HBV Diagnosis and On-treatment Monitoring

Transcription

1 HBV Diagnosis and On-treatment Monitoring Department of Microbiology Peking University Health Science Center Hui Zhuang 1

2 Discovery of Hepatitis B Virus Blumberg (39 yrs) discovered a new Ag in the serum of an Australian aboriginal using an agar gel diffusion technique (AGD) called immunodifusion (ID). [Blumberg BS, et al. Precipitating antibodies against a serum protein ( Australia antigen ) in the serum of transfused hemophilia patients, J Clin Invest 1965; 44:1029] Noble Prize in Medicine in

3 1970: HBV Particles Were Found in Serum of Patients with Australia-Antigen-Associated Hepatitis HBV Dane DS, Cameron CH, and Briggs M Dane DS, Cameron CH, and Briggs M. Virus-like particles in serum of patients with Australia-antigen-associated hepatitis. Lancet 1970; 1:

4 Development of HBsAg Tests HBsAg qualitative tests Blood screening Diagnosis of HBV infection HBsAg quantitative tests Monitoring antiviral therapy AGD CIEP RPHA RIA EIA CLIA (CMIA) qclia (CMIA) 1960s 1970s 1980s 1990s

5 Level Diagnosis of Acute and Chronic HBV Infection Acute HBV Infection Resolved HBeAg Acute (<6 months ) Chronic HBV Infection Chronic (>6months) Symptoms HBeAg Anti-HBe HBeAg Anti-HBe HBsAg HBV DNA Anti-HBc HBV DNA Anti-HBc HBsAg IgM Anti-HBc Anti-HBs IgM Anti-HBc Year Weeks after Exposure Weeks or Years after Exposure 5

6 Development of HBV DNA Testing Hybridization Polymerase Chain Reaction (PCR) Dot blot Situ hybridization Qualitative PCR Quantitative PCR 1980s 1990s 2000s Abbott M2000 (10~15 IU/mL) bdna (1987) ( cp/ml) COBAS TaqMan (12~20 IU/mL) 6

7 Linear Ranges of Current HBV DNA Quantitative Assays Amplicor HBV Monitor v2.0 (Roche) HBV Hybrid-Capture II (Digene) Ultra-sensitive HBV Hybrid-Capture II II Versant HBV DNA 3.0 (bdna, Siemens) CobasTaqman HBV (12~20 IU/mL) RealArt HBV LC PCR (ArtusBiotech) Abbot Real-time HBV (Abbott) (10~15 IU/mL) Versant HBV DNA 1.0 (kpcr, Siemens)* * 正研发 7

8 Pathways of HBV DNA and HBsAg Production Reverse transcription Chan HL. J Hepatol 2011; 55:

9 Different Meanings of HBV DNA and HBsAg in CHB HBV DNA HBsAg Dane particle Dane particle + Subviral particles Viral replication Viral replication cccdna transcription & mrna translation Decline of HBV DNA: Decline of replication Reduced after HBeAg seroconversion but relapse on immune escape Decline of HBsAg: Decline of cccdna, cccdna transcription/mrna translation Immune clearance of infected hepatocytes Brunetto MR, et al. Gastroenterology 2010;139:

10 HBsAg Has Moderate Correlation with Intrahepatic HBV cccdna and HBV DNA in CHB Wang MR, et al. J Med Virol

11 log HBsAg (IU/mL) log HBsAg ()IU/mL Correlation between HBV DNA and HBsAg in HBeAg (+) CHB Is Better than in HBeAg (-) CHB 1344 samples from 539 HBeAg (+) and 805 HBeAg (-) patients 6.00 HBeAg (+) CHB 6.00 HBeAg (-) CHB r = 0.798, p< r = 0.041, p= log HBV DNA (IU/mL) log HBV DNA (IU/mL) Sun KX, et al. Vaccine 2012; 30:

12 HBsAg Helps to Differentiate Active from Inactive HBV Infections HBsAg HBV DNA HBeAg Anti-HBe ALT Immune tolerant Immune clearance HBeAg (+) CHB Inactive CHB Reactivation HBeAg (-) CHB Treatment Treatment Lok ASF, et al. Arch Intern Med 2006; 166:

13 Low HBsAg and HBV DNA Levels Indicate Immune Control Chan HL, et al. Hepatology 2010; 52: ; Nguyen T, et al. J Hepatol 2010; 52: ; Jaroszewicz J, et al. J Hepatol 2010; 52:

14 Combined Single-Point Quantification of HBsAg <1,000 IU/mL and HBV DNA 2,000 IU/mL Identified Inactive Carriers Positive predictive value (PPV): 90 % Negative predictive value (NPV): 97 % Genotype D HBeAg (-) patients Liaw YF. Hepatology 2011; 53: ; Brunetto MR, et al. Gastroenterology 2010; 139:

15 HBsAg <1,000 IU/mL and HBV DNA <2,000 IU/mL Predicts Very Low Risk of HCC Tseng TC, et al. Gastroenterology 2012; 142: ;Chan HL et al. Gastroenterology 2012;142:

16 Mean change in HBsAg (log IU/mL) 0 Prediction of Sustained Response to PEG-IFN- 2b via HBsAg Decline Treatment Responders week 78 (N=43) Nonresponders week 78 (N=178) Responders clearly showed an early decline in HBsAg when compared to non-responders Week Mean change in serum HBsAg from baseline in patients who achieved a response (HBeAg loss and HBV DNA <10,000 copies/ml) at week 78 and those who did not. Sonneveld MJ, et al. Hepatology 2010; 52:

17 HBV DNA (log cp/ml) HBsAg (log IU/mL) HBsAg, More than HBV DNA, Can Distinguish Between Relapsers and Responders to PEG-IFN in HBeAg (-) CHB Sustained response (N=12)* Relapse (N=18)** Non-responder (N=18) Week Week Moucari R, et al. Hepatology 2009; 49: *HBV DNA negative by PCR at 1 year after antiviral therapy. ** HBV DNA was undetectable at the end of treatment, but positive at 24 weeks of the follow-up 17

18 HBeAg seroconversion at week 12 (%) HBeAg seroconversion at week 24 (%) Lowest HBsAg Levels at Week 12 and Week 24 Are Associated with Higher Rate of Sustained HBeAg Seroconversion Neptune study: PEG-IFN for 48 weeks 60 58% Week % Week % % /31 26/62 Low (<1500) Medium ( ,000) 0% 0/21 High (>20,000) /46 18/52 Low (<1500) Medium ( ,000) 0% 0/16 High (>20,000) HBsAg (IU/mL) at week 12 HBsAg (IU/mL) at week 24 Gane E, et al. EASL

19 HBeAg seroconversion at week 12 (%) HBeAg seroconversion at week 24 (%) Highest HBsAg Levels at Week 12 and week 24 are Associated with No Sustained HBeAg Seroconversion Neptune study: PEG-IFN for 48 weeks 60 58% Week % Week % % /31 26/62 Low (<1500) Medium ( ,000) HBsAg (IU/mL) at week 12 0% 0/21 High (>20,000) /46 18/52 Low (<1500) As an early stop rule Medium ( ,000) HBsAg (IU/mL) at week 24 0% 0/16 High (>20,000) Gane E, et al. EASL

20 Combination of Absolute HBsAg Level and Reduction at Week 24 Can Better Predict Response to PegIFN Therapy in HBeAg (+) CHB Best HBsAg cutoff at month 6 = 300 IU/ml Sensitivity = 62% Specificity = 89% PPV = 62% NPV = 89% Week IU/ml N=21 HBsAg at month 6 > 300 IU/ml N=71 > 1 log reduction N=12 1 log reduction N=9 SVR 9 patients 75% 4 patients 44% 8 patients 11% Chan HL, et al. Aliment Pharmacol Ther 2010; 32:

21 HBV DNA Decline (log copies/ml) HBV DNA decline (log copies/ml) HBeAg (-) CHB: Decline of HBV DNA and HBsAg in Responders and Nonresponders to PEG-IFN + RBV Therapy 133 HBeAg (-) patients treated with PEG-IFN ± RBV for 48 weeks Responder* (N=24) HBV DNA level Nonresponder (N=83) HBsAg level Week Week *HBV DNA <10,000 copies/ml and ALT nomorlization 6 months after treatment Rijckborst et al. Hepatology 2010 Rijckborst V, et al. Hepatology 2010; 52:

22 Combination of HBsAg and HBV DNA to Predict SVR in HBeAg (-) CHB 102 patients on PEG-IFN ±RVB x 48 wks HBsAg decline Week 12 No N = 54 (53%) Yes N = 48 (47%) HBV DNA decline Week 12 < 2 logs N = 20 (20%) 2 logs N = 34 (33%) < 2 logs N = 20 (20%) 2 logs N = 27 (27%) HBV DNA < 4 logs Week 72 0% 24% 25% 39% Stopping Rule Rijckborst V, et al. Hepatology 2010; 52:

23 HBsAg (IU/mL) Change from baseline in HBV DNA log 10 copies/ml) Monitor and Predict Potential HBsAg Clearance with Oral Antivirals N=266 patients treated with tenofovir (or adefovir-tenofovir) for 2 years 0 HBsAg levels during treatment 0 HBV DNA levels during treatment Weeks of study Weeks of study N=266 overall N=16 cleared HBsAg Heathcote E, et al. EASL and AASLD

24 HBsAg decline patterns (log IU/mL) during TRx with LdT On-treatment HBsAg Levels and Long-term Clearance of HBsAg during NAs Therapy Patients who clear HBsAg may be able to stop therapy 5 Rapid decline in HBsAg levels is associated with HBsAg clearance 4 Steady Decline during year 1 Patients (162) HBsAg loss at year 3 3 Slow Rapid>1log 20% (32) 25% (8) Rapid Slow<1log 45% (74) 1.4% (1) 2 Baseline Week 24 Year 1 Year 2 Year 3 Steady 35% (56) 0% (0) Monitoring HBsAg may help us identify patients who can stop NAs with a low chance of relapse Wursthorn K, et al. Hepatology 2010; 52:

25 Combination of HBsAg at End of Treatment and HBV DNA at Month 3 of Treatment with LAM Can Predict Virological Relapse Treatment naïve patients stopped NAs according to APASL criteria in Guangxi (N=62) Serum HBsAg at end of treatment 100 IU/ml N=11 > IU/ml N=20 >1000 IU/ml N=31 HBV DNA at month 3 of treatment 1000 copies/ml N=18 >1000 copies/ml N=2 Relapse HBV DNA > 1000 copies/ml N=1 (10%) N=4 (22%) N=2 (100%) N=17 (55%) Liang Y, et al. Aliment Pharmacol Ther 2011; 34:

26 Management Roadmap According to Week 24 Virological Response Week 24 Assess early predictors of efficacy Complete response HBV DNA negative by PCR Partial response HBV DNA 60 to < 2000 IU/mL Inadequate response HBV DNA 2000 IU/mL Continue therapy Add a more potent drug Keeffe E, et al. Clin Gastroenterol Hepatol 2008; 6:

27 HBV DNA (cp/ml) On-Treatment Monitoring of HBV DNA Can Determine Virological Breakthrough during Antiviral Therapy Clinical resistance 10 6 ALT Virological breakthrough Virological rebound Hepatitis flare HBV DNA Biochemical breakthrough ALT ULN 10 2 PCR 6 12 Month VB: HBV DNA level increased by 1 log IU/mL compared with the lowest point during treatment, and confirmed at the 2 nd time of detection after 1 month in patients with partial or complete virological response without changing TRx Santantonio T, et al. J Hepatol 2002; 36: Locarnini S. Hepatol Int, 2008, 2:

28 Summary (1) On-treatment monitoring of serum HBsAg can predict off-treatment response in patients treated with PEG-IFN. Very early data on oral antiviral therapy to predict off-treatment response according to monitoring of serum HBsAg. 28

29 Summary (2) Monitoring of HBV DNA is most important during oral antiviral therapy, but is less able to predict off-treatment response for PEG-IFN. Monitoring of HBV DNA can modify treatment regimen to reduce drug resistance to NAs. 29

30 Thank you! 30