Giovanni Battista GaetaUnità Epatiti Virali Acute e CronicheSeconda Università di Napoli

Paestum, 18 maggio 2006

Il portatore di HBV: inattivo o malato ?

Il progresso nella definizionedella malattia da HBV

HBsAg (Antigene Australia)

ALT (epatite post-trasfusionale a lunga

incubazione, evoluzione in cronicità)

Istologia (Desmet, 1973)

Biologia Molecolare

Anni’50-’60

’60

’70

‘90

2000Alta sensibilità

The “healthy carrier”: the histology era

de Franchis et al. Ann Intern Med 1993; 118:191-194

Baseline: 92 pts, HBsAg positive blood donors,

normal ALT

Follow-up: mean 130 mo., 68 pts; 21 with biopsy

HBV-DNA: spot-dot hybridization

No Caption FoundCharacteristics at the baseline

HBV-DNA : 10/60

End of follow-up

Limits of a healthy carrier definition based on liver

histology and low sensitivity DNA testing

–Dependent upon:•Length of biopsy – 20mm optimal •Number of biopsies performed•Type of biopsy needle used•Pathologist experience

–HBV-DNA testing:•Spot-dot hybridizazion reveals pg of DNA•Subjective lecture

Digene Corp.

Roche MolecularSystems

Bayer Corp.

102 104103 105 106 107 108 1010109101HBV DNA IU/mL

HBV Digene Hybrid-Capture I

HBV Digene Hybrid-Capture II

Ultra-Sensitive Digene Hybrid-Capture II

Amplicor HBV Monitor

Cobas Amplicor HBV Monitor

Versant HBV DNA 1.0 NA

Versant HBV DNA 3.0

Cobas Taqman 48 HBV

Available HBV DNA Assays

Locarnini et al., Antiv.Therapy 2004

Artus Biotech Real Art HBV LC PCR

102 104103 105 106 107 108 1010109101HBVDNA cp/mL

The era of molecular biology

Few copies of HBV-DNA can be detected

(10 –102)

What the clinical significance ?

infection/disease

Inactive HBsAg carrier

Presence of HBsAg and anti-HBe in serum Serum HBV DNA < 105 copies/ml Persistently normal serum ALT > 6 months Liver histology (not essential) HAI grade < 3

Standardisation of Nomenclature for Hepatitis B Standardisation of Nomenclature for Hepatitis B (EASL consensus conference September 2002)(EASL consensus conference September 2002)

Digene Corp.

Roche MolecularSystems

Bayer Corp.

102 104103 105 106 107 108 1010109101HBV DNA IU/mL

HBV Digene Hybrid-Capture I

HBV Digene Hybrid-Capture II

Ultra-Sensitive Digene Hybrid-Capture II

Amplicor HBV Monitor

Cobas Amplicor HBV Monitor

Versant HBV DNA 1.0 NA

Versant HBV DNA 3.0

Cobas Taqman 48 HBV

Available HBV DNA Assays

Locarnini et al., Antiv.Therapy 2004

Artus Biotech Real Art HBV LC PCR

102 104103 105 106 107 108 1010109101HBVDNA cp/mL

Serum HBV DNA and Liver Inflammation in Chronic Serum HBV DNA and Liver Inflammation in Chronic Hepatitis BHepatitis B

His

tolo

gy

Act

ivit

y In

dex

(H

AI)

HBV DNA level (log10 c/mL)

His

tolo

gy

Act

ivit

y In

dex

(H

AI)

HBV DNA level (log10 c/mL)

Review of 26 prospective studies

Correlation between HAI and HBV DNAin untreated patients (r=0.78; P=0.0001)

Mommeja-Marin H, et al. Hepatology. 2003:37:1309-1319.

Median log10 HBV DNA decrease

Med

ian

imp

rove

men

t in

HA

I

Median log10 HBV DNA decrease

Med

ian

imp

rove

men

t in

HA

I

Correlation between change in HBV DNA and HAI with treatment Review of 26 prospective studies

Mommeja-Marin H, et al. Hepatology. 2003:37:1309-1319.

(r=0.96; P<0.0000)

Natural history of inactive HBsAg carriersNatural history of inactive HBsAg carriersIncidence per 100 person years of major eventsIncidence per 100 person years of major events

De Franchis

1993

Bellentani

2002

Manno

2004

Hsu

2002

● area Europe Europe Europe Asia

● N° patients 68 46 296 189

● Median follow-up (yrs) 10 9 29 8

● Histologic deterioration

0.15 NR NR 0.06

● HCC 0 0 0.02 0.19

● Liver-related death 0 0 0.01 0

● HBsAg loss 1.0 0.9 1.0 0.6

NR = not reported

Survival in HBsAg carriers and controlspatients= 296

controls = 157

Manno et al., Gastroenterology 2004;127:756-763

Percentage of patients who cleared HBsAg

Manno et al., Gastroenterology 2004;127:756-763

Chronic HBsAg carriers: HBV DNA level

Villeneuve JP et al. Gastroenterology 1994. Martinot –Peignoux M et al. J.Hepatol 2002. Hsu et al Hepatology 2002. Mommeja-Marin H et al. Hepatology 2003; Manno,Gastroenterology 2004.

InactivePatients

CHBHBeAg +

Se

rum

HB

V D

NA

(c

op

ies

/mL

)

CHBHBeAg –

102

103

106

107

108

109

1010

104

105

23,820 enrolled

in 1991-1992

4,155 HBsAg positive 19,665 HBsAg negative

3,851 HBV-DNA tested

3,774 included in the analysis

395 with cirrhosis

The R.E.V.E.A.L. – HBV STUDYRisk Evaluation of Viral Load Elevation and Associated Liver Disease

Chen CJ, EASL Meeting 2005, Abs.#476

Cumulative incidence of cirrhosis

Iloeje et al, Gastroenterology 2006; 130:678-686

N = 3582N = 3582

P <0.001

Log rank test

P <0.001

Log rank test

HBeAg negative with normal ALT at Baseline n= 2925

Cumulative incidence of hepatocellular carcinoma

Chen CJ, JAMA 2006; 295:65-73

ALT flares in chronic hepatitis BALT flares in chronic hepatitis B

0

100

200

300

400

AL

T I

U/l

months

HBV-DNA, ALT and IgM anti-HBcHBV-DNA, ALT and IgM anti-HBcin 40 hepatitis exacerbations in 23 HBV carriersin 40 hepatitis exacerbations in 23 HBV carriers

HBV-DNAALTIgM anti-HBc

HBV-DNA increments preceded or were simultaneous to ALT elevations in 96.2% of cases. The ALT flares preceded or

were simultaneous to IgM anti-HBc increments in 96.2% of cases

Colloredo Mels G., 1994

Classification of inactive carrier vs. chronic hepatitis

HBV DNA

>vs < 30.000 cp

HBV DNA

>vs < 100.000 cp

anti-HBc IgM

>vs < 0.200

DNA + IgM

94.3

90.8

81.6

92.0

80.0

68.0

56.0

92.0

100.0

100.0

91.6

91.9

Correct Sensitivity Specificity

classification

Manesis, Am J Gastro 2003

705 HBsAg positive subjects in 18 Centers

202 inactive carriers (29%)

84 follow-up (6 mo.) 12% DNA increase >1 log

6.6% ALT elevation

1 anti-HBs seroconversion

Piccolo et al, EASL 2006, abs. # 469

Inactive HBV carriers in Central Italy

Outcome of anti-HBe pos chronic hepatitis B Outcome of anti-HBe pos chronic hepatitis B

102 Patients with chronic hepatitis at histology

From: Brunetto, 2002

cirrhosis

49.2%

Median follow-up

6 years (2-12)

cirrhosis

6.2%

Progression to cirrhosis

•2-5%/yr in HBeAg positive patients• 8-10% in HBeAg neg•Predictors: older age, alcohol, coinfections,•recurrent flares, bridging necrosis, •fibrosis stage, genotype(?)

Outcome of HBsAg/anti-HBe pos cirrhosis Outcome of HBsAg/anti-HBe pos cirrhosis

From: Brunetto, 2002

worsened

22%

Median follow-up

6 years (2-12)

cirrhosis

at

baseline

no. = 62

10 HCC

9 terminalevents

Hepatic decompensation• 3%/yr 47% with ascites 12% jaundice 9% variceal bleeding 30% more than one

Hepatocellular carcinomawithout cirrhosis < 0.2%/yr (Western areas) 0.6% in Asiawith cirrhosis > 2.0%/yrPredictors: older age, male gender, alcohol, environmental factors, coinfections, genotype

Cofactors influencing the outcomeof inactive HBV carriers

• HCV coinfection

• HDV coinfection

• HIV coinfection

• Alcohol abuse, steroids, immunosuppression

The “healthy” carrier ( inactive with chronic HBV; PNAL withchronic HCV)

viraemia

liver histology

outcome

HBV

<104 cp/ml

minimal,inactive fibrosis

stable

HCV

wide range

20%significant

20-30%progression

case-definition sensitive

A new type of HBV carrier:

The occult carrier

Occult HBV infectionHBV-DNA detectable in liver tissue (± serum) by PCR based methods following disappearance of HBsAg in

serum

30% in HCV chronic infections30% in HCV chronic infections

60% in HBsAg negative hepatocellular carcinoma60% in HBsAg negative hepatocellular carcinoma

Torberson & Thomas, Lancet Infect Dis, 2002Pollicino et al, Gastroenterology, 2004

HBV-DNA>10,000 cp/ml = area rischio

(2000 IU/ml)Seguire per un anno ad intervalli di

3 mesi ALT, anti-HBc IgM, HBV-DNA Biopsia epatica nei casi dubbi

Il portatore di HBV: inattivo o malato ?

Paziente HBsAg positivo con ALT normali: