Association of hepatitis delta virus with liver morbidity and mortality: A systematic literature review and meta-analysis

BACKGROUND AND AIMS

Studies have suggested that patients with chronic hepatitis B, either co- or superinfected, have more aggressive liver disease progression than those with the HDV. This systematic literature review and meta-analysis examined whether HDV RNA status is associated with increased risk of advanced liver disease events in patients who are HBsAg and HDV antibody positive.

APPROACH AND RESULTS

A total of 12 publications were included. Relative rates of progression to advanced liver disease event for HDV RNA+/detectable versus HDV RNA-/undetectable were extracted for analysis. Reported OR and HRs with 95% CI were pooled using the Hartung-Knapp-Sidik-Jonkman method for random-effects models. The presence of HDV RNA+ was associated with an increased risk of any advanced liver disease event [random effect (95% CI): risk ratio: 1.48 (0.93, 2.33); HR: 2.62 (1.55, 4.44)]. When compared to the patients with HDV RNA- status, HDV RNA+ was associated with a significantly higher risk of progressing to compensated cirrhosis [risk ratio: 1.74 (1.24, 2.45)] decompensated cirrhosis [HR: 3.82 (1.60, 9.10)], HCC [HR: 2.97 (1.87, 4.70)], liver transplantation [HR: 7.07 (1.61, 30.99)], and liver-related mortality [HR: 3.78 (2.18, 6.56)].

CONCLUSIONS

The patients with HDV RNA+ status have a significantly greater risk of liver disease progression than the patients who are HDV RNA-. These findings highlight the need for improved HDV screening and linkage to treatment to reduce the risk of liver-related morbidity and mortality.

Utility of novel viral and immune markers in predicting HBV treatment endpoints: A systematic review of treatment discontinuation studies

Background & Aims

Antivirals represent the mainstay of chronic hepatitis B treatment given their efficacy and tolerability, but rates of functional cure remain low during long-term therapy. Treatment discontinuation has emerged as a strategy to maintain partial cure and achieve functional cure in select patient groups. We aimed to evaluate how data from treatment discontinuation studies exploring novel viral and/or immune markers could be applied to the functional cure program.

Methods

Treatment discontinuation studies evaluating novel viral and/or immune markers were identified by a systematic search of the PubMed database through to October 30, 2022. Data extraction focused on information regarding novel markers, including identified cut-off levels, timing of measurement, and associated effect on study outcomes of virological relapse, clinical relapse, and HBsAg seroclearance.

Results

From a search of 4,492 citations, 33 studies comprising a minimum of 2,986 unique patients met the inclusion criteria. Novel viral markers, HBcrAg and HBV RNA, were demonstrated across most studies to be helpful in predicting off-therapy partial cure, with emerging evidence to support a link with functional cure. From novel immune marker studies, we observed that treatment discontinuation has the potential to trigger immune restoration, which may be associated with a transient virological relapse. To this end, these studies support the combination of virus-directing agents with immunomodulator therapies to induce two key steps underlying functional cure: viral antigen load reduction and restoration of the host immune response.

Conclusions

Patients with a favourable profile of novel viral and immune markers stand to benefit from a trial of antiviral treatment discontinuation alongside novel virus-directing agents with the aim of achieving functional cure without excessive risk of severe clinical relapse.

Impact and implications

Select patients with chronic hepatitis B undergoing nucleoside analogue therapy may benefit from a trial of treatment discontinuation, aiming to maintain partial cure and/or achieve functional cure. We propose a profile of novel viral and immune markers to identify patients who are likely to achieve these goals without excessive risk of hepatic decompensation. Furthermore, treatment discontinuation may also be considered as a therapeutic strategy to trigger immune restoration, which may increase the chance of functional cure when used in conjunction with novel virus-directing agents.

PD-1 blockade partially recovers dysfunctional virus-specific B cells in chronic hepatitis B infection

Chronic HBV (CHB) infection suppresses virus-specific T cells, but its impact on humoral immunity has been poorly analyzed. Here, we developed a dual-staining method that utilizes hepatitis B virus (HBV) surface antigens (HBsAg) labeled with fluorochromes as "baits" for specific ex vivo detection of HBsAg-specific B cells and analysis of their quantity, function, and phenotype. We studied healthy vaccinated subjects (n = 18) and patients with resolved (n = 21), acute (n = 11), or chronic (n = 96) HBV infection and observed that frequencies of circulating HBsAg-specific B cells were independent of HBV infection status. In contrast, the presence of serum HBsAg affected function and phenotype of HBsAg-specific B cells that were unable to mature in vitro into Ab-secreting cells and displayed an increased expression of markers linked to hyperactivation (CD21lo) and exhaustion (PD-1). Importantly, B cell alterations were not limited to HBsAg-specific B cells, but affected the global B cell population. HBsAg-specific B cell maturation could be partially restored by a method involving the combination of the cytokines IL-2 and IL-21 and CD40L-expressing feeder cells and was further boosted by the addition of anti-PD-1 Abs. In conclusion, HBV infection has a marked impact on global and HBV-specific humoral immunity, yet HBsAg-specific B cells are amenable to a partial rescue by B cell-maturing cytokines and PD-1 blockade.

Circulating and intrahepatic antiviral B cells are defective in hepatitis B

B cells are increasingly recognized as playing an important role in the ongoing control of hepatitis B virus (HBV). The development of antibodies against the viral surface antigen (HBV surface antigen [HBsAgs]) constitutes the hallmark of resolution of acute infection and is a therapeutic goal for functional cure of chronic HBV (CHB). We characterized B cells directly ex vivo from the blood and liver of patients with CHB to investigate constraints on their antiviral potential. Unexpectedly, we found that HBsAg-specific B cells persisted in the blood and liver of many patients with CHB and were enriched for T-bet, a signature of antiviral potential in B cells. However, purified, differentiated HBsAg-specific B cells from patients with CHB had defective antibody production, consistent with undetectable anti-HBs antibodies in vivo. HBsAg-specific and global B cells had an accumulation of CD21-CD27- atypical memory B cells (atMBC) with high expression of inhibitory receptors, including PD-1. These atMBC demonstrated altered signaling, homing, differentiation into antibody-producing cells, survival, and antiviral/proinflammatory cytokine production that could be partially rescued by PD-1 blockade. Analysis of B cells within healthy and HBV-infected livers implicated the combination of this tolerogenic niche and HBV infection in driving PD-1hiatMBC and impairing B cell immunity.

A baseline tool for predicting response to peginterferon alfa-2a in HBeAg-positive patients with chronic hepatitis B

BACKGROUND

Peginterferon induces off-treatment responses in approximately one-third of patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B.

AIM

To develop an easy-to-use baseline prediction score to identify hepatitis B virus (HBV) genotype B-/C-infected HBeAg-positive Asian patients likely to respond to peginterferon alfa-2a.

METHODS

Generalised additive models, multiple logistic regression (MLR) analysis and internal validation methods were applied to data from 647 HBeAg-positive patients from China, Hong Kong and Taiwan to develop a scoring system to predict response 24 weeks after completing a 48-week course of peginterferon alfa-2a.

RESULTS

Five baseline factors (age, sex, alanine aminotransferase ratio, hepatitis B surface antigen (HBsAg) level and HBV DNA level) were retained in the final MLR for HBeAg seroconversion and used to develop a scoring system from 0 to 7. Among patients with scores of 0-1, 2-3, 4 or ≥5, HBeAg seroconversion was achieved in 6.4% (6/94), 23.0% (61/265), 36.4% (67/184) and 54.8% (57/104), respectively, and a combined response (HBeAg seroconversion plus HBV DNA <2000 IU/mL) in 5.3% (5/94), 12.8% (34/265), 25.0% (46/184) and 36.5% (38/104), respectively. Among patients with scores of 0-1, 2-3, 4 or ≥5, 57.0% (53/93), 12.3% (31/253), 3.4% (6/178) and 1.0% (1/100) had HBsAg ≥20 000 IU/mL at treatment Week 12; only 3/91 (3.3%) with HBsAg ≥20 000 IU/mL experienced a combined response at 24 weeks post-treatment (negative predictive value = 97% [88/91]).

CONCLUSION

A pre-treatment scoring system using readily available baseline characteristics identifies HBeAg-positive Asian patients likely to experience sustained HBeAg seroconversion after treatment with peginterferon alfa-2a.

HBV DNA Integration and Clonal Hepatocyte Expansion in Chronic Hepatitis B Patients Considered Immune Tolerant

BACKGROUND & AIMS

Chronic infection with hepatitis B virus (HBV) progresses through different phases. The first, called the immune-tolerant phase, has been associated with a lack of disease activity. We examined HBV-DNA integration, clonal hepatocyte expansion, HBV antigen expression, and HBV-specific immune responses in patients in the immune-tolerant phase to assess whether this designation is appropriate or if there is evidence of disease activity.

METHODS

We studied HBV-DNA integration, clonal hepatocyte expansion, and expression of hepatitis B surface antigen and core antigen in liver tissues from 26 patients with chronic HBV infection (ages, 14-39 y); 9 patients were positive for hepatitis B e antigen (HBeAg) in the immune-tolerant phase and were matched for age with 10 HBeAg-positive patients with active disease and 7 HBeAg-negative patients with active disease. Peripheral blood samples were collected and HBV-specific T cells were quantified for each group.

RESULTS

Detection of HBV antigens differed among groups. However, unexpectedly high numbers of HBV-DNA integrations, randomly distributed among chromosomes, were detected in all groups. Clonal hepatocyte expansion in patients considered immune tolerant also was greater than expected, potentially in response to hepatocyte turnover mediated by HBV-specific T cells, which were detected in peripheral blood cells from patients in all phases of infection.

CONCLUSIONS

We measured HBV-specific T cells, HBV-DNA integration, and clonal hepatocyte expansion in different disease phases of young patients with chronic hepatitis B, with emphasis on the so-called immune-tolerant phase. A high level of HBV-DNA integration and clonal hepatocyte expansion in patients considered immune tolerant indicated that hepatocarcinogenesis could be underway-even in patients with early stage chronic HBV infection. Our findings do not support the concepts that this phase is devoid of markers of disease progression or that an immune response has not been initiated. We propose that this early phase be called a high-replication, low-inflammation stage. The timing of therapeutic interventions to minimize further genetic damage to the hepatocyte population should be reconsidered.

Anchoring a migrating inferior vena cava stent with use of a T-fastener

An attempt to treat symptomatic stenosis of the inferior vena cava in a patient with metastatic liver disease was complicated by migration of a Wallstent into the right atrium. Effective palliation was achieved by insertion of a second stent, which was anchored by transhepatic insertion of a T-fastener into the intracaval stent. This anchoring maneuver was performed safely under sonographic and fluoroscopic guidance.

Conscious sedation and analgesia for routine aortofemoral arteriography: a prospective evaluation

PURPOSE

To compare the effectiveness of temazepam and midazolam hydrochloride with or without fentanyl citrate versus a placebo in promoting patient acceptance of diagnostic aortofemoral arteriography.

MATERIALS AND METHODS

One hundred twenty-five patients undergoing aortofemoral arteriography were prospectively and randomly assigned to one of four treatment arms: placebo (group A), oral temazepam (group B), intravenous midazolam (group C), or intravenous midazolam and fentanyl (group D). Patients were blinded to the administered sedative. Five-point scales were used to assess degree of patient discomfort, willingness to undergo the same procedure again, patient compliance, and preprocedural anxiety.

RESULTS

There was no difference between patient groups in willingness to return for a repeat procedure (P: =.89). Group C patients were less compliant during the procedure (P: =.034). Mean patient discomfort scores were 1.81 for group A, 1.84 for group B, 1. 53 for group C, and 1.27 for group D. Discomfort experienced during the procedure was not related to the degree of preprocedural anxiety (P: =.42). Patients who had previously undergone arteriography reported a higher level of pain than did those who had not (P: =. 021).

CONCLUSION

Most patients experienced only low-level discomfort during diagnostic aortofemoral arteriography. In the authors' opinion, conscious sedation should only be used selectively, not routinely, for diagnostic aortofemoral arteriography.

Early experience using duplex ultrasonography in the diagnosis of deep venous thrombosis; a prospective evaluation

Duplex ultrasound is used in many radiology departments as the first line of investigation for symptomatic deep venous thrombosis. Before changing the practice of our department from venography to duplex ultrasonography, we wanted to assess our ability to identify deep venous thrombosis on ultrasound. Thirty-eight patients were investigated for suspected deep venous thrombosis by venography and duplex ultrasound. The results were compared using venography as the 'gold standard'. Duplex ultrasound correctly identified 13 out of 16 limbs with deep venous thrombosis. Four of the 38 duplex ultrasound examinations (11%) were described as inadequate at the time of examination, and when these are excluded from the analysis a sensitivity of 93 %, and specificity of 80 % are achieved. We conclude that there is a significant learning curve when performing duplex ultrasound of the lower limb, and that change-over from venography to ultrasound should include a period during which both examinations are routinely performed.

Ultrasonography of intratesticular lesions: its role in clinical management

Ultrasound is the primary imaging modality in the investigation of patients with symptoms related to the scrotum, and is pivotal to the diagnosis of suspected testicular malignancy. This retrospective study analysed the results of testicular ultrasound at a large teaching hospital over a five year period. We wished to examine the clinical consequences for patients in whom ultrasound findings were suspicious of testicular cancer, and the accuracy of the ultrasound diagnosis. Real time ultrasound examinations were performed, providing multiplanar imaging of the testis and para testicular tissues. Over a five year period 661 examinations were carried out. An intratesticular lesion was identified in 44 patients; nineteen of these patients were shown to have testicular malignancy following tissue diagnosis. When ultrasound was used to identify testicular malignancy in those patients with an intratesticular lesion, it had a sensitivity of 94.7% and a specificity of 59.1%. A tissue diagnosis was obtained in 93% of those patients thought likely to have a testicular malignancy on sonographic assessment, and in 40% of those in whom a diagnosis of malignancy was possible, but less likely. Our study shows that this modality can be used to aid the clinician in deciding which patients should undergo orchidectomy, invasive biopsy or clinical surveillance.

Synovial chondromatosis of the cubometatarsal joint

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