ooccult by dr mokhtar

7/30/2019 Ooccult by Dr Mokhtar

1/43

Pegylatedinterferon

in

CHB

treatment:thechallengesof

diagnosis

FerruccioBonino,MD

Universityof

Pisa,

Pisa,

Italy

FoundationNationalTranslationalResearchInstitute(IRCCS)

Policlinico ofMilan,Milan,Italy

InternationalRoche

Infectious

Diseases

Symposium

EnablingClinicalDecisions

Barcelona,October8th/9th,2009


2/43

CHB anoftensilent progressive

disease

Normalliver

60%Liverstaysnormalformanyyears

Chronic

HBV

infection

CIRRHOSIS/

ESLDHCCCIRRHOSIS

2030years

Liver

damage

=

the

result

of

unsuccessful

attempts

to

clear

infectedhepatocytesintheimmunoclearancestageofdisease

40%


3/43

HepatitisBvirus smallbutpacked

withcomplexity

HBVDNA

Coreantigen

(HBcAg)

Surfaceantigen

(HBsAg)

Serum HBsAg:Virions 42 nm

Filaments 22 nmSpherical particles 22nm

Defective particles exceed virions

by a factor of 103-105


4/43

Immune-toleranceImmune-activation

Immune-control

HBeAg Anti-HBe

HBV

DNA

(log10g

en.Eq./ml)

A

LT

(U

/L)

Phasesin

the

natural

history

of

CHB


5/43

Early history of HBV DNA detection (hybridization assay) in the serum of HBeAg

negative, anti-HBe positive HBV carriers

HBV DNA + Chronic Hepatitis

11/19 58% 11/14 79% Bonino 1980

7/13 54% - Scotto 198316/32 50% - Liebermann 1983

14/24 58% 14/18 78% Hadziyannis 1983

28/106 26% 28/46 65% Bonino 1984

8/30 27% 8/21 38% Lok 198410/153 7% 1/5 20% Tur Kaspa 1984

14/78 18% 10/38 26% Wu 1986

116/455 25% 72/139 52%

Thediscovery

of

HBeAg

negative

CHB


6/43

0

1

2

3

4

5

6

78

9

10

Copynu

mber(log

10)

Nucleicac

id

amplification

Br

anched

probe

Isotopic

probe

(fulll

ength)

Sensitivityofnucleicaciddetection

methods


7/43

HBsAg

HBV DNAby PCR

Anti-HBc

Occult HBV

Infection

Cacciola et al.

NEJM, 1999

Identificationof

HBV

carriers


8/43

Torbenson&Thomas.LancetInfectDis2002

OccultHBV

infection

DetectionofHBVDNA inthe

serum orlivertissue of

HBsAgnegative

patients,

bothantiHBcpositive or

negative


9/43

HepatitisBserologicalstudies

inpatients

with

HBV

DNA

in

the

liver

Cacciola (NEJM,1999)

Jilg (J Hep,1995)

Fukada (J Med Vir,1999)

Sagnelli (J Med Vir, 2001)

Uchida (J Med Vir, 1997)

Koike (J Med Vir, 1998)

Nirei (Intervir, 2000)

Kazemi-Shirazi (J Hep, 2000)

Villa (Dig Dis Sci, 1995)

Zignego (J Med Vir, 1997)

De Maria (Am J Gastr, 2000)

Anti-HBc + Anti-HBc -

78% 22%

AdaptedfromTorbenson&Thomas.LancetInfectDis2002


10/43

Anti-HBc HBV-DNA

HBsAg


11/43

AntiHBc

alone

HBV

DNA

alone

HBsAgAntiHBc

and

HBVDNA

HBVinfectionsaccordingtoHBVmarkers

SecondaryOccult

PatentInfection

PrimaryOccult

SecondaryOccult

Identifiedbya

non

invasiveandroutinetests,

butfrequently

neglectedby

hepatologists

Primary

Occult

Identifiedonly

byintrahepatic

HBVDNA

detection

inabsence

ofother

HBV

markers

Primary

Occult??


12/43

HBVHBV Diagnostic categoriesDiagnostic categories

anti-HBs immunity

anti-HBc exposure

HBsAg infection

HBV-DNA, HBeAg replication

diseaseIgM anti-HBc

HBV DNA

HBV DNA


13/43

a direct markerof HBV infection a direct markerof HBV replication an indirect markerof HBV induced liver disease,

if >105 cp/ml in an anti-HBe positive carrier

be a marker of HBV induced liver damage in HBeAgpositive carriers exclude the presence of HBV induced liver disease,

if found


14/43

WHO

HBV

DNA

standard ProducedbytheNationalInstituteforBiologicalStandardsandControls(NIBSC)(Saldanhaetal.,VoxSang2001;80:6371)

MadefromhightiterHBVDNApositivesampledilutedincryopreservativeandthen

lyophilized

Assignedavalueat1,000,000InternationalUnits(IU)/ml

TheHBVDNAIUdoesnotrepresenttheactualnumberofviralparticlesinthe

preparation

ConversiontoIUs*ConversiontoIUs*

VersantHBVDNA3.0(bDNA): 1IU/ml=5.2copies/ml1IU/ml=5.2copies/ml(BayerDiagnostics)

CobasAmplicorHBVMonitor: 1IU/ml=5.6copies/ml1IU/ml=5.6copies/ml(RocheMolecularSystems)

CobasTaqman48HBV: 1IU/ml=5.8copies/ml1IU/ml=5.8copies/ml(RocheMolecularSystems)

*Conversionfactorsgivenbythemanufacturers


15/43

Serum

HBV

DNA

levels

in

HBV

carriers

Inactive

Carrier

State

HBeAg (+)

CHB

SerumHBVDN

A(IU/ml)

HBeAg (-)

CHB

102

103

106

107

108

109

1010

104

105

10


16/43

Healthy

Inactive


17/43

Identification

of

HBV

indiced

liver

diseaseViralinfection LiverDisease

Otherfactors

causing

liverdamagedismetabolisms,

drugs,

otherhepatotropic

viruses

HEPATITIS


18/43

BrunettoMR,JHep2002

AL

T

73 pts

(44.5%)

59 pts

(36%)

32 pts

(19.5%)

Patterns

of

ALT


19/43

Dynamic analysis of HBV DNA, ALT and IgM anti-HBcin 40 hepatitis exacerbations in 23 HBV carriers

ColloredoMelsetal.Liver1994

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

FluctuationsinHBVDNA,ALTandIgMantiHBcin

CHB

patientswithdiseaseexacerbations


20/43


21/43

4349 9.12 N, 745 43.92 E; 8.15 a.m., 19.09.09

Longitude

Latitude

Time

Date

ALT

HBV DNA

IgM anti-HBc

Effectivenavigation requiresavarietyof

parameters

IdentificationofHBVcarrierswithHBVinducedliver

diseaserequiresthesame


22/43

Diagnosisusingacombinationofmarkersis

key

ViralAntigens

and

antibodiesHBVDNA

Immunohistochemistry


23/43

Diagnosisfordecisionmakingusinga

combinationof

virus

specific

markersiskey

Elecsys hepatitisB

assaysforantigensandantibodies

HBeAg,AntiHBe HBsAg,AntiHBs AntiHBc,AntiHBcIgM

HBVDNA

Quantification

usingAMPLICOR

Helpsidentify

phase

ofinfectionand

diseaseand

differentiateinactive

vsactive

carriers

HBcAgImmunohistochemistry

Spotted DiffuseHBsAg,AntiHBs Nuclearand\orcytoplasmic


24/43

Liver Biopsy

for

Staging of disease

Diagnosisfordecisionmakingusing

nonvirus

specific

markers

of

liver

disease

Elastometry for non invasive detectionof both inflammation and fibrosis

Liver enzymes in serum as markers of necroinflammation


25/43

Immune tolerance phase

Normal liver histology

Diffuse Nuclear HBcAg staining

Immune clearance phase

Necroinflammation

Spotted nuclear and cytoplasmic HBcAg

Hallmark of HBeAg-negative CHB

Bonino et al. Gastroenterology 1986


26/43

Aims

of

treatment SwitchCHBintotheinactive(immunecontrolor

lowreplicative)HBVcarrier

ThroughsustainedimmunecontrolwithIFNbasedtherapy(PEGASYS)

Finite48

week

course

of

therapy

MaintainHBVDNAsuppressiontoundetectablelevelswithnucleos(t)ideanalogs(NAs)LongtermmaintenanceHowlong?Evidencebaseddatamissing


27/43

Phasesinthenaturalhistoryof

CHBinfection

AntiHBeHBVDNA

ALT

Immune

tolerant

Immuneclearance

HBeAg+veCHBHBeAgve

CHB

Whento

treat

InactiveHBV

Carrier

Immunecontrol

isthekeyaimof

treatment

HBeAg


28/43

InactiveCHBisassociatedwithexcellent

longterm

outcome

HBeAg/HBVDNA+

orHBeAg

reversion

0

100

80

60

40

20

0 5 10 15 20 25

Su

rvivalprobability(%)

HBVDNA


29/43

Combination?

Treatment

approachesDualMoA

Immunomodulatoryeffect

Antiviraleffect

SingleMoA

Potentantiviraleffect

Potentialsynergy

PEGIFN

NAs


30/43

HBsAgclearance

thebest

outcome

we

can

achieve

Occursspontaneouslyinnaturalhistoryata

verylow

rate

It

is

universally

considered

closest

means

to

cure:

Associatedwithgoodlongtermprognosis

Reducedcirrhosis

and

HCC

Reducedmortality


31/43

SurvivalinpatientswithandwithoutHBsAgclearance

Fattovichetal.AmJGastroenterol1998

0

NoHBsAg

clearance

20

40

60

80

100

S

urvival(%

ofpatients)

WithHBsAg

clearance

P


32/43

Europeantreatmentguidelines(EASL)

acknowledgethe

importance

of

HBsAg

Idealgoal=HBsAgclearance

Itiswhatweultimatelystrivefor

QuantificationofserumHBsAglevelsisanew

HBVmonitoringtool:

LearnmoreaboutHBsAginnaturalhistory

Monitorresponsetotherapy


33/43

QuantificationofserumHBsAgusingthe

Elecsys HBsAgII

screening

assay*

Elecsys HBsAgIIassaycombines

high

specificity

with

high

sensitivity

Asestablishedin3studies1,2,3

ReliabledetectionofHBsAgmutants

Commerciallyavailablein >70countries

1.JiaetalAPASL2009;2.Louisirirotchanakuletal.APASL20091.Muhlbacheretal.MedMicrobiolImmuno2008; JiaetalAPASL 2009;2.Louisirirotchanakuletal.APASL2009

1.Boninoetal. AASLD2008;2.Boninoetal.APASL2009*Research protocol


34/43

QuantitativeApplicationofElecsys HBsAgII

TestingAlgorithm

for

Therapy

Monitoring

Boninoetal. AASLD2008;Boninoetal.APASL2009


35/43

QuantitativeApplicationofElecsys HBsAgII

Correlationc.o.i

vs.

IU/ml

linear

over

56logs

0,1

1,0

10,0

100,0

1000,0

10000,0

100000,0

1000000,0

0,1 1 10 100 1000 10000 100000

IU/ml

c.o

.i

The correlation between IU/ml and c.o.i

was linear across the entire (5 6 log)

range

Boninoetal. AASLD2008


36/43

Architect IU/mL

ElecsysIU/mL

R2=0.9718n=40

1

10

100

1.000

10.000

100.000

1.000.000

1 10 100 1.000 10.000 100.000 1.000.000

Boninoetal.APASL2009

GoodcorrelationbetweenElecsys HBsAgII

andArchitect values


37/43

HBsAgandHBeAglevelsindifferentstagesof

HBVdisease/natural

history

HBsAg and HBeAg titers change over the naturalhistoryofCHB

Higher

HBsAg

titers

in

HBeAgpositive

vs

HBeAgnegativedisease

HBsAg

titers

were

lowest

in

the

inactive

(lowreplicative)orimmunecontrolphase

Nguyenetal. EASL 2009poster(A370)


38/43

LowestHBsAgandHBVDNAlevelsfoundinthe

inactive(immune

control)

phase

Nguyenetal.JHepatol2009(A370)

Immunetolerant Immuneclearance Inactive(immunecontrol)

HBeAg-negative(reactivation)

N=49N=25N=29N=18

HBV DNA HBsAg HBeAg

0

2

4

6

8

Log10HBVDNAIU/mL;

HBsAgI

U/mL;HBeAg

PEI/mL


39/43

HBsAgserumlevelsandphasesofHBV

infection

Parameter

Immune

tolerance(n=25)

Immune

clearance(n=29)

Inactive(low

replicative/

immune

control)

(n=46)

HBeAgve

Hepatitis(Reactivation)

(n=58)

Pvalue

Ageyr,median

(range)

14

(4 34)

35

(15 83)

41

(18 76)

43

(14 80)


40/43

Themostaccurateuse

ofviralmarkers

ismandatory

forthemanagement

oftheHBVcarrier

andCHBdiagnosis

andtreatment


41/43

Personalizedhealthcareapproach

Individualizedand

personalized

healthcare

(IPHC)approachtotherapyandmonitoring

usingallavailableresources


42/43

Italianguidelines how,whom,whentotreat

andwhich

strategy?

NAPEGIFN

LiverdiseasestageMildIshak

S0S1

Moderate

S2

Moderate

S3 S4

Cirrhosis

S5 S6 Decompensated

TreatConsidertreatment

ELEVATEDALT ANY

ALT

HBeAgpos:

HBeAgneg:

HBVDNA>20,000IU/mL

HBVDNA>2,000IU/mL

>2,000IU/mL

>200IU/mL

Carosi,Rizzetto.DigestiveLiverDisease2008

H t l U it U i it H it l f Pi


43/43

Hepatology Unit University Hospital of Pisa

Medical Doctors

Pietro Ciccorossi

Barbara Coco

Piero Colombatto

Filippo Oliveri

Veronica Romagnoli

Beatrice Cherubini

Biologists

Francesco Moriconi

Daniela Cavallone

Anna Maria MainaAngela Stabile

Bio-PhysicsLuigi Civitano

Ranieri Bizzarri

Ferruccio Bonino

Chief Scientific Officer

Director Maurizia R. Brunetto

Foundation National Institute for Translational Research

IRCSS Ospedale Maggiore Policlinico Mangiagalli, Milan, Italy

ooccult by dr mokhtar

Documents