Origin, HDV genotype and persistent viremia determine outcome and treatment response in patients with chronic hepatitis delta

BACKGROUND & AIMS

HDV infection causes severe chronic liver disease in individuals infected with HBV. However, the factors associated with poor prognosis are largely unknown. Thus, we aimed to identify prognostic factors in patients with HDV infection.

METHODS

The French National Reference Centre for HDV performed a nationwide retrospective study on 1,112 HDV-infected patients, collecting epidemiological, clinical, virological and histological data from the initial referral to the last recorded follow-up.

RESULTS

The median age of our cohort was 36.5 (29.9-43.2) years and 68.6% of our cohort were male. Most patients whose birthplace was known were immigrants from sub-Saharan Africa (52.5%), southern and eastern Europe (21.3%), northern Africa and the Middle East (6.2%), Asia (5.9%) and South America (0.3%). Only 150 patients (13.8%) were French native. HDV load was positive in 659 of 748 tested patients (88.1%). HDV-1 was predominant (75.9%), followed by sub-Saharan genotypes: HDV-5 (17.6%), HDV-7 (2.9%), HDV-6 (1.8%) and HDV-8 (1.6%). At referral, 312 patients (28.2%) had cirrhosis, half having experienced at least 1 episode of hepatic decompensation. Cirrhosis was significantly less frequent in African than in European patients regardless of HDV genotype. At the end of follow-up (median 3.0 [0.8-7.2] years), 48.8% of the patients had developed cirrhosis, 24.2% had ≥1 episode(s) of decompensation and 9.2% had hepatocellular carcinoma. European HDV-1 and African HDV-5 patients were more at risk of developing cirrhosis. Persistent replicative HDV infection was associated with decompensation, hepatocellular carcinoma and death. African patients displayed better response to interferon therapy than non-African patients (46.4% vs. 29.1%, p <0.001). HDV viral load at baseline was significantly lower in responders than in non-responders.

CONCLUSION

Place of birth, HDV genotype and persistent viremia constitute the main determinants of liver involvement and response to treatment in chronic HDV-infected patients.

LAY SUMMARY

Chronic liver infection by hepatitis delta virus (HDV) is the most severe form of chronic viral hepatitis. Despite the fact that at least 15-20 million people are chronically infected by HDV worldwide, factors determining the severity of liver involvement are largely unknown. By investigating a large cohort of 1,112 HDV-infected patients followed-up in France, but coming from different areas of the world, we were able to determine that HDV genotype, place of birth (reflecting both viral and host-related factors) and persistent viremia constitute the main determinants of liver involvement and response to treatment.

Hepatitis C treatment with all-oral direct-acting antivirals: Effectiveness and tolerance in a multicenter, prospective, observational study from French general hospitals (APROVVIE, ANGH)

BACKGROUND AND AIMS

According to clinical trials, the treatment of patients with chronic hepatitis C (CHC) with second-generation direct acting antiviral agents (DAAs) is highly efficient and well tolerated. The goal of this study was to investigate the effectiveness and safety of various combinations of these drugs during their first 2 years of use in the real-world practice of French general hospitals.

METHODS

Data from patients treated with all-oral DAAs in 24 French non-academic hospital centers from March 1, 2014 to January 1, 2016, were prospectively recorded. The sustained virological response 12-24 weeks after treatment (SVR 12-24) was estimated and severe adverse events (SAE) were evaluated and their predictive factors were determined using logistic regression.

RESULTS

Data from 1123 patients were analyzed. The population was 69% genotype (G) 1, 13% G3, 11.5% G4, 5% G2, 49% with cirrhosis and 55% treatment-experienced. The treatment regimens were sofosbuvir/ledipasvir (38%), sofosbuvir/daclatasvir (32%), sofosbuvir/simeprevir (17%), ombitasvir+paritaprevir+ritonavir (5%) (with dasabuvir 3.5%), and sofosbuvir/ribavirin (8%). Ribavirin was given to 24% of patients. The SVR 12-24 was 91.0% (95% CI: 89.2-92.5%). Sofosbuvir-ribavirin was less effective than other regimens. The independent predictors of SVR 12-24 by logistic regression were body weight, albumin, previous hepatocellular carcinoma and treatment regimen (sofosbuvir/ribavirin vs. others). Sixty-four severe adverse events (SAE) were observed in 59 [5.6%] patients, and were independently predicted by cirrhosis and baseline hemoglobin. Serum creatinine increased during treatment (mean 8.5%, [P<10^-5]), satisfying criteria for acute kidney injury in 62 patients (7.3%). Patient-reported overall tolerance was excellent, and patient-reported fatigue decreased during and after treatment.

CONCLUSIONS

Second generation DAAs combinations are as effective and well tolerated in a « real-world » population as in clinical trials. Further studies are needed on renal tolerance.

Coeliac disease in chronic hepatitis C: a French multicentre prospective study

BACKGROUND

A prevalence of 1.2% of coeliac disease (CD) in patients with chronic hepatitis C was recently reported, suggesting a possible epidemiological link between these two diseases. However, other studies have not found this relationship.

AIM

To conduct a French multicentre prospective study to assess the prevalence of CD in hepatitis C virus (HCV)-infected patients.

METHODS

Between June 2003 and November 2005, 624 consecutive HCV-positive out-patients were tested for antiendomysial IgA antibodies (AEA), antigliadin IgA and IgG antibodies (AGA). Patients with positive AEA or IgA AGA and positive IgG AGA in a context of a high suspicion of CD were asked to undergo gastroscopy with duodenal biopsies.

RESULTS

Isolated IgA AEA, IgA AGA and IgG AGA were 0.16%, 5.7% and 4.4%, respectively. Gastroscopy was required for 39 patients, 31 were performed (eight refusals), but only 25 duodenal biopsies were performed as six patients had cirrhosis. CD was never detected.

CONCLUSIONS

The prevalence of CD in HCV-positive patients was 0% (95% confidence interval: 0-0.59%), but there is a low prevalence of CD in the whole French population.

A randomized controlled trial of ursodeoxycholic acid in patients with alcohol-induced cirrhosis and jaundice

The aim of our multicenter study was to assess the efficacy of ursodeoxycholic acid (UDCA) on the survival of patients with alcohol-induced cirrhosis and jaundice. We included patients with histologically proven alcohol-induced cirrhosis and serum bilirubin >50 micromol/L. After randomization, patients received either UDCA (13-15 mg/kg/d) or a placebo for 6 months. Two hundred twenty-six patients (113 in each group) were included in 24 centers. There were 139 men and 87 women, mean age of 50.3 years. Seventy-four percent had associated alcohol-induced hepatitis, and 24% received a corticosteroid therapy. At inclusion, the 2 groups were comparable for the main clinical and biologic parameters, but serum bilirubin was higher in the UDCA group than in the placebo group (163 micromol/L vs. 145 micromol/L, P <.03). The percentage of patients lost at follow-up or who resumed their alcoholism during the study was comparable in the 2 groups. During the study, 55 patients died, 35 in the UDCA group and 20 in the placebo group. In the intention to treat analysis, the probability of survival at 6 months (Kaplan-Meier method) was lower in the UDCA than in the P group (69% vs. 82%, respectively; P =.04, log-rank test). After adjustment on the bilirubin level at entry (Cox model), the independent predictive value of the treatment group did not reach the statistical level (RR = 1.64, CI 0.85-2.85; P =.077). In conclusion, UDCA administered at the dose recommended in primary biliary cirrhosis has no beneficial effect on the 6-month survival of patients with severe alcohol-induced cirrhosis. An inappropriate dosage of UDCA cannot be excluded as an explanation for the lack of therapeutic benefit.

Tertiary hepatic syphilis. A treatable cause of multinodular liver

Although the incidence of syphilis is increasing, liver involvement in tertiary syphilis remains exceptional. We report a case of tertiary syphilis revealed by liver localization. The clinical picture was misleading, mimicking multinodular hepatic metastasis. The final diagnosis was suspected following a fine-needle ultrasound-guided biopsy of a liver nodule showing granulomas as well as acellular necrosis and confirmed by positive serum syphilitic reactions and the presence of spirochetes in the liver. The outcome was uneventful following antibiotic treatment. It is important to be aware of the misleading picture of the disease, which has a favorable prognosis provided that simple treatment is rapidly initiated.

Does elective sclerotherapy improve the efficacy of long-term propranolol for prevention of recurrent bleeding in patients with severe cirrhosis? A prospective multicenter, randomized trial

We conducted a prospective, multicenter, randomized trial to compare the efficacy of sclerotherapy plus propranolol with that of propranolol alone in the prevention of recurrent gastroesophageal bleeding in severely cirrhotic patients. For 2 yr (1987 to 1988) 131 patients (96% of whom were alcoholic) with Child-Pugh class B or C cirrhosis (56% were class B and 44% were class C) were randomly assigned to one of our two treatment groups after cessation of variceal bleeding, without hemostatic sclerosis, and were observed for at least 2 yr. Treatment observance was good in 89% of cases; alcohol withdrawal was observed in 62% of cases. Sclerotherapy was performed weekly with 1% polidocanol, and variceal obliteration was obtained in 83% of cases, in a mean number of four sessions. The cumulative percentages (expressed as mean +/- S.D.) of recurrent bleeding at 2 yr were 42% +/- 6% for propranolol plus sclerotherapy and 59% +/- 6% for propranolol alone (a nonsignificant difference). Twenty-eight patients from the propranolol group but only 12 patients from the propranolol-plus-sclerotherapy group had recurrent bleeding from esophageal variceal rupture (p less than 0.01). The total number of blood units per patient with recurrent bleeding was slightly but not significantly more important in the propranolol group (8 +/- 7) than in the propranolol-plus-sclerotherapy group (5 +/- 5; p = 0.09).(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of severe alcoholic hepatitis by infusion of insulin and glucagon: a multicenter sequential trial

Severe alcoholic hepatitis is still a therapeutic challenge. It has been recently advocated that a 3-wk infusion with insulin and glucagon reduces its short-term mortality rate. A multicenter, randomized, single-blind, sequential trial was designed to compare this treatment with placebo. The triangular boundary was defined with alpha = 0.05, beta = 0.10 and estimated survival at 4 wk of 50% with placebo, 75% with treatment. Patients with biopsy-proven severe alcoholic hepatitis (presence of one or more of three criteria: encephalopathy, prothrombin activity less than or equal to 50%, bilirubinemia greater than or equal to 100 mumol/L) were randomized into two groups; one treatment group received an infusion (12 hr/day) of an association of insulin (30 IU) and glucagon (3 mg), and a control group received an infusion of glucose. Treatments were administered during a 3-wk period, and the mortality rate was noted at 4 wk. The decision to discontinue the trial was reached on the basis of results from the first 44 patients. Overall results were assessed in the 72 patients included at the time of this decision (treatment group: n = 37; control group: n = 35). Fifty-three patients had cirrhosis. No significant differences were noted between the two groups at inclusion on the basis of clinical, laboratory and histological criteria. The mortality rate was not significantly different in the two groups; 10 patients (27%) in the treatment group and 5 patients (14%) in the control group died. Causes of death were similar in the two groups and consisted primarily of gastrointestinal hemorrhage, hepatic failure and infectious events.(ABSTRACT TRUNCATED AT 250 WORDS)

[Vitamin C. From scurvy to the ideal vitamin balance]

Scurvy is caused by severe deficiency of vitamin C or ascorbic acid, and is usually diagnosed by the overt clinical signs which appear at an advanced stage. Laboratory examinations, and in particular ascorbic acid assays, do not yet enable subclinical vitamin C deficiency to be reliably detected; hence the importance of knowing the situation which expose to this deficiency.

[Serum and tissue concentrations of zinc after oral supplementation in chronic alcoholics with or without cirrhosis]

Seric and hepatic zinc concentrations are decreased in chronic alcoholics, particularly those with cirrhosis. The purpose of this study was: 1) to assess the duration of zinc intake necessary to normalize seric and hepatic zinc concentrations; 2) to demonstrate that this supplementation did not increase zinc concentrations in other tissues (erythrocytes, leukocytes and hair) and did not induce adverse reactions. Twenty alcoholic patients with (group A: n = 13 or without (group B: n = 7) cirrhosis received zinc sulfate 600 mg daily during 10 days, 10 patients with alcoholic cirrhosis during 30 days (group C) and 7 during 60 days (group D) and were compared with a group of 30 normal subjects. Serum zinc concentrations increased to normal values in all groups of patients. Hepatic zinc increased significantly in groups B (p less than 0.05) and D (p less than 0.01). Zinc concentrations in erythrocytes, leukocytes and hair were unchanged. No adverse reactions were observed. We conclude that seric zinc concentrations reached normal values in alcoholics with or without cirrhosis by daily supplementation of 600 mg zinc sulfate during 10 days to 2 months while hepatic zinc concentrations increased but remained under normal values in some patients, particularly those with cirrhosis.

[Fibronectin in the ascitic fluid: its diagnostic significance]

We studied fibronectin concentration in the ascitic fluid of 102 patients, 71 with cirrhosis, 13 with hepatocellular carcinoma, 12 with malignant peritonitis, and six with miscellaneous disease. Fibronectin concentrations in the first three groups were 45 +/- 45 mg/l, 54 +/- 84 mg/l, and 144 +/- 123 mg/l, respectively. The difference between patients with cirrhosis and malignant peritonitis was significant (p less than 0.01). However, fibronectin concentration greater than 100 mg/l had a sensitivity of 58 per cent and a specificity of 86 per cent for the diagnosis of malignant peritonitis. Ascitic fluid protein content over 30 g/l had the same sensitivity and specificity was 90 per cent. Among cirrhotic patients, high fibronectin concentrations were demonstrated in those with long-standing ascites (m = 134 +/- 58 mg/l) whereas the lowest concentrations were found in patients with severe hepatocellular failure (m = 12 +/- 9 mg/l). Concentrations were significantly different, according to whether or not spontaneous bacterial peritonitis occurred later (20 +/- 13 mg/l versus 52 +/- 49 mg/l); 83 per cent of patients with spontaneous bacterial peritonitis during their clinical course had initial fibronectin concentrations above 30 mg/l in their ascites. We conclude that: 1) measurement of fibronectin concentration in ascitic fluid is of poor diagnostic value for discrimination between malignant and non malignant ascitic, 2) low concentrations of fibronectin are associated with the occurrence of spontaneous bacterial peritonitis in cirrhotic patients. Hypothetically, the quantitative defect of fibronectin could be responsible for bacterial opsonization impairment in these patients.

[Does oral zinc improve the cellular immunity of patients with alcoholic cirrhosis?]

A depressed response to delayed hypersensitivity skin tests is frequent in patients with alcoholic cirrhosis. Immune dysfunction in these patients is presumably dependent on nutritional factors. Zinc deficiency, a common finding in alcoholic cirrhosis, inhibits cellular immunity and might be one of these factors. The aim of our study was to show that zinc supplementation may improve cellular immunity in patients with alcoholic cirrhosis. We therefore compared 2 groups of patients: patients in the treated group (n = 18) had a daily oral intake of zinc-sulfate, 200 mg, during 2 months, patients in the non treated group (n = 20) received no supplementation. Both groups had a free diet. Delayed hypersensitivity skin tests to 7 antigens were performed with the Multitest IMC System at the beginning and at the end of the study. The immunity score was determined by the number of tests producing a skin induration greater than 2 mm. The evolutive index, calculated in each patient, was the difference between the final and initial immunity scores. The 2 groups were similar for all studied parameters. Cumulated immunity scores improved from 35 to 53 in treated patients (p less than 0.02), and from 42 to 44 (NS) in non treated patients. The evolutive index was 1 +/- 1.4 in treated patients and 0.1 +/- 1 in non treated patients (p less than 0.05). We conclude that in patients with alcoholic cirrhosis, daily intake of zinc sulfate, 200 mg, improves responsiveness to delayed hypersensitivity skin tests.(ABSTRACT TRUNCATED AT 250 WORDS)

CA 125 (ovarian tumour-associated antigen) in ascitic liver diseases

The presence of Ca 125, an ovarian cancer-associated antigen, was assessed in serum from patients with liver diseases with (n = 26) and without (n = 26) ascites. Abnormal levels of serum CA 125 were observed in all patients with ascites and in 4 patients without ascites (15%). We conclude that CA 125 is a non-specific marker of ascites whatever the origin: ovarian carcinoma, cirrhosis or peritoneal inflammatory process.

[Hepatitis and mononucleosis syndrome related to the ingestion of salazosulfapyridine]

The authors report the case of a patient treated by salazosulfapyridine and presenting with hepatitis and mononucleosis. The clinical pattern was similar to infectious mononucleosis including pharyngitis and lymphadenopathy but infection by Epstein Barr virus or cytomegalovirus has been ruled out by serological tests. Responsibility of salazosulfapyridine was highly suggested by the following facts: hepatocellular necrosis was sharply centrolobular, plasmocytosis was the main finding in the white blood cells count and all abnormalities rapidly improved after treatment withdrawal. The authors point out that salazosulfapyridine intolerance could mimic infectious mononucleosis and viral hepatitis. In such cases the drug must be rapidly withdrawn to avoid massive hepatic necrosis.

[Hepatocellular carcinoma and the alpha 1-antitrypsin phenotype]

To determine whether or not alpha 1-antitrypsin phenotype PiMZ is a predisposing factor for hepatocellular carcinoma alpha 1-antitrypsin phenotype was studied in 83 French patients with hepatocellular carcinoma compared with 1,030 blood donors. In 66 patients, alpha 1-antitrypsin phenotype was determined by isoelectric focusing which allows the distinction between subtypes of phenotype M. No difference has been shown between the two groups for alpha 1-antitrypsin alleles or subtypes of allele Pi*M. The authors conclude that phenotype PiMZ is not a significant predisposing factor for hepatocellular carcinoma in French people. As well, a review of literature suggests that, in contrast with the conclusion of previous reports, the link between alpha 1-antitrypsin phenotype PiMZ and hepatocellular carcinoma is either nonexistent or very weak.