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Khattak A, Vongsavath T, Haque L, Narwan A, Gish RG. The Forgotten Virus, Hepatitis D: A Review of Epidemiology, Diagnosis, and Current Treatment Strategies. J Clin Exp Hepatol 2024; 14:101395. [PMID: 38617106 PMCID: PMC11015125 DOI: 10.1016/j.jceh.2024.101395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/05/2024] [Indexed: 04/16/2024] Open
Abstract
Hepatitis D virus (HDV) is an RNA subvirus that infects patients with co-existing hepatitis B virus (HBV) infections. HDV burden is estimated to be approximately 15-20 million people worldwide. Despite HDV severity, screening for HDV remains inadequate. HDV screening would benefit from a revamped approach that automatically reflexes testing when individuals are diagnosed with HBV if HBsAg-positive, to total anti-HDV, and then to quantitative HDV-RNA polymerase chain reaction (PCR) rather than only testing those at high risk sequentially. There are no current treatments in the United States that are Food and Drug Administration (FDA)-approved for the treatment of HDV; however, bulevirtide (BLV) is approved in the European Union conditionally and is under review with the United States FDA. Current treatment strategies in many countries are centered on the use of pegylated-interferon-alfa-2a (PEG-IFNa-2a). There are other therapies in development globally that have shown promise, including BLV, pegylated-interferon-lambda (PEG-IFN-lambda), and lonafarnib (LNF). LNF has shown substantial response in the LOWR trials. BLV is a well-tolerated drug, but it is not finite therapy and has shown significant on-treatment responses in the MYR clinical trials, and the FDA cited concerns with the manufacturing and patient preparation of the drug that have delayed approval. The PDUFA date for BLV in the United States is mid-2024. Current studies with both BLV and LNF are limited in providing sustained virological response (SVR); future trials will need to demonstrate more substantial SVR with possible triple combination trials as options.
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Affiliation(s)
- Adam Khattak
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, NV, USA
| | - Tahne Vongsavath
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, NV, USA
| | - Lubaba Haque
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, NV, USA
| | - Amrit Narwan
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, NV, USA
| | - Robert G. Gish
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at University of Nevada, Las Vegas, NV, USA
- Hepatitis B Foundation, Doylestown, PA, USA
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Vanwolleghem T, Armstrong PA, Buti M, FitzSimons D, Valckx S, Hendrickx G, Van Damme P. The elimination of hepatitis D as a public health problem: Needs and challenges. J Viral Hepat 2024; 31:47-50. [PMID: 37789715 PMCID: PMC11042504 DOI: 10.1111/jvh.13891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/08/2023] [Accepted: 09/24/2023] [Indexed: 10/05/2023]
Abstract
Infection with hepatitis D virus leads to liver disease and cancer most rapidly of all hepatitis viruses. However, knowledge about hepatitis D remains poor and the burden and impact are underestimated, even though some 12-15 million people mainly in low- and middle-income countries may be affected. Its epidemiology is changing, with increasing migration leading to increased risks of infection and disease. A recent Viral Hepatitis Prevention Board meeting reviewed the current epidemiological status, improvements in diagnostic testing, advances in the development of novel antiviral agents in phase III trials and the need for a greater public health response, such as new guidelines and recommended testing of all people newly identified as infected with hepatitis B virus for hepatitis D virus infection. It identified issues and needs for attention with regard to prevention, diagnosis and treatment.
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Affiliation(s)
- Thomas Vanwolleghem
- Laboratory for Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Universitair Ziekenhuis Antwerpen, Edegem, Belgium
- Viral Hepatitis Prevention Board, Centre for the Evaluation of Vaccination (CEV), VAXINFECTIO, University of Antwerp, Antwerp, Belgium
| | - Paige A. Armstrong
- Viral Hepatitis Prevention Board, Centre for the Evaluation of Vaccination (CEV), VAXINFECTIO, University of Antwerp, Antwerp, Belgium
- Division of Viral Hepatitis, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Maria Buti
- Viral Hepatitis Prevention Board, Centre for the Evaluation of Vaccination (CEV), VAXINFECTIO, University of Antwerp, Antwerp, Belgium
- Hospital General Universitari Valle Hebron, Barcelona, Spain
| | - David FitzSimons
- Viral Hepatitis Prevention Board, Centre for the Evaluation of Vaccination (CEV), VAXINFECTIO, University of Antwerp, Antwerp, Belgium
- Independent Researcher, London, UK
| | - Sara Valckx
- Viral Hepatitis Prevention Board, Centre for the Evaluation of Vaccination (CEV), VAXINFECTIO, University of Antwerp, Antwerp, Belgium
| | - Greet Hendrickx
- Viral Hepatitis Prevention Board, Centre for the Evaluation of Vaccination (CEV), VAXINFECTIO, University of Antwerp, Antwerp, Belgium
| | - Pierre Van Damme
- Viral Hepatitis Prevention Board, Centre for the Evaluation of Vaccination (CEV), VAXINFECTIO, University of Antwerp, Antwerp, Belgium
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Abstract
Importance Hepatitis D virus (HDV) infection occurs in association with hepatitis B virus (HBV) infection and affects approximately 12 million to 72 million people worldwide. HDV causes more rapid progression to cirrhosis and higher rates of hepatocellular carcinoma than HBV alone or hepatitis C virus. Observations HDV requires HBV to enter hepatocytes and to assemble and secrete new virions. Acute HDV-HBV coinfection is followed by clearance of both viruses in approximately 95% of people, whereas HDV superinfection in an HBV-infected person results in chronic HDV-HBV infection in more than 90% of infected patients. Chronic hepatitis D causes more rapidly progressive liver disease than HBV alone. Approximately 30% to 70% of patients with chronic hepatitis D have cirrhosis at diagnosis and more than 50% die of liver disease within 10 years of diagnosis. However, recent studies suggested that progression is variable and that more than 50% of people may have an indolent course. Only approximately 20% to 50% of people infected by hepatitis D have been diagnosed due to lack of awareness and limited access to reliable diagnostic tests for the HDV antibody and HDV RNA. The HBV vaccine prevents HDV infection by preventing HBV infection, but no vaccines are available to protect those with established HBV infection against HDV. Interferon alfa inhibits HDV replication and reduces the incidence of liver-related events such as liver decompensation, hepatocellular carcinoma, liver transplant, or mortality from 8.5% per year to 3.3% per year. Adverse effects from interferon alfa such as fatigue, depression, and bone marrow suppression are common. HBV nucleos(t)ide analogues, such as entecavir or tenofovir, are ineffective against HDV. Phase 3 randomized clinical trials of bulevirtide, which blocks entry of HDV into hepatocytes, and lonafarnib, which interferes with HDV assembly, showed that compared with placebo or observation, these therapies attained virological and biochemical response in up to 56% of patients after 96 weeks of bulevirtide monotherapy and 19% after 48 weeks of lonafarnib, ritonavir, and pegylated interferon alfa treatment. Conclusions and Relevance HDV infection affects approximately 12 million to 72 million people worldwide and is associated with more rapid progression to cirrhosis and liver failure and higher rates of hepatocellular carcinoma than infection with HBV alone. Bulevirtide was recently approved for HDV in Europe, whereas pegylated interferon alfa is the only treatment available in most countries.
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Affiliation(s)
- Francesco Negro
- Division of Gastroenterology and Hepatology, Geneva University Hospitals, Geneva, Switzerland
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
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Rong Y, Ju X, Sun P, Wang Y. Comparative effectiveness of seven interventions for chronic hepatitis D: a systematic review and network meta-analysis of randomized controlled trials. BMC Infect Dis 2023; 23:726. [PMID: 37880598 PMCID: PMC10601284 DOI: 10.1186/s12879-023-08718-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 10/16/2023] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVE To compare the effectiveness of seven major interventions [Bulevirtide (BLV), Interferon (IFN), Nucleoside analogs (NAs), BLV + IFN, BLV + NAs, IFN + NAs, and Placebo] to treat chronic hepatitis D. METHODS We followed PRISMA-NMA guidelines, searched databases (Cochrane Library, PubMed, EMBASE, and Web Of Science) for eligible randomized controlled trials (RCTs), and applied STATA17.0 software to execute the meta-analysis. RESULTS We included 14 randomized controlled trials (814 patients) comparing seven different interventions. The results of the network meta-analysis showed that: ① Sustained virological response (after 24 weeks of follow-up): Four intervention groups (BLV + IFN, IFN alone, IFN + NAs, and NAs alone) were effective (relative risk (RR) = 13.30, 95% confidence interval (Cl) [1.68,105.32], RR = 12.13, 95% Cl [1.46,101.04], RR = 5.05, 95% Cl [1.68,15.19], RR = 5.03, 95% Cl [1.66,15.20]), with no statistically significant differences between the four groups. The top three in probability rankings were: BLV + NAs, BLV + IFN, and BLV alone (surface under the cumulative ranking curve (SUCRA) = 86.8%, 80.3%, and 48.4%; ② Sustained biochemical response (after 24 weeks of follow-up): BLV + IFN and IFN were superior to BLV (RR = 14.71, 95% Cl [1.14,189.07], RR = 16.67, 95% Cl [1.39,199.52]). The top three were BLV alone, BLV + NAs, and BLV + IFN (SUCRA = 86.9%,81.2%, and 64.3%). ③ Histological response: NAs were superior to BLV (RR = 2.08, 95% Cl [1.10,3.93]), whereas the difference between other treatment regimens was not statistically significant, and the top three in the probability ranking were BLV alone, BLV + NAs, and BLV + IFN (SUCRA = 75.6%, 75.6%, and 61.8%). CONCLUSIONS IFN, IFN + BLV, and IFN + NAs were effective in clearing HDV RNA and normalizing alanine aminotransferase levels; however, IFN and IFN + NAs had a high rate of viral relapse at 24 weeks post-treatment follow-up. There was no additional benefit of adding NAs to IFN therapy for chronic hepatitis D; however, the combination of IFN + BLV significantly improved short-term HDV RNA clearance, which showed strong synergistic effects. The seven regimens included in the study did not contribute significantly to liver histological improvement. Therefore, the IFN + BLV combination has the most potential as a treatment option to improve the long-term prognosis or even cure chronic hepatitis D. TRIAL REGISTRATION This systematic evaluation and meta-analysis was registered with PROSPERO under the registration number: CRD42022314544.).
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Affiliation(s)
- Yangdan Rong
- Department of Infectious Diseases, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, 610500, China
| | - Xuegui Ju
- Department of General Practice, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, 610500, China
| | - Peng Sun
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, 610500, China
| | - Yali Wang
- Department of Infectious Diseases, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, 610500, China.
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Nemteanu R, Clim A, Hincu CE, Gheorghe L, Ciortescu I, Plesa A. Interferon-Free Regimens and Direct-Acting Antiviral Agents for Delta Hepatitis: Are We There Yet? Curr Issues Mol Biol 2023; 45:7878-7890. [PMID: 37886941 PMCID: PMC10605217 DOI: 10.3390/cimb45100498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
Chronic delta hepatitis is a global health problem. Although a smaller percentage of chronic HBV-infected patients are coinfected with the hepatitis delta virus, these patients have a higher risk of an accelerated progression to fulminant "delta hepatitis", cirrhosis, hepatic decompensation, and hepatocellular carcinoma, putting a financial strain on the healthcare system and increasing the need for a liver transplant. Since its discovery, tremendous efforts have been directed toward understanding the intricate pathogenic mechanisms, discovering the complex viral replication process, the essential replicative intermediates, and cell division-mediated viral spread, which enables virion viability. The consideration of the interaction between HBV and HDV is crucial in the process of developing novel pharmaceuticals. Until just recently, interferon-based therapy was the only treatment available worldwide. This review aims to present the recent advancements in understanding the life cycle of HDV, which have consequently facilitated the development of innovative drug classes. Additionally, we will examine the antiviral strategies currently in phases II and III of development, including bulevirtide (an entry inhibitor), lonafarnib (a prenylation inhibitor), and REP 2139 (an HBsAg release inhibitor).
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Affiliation(s)
- Roxana Nemteanu
- Medical I Department, Grigore T. Popa University of Medicine and Pharmacy, 700100 Iasi, Romania; (A.C.); (L.G.); (A.P.)
- Institute of Gastroenterology and Hepatology, “Sfantul. Spiridon” University Hospital, 700111 Iasi, Romania
| | - Andreea Clim
- Medical I Department, Grigore T. Popa University of Medicine and Pharmacy, 700100 Iasi, Romania; (A.C.); (L.G.); (A.P.)
| | - Corina Elena Hincu
- Department of Radiology, “Sfantul Spiridon” Hospital, 700111 Iasi, Romania;
| | - Liliana Gheorghe
- Medical I Department, Grigore T. Popa University of Medicine and Pharmacy, 700100 Iasi, Romania; (A.C.); (L.G.); (A.P.)
- Department of Radiology, “Sfantul Spiridon” Hospital, 700111 Iasi, Romania;
| | - Irina Ciortescu
- Medical I Department, Grigore T. Popa University of Medicine and Pharmacy, 700100 Iasi, Romania; (A.C.); (L.G.); (A.P.)
- Institute of Gastroenterology and Hepatology, “Sfantul. Spiridon” University Hospital, 700111 Iasi, Romania
| | - Alina Plesa
- Medical I Department, Grigore T. Popa University of Medicine and Pharmacy, 700100 Iasi, Romania; (A.C.); (L.G.); (A.P.)
- Institute of Gastroenterology and Hepatology, “Sfantul. Spiridon” University Hospital, 700111 Iasi, Romania
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Brunetto MR, Ricco G, Negro F, Wedemeyer H, Yurdaydin C, Asselah T, Papatheodoridis G, Gheorghe L, Agarwal K, Farci P, Buti M. EASL Clinical Practice Guidelines on hepatitis delta virus. J Hepatol 2023; 79:433-460. [PMID: 37364791 DOI: 10.1016/j.jhep.2023.05.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 06/28/2023]
Abstract
Hepatitis D virus (HDV) is a defective virus that requires the hepatitis B virus to complete its life cycle and cause liver damage in humans. HDV is responsible for rare acute and chronic liver diseases and is considered the most aggressive hepatitis virus. Acute infection can cause acute liver failure, while persistent infection typically causes a severe form of chronic hepatitis which is associated with rapid and frequent progression to cirrhosis and its end-stage complications, hepatic decompensation and hepatocellular carcinoma. Major diagnostic and therapeutic innovations prompted the EASL Governing Board to commission specific Clinical Practice Guidelines on the identification, virologic and clinical characterisation, prognostic assessment, and appropriate clinical and therapeutic management of HDV-infected individuals.
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Soriano V, de Mendoza C, Treviño A, Ramos-Rincón JM, Moreno-Torres V, Corral O, Barreiro P. Treatment of hepatitis delta and HIV infection. Liver Int 2023; 43 Suppl 1:108-115. [PMID: 35748639 DOI: 10.1111/liv.15345] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 06/20/2022] [Indexed: 01/18/2023]
Abstract
Hepatitis delta virus (HDV) is a defective agent that only infects individuals with hepatitis B virus (HBV). Around 5-10% of chronic hepatitis B patients worldwide are superinfected with HDV, which means 15-25 million people. Hepatitis delta is the most severe of all chronic viral hepatitis, leading to cirrhosis, liver cancer and/or transplantation in most patients. Despite it, many HDV patients remain undiagnosed. The only treatment available until recently was peginterferon alfa, with poor results and significant side effects. The recent approval of bulevirtide, a lipopeptide that blocks HBV/HDV entry, has revolutionized the field. Another drug, lonafarnib, already approved to treat progeria, is expected to be available soon as HDV therapy. Since there is no cell reservoir for the HDV RNA genome, hypothetically viral clearance could be achieved if complete blocking of viral replication occurs for a minimum time frame. This is what happens in hepatitis C using direct-acting antivirals, with the achievement of cure in nearly all treated patients. We envision the cure of hepatitis delta using combination antiviral therapy. Given that sexual and parenteral transmission routes are the most frequent for the acquisition of HBV and HDV, shared with HIV infection and HBV/HDV and HIV coinfection. The clinical outcome of hepatitis delta is worst in the HIV setting, with more frequent liver complications. Since most persons infected with HIV are on regular health care follow-up, we propose that HIV-HDV patients should be prioritized for moving forward new and potentially curative treatments for hepatitis delta.
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Affiliation(s)
| | - Carmen de Mendoza
- Department of Internal Medicine, Puerta de Hierro Research Institute & University Hospital, Madrid, Spain
| | - Ana Treviño
- UNIR Health Sciences School & Medical Center, Madrid, Spain
| | - José Manuel Ramos-Rincón
- Medicine Department, Alicante University Hospital & Alicante Institute of Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Víctor Moreno-Torres
- Department of Internal Medicine, Puerta de Hierro Research Institute & University Hospital, Madrid, Spain
| | - Octavio Corral
- UNIR Health Sciences School & Medical Center, Madrid, Spain
| | - Pablo Barreiro
- Public Health Regional Laboratory, Hospital Isabel Zendal, Madrid, Spain
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Kamal H, Aleman S. Natural history of untreated HDV patients: Always a progressive disease? Liver Int 2023; 43 Suppl 1:5-21. [PMID: 36308026 DOI: 10.1111/liv.15467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 10/20/2022] [Accepted: 10/25/2022] [Indexed: 02/13/2023]
Abstract
A severe course has been described in early studies on chronic hepatitis D (CHD), with faster pace towards liver cirrhosis with subsequent high liver-related morbidity and mortality in the majority of patients. Earlier studies have included risk groups as people using intravenous drugs (PWID) or those with multiple co-morbidities. During the last decade, the epidemiological landscape of CHD has changed with domestic cases decreasing while increasing cases of CHD consisting of younger persons immigrating from endemic regions to low-endemic regions. Recently, further insights into the spectrum of the disease with an indolent disease course in a substantial proportion of persons with CHD have been gained. At diagnosis, ≥30%-50% had already established liver cirrhosis. Older age, liver cirrhosis, co-infection with HIV and lack of interferon (IFN) therapy are the main predictors of worse clinical outcome. The newly introduced and upcoming antivirals against CHD are highly anticipated, considering the historically low virological response rates to antiviral therapy. Further knowledge is needed to fully comprehend the natural course and the spectrum of this severe form of viral hepatitis. This is also to be able to evaluate the long-term effects of the new antivirals on disease progression.
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Affiliation(s)
- Habiba Kamal
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Infectious Diseases, Karolinska Institute, Stockholm, Sweden
| | - Soo Aleman
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Infectious Diseases, Karolinska Institute, Stockholm, Sweden
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Rakhanova Y, Almawi WY, Aimagambetova G, Riethmacher D. The effects of sildenafil citrate on intrauterine growth restriction: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2023; 23:409. [PMID: 37268873 DOI: 10.1186/s12884-023-05747-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/30/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND An increase in vascular resistance of uterine vessels is associated with intrauterine growth restriction (IUGR). Sildenafil citrate, a phosphodiesterase-5 inhibitor that stabilizes cyclic guanosine monophosphate (cGMP) and increases nitric oxide levels, improves placental perfusion by dilation of spiral arteries and is beneficial in managing IUGR. This study aims to determine the effectiveness of sildenafil citrate in improving perinatal outcomes in IUGR pregnancies. METHODS Meta-analysis was performed on data extracted from all studies specific to sildenafil citrate in IUGR management, searching relevant articles on PubMed, Medline, Google Scholar, Embase, and Cochrane databases. Publications identified by the manual search, based on references in reviews, were also included. Dichotomous results were presented as risk ratio (95% confidence interval), while continuous results were expressed as mean difference (MD); samples represented by the random effects model. RESULTS Nine trials were included where the sildenafil citrate effect was compared with a placebo or no intervention. A significant increase in birth weight [SMD (95% CI), 0.69 (0.31, 1.07)] was seen in IUGR pregnancies managed with sildenafil. However, gestational age (SMD (95% CI), 0.44 (-0.05, 0.94], fetal death rate [RR (95% CI), 0.56 (0.17, 1.79)] in IUGR pregnancies was not changed by sildenafil. Neonatal death [RR (95% CI), 0.93 (0.47, 1.86)] and neonatal intensive care unit (NICU) admissions [RR (95% CI), 0.76 (0.50, 1.17)] were not significantly different between sildenafil and control groups. CONCLUSION Sildenafil citrate increases birth weight and prolonged pregnancies but did not affect stillbirth rate, neonatal death, and NICU admission. TRIAL REGISTRATION The study was registered in PROSPERO on September 18, 2021 (CRD42021271992).
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Affiliation(s)
- Yenlik Rakhanova
- School of Medicine, Nazarbayev University, 010000, Astana, Kazakhstan
| | - Wassim Y Almawi
- Faculté Des Sciences de Tunis, Université de Tunis - El Manar, Tunis, Tunisia
- Department of Biomedical Sciences, School of Medicine, Nazarbayev University, 010000, Astana, Kazakhstan
| | - Gulzhanat Aimagambetova
- Department of Surgery, School of Medicine, Nazarbayev University, 010000, Astana, Kazakhstan.
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Mangia A, Squillante MM, Fraticelli F, Cavorsi MC, Paroni G, Zaffarano L, Piazzolla AV. HDV RNA Levels and Progression of Hepatitis Delta Infection: A 14 Year Follow Up Experience in Italy. Cells 2023; 12:1413. [PMID: 37408247 DOI: 10.3390/cells12101413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Identification of outcome predictors is one of the unmet needs in chronic HDV infection. Until recently, no reliable quantitative assays for HDV RNA were available. AIMS To evaluate the impact of baseline viremia on natural history of HDV infection in a cohort of patients whose serum samples were stored at their first visit 15 years ago. METHODS Quantitative HBsAg, HBeAg, HBeAb, HBV DNA, HDV RNA, genotypes, and liver disease severity were assessed at baseline. Patients who were no longer on active follow-up were recalled and re-evaluated in August 2022. RESULTS The majority of patients were male (64.9%); the median age was 50.1 years; and all patients were Italian, with only three born in Romania. All were HBeAg negative with HBV genotype D infection. Patients were subdivided three groups: 23 were in active follow-up (Group 1), 21 were recalled due to no longer being in follow-up (Group 2), and 11 died (Group 3). Liver cirrhosis was diagnosed in 28 subjects at the first visit; 39.3% of diagnosed patients were in Group 3, 32.1% were in Group 1 and 28.6% were in Group 2 (p = 0.001). Baseline HBV DNA IU/mL Log10 were 1.6 (1.0-5.9) in Group 1, 1.3 (1.0-4.5) in Group 2, and 4.1 (1.5-4.5) in Group 3; median baseline HDV RNA Log10 levels were 4.1 (0.7-6.7) in Group 1, 3.2 (0.7-6.2) in Group 2, and 5.2 (0.7-6.7) in Group 3, resulting significantly higher rates among patients in Group 3 compared to the other groups (p = 0.038). Eighteen patients in Group 2, as compared to 7 in Group 1, had undetectable HDV RNA at the follow-up evaluation (p = 0.001). CONCLUSIONS HDV chronic infection is a heterogeneous disease. It may not only progress but also improve over time in patients, who eventually become HDV RNA-undetectable. HDV RNA levels may help identify the subgroup of patients with less progressive liver disease.
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Affiliation(s)
- Alessandra Mangia
- Liver Unit, IRCCS Fondazione "Casa Sollievo della Sofferenza", 71013 San Giovanni Rotondo, Italy
| | | | - Filippo Fraticelli
- Liver Unit, IRCCS Fondazione "Casa Sollievo della Sofferenza", 71013 San Giovanni Rotondo, Italy
| | - Maria Chiara Cavorsi
- Liver Unit, IRCCS Fondazione "Casa Sollievo della Sofferenza", 71013 San Giovanni Rotondo, Italy
| | - Giulia Paroni
- Blood Bank, IRCCS Fondazione "Casa Sollievo della Sofferenza", 71013 San Giovanni Rotondo, Italy
| | - Lucia Zaffarano
- Blood Bank, IRCCS Fondazione "Casa Sollievo della Sofferenza", 71013 San Giovanni Rotondo, Italy
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Blaney H, Khalid M, Heller T, Koh C. Epidemiology, presentation, and therapeutic approaches for hepatitis D infections. Expert Rev Anti Infect Ther 2023; 21:127-142. [PMID: 36519386 PMCID: PMC9905306 DOI: 10.1080/14787210.2023.2159379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Chronic Hepatitis D virus (HDV) infection remains an important global public health problem, with a changing epidemiological landscape over the past decade along with widespread implementation of hepatitis B vaccination and human migration. The landscape of HDV treatments has been changing, with therapies that have been under development for the last decade now in late stage clinical trials. The anticipated availability of these new therapies will hopefully replace the current therapies which are minimally effective. AREAS COVERED This narrative review discusses the clinical course, screening and diagnosis, transmission risk factors, epidemiology, current and investigational therapies, and liver transplantation in HDV. Literature review was performed using PubMed and ClinicalTrials.gov and includes relevant articles from 1977 to 2022. EXPERT OPINION HDV infection is an important global public health issue with a true prevalence that is still unknown. The distribution of HDV infection has changed globally with the availability of HBV vaccination and patterns of human migration. As HDV infection is associated with accelerated disease courses and poor outcomes, the global community needs to agree upon a uniform HDV screening strategy to understand the truth of global prevalence such that new therapies can target appropriate individuals as they become available in the future.
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Affiliation(s)
- Hanna Blaney
- Digestive Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Mian Khalid
- Digestive Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Christopher Koh
- Liver Diseases Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Hepatitis B and Hepatitis D Viruses: A Comprehensive Update with an Immunological Focus. Int J Mol Sci 2022; 23:ijms232415973. [PMID: 36555623 PMCID: PMC9781095 DOI: 10.3390/ijms232415973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Hepatitis B virus (HBV) and hepatitis delta virus (HDV) are highly prevalent viruses estimated to infect approximately 300 million people and 12-72 million people worldwide, respectively. HDV requires the HBV envelope to establish a successful infection. Concurrent infection with HBV and HDV can result in more severe disease outcomes than infection with HBV alone. These viruses can cause significant hepatic disease, including cirrhosis, fulminant hepatitis, and hepatocellular carcinoma, and represent a significant cause of global mortality. Therefore, a thorough understanding of these viruses and the immune response they generate is essential to enhance disease management. This review includes an overview of the HBV and HDV viruses, including life cycle, structure, natural course of infection, and histopathology. A discussion of the interplay between HDV RNA and HBV DNA during chronic infection is also included. It then discusses characteristics of the immune response with a focus on reactions to the antigenic hepatitis B surface antigen, including small, middle, and large surface antigens. This paper also reviews characteristics of the immune response to the hepatitis D antigen (including small and large antigens), the only protein expressed by hepatitis D. Lastly, we conclude with a discussion of recent therapeutic advances pertaining to these viruses.
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13
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Ferenci P, Reiberger T, Jachs M. Treatment of Chronic Hepatitis D with Bulevirtide-A Fight against Two Foes-An Update. Cells 2022; 11:cells11223531. [PMID: 36428959 PMCID: PMC9688382 DOI: 10.3390/cells11223531] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/30/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022] Open
Abstract
HDV infection frequently causes progression to cirrhosis and hepatocellular carcinoma (HCC). In summer 2020, the first potentially effective drug Bulevirtide (BLV) has been approved for the treatment of HDV by the EMA. BLV is a synthetic N-acylated pre-S1 lipopeptide that blocks the binding of HBsAg-enveloped particles to the sodium taurocholate co-transporting polypeptide (NTCP), which is the cell entry receptor for both HBV and HDV. In this review, we discuss the available data from the ongoing clinical trials and from "real world series". Clinical trials and real-world experiences demonstrated that BLV 2 mg administered for 24 or 48 weeks as monotherapy or combined with pegIFNα reduces HDV viremia and normalizes ALT levels in a large proportion of patients. The combination of BLV and pegIFNα shows a synergistic on-treatment effect compared with either one of the monotherapies.
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Affiliation(s)
- Peter Ferenci
- Correspondence: ; Tel.: +43-140-4004-7410; Fax: +43-140-4004-7350
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14
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Zhang Z, Ni Y, Lempp FA, Walter L, Mutz P, Bartenschlager R, Urban S. Hepatitis D virus-induced interferon response and administered interferons control cell division-mediated virus spread. J Hepatol 2022; 77:957-966. [PMID: 35636579 DOI: 10.1016/j.jhep.2022.05.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 04/29/2022] [Accepted: 05/12/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Besides HBV-dependent de novo infection, cell division-mediated spread contributes to HDV persistence and dampens the effect of antivirals that abrogate de novo infection. Nonetheless, the combination of these antivirals with interferons (IFNs) showed strong synergism in recent clinical trials, implying a complementary mode-of-action of IFNs. Therefore, we investigated the effect of IFN response on cell division-mediated HDV spread. METHODS Cells infected with HDV were passaged to undergo cell division. The effect of the IFN response was evaluated by blocking HDV-induced IFN activation, by applying different IFN treatment regimens, and by adjusting HDV infection doses. RESULTS Cell division-mediated HDV spread was highly efficient following infection of HuH7NTCP cells (defective in IFN production), but profoundly restricted in infected IFN-competent HepaRGNTCP cells. Treatment with IFN-α/-λ1 inhibited HDV spread in dividing HuH7NTCP cells, but exhibited a marginal effect on HDV replication in resting cells. Blocking the HDV-induced IFN response with the JAK1/2 inhibitor ruxolitinib or knocking down MDA5 augmented HDV spread in dividing HepaRGNTCP cells. The virus-induced IFN response also destabilized HDV RNA in dividing cells. Moreover, the effect of exogenous IFNs on cell division-mediated HDV spread was more pronounced at low multiplicities of infection with weak virus-induced IFN responses. CONCLUSIONS Both HDV-induced IFN response and exogenous IFN treatment suppress cell division-mediated HDV spread, presumably through acceleration of HDV RNA decay. Our findings demonstrate a novel mode-of-action of IFN, explain the more pronounced effect of IFN therapy in patients with lower HDV serum RNA levels, and provide insights for the development of combination therapies. LAY SUMMARY Chronic hepatitis D is a major health problem. The causative pathogen hepatitis D virus (HDV) can propagate through viral particle-mediated infection and the division of infected cells. Although viral particle-dependent infection can be blocked by recently developed drugs, therapies addressing the cell division route have not been reported. Taking advantage of relevant cell culture models, we demonstrate that the widely used immune modulator interferon can efficiently suppress HDV spread through cell division. This work unveils a new function of interferon and sheds light on potentially curative combination therapies.
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Affiliation(s)
- Zhenfeng Zhang
- Department of Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany
| | - Yi Ni
- Department of Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany
| | - Florian A Lempp
- Department of Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany
| | - Lisa Walter
- Department of Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany
| | - Pascal Mutz
- Department of Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany; Division of Virus-Associated Carcinogenesis, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ralf Bartenschlager
- Department of Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany; German Center for Infection Research (DZIF) - Heidelberg Partner Site, Heidelberg, Germany; Division of Virus-Associated Carcinogenesis, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stephan Urban
- Department of Infectious Diseases, Molecular Virology, Heidelberg University, Heidelberg, Germany; German Center for Infection Research (DZIF) - Heidelberg Partner Site, Heidelberg, Germany.
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15
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Desmares M, Delphin M, Chardès B, Pons C, Riedinger J, Michelet M, Rivoire M, Verrier B, Salvetti A, Lucifora J, Durantel D. Insights on the antiviral mechanisms of action of the TLR1/2 agonist Pam3CSK4 in hepatitis B virus (HBV)-infected hepatocytes. Antiviral Res 2022; 206:105386. [PMID: 35963549 DOI: 10.1016/j.antiviral.2022.105386] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Pegylated-interferon-alpha (Peg-IFNα), an injectable innate immune protein, is still used to treat chronically HBV-infected patients, despite its poor tolerability. Peg-IFNα has the advantage over nucleos(t)ide analogues (NAs) to be administrated in finite regimen and to lead to a higher HBsAg loss rate. Yet it would be interesting to improve the efficacy (i.e. while decreasing doses), or replace, this old medicine by novel small molecules/stimulators able to engage innate immune receptors in both HBV replicating hepatocytes and relevant innate immune cells. We have previously identified the Toll-Like-Receptor (TLR)-2 agonist Pam3CSK4 as such a potential novel immune stimulator. The aim of this study was to gain insights on the antiviral mechanisms of action of this agonist in in vitro cultivated human hepatocytes. DESIGN We used in vitro models of HBV-infected cells, based on both primary human hepatocytes (PHH) and the non-transformed HepaRG cell line to investigate the MoA of Pam3SCK4 and identify relevant combinations with other approved or investigational drugs. RESULTS We exhaustively described the inhibitory anti-HBV phenotypes induced by Pam3CSK4, which include a strong decrease in HBV RNA production (inhibition of synthesis and acceleration of decay) and cccDNA levels. We confirmed the long-lasting anti-HBV activity of this agonist, better described the kinetics of antiviral events, and demonstrated the specificity of action through the TLR1/2- NF-κB canonical-pathway. Moreover, we found that FEN-1 could be involved in the regulation and inhibitory phenotype on cccDNA levels. Finally, we identified the combination of Pam3CSK4 with IFNα or an investigational kinase inhibitor (called 1C8) as valuable strategies to reduce cccDNA levels and obtain a long-lasting anti-HBV effect in vitro. CONCLUSIONS TLR2 agonists represent possible assets to improve the rate of HBV cure in patients. Further evaluations, including regulatory toxicity studies, are warranted to move toward clinical trials.
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Affiliation(s)
- Manon Desmares
- INSERM, U1052, Cancer Research Center of Lyon (CRCL), University of Lyon (UCBL1), CNRS UMR_5286, Centre Léon Bérard, Lyon, France
| | - Marion Delphin
- INSERM, U1052, Cancer Research Center of Lyon (CRCL), University of Lyon (UCBL1), CNRS UMR_5286, Centre Léon Bérard, Lyon, France
| | - Brieux Chardès
- INSERM, U1052, Cancer Research Center of Lyon (CRCL), University of Lyon (UCBL1), CNRS UMR_5286, Centre Léon Bérard, Lyon, France
| | - Caroline Pons
- INSERM, U1052, Cancer Research Center of Lyon (CRCL), University of Lyon (UCBL1), CNRS UMR_5286, Centre Léon Bérard, Lyon, France; INSERM, U1111, Centre International de Recherche en Infectiologie (CIRI), University of Lyon (UCBL1), CNRS UMR_5308, ENS de Lyon, Lyon, France
| | - Juliette Riedinger
- INSERM, U1111, Centre International de Recherche en Infectiologie (CIRI), University of Lyon (UCBL1), CNRS UMR_5308, ENS de Lyon, Lyon, France
| | - Maud Michelet
- INSERM, U1052, Cancer Research Center of Lyon (CRCL), University of Lyon (UCBL1), CNRS UMR_5286, Centre Léon Bérard, Lyon, France
| | | | - Bernard Verrier
- Laboratoire de Biologie Tissulaire et Ingénierie Thérapeutique, CNRS UMR_5305, University of Lyon (UCBL1), Lyon, France
| | - Anna Salvetti
- INSERM, U1052, Cancer Research Center of Lyon (CRCL), University of Lyon (UCBL1), CNRS UMR_5286, Centre Léon Bérard, Lyon, France; INSERM, U1111, Centre International de Recherche en Infectiologie (CIRI), University of Lyon (UCBL1), CNRS UMR_5308, ENS de Lyon, Lyon, France
| | - Julie Lucifora
- INSERM, U1052, Cancer Research Center of Lyon (CRCL), University of Lyon (UCBL1), CNRS UMR_5286, Centre Léon Bérard, Lyon, France; INSERM, U1111, Centre International de Recherche en Infectiologie (CIRI), University of Lyon (UCBL1), CNRS UMR_5308, ENS de Lyon, Lyon, France
| | - David Durantel
- INSERM, U1052, Cancer Research Center of Lyon (CRCL), University of Lyon (UCBL1), CNRS UMR_5286, Centre Léon Bérard, Lyon, France; INSERM, U1111, Centre International de Recherche en Infectiologie (CIRI), University of Lyon (UCBL1), CNRS UMR_5308, ENS de Lyon, Lyon, France.
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16
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Tan YC, Lee GH, Huang DQ, Lim SG. Future anti-HDV treatment strategies, including those aimed at HBV functional cure. Liver Int 2022; 43:1157-1169. [PMID: 35946084 DOI: 10.1111/liv.15387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/11/2022] [Accepted: 08/08/2022] [Indexed: 02/13/2023]
Abstract
HDV is a defective virus that uses the HBV surface antigen to enter hepatocytes. It is associated with an accelerated course of liver fibrosis progression and an increased risk of hepatocellular carcinoma. Negative HDV RNA 24 weeks after the end of therapy has been proposed as an endpoint but late relapses make this endpoint suboptimal, hence HBsAg loss appears to be more appropriate. Current HBV antiviral agents have poor activity against HDV hence the search for improved therapy. Drugs only active against HDV, such as lonafarnib, have shown efficacy in combination with nucleoside analogues and peginterferon, but do not lead to HBsAg loss. HBsAg loss sustained 24 weeks after the end of therapy with negative HBV DNA is termed functional cure. Agents that are being investigated for functional cure include those that inhibit replication such as entry inhibitors, polymerase inhibitors and capsid assembly modulators but seldom lead to functional cure. Agents that reduce HBV antigen load such as RNA interference and inhibitors of HBsAg secretion are promising. Immunomodulators on their own seldom achieve functional cure, hence these agents in combination to assess the optimal combination are being investigated. Consequently, agents leading to functional cure of HBV are ideal for both HBV and HDV.
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Affiliation(s)
- Yong Chuan Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Gastroenterology and Hepatology, National University Health System, Singapore
| | - Guan Huei Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Gastroenterology and Hepatology, National University Health System, Singapore
| | - Daniel Q Huang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Gastroenterology and Hepatology, National University Health System, Singapore
| | - Seng Gee Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Gastroenterology and Hepatology, National University Health System, Singapore
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17
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Jachs M, Schwarz C, Panzer M, Binter T, Aberle SW, Hartl L, Dax K, Aigner E, Stättermayer AF, Munda P, Graziadei I, Holzmann H, Trauner M, Zoller H, Gschwantler M, Mandorfer M, Reiberger T, Ferenci P. Response-guided long-term treatment of chronic hepatitis D patients with bulevirtide-results of a "real world" study. Aliment Pharmacol Ther 2022; 56:144-154. [PMID: 35514008 PMCID: PMC9321570 DOI: 10.1111/apt.16945] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/21/2022] [Accepted: 04/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Bulevirtide (BLV) blocks the uptake of the hepatitis D virus (HDV) into hepatocytes via the sodium/bile acid cotransporter NTCP. BLV was conditionally approved by the EMA but real-life data on BLV efficacy are limited. METHODS Patients were treated with BLV monotherapy. Patients who did not achieve further decreases in HDV-RNA after 24 weeks were offered PEG-IFN as an add-on therapy in a response-guided manner. RESULTS Twenty-three patients (m: 10, f: 13; mean age: 47.9 years, cirrhosis: 16; median ALT: 71 IU/ml; median HDV-RNA: 2.1 × 105 copies/ml) started BLV monotherapy (2 mg/day: 22; 10 mg/day: 1). Twenty-two completed ≥24 weeks of treatment (24-137 weeks): Ten (45%) were classified as BLV responders at week 24. BLV was stopped in two patients with >6 months HDV-RNA undetectability, but both became HDV-RNA positive again. One patient was transplanted at week 25. One patient terminated treatment because of side effects at week 60. Ten patients are still on BLV monotherapy. Adding PEG-IFN in eight patients induced an HDV-RNA decrease in all (1.29 ± 0.19 [SD] log within 12 weeks). HDV-RNA decreased by >2log or became undetectable in 45%(10/22), 55%(11/20), 65% (13/20) and 69% (9/13); and ALT levels normalised in 64% (14/22), 85% (17/20), 90% (18/20) and in 92% (12/13) patients at weeks 24, 36, 48 and 60, respectively. Portal pressure decreased in 40% (2/5) of patients undergoing repeated measurement under BLV therapy. CONCLUSION Long-term BLV monotherapy is safe and effectively decreases HDV-RNA and ALT-even in patients with cirrhosis. The optimal duration of BLV treatment alone or in combination with PEG-IFN remains to be established. An algorithm for a response-guided BLV treatment approach is proposed.
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Affiliation(s)
- Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | | | | | - Teresa Binter
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | - Stephan W Aberle
- Center of Clinical Virology, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | | | - Elmar Aigner
- SALK und Paracelsus Medical University, Salzburg, Austria
| | - Albert F Stättermayer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | - Petra Munda
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Ivo Graziadei
- Department of Medicine, Landeskrankenhaus Hall, Austria
| | | | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | - Heinz Zoller
- Medical University of Innsbruck, Innsbruck, Austria
| | | | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.,Rare Liver Disease (RALID) Center of the European Reference Network for Rare Hepatological Diseases (ERN RARE-LIVER), Medical University Vienna, Vienna, Austria
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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18
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Brillanti S. Management of Delta Hepatitis 45 Years after the Discovery of HDV. J Clin Med 2022; 11:jcm11061587. [PMID: 35329913 PMCID: PMC8953848 DOI: 10.3390/jcm11061587] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/08/2022] [Accepted: 03/11/2022] [Indexed: 02/01/2023] Open
Abstract
In 1977 the viral Delta agent was discovered and subsequently characterized as the hepatitis Delta virus (HDV). HDV infection is associated with HBV infection since the defective HDV needs HBV to infect and replicate in the liver. Even if not a frequent cause of chronic liver disease, HDV infection is responsible for an aggressive progression of hepatitis towards advanced liver disease. At present, no FDA approved treatment exists for this specific form of hepatitis. Interferon alfa has been recommended as off-label therapy by major scientific societies (AASLD, EASL and APASL) and has proved effective in about one quarter of patients. In recent years, new therapeutic approaches have been studied, and EMA has approved a new drug (bulevirtide) for Delta hepatitis. In this review, we encompass the 45-year journey of managing Delta hepatitis and address the most recent developments in treating this severe and aggressive liver disease.
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Affiliation(s)
- Stefano Brillanti
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
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19
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Jachs M, Binter T, Schmidbauer C, Hartl L, Strasser M, Laferl H, Hametner‐Schreil S, Lindorfer A, Dax K, Stauber RE, Kessler HH, Bernhofer S, Maieron A, Loacker L, Bota S, Santonja I, Munda P, Mandorfer M, Peck‐Radosavljevic M, Holzmann H, Gschwantler M, Zoller H, Ferenci P, Reiberger T. Hepatitis D virus (HDV) prevalence in Austria is low but causes considerable morbidity due to fast progression to cirrhosis. United European Gastroenterol J 2021; 9:1119-1127. [PMID: 34873866 PMCID: PMC8672089 DOI: 10.1002/ueg2.12163] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/19/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hepatitis D virus (HDV) coinfection aggravates the course of hepatitis B virus (HBV). The prevalence of HDV in Austria is unknown. OBJECTIVE This national study aimed at (i) recording the prevalence of HDV-infection in Austria and (ii) characterizing the "active" HDV cohort in Austria. METHODS A total of 10 hepatitis treatment centers in Austria participated in this multicenter study and retrospectively collected their HDV patients between Q1/2010 and Q4/2020. Positive anti-HDV and/or HDV-RNA-polymerase chain reaction (PCR) results were retrieved from local database queries. Disease severity was assessed by individual chart review. Viremic HDV patients with clinical visits in/after Q1/2019 were considered as the "active" HDV cohort. RESULTS A total of 347 anti-HDV positive patients were identified. In 202 (58.2%) patients, HDV-RNA-PCR test was performed, and 126/202 (62.4%) had confirmed viremia. Hepatocellular carcinoma was diagnosed in 7 (5.6%) patients, 7 (5.6%) patients underwent liver transplantation, and 11 (8.7%) patients died during follow-up. The "active" Austrian HDV cohort included 74 (58.7%) patients: Evidence for advanced chronic liver disease (ACLD, i.e., histological F3/F4 fibrosis, liver stiffness ≥10 kPa, varices, or hepatic venous pressure gradient ≥6 mmHg) was detected in 38 (51.4%) patients, including 2 (5.3%) with decompensation (ascites/hepatic encephalopathy). About 37 (50.0%) patients of the "active" HDV cohort had previously received interferon treatment. Treatment with the sodium-taurocholate cotransporting polypeptide inhibitor bulevirtide was initiated in 20 (27.0%) patients. CONCLUSION The number of confirmed HDV viremic cases in Austria is low (<1% of HBV patients) but potentially underestimated. Testing all HBV patients will increase the diagnostic yield. More than half of viremic HDV patients had ACLD. Improved HDV testing and workup strategies will facilitate access to novel antiviral therapies.
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Affiliation(s)
- Mathias Jachs
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
- HIV and Liver Disease Study GroupMedical University of ViennaViennaAustria
| | - Teresa Binter
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
- HIV and Liver Disease Study GroupMedical University of ViennaViennaAustria
| | - Caroline Schmidbauer
- HIV and Liver Disease Study GroupMedical University of ViennaViennaAustria
- Division of Gastroenterology and HepatologyDepartment of Medicine IIKlinik OttakringViennaAustria
| | - Lukas Hartl
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
- HIV and Liver Disease Study GroupMedical University of ViennaViennaAustria
| | - Michael Strasser
- First Department of MedicineParacelsus Medical UniversitySalzburgAustria
| | - Hermann Laferl
- Department of Infectious Diseases and Tropical MedicineKlinik FavoritenViennaAustria
| | | | - Alexander Lindorfer
- Department of Gastroenterology and HepatologyOrdensklinikum Linz Barmherzige SchwesternLinzAustria
| | - Kristina Dax
- Department of Internal Medicine and Gastroenterology and HepatologyKepler UniversitätsklinikumLinzAustria
| | - Rudolf E. Stauber
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Harald H. Kessler
- Institute for Hygiene, Microbiology and Environmental MedicineMedical University of GrazGrazAustria
| | - Sebastian Bernhofer
- Department of Internal Medicine IIUniversity Hospital St. PöltenSt. PöltenAustria
| | - Andreas Maieron
- Department of Internal Medicine IIUniversity Hospital St. PöltenSt. PöltenAustria
| | - Lorin Loacker
- Central Institute for Medical and Chemical Laboratory DiagnosticsMedical University of InnsbruckInnsbruckAustria
| | - Simona Bota
- Department of Internal Medicine and Gastroenterology, Hepatology, Endocrinology, Rheumatology and NephrologyKlinikum Klagenfurt am WörtherseeKlagenfurtAustria
| | - Isabel Santonja
- Center for VirologyMedical University of ViennaViennaAustria
| | - Petra Munda
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Mattias Mandorfer
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
- HIV and Liver Disease Study GroupMedical University of ViennaViennaAustria
| | - Markus Peck‐Radosavljevic
- Department of Internal Medicine and Gastroenterology, Hepatology, Endocrinology, Rheumatology and NephrologyKlinikum Klagenfurt am WörtherseeKlagenfurtAustria
| | | | - Michael Gschwantler
- HIV and Liver Disease Study GroupMedical University of ViennaViennaAustria
- Division of Gastroenterology and HepatologyDepartment of Medicine IIKlinik OttakringViennaAustria
| | - Heinz Zoller
- Department of Internal Medicine IMedical University of InnsbruckInnsbruckAustria
| | - Peter Ferenci
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Thomas Reiberger
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
- HIV and Liver Disease Study GroupMedical University of ViennaViennaAustria
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Bogomolov PO, Ivashkin VT, Bueverov AO, Maev IV, Sagalova OI, Sleptsova SS, Yushuk ND, Gusev DA, Zhdanov KV, Chulanov VP. Efficacy and safety of bulevirtide in patients with chronic hepatitis D and compensated cirrhosis. TERAPEVT ARKH 2021; 93:1290-1299. [DOI: 10.26442/00403660.2021.11.201163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 11/22/2022]
Abstract
Aim. To study the efficacy and safety of bulevirtide, the HBV and HDV entry inhibitor.
Materials and methods. Analysis of the results of using bulevirtide in randomized controlled open-label comparative studies MYR202 and MYR203 in 56 patients with chronic hepatitis D and compensated cirrhosis, in monotherapy and combination with pegylated interferon alpha-2a (PEG-IFN).
Results. Monotherapy with bulevirtide for 24 weeks in the MYR202 study in 46 patients with compensated liver cirrhosis demonstrated: 1) a high rate of virological (100%) and biochemical response (alanine aminotransferase normalization rate 45.7%), 2) superiority of bulevirtide in efficacy over the control group (tenofovir), 3) comparability of treatment efficacy in patients with and without cirrhosis, 4) no progression of liver fibrosis with elastometry in most patients.
Treatment with bulevirtide in monotherapy and combination with PEG-IFN for 48 weeks in 10 patients with compensated liver cirrhosis in the MYR203 study was accompanied by a high rate of virological response (80%) and normalization of alanine aminotransferase (70%).
Bulevirtide was well tolerated, there was no deterioration in tolerability compared with patients without cirrhosis, there were no serious adverse events and cases of treatment cancellation due to adverse events.
Conclusion. Bulevirtide is recommended as the first line of treatment for chronic hepatitis D in patients with compensated cirrhosis in monotherapy and combination with PEG-IFN.
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Niro GA, Ferro A, Cicerchia F, Brascugli I, Durazzo M. Hepatitis delta virus: From infection to new therapeutic strategies. World J Gastroenterol 2021; 27:3530-3542. [PMID: 34239267 PMCID: PMC8240063 DOI: 10.3748/wjg.v27.i24.3530] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/07/2021] [Accepted: 05/27/2021] [Indexed: 02/06/2023] Open
Abstract
The hepatitis delta virus (HDV) is a small RNA virus that encodes a single protein and which requires the hepatitis B virus (HBV)-encoded hepatitis B surface antigen (HBsAg) for its assembly and transmission. HBV/HDV co-infections exist worldwide and show a higher prevalence among selected groups of HBV-infected populations, specifically intravenous drug users, practitioners of high-risk sexual behaviours, and patients with cirrhosis and hepatocellular carcinoma. The chronic form of HDV-related hepatitis is usually severe and rapidly progressive. Patterns of the viral infection itself, including the status of co-infection or super-infection, virus genotypes (both for HBV and HDV), and persistence of the virus’ replication, influence the outcome of the accompanying and manifested liver disease. Unfortunately, disease severity is burdened by the lack of an effective cure for either virus type. For decades, the main treatment option has been interferon, administered as mono-therapy or in combination with nucleos(t)ide analogues. While its efficacy has been reported for different doses, durations and courses, only a minority of patients achieve a sustained response, which is the foundation of eventual improvement in related liver fibrosis. The need for an efficient therapeutic alternative remains. Research efforts towards this end have led to new treatment options that target specific steps in the HDV life cycle; the most promising among these are myrcludex B, which inhibits virus entry into hepatocytes, lonafarnib, which inhibits farnesylation of the viral-encoded L-HDAg large hepatitis D antigen, and REP-2139, which interferes with HBsAg release and assembly.
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Affiliation(s)
- Grazia A Niro
- Department of Gastroenterology, IRCCS Casa Sollievo della Sofferenza Hospital Foundation, San Giovanni Rotondo 71013, Italy
| | - Arianna Ferro
- Department of Medical Sciences, University of Turin, Turin 10126, Italy
| | | | | | - Marilena Durazzo
- Department of Medical Sciences, University of Turin, Turin 10126, Italy
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Papatheodoridi M, Papatheodoridis GV. Current status of hepatitis delta. Curr Opin Pharmacol 2021; 58:62-67. [PMID: 33895531 DOI: 10.1016/j.coph.2021.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/10/2021] [Accepted: 03/19/2021] [Indexed: 12/18/2022]
Abstract
Hepatitis D virus (HDV) infection in patients chronically infected with hepatitis B virus (HBV) causes the most severe form of chronic viral hepatitis and continues to represent a major health problem. The latest data show that the global prevalence is much higher than previously considered. Therefore, screening with the detection of anti-HDV antibodies is mandatory for all chronic HBV patients. In spite of the severity of liver disease, the only recommended treatment today is pegylated interferon-alpha, which has limited efficacy. Novel host-targeting molecules are now under investigation. The current phase 2 clinical trials include pegylated interferon-lambda, bulevirtide, lonafarnib, and REP-2139. This review focuses on the current status of epidemiology, diagnosis, and treatment of HDV infection.
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Affiliation(s)
- Margarita Papatheodoridi
- University College of London, Institute of Liver and Digestive Health, Royal Free Campus, London, UK
| | - George V Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece.
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