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Mentzer AJ, O'Connor D, Pollard AJ, Hill AVS. Searching for the human genetic factors standing in the way of universally effective vaccines. Philos Trans R Soc Lond B Biol Sci 2016; 370:rstb.2014.0341. [PMID: 25964463 DOI: 10.1098/rstb.2014.0341] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Vaccines have revolutionized modern public health. The effectiveness of some vaccines is limited by the variation in response observed between individuals and across populations. There is compelling evidence that a significant proportion of this variability can be attributed to human genetic variation, especially for those vaccines administered in early life. Identifying and understanding the determinants of this variation could have a far-reaching influence upon future methods of vaccine design and deployment. In this review, we summarize the genetic studies that have been undertaken attempting to identify the genetic determinants of response heterogeneity for the vaccines against hepatitis B, measles and rubella. We offer a critical appraisal of these studies and make a series of suggestions about how modern genetic techniques, including genome-wide association studies, could be used to characterize the genetic architecture of vaccine response heterogeneity. We conclude by suggesting how the findings from such studies could be translated to improve vaccine effectiveness and target vaccination in a more cost-effective manner.
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Affiliation(s)
- Alexander J Mentzer
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - Daniel O'Connor
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK Oxford Biomedical Research Centre, Oxford OX3 7LE, UK
| | - Andrew J Pollard
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK Oxford Biomedical Research Centre, Oxford OX3 7LE, UK
| | - Adrian V S Hill
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK Oxford Biomedical Research Centre, Oxford OX3 7LE, UK
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Hou SH, Hu J, Zhang Y, Li QL, Guo JJ. Effects of interaction between genetic variants in human leukocyte antigen DQ and granulysin genes in Chinese Han subjects infected with hepatitis B virus. Microbiol Immunol 2016; 59:209-18. [PMID: 25644528 DOI: 10.1111/1348-0421.12239] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/25/2015] [Accepted: 01/28/2015] [Indexed: 12/13/2022]
Abstract
Single nucleotide polymorphisms (SNPs) of HLA-DQ and granulysin (GNLY) are reportedly associated with HBV infection. The aim of this study was to investigate the effects of interactions between SNPs in HLA-DQ and GNLY on the outcome of hepatitis B virus (HBV) infection in Chinese Han subjects. HLA-DQ (rs9275572) and GNLY (rs1866139 and rs11127) were genotyped in 310 subjects with HBV-related chronic liver disease, 295 in whom spontaneous clearance of HBV had occurred and 316 who had not been exposed to HBV. HLA-DQ rs9275572 was significantly correlated with HBV clearance (dominant genetic model: OR, 1.84; 95% CI, 1.30-2.61; adjusted P = 0.001). There was no statistical association of GNLY rs1866139 and rs11127with HBV infection outcomes. However, significant sex-specific associations with HBV susceptibility were observed in men who carried rs1866139 CG or rs11127 TC and in women who carried rs1866139 GG or rs11127 CC. The findings were the same in the validation cohort, which was composed of 829 subjects. Based on a multifactor dimensionality reduction test with permutation correction, a three-way interaction between SNPs in HLA-DQ and GNLY was identified in terms of HBV clearance. In conclusion, additional evidence for an association of HLA-DQ and GNLY SNPs with HBV infection outcomes has been identified and a SNP-SNP interaction between HLA-DQ and GNLY on HBV clearance observed.
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Affiliation(s)
- Si-hui Hou
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Chongqing Medical University
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Quantitative assessment of common genetic variations in HLA-DP with hepatitis B virus infection, clearance and hepatocellular carcinoma development. Sci Rep 2015; 5:14933. [PMID: 26462556 PMCID: PMC4604517 DOI: 10.1038/srep14933] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 09/11/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B virus (HBV) infection is the predominant risk factor for chronic hepatitis B (CHB), liver cirrhosis (LC) and hepatocellular carcinoma (HCC). Recently, genome-wide association studies have identified human leukocyte antigen (HLA)-DP polymorphisms (rs3077 and rs9277535) as a new chronic HBV infection susceptibility locus. Since then, the relationship between HLA-DP polymorphisms and various outcomes of HBV infection has been reported. However, the results have been inconclusive. To derive a more precise estimation of the relationship between HLA-DP polymorphisms and various outcomes of HBV infection, a meta-analysis of 62,050 subjects from 29 case-control studies was performed. We found that rs3077 and rs9277535 in HLA-DP significantly decreased HBV infection risks and increased HBV clearance possibility in a dose-dependent manner. In the subgroup analysis by ethnicity, study design and sample size, significant associations were found for these polymorphisms in almost all comparisons. Meanwhile, haplotype analyses of the two polymorphisms revealed a significant association between the combination of these alleles and HBV infection outcomes. However, no significant results were observed in HCC development. Our results further confirm that genetic variants in the HLA-DP locus are strongly associated with reduced HBV infection and increased the likelihood of spontaneous viral clearance.
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Matsuura K, Isogawa M, Tanaka Y. Host genetic variants influencing the clinical course of hepatitis B virus infection. J Med Virol 2015; 88:371-9. [PMID: 26255971 DOI: 10.1002/jmv.24350] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2015] [Indexed: 12/22/2022]
Abstract
The clinical course of hepatitis B virus (HBV) infection greatly differs in individuals. Various viral, host, and environmental factors influence the natural history of HBV infection. Recent genome-wide association studies identified several host genetic factors influencing the clinical course of HBV infection. Genetic variations in HLA class II loci were significantly associated with susceptibility to persistent HBV infection. Other polymorphisms in or near the genes EHMT2, TCF19, and HLA-C, located near HLA class II loci, and UBE2L3 were also associated with persistent HBV infection. Meanwhile, polymorphisms in KIF1B, GRIK1, and STAT4 were associated with HBV-related hepatocellular carcinoma (HCC). Interestingly, HLA class II genetic variations were strongly associated with not only persistent HBV infection, but also disease progression and HBV-related HCC in chronic hepatitis B. Understanding the various genetic factors associated with the clinical course of HBV infection is essential for personalized treatment and surveillance of disease progression and HCC.
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Affiliation(s)
- Kentaro Matsuura
- Department of Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.,Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.,Infectious Disease and Immunogenetics Section, Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Masanori Isogawa
- Department of Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yasuhito Tanaka
- Department of Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Whitaker JA, Ovsyannikova IG, Poland GA. Adversomics: a new paradigm for vaccine safety and design. Expert Rev Vaccines 2015; 14:935-47. [PMID: 25937189 DOI: 10.1586/14760584.2015.1038249] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Despite the enormous population benefits of routine vaccination, vaccine adverse events (AEs) and reactions, whether real or perceived, have posed one of the greatest barriers to vaccine acceptance--and thus to infectious disease prevention--worldwide. A truly integrated clinical, translational, and basic science approach is required to understand the mechanisms behind vaccine AEs, predict them, and then apply this knowledge to new vaccine design approaches that decrease, or avoid, these events. The term 'adversomics' was first introduced in 2009 and refers to the study of vaccine adverse reactions using immunogenomics and systems biology approaches. In this review, we present the current state of adversomics research, review known associations and mechanisms of vaccine AEs/reactions, and outline a plan for the further development of this emerging research field.
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56
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Genetics of liver disease: From pathophysiology to clinical practice. J Hepatol 2015; 62:S6-S14. [PMID: 25920091 DOI: 10.1016/j.jhep.2015.02.025] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 02/14/2015] [Accepted: 02/16/2015] [Indexed: 12/24/2022]
Abstract
Paralleling the first 30 years of the Journal of Hepatology we have witnessed huge advances in our understanding of liver disease and physiology. Genetic advances have played no small part in that. Initial studies in the 1970s and 1980s identified the strong major histocompatibility complex associations in autoimmune liver diseases. During the 1990 s, developments in genomic technologies drove the identification of genes responsible for Mendelian liver diseases. Over the last decade, genome-wide association studies have allowed for the dissection of the genetic susceptibility to complex liver disorders, in which also environmental co-factors play important roles. Findings have allowed the identification and elaboration of pathophysiological processes, have indicated the need for reclassification of liver diseases and have already pointed to new disease treatments. In the immediate future genetics will allow further stratification of liver diseases and contribute to personalized medicine. Challenges exist with regard to clinical implementation of rapidly developing technologies and interpretation of the wealth of accumulating genetic data. The historical perspective of genetics in liver diseases illustrates the opportunities for future research and clinical care of our patients.
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Geller G, Dvoskin R, Thio CL, Duggal P, Lewis MH, Bailey TC, Sutherland A, Salmon DA, Kahn JP. Genomics and infectious disease: a call to identify the ethical, legal and social implications for public health and clinical practice. Genome Med 2014; 6:106. [PMID: 25593592 PMCID: PMC4295297 DOI: 10.1186/s13073-014-0106-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Advances in genomics are contributing to the development of more effective, personalized approaches to the prevention and treatment of infectious diseases. Genetic sequencing technologies are furthering our understanding of how human and pathogen genomic factors - and their interactions - contribute to individual differences in immunologic responses to vaccines, infections and drug therapies. Such understanding will influence future policies and procedures for infectious disease management. With the potential for tailored interventions for particular individuals, populations or subpopulations, ethical, legal and social implications (ELSIs) may arise for public health and clinical practice. Potential considerations include balancing health-related benefits and harms between individuals and the larger community, minimizing threats to individual privacy and autonomy, and ensuring just distribution of scarce resources. In this Opinion, we consider the potential application of pathogen and host genomic information to particular viral infections that have large-scale public health consequences but differ in ELSI-relevant characteristics such as ease of transmission, chronicity, severity, preventability and treatability. We argue for the importance of anticipating these ELSI issues in advance of new scientific discoveries, and call for the development of strategies for identifying and exploring ethical questions that should be considered as clinical, public health and policy decisions are made.
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Affiliation(s)
- Gail Geller
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21205 USA ; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205 USA ; Department of Health, Behavior & Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205 USA ; Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205 USA
| | - Rachel Dvoskin
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21205 USA
| | - Chloe L Thio
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205 USA
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205 USA
| | - Michelle H Lewis
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21205 USA
| | - Theodore C Bailey
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21205 USA ; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205 USA
| | - Andrea Sutherland
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205 USA
| | - Daniel A Salmon
- Department of Health, Behavior & Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205 USA ; Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205 USA
| | - Jeffrey P Kahn
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21205 USA ; Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205 USA
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58
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Tong HV, Thomas Bock C, Velavan TP. Genetic insights on host and hepatitis B virus in liver diseases. MUTATION RESEARCH-REVIEWS IN MUTATION RESEARCH 2014; 762:65-75. [PMID: 25475418 DOI: 10.1016/j.mrrev.2014.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 06/16/2014] [Accepted: 06/17/2014] [Indexed: 02/08/2023]
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Osthoff M, Irungu E, Ngure K, Mugo N, Thomas KK, Baeten JM, Eisen DP. Mannose-binding lectin and ficolin-2 do not influence humoral immune response to hepatitis B vaccine. Vaccine 2014; 32:4772-7. [PMID: 25024112 PMCID: PMC4374143 DOI: 10.1016/j.vaccine.2014.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 04/17/2014] [Accepted: 06/06/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Host genetics appear to be an important factor in the failure to generate a protective immune response after hepatitis B (HBV) vaccination. Mannose-binding lectin (MBL) and ficolin-2 (FCN2), two pattern recognition receptors of the lectin pathway of complement, influence the clinical outcome of HBV, and MBL deficiency has been shown to augment the humoral response to HBV vaccination in several experimental models. Here, we investigated the association of MBL and FCN2 with the humoral response to HBV vaccination in a candidate gene and functional study. PATIENTS AND METHODS A post hoc analysis of a prospective, interventional HBV vaccination study among human immunodeficiency virus type 1 (HIV-1) uninfected individuals in Kenya was conducted. Serum levels and polymorphisms of MBL and FCN2 were analysed in relation to the immune response to HBV vaccination. RESULTS Protective hepatitis B surface antibody levels (≥ 10 mI U/mL) were evident in 251/293 (85.7%) individuals. Median MBL and FCN2 levels were similar in responders vs. non-responders with a weak trend towards lower median MBL levels in non-responders (1.0 vs. 1.6μg/mL, p=0.1). Similarly, there was no difference in four MBL and six FCN2 polymorphisms analysed in the two groups with the exception of an increased frequency of a homozygous MBL codon 57 mutation in non-responders (4 (9.5%) vs. 8 (3.2%), p=0.05) corresponding to lower MBL levels. Results were similar after adjusting for age and sex. CONCLUSIONS Our study does not support a prominent role of the lectin pathway of complement in general and MBL and FCN2 in particular in the humoral immune response to HBV vaccination in African adults.
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Affiliation(s)
- Michael Osthoff
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | | | - Kenneth Ngure
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Nelly Mugo
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jared M Baeten
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Damon P Eisen
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia.
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Abel L, Alcaïs A, Schurr E. The dissection of complex susceptibility to infectious disease: bacterial, viral and parasitic infections. Curr Opin Immunol 2014; 30:72-8. [PMID: 25083600 DOI: 10.1016/j.coi.2014.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 06/17/2014] [Accepted: 07/06/2014] [Indexed: 01/01/2023]
Abstract
Infectious diseases are the result of the exposure of susceptible hosts to pathogenic microbes. Genetic factors are important determinants of host susceptibility and efforts are being made to establish the molecular identity of such genetic susceptibility variants by genome-wide association studies. Results obtained to date partly confirm already known genetic vulnerabilities, but also point to new and unexpected mechanisms of susceptibility that extend from classical innate and acquired immunity to weaknesses in constitutional resistance. These studies also revealed an overlap in genetic control between infectious disease and other common immune and inflammatory disorders.
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Affiliation(s)
- Laurent Abel
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U.980, University Paris Descartes, Necker Enfants-Malades Hospital, Paris 75015, France; St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA
| | - Alexandre Alcaïs
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U.980, University Paris Descartes, Necker Enfants-Malades Hospital, Paris 75015, France; St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA; URC, CIC, Necker and Cochin Hospitals, Paris, France
| | - Erwin Schurr
- McGill International TB Centre & Departments of Human Genetics and Medicine, McGill University, Montreal, Quebec, Canada; Program in Immunology and Infectious Diseases in Global Health, The Research Institute of the McGill University Health Centre, Canada.
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61
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Kennedy RB, Ovsyannikova IG, Lambert ND, Haralambieva IH, Poland GA. The personal touch: strategies toward personalized vaccines and predicting immune responses to them. Expert Rev Vaccines 2014; 13:657-69. [PMID: 24702429 DOI: 10.1586/14760584.2014.905744] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The impact of vaccines on public health and wellbeing has been profound. Smallpox has been eradicated, polio is nearing eradication, and multiple diseases have been eliminated from certain areas of the world. Unfortunately, we now face diseases such as hepatitis C, malaria or tuberculosis, as well as new and re-emerging pathogens for which we lack effective vaccines. Empirical approaches to vaccine development have been successful in the past, but may not be up to the current infectious disease challenges facing us. New, directed approaches to vaccine design, development, and testing need to be developed. Ideally these approaches will capitalize on cutting-edge technologies, advanced analytical and modeling strategies, and up-to-date knowledge of both pathogen and host. These approaches will pay particular attention to the causes of inter-individual variation in vaccine response in order to develop new vaccines tailored to the unique needs of individuals and communities within the population.
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Chang SW, Fann CSJ, Su WH, Wang YC, Weng CC, Yu CJ, Hsu CL, Hsieh AR, Chien RN, Chu CM, Tai DI. A genome-wide association study on chronic HBV infection and its clinical progression in male Han-Taiwanese. PLoS One 2014; 9:e99724. [PMID: 24940741 PMCID: PMC4062466 DOI: 10.1371/journal.pone.0099724] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 05/18/2014] [Indexed: 02/07/2023] Open
Abstract
It is common to observe the clustering of chronic hepatitis B surface antigen (HBsAg) carriers in families. Intra-familial transmission of hepatitis B virus (HBV) could be the reason for the familial clustering of HBsAg carriers. Additionally, genetic and gender factors have been reported to be involved. We conducted a three-stage genome-wide association study to identify genetic factors associated with chronic HBV susceptibility. A total of 1,065 male controls and 1,623 male HBsAg carriers were included. The whole-genome genotyping was done on Illumina HumanHap550 beadchips in 304 healthy controls and HumanHap610 beadchips in 321 cases. We found that rs9277535 (HLA-DPB1, P = 4.87×10(-14)), rs9276370 (HLA-DQA2, P = 1.9×10(-12)), rs7756516 and rs7453920 (HLA-DQB2, P = 1.48×10(-11) and P = 6.66×10(-15) respectively) were significantly associated with persistent HBV infection. A novel SNP rs9366816 near HLA-DPA3 also showed significant association (P = 2.58×10(-10)). The "T-T-G-G-T" haplotype of the five SNPs further signified their association with the disease (P = 1.48×10(-12); OR = 1.49). The "T-T" haplotype composed of rs7756516 and rs9276370 was more prevalent in severe disease subgroups and associated with non-sustained therapeutic response (P = 0.0262). The "G-C" haplotype was associated with sustained therapeutic response (P = 0.0132; OR = 2.49). We confirmed that HLA-DPB1, HLA-DQA2 and HLA-DQB2 loci were associated with persistent HBV infection in male Taiwan Han-Chinese. In addition, the HLA-DQA2 and -DQB2 complex was associated with clinical progression and therapeutic response.
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Affiliation(s)
- Su-Wei Chang
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | | | - Wen-Hui Su
- Department of Biomedical Sciences, Graduate Institute of Biomedical Sciences, Chang Gung Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Yu Chen Wang
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chia Chan Weng
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chia-Jung Yu
- Department of Cell and Molecular Biology, College of Medicine and Molecular Medicine Research Center, Chang Gung University, Tao-Yuan, Taiwan
| | - Chia-Lin Hsu
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Ai-Ru Hsieh
- Graduate Institute of Biostatistics, China Medical University, Taichung, Taiwan
| | - Rong-Nan Chien
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chia-Ming Chu
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Dar-In Tai
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou, Taiwan
- * E-mail:
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