design a tool able to help in the study of adequate therapies. Firstly, a conceptual framework with the main components of the immune system and viral dynamics was constructed providing an overall insight on the pathways and interactions implied in this disease. Secondly, a review of the literature was performed in a modular fashion: (i) viral dynamics, (ii) innate immune response, (iii) humoral and (iv) cellular adaptive immune responses and (v) tolerogenic aspects. Finally, the information collected was integrated into a single topological representation that could serve as the plan for the systems pharmacology model architecture. This representation can be considered as the previous unavoidable step to the construction of a quantitative model that could assist in biomarker and target identification, drug design and development, dosing optimization and disease progression analysis.

Novel Hepatitis B Virus Capsid-Targeting Antiviral That Aggregates Core Particles and Inhibits Nuclear Entry of Viral Cores

An estimated 240 million are chronically infected with hepatitis B virus (HBV), which can lead to liver disease, cirrhosis, and hepatocellular carcinoma. Currently, HBV treatment options include only nucleoside reverse transcriptase inhibitors and the immunomodulatory agent interferon alpha, and these treatments are generally not curative. New treatments with novel mechanisms of action, therefore, are highly desired for HBV therapy. The viral core protein (Cp) has gained attention as a possible therapeutic target because of its vital roles in the HBV life cycle. Several classes of capsid assembly effectors (CAEs) have been described in detail, and these compounds all increase capsid assembly rate but inhibit HBV replication by different mechanisms. In this study, we have developed a thermal shift-based screening method for CAE discovery and characterization, filling a much-needed gap in high-throughput screening methods for capsid-targeting molecules. Using this approach followed by cell-based screening, we identified the compound HF9C6 as a CAE with low micromolar potency against HBV replication. HF9C6 caused large multicapsid aggregates when capsids were assembled in vitro and analyzed by transmission electron microscopy. Interestingly, when HBV-expressing cells were treated with HF9C6, Cp was excluded from cell nuclei, suggesting that this compound may inhibit nuclear entry of Cp and capsids. Furthermore, mutational scanning of Cp suggested that HF9C6 binds the known CAE binding pocket, indicating that key Cp-compound interactions within this pocket have a role in determining the CAE mechanism of action.

Sustained serological and complete responses in HBeAg-positive patients treated with Peginterferon alfa-2b: a 6-year long-term follow-up of a multicenter, randomized, controlled trial in China

BACKGROUND

Pegylated interferon (PEG-IFN) alfa-2b is recommended for chronic hepatitis B (CHB). We aimed to investigate the sustainability of off-treatment responses among Chinese HBeAg-positive CHB patients treated with PEG-IFN alfa-2b from a randomized trial.

METHODS

Eligible Chinese patients (n = 322) were followed up by one visit after a median of 6 years (LTFU) following their participation in a randomized trial evaluating the efficacy of three PEG-IFN alfa-2b dosing regimens (1.0 or 1.5 μg/kg/wk. 24 weeks or 1.5 μg/kg/wk. 48 weeks). Primary endpoints at the LTFU were sustained SR and CR (SR/CR at the end of original study [EOS] and at the LTFU). SR was defined as HBeAg loss and seroconversion to anti-HBe and CR as HBeAg loss and seroconversion to anti-HBe and HBV-DNA < 2000 IU/mL.

RESULTS

The proportions of patients achieving sustained SR among patients who had SR at EOS were high in three treatment groups (61.9, 65.5, 76.5%, respectively, p = 0.46); treatment with PEG-IFN alfa-2b 1.5 μg/kg/wk. 48 weeks had the highest proportion of a sustained CR among patients who had CR at EOS (75.0%, p = 0.05). A considerable number of patients achieved sustained SR (18.2-29.9%) and sustained CR (14.8-18.3%) after EOS despite no further NA treatment. At the LTFU, rates of SR and CR were less than 70.0 and 50.0%, respectively, among all enrolled patients regardless of additional nucleos(t)ide analogs before the LTFU.

CONCLUSIONS

PEG IFN alfa-2b therapy had considerable off-treatment sustainability in Chinese HBeAg positive chronic hepatitis B patients with serological and complete responses.

Real-Life State of Anti-Hepatitis B Virus Drug Choice in Child-Bearing Age Male Patients and Effect on Fertility and Fetal Safety

Research on effects of anti-hepatitis B virus (HBV) nucleoside analogs on male fertility and birth defects is limited and safety of nucleoside analogs in pregnancy is still a concern. Chronic hepatitis B (CHB) patients in Guangdong province were surveyed using a structured questionnaire. We collected data including medication type, fertility, and birth defects. Moreover, a survey of the knowledge of antiviral nucleoside analogs safety in fertility of male patients was conducted among physicians nationwide. Semen samples of 30 patients were collected. We screened 1050 HBV-positive male patients. Reasons for not receiving antivirals in 150 patients were "did not meet criteria for antiviral therapy," fertility, and financial. Furthermore, 900 participants received antivirals (85.71%, 900/1050), including 792 patients with children and 15.15% (120/792) took anti-HBV treatment when preparing for pregnancy. Based on whether they received antiviral therapy during conception or not, we divided patients into two groups. In the child-bearing age group, 88.33% (106/120) of patients received telbivudine (LDT), whereas the other group mainly received entecavir (ETV) (87.20%, 586/672). No significant difference occurred in birth defect incidence rates between both groups. Furthermore, 558 physicians completed questionnaires. Reasons that influenced drug selection were "patient's condition," "fertility demand," "financial condition," and "compliance." Telbivudine was the first-choice drug (32.80%, 183/558) while tenofovir (TDF) was the second (2.69%, 15/558). Additionally, 61.47% of physicians considered telbivudine or tenofovir as the first choice for male patients who met antiviral criteria, whereas 19% suggested delayed therapy and follow-up until childbirth. No significant changes occurred in semen volume, concentration, mobility, and percentage before and after administration of anti-HBV nucleoside analogs, which did not affect male fertility and birth defect incidence while the desire for pregnancy influenced drug selection and timing of administration. Further research on the effects of analogs on male fertility and fetal safety is required.

Diagnosis and Management of Hepatitis B and C

Hepatitis B and C are complex and dynamic viral infections. An infected individual spreads the viruses to an uninfected individual in contaminated blood and body fluids. Acute hepatitis B and C infections may or may not produce mild symptoms and spontaneously resolve. Some individuals will progress to chronic hepatitis B and C, which can lead to liver fibrosis, cirrhosis, hepatocellular carcinoma, and possibly death. Choosing medications available to treat chronic hepatitis B and C is based on individual serology results, including genotype and level of liver damage. Treatment has been successful in inducing remission and complete recovery in many individuals.

Current state-of-the-art pharmacotherapy for the management of hepatitis B infection

INTRODUCTION

Hepatitis B virus (HBV) infection remains a global challenge with several hundred million infected individuals. Disease activity can be controlled, and adverse outcomes prevented when treatment can be provided. Frequently life-long therapy is required instead of defined treatment periods such as with the case of Hepatitis C Virus (HCV) infection.

AREAS COVERED

In this review, the authors provide an overview of current start of the art therapy for HBV and indicate where variation from the current guidelines could be considered. Certain patients may be eligible for treatment with suboptimal therapies when their baseline viral load is low. Identifying ideal candidates for interferon therapy will result in good sustained responses for some patients.

EXPERT OPINION

The biggest challenge remains linking patients to care and therapy. Patients can nowadays be sufficiently treated before the disease advances to a more progressed phase. However, future therapies must be extremely safe and ideally limit the required treatment period. Given Hepatitis D Virus's dependence on HBV and being a disease with an unmet clinical need, HDV may be the best target group for the development of a functional cure for hepatitis B.

Yinchenhao decoction for chronic hepatitis B: Protocol for a systematic review and meta-analysis

BACKGROUND

Chronic hepatitis B (CHB) is a very critical threat to public health worldwide, and is the primary cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC). Yinchenhao decoction (YCHD) is a classic prescription of traditional Chinese medicine for the treatment of jaundice. Despite the satisfactory clinical efficacy of YCHD in the treatment of CHB, the safety of YCHD is still uncertain. Therefore, we will provide a systematic review of YCHD in CHB treatments.

METHODS

The purpose of this review is to retrieve relevant literature on YCHD therapy for CHB in the electrical databases, including 4 Chinese databases (e.g., Wanfang database, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical database (CBM), Chinese Science and Technology Periodical database (VIP)) and 3 English databases (e.g., PubMed, Cochrane Library, and EMBASE). The literatures involved are from the establishment of the databases to January 2019. The primary outcomes are HBV-DNA, HBeAg, and ALT. We will calculate the data synthesis for meta-analysis using RevMan V.5.3 software if the results are suitable.

RESULTS

This study will offer a high-quality composite of existing evidence for YCHD in CHB treatment according to HBV-DNA quantitative detection, HBeAg qualitative detection, ALT levels, TCM syndrome evaluation criteria, status changes in quality of life assessment participants, and adverse events.

CONCLUSION

This systematic review will provide evidence to assess the clinical efficacy of YCHD in the treatment of patients with CHB.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019119720.

B-Cell Lymphoma 6 (BCL6) Is a Host Restriction Factor That Can Suppress HBV Gene Expression and Modulate Immune Responses

Hepatitis B virus (HBV) infection causes acute and chronic liver inflammation. Recent studies have demonstrated that some viral antigens can suppress host innate and adaptive immunity, and thus lead to HBV liver persistency. However, the cellular factors that can help host cells to clear HBV during acute infection remain largely unknown. Here, we used HBV-cleared and HBV-persistent mouse models to seek for cellular factors that might participate in HBV clearance. HBV replicon DNA was delivered into the mouse liver by hydrodynamic injection. RNA-Seq analysis was conducted to identify immune-related genes that were differentially expressed in HBV-persistent and HBV-cleared mouse models. A cellular factor, B cell lymphoma 6 (BCL6), was found to be significantly upregulated in the liver of HBV-cleared mice upon HBV clearance. Co-expression of BCL6 and a persistent HBV clone rendered the clone largely cleared, implicating an important role of BCL6 in controlling HBV clearance. Mechanistic studies demonstrated that BCL6 functioned as a repressor, binding to and suppressing the activities of the four HBV promoters. Correspondingly, BCL6 expression significantly reduced the levels of HBV viral RNA, DNA, and proteins. BCL6 expression could be stimulated by inflammatory cytokines such as TNF-α; the BCL6 in turn synergized TNF-α signaling to produce large amounts of CXCL9 and CXCL10, leading to increased infiltrating immune cells and elevated cytokine levels in the liver. Thus, positive feedback loops on BCL6 expression and immune responses could be produced. Together, our results demonstrate that BCL6 is a novel host restriction factor that exerts both anti-HBV and immunomodulatory activities. Induction of BCL6 in the liver may ultimately assist host immune responses to clear HBV.

Assessment of histopathological alterations in patients with chronic hepatitis B infection following long-term oral antiviral therapy

Objectives:

To evaluate the histopathological changes in the liver after oral antiviral therapy in patients with chronic hepatitis B.

Methods:

A total of 79 HBeAg-negative and positive patients who had been on lamivudine, entecavir, or tenofovir disoproxil for at least 3 years prior to inclusion were enrolled between March 2015 and 2016, retrospectively. There were 23 patients on lamivudine, 21 patients on entecavir, and 35 on tenofovir. All patients underwent a follow-up liver biopsy. Biochemical, serological, virological and histopathological data were recorded in all patients and were compared after at least 3 years of treatment with oral antiviral agents.

Results:

Histological activity index scores were reduced in patients who received lamivudine (p=0.011), entecavir (p=0.002), and tenofovir (p=0.001). Also, in contrast with a significant improvement in fibrosis scores in lamivudine (p=0.033) and tenofovir (p=0.001) groups no improvements were found in patients who received entecavir (p=0.090).

Conclusion:

Long term treatment with oral antiviral agents was associated with biochemical, virological, serological, and histopathological improvements. Long-term use of anti-viral agents as well as continuous suppression of HBV DNA are prerequisites for histopathological improvement.

Serum NGAL Is Superior to Cystatin C in Predicting the Prognosis of Acute-on-Chronic Liver Failure

INTRODUCTION AND AIM

Acute-on-chronic liver failure (ACLF) is a syndrome with high short-term mortality, and predicting the prognosis is challenging. This study aimed to compare the performance of neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C (CysC) in predicting the 90-day mortality in patients with hepatitis B virus (HBV)-associated ACLF (HBV-ACLF).

MATERIALS AND METHODS

This prospective, observational study enrolled 54 patients with HBV-ACLF. The serum NGAL and CysC levels were determined. A multivariate logistic regression analysis was used to analyze the independent risk factors of mortality.

RESULTS

Serum NGAL, but not CysC, was found to significantly correlate with the total bilirubin, international normalized ratio, and model for end-stage liver disease (MELD). Serum NGAL [odds ratio (OR), 1.008; 95% confidence interval (CI), 1.004-1.012; P < 0.01], but not CysC, was an independent risk factor for developing hepatorenal syndrome. Moreover, NGAL (OR, 1.005; 95% CI, 1.001-1.010; P < 0.01) along with the MELD score was independently associated with the overall survival in patients with HBV-ACLF. Patients with HBV-ACLF were stratified into two groups according to the serum NGAL level at baseline (low risk: <217.11 ng/mL and high risk: ≥ 217.11 ng/mL). The 90-day mortality rate was 22.73% (5/22) in the low-risk group and 71.88% (23/32) in the high-risk group. Moreover, NGAL, but not CysC, significantly improved the MELD score in predicting the prognosis of HBV-ACLF.

CONCLUSION

The serum NGAL might be superior to CysC in predicting the prognosis of HBV-ACLF with the normal creatinine level.

The immunological function of extracellular vesicles in hepatitis B virus-infected hepatocytes

Hepatitis B virus (HBV) generates large amounts of complete and incomplete viral particles. Except for the virion, which acts as infectious particles, the function of those particles remains elusive. Extracellular vesicles (EVs) have been revealed to have biological functions. The EVs which size are less than 100 nm in diameter, were collected from HBV infected-patients. These vesicles contain, complete and incomplete virions, and exosomes, which have been recently shown to be critical as intercellular communicators. Here, the effects of the exosome, the complete, and the incomplete particles on the target cells were investigated. These particles are endocytosed by monocyte/macrophages and function primarily to upregulate PD-L1. The functions and composition of the EVs were affected by nucleotide reverse transcriptase inhibitors (NRTIs), suggesting that the EVs are involved in the pathogenesis of HBV hepatitis and clinical course of those patients treated by NRTIs.

Renal complications of liver diseases

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are the major causes of chronic liver disease. HBV and HCV affect nearly 7% of the world's population. Extra-hepatic complications and particularly renal failure have different mechanisms and manifestations. The underlying mechanism, although differing for each disease, mainly involves the immune system and antibody deposits in the kidney, which can lead to tissue damage. Areas covered: We do not cover in this review hepatorenal syndrome. We report on the renal complications of viral hepatitis (HBV, HCV, hepatitis E), autoimmune hepatitis, cirrhosis, and Wilson's disease. The most frequent renal disorders are those related to HBV, and HCV due to their high prevalence worldwide. Expert commentary: Thanks to generalization of vaccination against HBV, prevalence of HBV-related liver diseases will decrease, and thereby its associated renal involvement such as polyarteritis nodosa (an exceptional condition), and glomerulonephritis such as membranous nephropathy. Thanks to direct acting antiviral agents HCV infection will be cured within the next decade. However, HCV-related cryoglobulinemia with or without renal involvement might evolve on its own after the patient has eliminated HCV, necessitating then rituximab therapy. Conversely, orofecal-transmitted hepatitis viruses such as hepatitis A and hepatitis E are still very prevalent in developing countries; however, they are rarely associated with renal manifestations.

Comprehensive Analysis of Hepatitis B Virus Promoter Region Mutations

Over 250 million people are infected chronically with hepatitis B virus (HBV), the leading cause of liver cancer worldwide. HBV persists, due, in part, to its compact, stable minichromosome, the covalently-closed, circular DNA (cccDNA), which resides in the hepatocytes' nuclei. Current therapies target downstream replication products, however, a true virological cure will require targeting the cccDNA. Finding targets on such a small, compact genome is challenging. For HBV, to remain replication-competent, it needs to maintain nucleotide fidelity in key regions, such as the promoter regions, to ensure that it can continue to utilize the necessary host proteins. HBVdb (HBV database) is a repository of HBV sequences spanning all genotypes (A⁻H) amplified from clinical samples, and hence implying an extensive collection of replication-competent viruses. Here, we analyzed the HBV sequences from HBVdb using bioinformatics tools to comprehensively assess the HBV core and X promoter regions amongst the nearly 70,000 HBV sequences for highly-conserved nucleotides and variant frequencies. Notably, there is a high degree of nucleotide conservation within specific segments of these promoter regions highlighting their importance in potential host protein-viral interactions and thus the virus' viability. Such findings may have key implications for designing antivirals to target these areas.

Long-term clinical outcomes in patients with viral hepatitis related liver cirrhosis after transjugular intrahepatic portosystemic shunt treatment. Virol J. 2018;15:151. [PMID: 30285813 PMCID: PMC6167830 DOI: 10.1186/s12985-018-1067-7]

Background

Transjugular intrahepatic portosystemic shunt (TIPS) procedure has played a vital role in management of portal hypertension. Thus, we aimed to investigate the natural history, long-term clinical outcome, predictors of survival in viral hepatitis related cirrhotic patients post-TIPS.

Method

A total of 704 patients with complete followed-up data were enrolled, and clinical characteristics of patients were collected and analyzed. Kaplan-Meier method was used to calculate survival, and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model.

Results

TIPS implatantion significantly decreased portal vein pressure with 9.77 cmH₂O reduction, without influencing long-term liver functions. The total incidence rate of major complication post-TIPS, including HE and re-bleeding/bleeding, was 37.9% and 15.5%, respectively. Patients in Child-Pugh C stage revealed higher overt hepatic encephalopathy (HE) occurrence (65.6%), while patients receiving covered, 6 mm in diameter stents indicated notably lower incidence of HE in comparison with other groups (6.4%). The median survival was > 60 months, 27.0 months, and 11.5 months in cirrhotic patients with variceal bleeding, refractory ascites, and both complications, respectively. The cumulative 5-year survival was significantly higher in patients with variceal bleeding (75.6%) in comparison with either that in patients with refractory ascites (12.5%) or that in patients with both complications (1.96%) (P < 0.0001). Covered stents usage, baseline model for end-stage liver disease (MELD) score, and baseline Child-Pugh classification were predictive of survival (P < 0.001). Other variables including age, male gender, and pre-TIPS PVP were not emerged as significant predictors (P > 0.05).

Conclusion

TIPS was an effective and safe therapeutic method for decompression of portal hypertension and for treatment of its complications. Careful selection of patients with minimal liver dysfunction for TIPS implantation was essential for better long-term outcomes.

High Prevalence of Cirrhosis at Initial Presentation Among Safety-Net Adults with Chronic Hepatitis B Virus Infection

BACKGROUND AND AIMS

Delays in diagnosis of chronic hepatitis B virus infection (HBV) may be more common among underserved safety-net populations, contributing to more advanced disease at presentation. We aim to evaluate rates of and predictors of cirrhosis and cirrhosis-related complications among adults with chronic HBV.

METHODS

We retrospectively evaluated consecutive chronic HBV adults from gastroenterology clinics from July 2014 to May 2016 at a community-based safety-net hospital. Prevalence of cirrhosis or cirrhosis-related complications (ascites, variceal bleeding, hepatic encephalopathy (HE), hepatocellular carcinoma (HCC)) at initial presentation was stratified by sex and race/ethnicity. Predictors of cirrhosis or cirrhosis-related complications at presentation were evaluated with multivariate logistic regression.

RESULTS

Among 329 chronic HBV patients (mean age 49.1 years, 55.3% male, 66.5% Asian, 18.6% HBeAg positive) 27.7% had cirrhosis at presentation, 4.3% ascites, 3.7% variceal bleeding, 4.9% HE, and 4.0% HCC. Compared to women, men were more likely to have cirrhosis (34.6% vs. 19.1%, P < 0.01) and variceal bleeding (5.6% vs. 1.4%, P < 0.05) at presentation. On multivariate regression, older age at presentation (OR, 1.04; 95% CI, 1.01-1.07; P = 0.003) and positive HBeAg (OR, 2.57; 95% CI, 1.20-5.51; P = 0.015) were associated with higher odds of cirrhosis at presentation, whereas men had a non-significant trend toward higher odds of cirrhosis (OR, 1.88; 95% CI, 0.99-3.58; P = 0.055).

CONCLUSION

Among adults with chronic HBV at an ethnically diverse safety-net hospital system, nearly 30% of patients had cirrhosis at initial presentation, with the greatest risk seen among patients of male sex, older age, and with positive HBeAg.

Antiviral effects of hepatitis B virus S gene-specific anti-gene locked nucleic acid in transgenic mice

AIM

To assess the antiviral effects of hepatitis B virus (HBV) S gene-specific anti-gene locked nucleic acid (LNA) in transgenic mice.

METHODS

Thirty HBV transgenic mice were acclimatized to laboratory conditions and positive for serum HBV surface antigen (HBsAg) and HBV DNA, were randomly divided into 5 groups (n = 7), including negative control (blank control, unrelated sequence control), positive control (lamivudine, anti-sense-LNA), and anti-gene-LNA experimental group. LNA was injected into transgenic mice by tail vein while lamivudine was administered by gavage. Serum HBV DNA and HBsAg levels were determined by fluorescence-based PCR and enzyme-linked immune sorbent assay, respectively. HBV S gene expression amounts were assessed by reverse transcription polymerase chain reaction. Positive rates of HBsAg in liver cells were evaluated immunohistochemistry.

RESULTS

Average rate reductions of HBsAg after treatment on the 3^rd, 5^th, and 7^th days were 32.34%, 45.96%, and 59.15%, respectively. The inhibitory effect of anti-gene-LNA on serum HBsAg peaked on day 7, with statistically significant differences compared with pre-treatment (0.96 ± 0.18 vs 2.35 ± 0.33, P < 0.05) and control values (P < 0.05 for all). Average reduction rates of HBV DNA on the 3^rd, 5^th, and 7^th days were 38.55%, 50.95%, and 62.26%, respectively. This inhibitory effect peaked on the 7^th day after treatment with anti-gene-LNA, with statistically significant differences compared with pre-treatment (4.17 ± 1.29 vs 11.05 ± 1.25, P < 0.05) and control values (P < 0.05 for all). The mRNA levels of the HBV S gene (P < 0.05 for all) and rates of HBsAg positive liver cells (P < 0.05 for all) were significantly reduced compared with the control groups. Liver and kidney function, and histology showed no abnormalities.

CONCLUSION

Anti-gene-LNA targeting the S gene of HBV displays strong inhibitory effects on HBV in transgenic mice, providing theoretical and experimental bases for gene therapy in HBV.

48-Week Outcome after Cessation of Nucleos(t)ide Analogue Treatment in Chronic Hepatitis B Patient and the Associated Factors with Relapse

Background and Aims

We aimed to ascertain the feasibility and safety of NA cessation, the status of patients after cessation, and the predictive factors for relapse and subsequent retreatment.

Methods

A total of 92 patients were enrolled in this prospective study. Patients were monitored every month for the first 3 months after cessation and every 3 months thereafter.

Results

Sixty-two patients finished 48 weeks of follow-up. None died or developed liver failure, cirrhosis, or HCC. The 62 patients could be divided into 4 categories according to the 48-week clinical development of relapse. Virologic relapses occurred in 39 (62.9%) patients, with 72.7% occurring in the first 24 weeks in origin HBeAg positive patients and 82.4% in the first 12 weeks in origin HBeAg negative patients. Age (OR = 1.06, 95% CI = 1.02-1.10; p = 0.003), the HBsAg level (OR = 2.21, 95% CI = 1.47-3.32; p < 0.001), and positive origin HBeAg status (OR = 0.32, 95% CI = 0.14-0.74; p = 0.008) were predictive factors to virologic relapse. HBV DNA level (OR = 1.34, 95% CI = 1.13-1.58; p < 0.001) was predictive factor to retreatment.

Conclusions

NA cessation is safe under supervision. Age, HBsAg level, and origin HBeAg status can be predictive factors for virologic relapse. The study was submitted to ClinicalTrials.gov Protocol Registration and Results System with the assigned NCT ID NCT02883647.

Pharmacokinetics studies of 4'-cyano-2'-deoxyguanosine, a potent inhibitor of the hepatitis B virus, in rats

OBJECTIVES

4'-cyano-2'-deoxyguanosine (CdG), a novel nucleoside analogue, has a high degree of antiviral activity against the chronic hepatitis B virus (HBV). The objective of this study was to develop an analytical method for quantitatively determining CdG levels in biological samples by liquid chromatography-mass spectrometry (LC/MS) and to investigate the pharmacokinetic properties of CdG in rats after intravenous and oral administration.

METHODS

An analytical method using a UPLC system interfaced with a TOF-MS system was developed and validated. The pharmacokinetic properties after the intravenous and oral administration of CdG to rats were evaluated. In vivo pharmacokinetic interactions between CdG and entecavir were also investigated.

KEY FINDINGS

A rapid, simple and selective method for the quantification of CdG in biological samples was established using LC/MS with solid-phase extraction. In vivo pharmacokinetic studies of CdG in rats demonstrated that CdG is highly bioavailable, is rapidly absorbed from the intestinal tract, is then distributed to the liver rather than kidney and is ultimately excreted via the urine in an unchanged form. The co-administration of CdG and entecavir led to pharmacokinetic interactions with each other.

CONCLUSIONS

The data generated in this study provide support for the clinical development of CdG for use in the treatment of HBV.

Prevalence and natural course of occult hepatitis B virus infection in residents of 2 communities of Wuwei City, Gansu Province, China

Occult hepatitis B infection (OBI) is characterized by serum hepatitis B surface antigen (HBsAg) negative and hepatitis B virus (HBV) DNA positive (HBsAg-/HBV DNA+). Occult hepatitis B infection in community-based populations has been scarcely investigated, and OBI outcomes remain unclear, especially in Wuwei, a region located in Northwest China. This region is one of the areas in China that has the highest prevalence of chronic HBV infection. A prospective study was performed in the general population of 2 towns of Wuwei from June 2011 to May 2014. A questionnaire was used to collect demographic and medical data, and serum samples were collected from the participants and stored until analysis. DNA was detected using quantitative PCR (qPCR) or nested PCR, the HBV DNA from HBV DNA-positive or possible positive (below the detection limit) subjects was extracted and amplified by nested PCR, and the PCR products were sequenced. Sequence analysis was performed using the Mega 6.0 program and CLC sequence viewer software. Hepatitis B virus DNA was detected in 90 of 3,080 HBsAg-negative subjects, and the prevalence of OBI in the study population was 2.92% (90/3,080, 95% CI: 2.33%-3.51%). Hepatitis B virus genomes in 51 of 80 objects (63.75%) contained mutations in the "a" determinant of HBsAg. After 2 years follow-up, 42 of 90 HBV DNA of OBI subjects remained positive, and the natural clearance rate of OBI subjects was 53.3%. Occult hepatitis B infection prevalence in this cohort was much lower than chronic HBV infection in the same region. HBV DNA was cleared in most OBI subjects during the 2 year period. Our data suggest that some OBI may represent a late stage of resolving the HBV infection process.