Current treatment and future directions in the management of chronic hepatitis B viral infection

Bioactivity Profile of the Diterpene Isosteviol and its Derivatives

Steviosides, rebaudiosides and their analogues constitute a major class of naturally occurring biologically active diterpene compounds. The wide spectrum of pharmacological activity of this group of compounds has developed an interest among medicinal chemists to synthesize, purify, and analyze more selective and potent isosteviol derivatives. It has potential biological applications and improves the field of medicinal chemistry by designing novel drugs with the ability to cope against resistance developing diseases. The outstanding advancement in the design and synthesis of isosteviol and its derivative has proved its effectiveness and importance in the field of medicinal chemical research. The present review is an effort to integrate recently developed novel drugs syntheses from isosteviol and potentially active pharmacological importance of the isosteviol derivatives covering the recent advances.

Hepatitis delta virus: A fascinating and neglected pathogen

Hepatitis delta virus (HDV) is the etiologic agent of the most severe form of virus hepatitis in humans. Sharing some structural and functional properties with plant viroids, the HDV RNA contains a single open reading frame coding for the only virus protein, the Delta antigen. A number of unique features, including ribozyme activity, RNA editing, rolling-circle RNA replication, and redirection for a RNA template of host DNA-dependent RNA polymerase II, make this small pathogen an excellent model to study virus-cell interactions and RNA biology. Treatment options for chronic hepatitis Delta are scarce and ineffective. The disease burden is perhaps largely underestimated making the search for new, specific drugs, targets, and treatment strategies an important public health challenge. In this review we address the main features of virus structure, replication, and interaction with the host. Virus pathogenicity and current treatment options are discussed in the light of recent developments.

The value of liver and spleen ADC measurements in the diagnosis and follow up of hepatic fibrosis in chronic liver disease

AIMS

To evaluate the value of spleen and liver apparent diffusion coefficients (ADC) in chronic liver disease patients, with and without hepatocellular carcinoma (HCC), and to investigate the use of diffusion-weighted imaging (DWI) in the diagnosis and follow-up of hepatic fibrosis.

MATERIALS AND METHODS

This study population comprised 68 chronic liver disease patients (Group 1) and 70 healthy volunteers as controls (Group 2). In Group 1, 40 patients had chronic hepatitis-B, 20 had chronic hepatitis-C, 5 had non-alcoholic steatohepatitis and 3 had alcoholic steatohepatitis. Diagnosis of chronic liver disease was made by percutaneous liver biopsy and the degree of fibrosis (stage) was determined using the METAVIR scoring system. HCC diagnosis was made with a lesion biopsy. The patient group was subdivided based on the degree of fibrosis (F1, F2, F3 and F4) and presence of HCC. After patient and control groups underwent b-value 600 s/mm(2) DWI examination, liver and spleen ADC values were mapped and measured. The ADC values of the patient groups (F1, F2, F3, F4; with HCC, without HCC) were compared with each other and with the control group.

RESULTS

Liver ADC values were lower in Group 1 compared to Group 2 (P<0·001). There was a statistically significant difference between the patient and control groups liver right lobe, left lobe and caudate lobe ADC values (P<0·001). Comparing the F1, F2, F3 and F4 groups, there was no statistically significant difference found in terms of ADC values (P>0·05). However, as degree of fibrosis increased there was a reduction in ADC values, though not statistically significant. Comparing the groups with HCC and without HCC, there was no statistically significant difference in ADC values (P>0·05). There was no statistical difference in average spleen ADC values between patient and control groups (P>0·05).

CONCLUSIONS

In chronic liver disease, ADC values were lower. As the degree of liver fibrosis increased, ADC levels decreased, though the relationship between ADC values and fibrosis degree was not statistically significant. Quantitative DWI may help in the diagnosis of fibrosis in chronic liver disease patients, however as it does not show the degree of fibrosis, its use in treatment planning and follow-up is controversial. Spleen DWI measurement is not a sufficient method to diagnose and determine the degree of fibrosis in chronic liver disease patients.

Anti-viral effect of a compound isolated from Liriope platyphylla against hepatitis B virus in vitro

The compound LPRP-Et-97543 was isolated from Liriope platyphylla roots and was observed to have potential anti-viral effects in HepG2.2.15 cells against hepatitis B virus (HBV). The antiviral mode was further clarified, and the HBV-transfected Huh7 cells were used as the platform. During viral gene expression, LPRP-Et-97543 treatment had apparent effects on the viral precore/pregenomic and S/preS RNA. Promoter activity analysis demonstrated that LPRP-Et-97543 significantly reduced Core, S, and preS but not X promoter activities. Further examination showed that putative signaling pathways were involved in this inhibitory effect, indicating that NF-κB may serve a putative mediator of HBV gene regulation with LPRP-Et-97543. In addition, the nuclear expression of p65/p50 NF-κB member proteins was attenuated with LPRP-Et-97543 and augmented cytoplasmic IκBα protein levels but without affecting the expression of these proteins in HBV non-transfected cells during treatment. Moreover, LPRP-Et-97543 reduced the binding activity of NF-κB protein to CS1 element of HBV surface gene in a gel retardation analysis and inhibited CS1 containing promoter activity in HBV expressed cells. However, HBV transfection significantly enhances CS1 containing promoter activity without compound treatment in cells. Finally, transfection of the p65 expression plasmid significantly reversed the inhibitory effect of LPRP-Et-97543 on the replicated HBV DNA level in HBV positive cells. In conclusion, this study suggests that the mechanism of HBV inhibition by LPRP-Et-97543 may involve the feedback regulation of viral gene expression and viral DNA replication by HBV viral proteins, which interferes with the NF-κB signaling pathway.

X gene/core promoter deletion mutation: a novel mechanism leading to hepatitis B 'e' antigen‑negative chronic hepatitis B

Mutations in the precore and core promoter regions of hepatitis B 'e' antigen (HBeAg) are implicated in HBeAg‑negative chronic hepatitis B virus (HBV) infection (CHB). The objective of the current study was to investigate novel mutant patterns that lead to HBeAg‑negative CHB. The . PreX-X genomic region from the sera of HBV‑infected patients was amplified, and analysis of the sequences displayed a unique deletion region, 234 nucleotides in length, which was observed in 54 clones and named core promoter deletion (CPD). CPD may have an important role in the cause of HBeAg‑negative CHB. In addition, a novel deletion mutation in the X gene was observed in patients with CHB. This deletion mutant codes a 76‑amino‑acid X factor instead of the X protein. In the present study, a new mutation pattern was discovered that may contribute to the cause of HBeAg-negative CHB, and therefore it is worthy of future studies.

Synthesis and antiviral effects of isosteviol-derived analogues against the hepatitis B virus

Among several isosteviol-derived analogues, NC-8 (ent-16-oxobeyeran-19-N-methylureido) showed inhibitory potency against the hepatitis B virus (HBV) in HepG2 2.2.15 cells. Its anti-HBV mechanism was then next investigated in a human hepatoma cell culture system. Results showed that it specifically inhibited viral gene expression and reduced the level of encapsidated viral DNA intermediates in Huh7 cells that expressed replicating HBV. It also potently attenuated all viral promoter activity in HBV-expressing Huh7 cells, but not in cells lacking HBV expression. By examining its antiviral mechanism in cellular signaling pathways, NC-8 was found to inhibit the activity of the nuclear factor (NF)-κB element-containing promoter, but only slightly enhanced activities of activator protein (AP)-1- and interferon-sensitive response element (ISRE)-containing promoters in HBV-expressing cells. NC-8 also significantly eliminated NF-κB (p65/p50) and Toll-like receptor (TLR)2 proteins, but increased the IκBα protein level in a dose-dependent manner in HBV-transfected Huh7 cells, while these protein levels were apparently unchanged in non-transfected cells. Meanwhile, NC-8-treated nuclear extracts that co-expressed HBV inhibited the binding of NF-κB to the CS1 site of HBV major surface gene and specifically attenuated CS1-containing promoter activity. Taken together, this study suggests that the antiviral mechanism of NC-8 appears to be mediated by disturbing replication and gene expression of HBV and by inhibiting the host TLR2/NF-κB signaling pathway.

Antiviral activity of methyl helicterate isolated from Helicteres angustifolia (Sterculiaceae) against hepatitis B virus

The anti-HBV effect of methyl helicterate (MH), a triterpenoid isolated from the Chinese herb Helicteres angustifolia, was explored both in vitro and in vivo. In the HBV-transfected cell line HepG2.2.15, the secretion of HBsAg/HBeAg, the levels of HBV DNA and cccDNA, and the amount of viral RNA were significantly decreased after treatment with MH for 144h. In addition, MH had no inhibitory effect on the mitochondrial DNA content. In DHBV-infected ducklings, MH significantly reduced the serum DHBV DNA, liver total viral DNA, and cccDNA levels. Furthermore, analysis of the liver pathological changes confirmed the hepatoprotective effect of MH. These results indicate that MH efficiently inhibits HBV replication both in vitro and in vivo and that MH may be a major bioactive ingredient in H. angustifolia.

Evaluation of susceptibility locus for response to interferon-α based therapy in chronic hepatitis B patients in Chinese

In 2009, three independent genome-wide association studies reported that genetic variation in the interleukin 28B gene to be associated with the response to interferon-α/ribavirin therapy in hepatitis C virus genotype 1 infected patients. We carried out the present study to assess whether such polymorphisms also affect the therapy effect of another interferon-α responsive illness as chronic hepatitis B. Five hundred and twelve interferon-α treatment-naïve HBeAg seropositive chronic hepatitis B patients were enrolled in the present retrospective nested case-control study. All patients received PEG-IFN-α-2a based treatment and were examined for the therapy efficacy. SNP rs8099917 was genotyped using the MassArray system (Sequenom). Interestingly, the frequency of G allele of rs8099917 was significantly higher in response group than in non response group (8.3% vs. 3.9%, p=0.003, OR=0.44, 95%CI=0.25-0.79). The genotype distributions of this SNP also differed significantly between two groups (p=0.003). Our study suggested that the G allele of rs8099917 was associated with higher rate of response in HBeAg seropositive chronic hepatitis B patients treated with interferon α.

Development of HBsAg-binding aptamers that bind HepG2.2.15 cells via HBV surface antigen

Hepatitis B virus surface antigen (HBsAg), a specific antigen on the membrane of Hepatitis B virus (HBV)-infected cells, provides a perfect target for therapeutic drugs. The development of reagents with high affinity and specificity to the HBsAg is of great significance to the early-stage diagnosis and treatment of HBV infection. Herein, we report the selection of RNA aptamers that can specifically bind to HBsAg protein and HBsAg-positive hepatocytes. One high affinity aptamer, HBs-A22, was isolated from an initial 115 mer library of ~1.1 x 10¹⁵ random-sequence RNA molecules using the SELEX procedure. The selected aptamer HBs-A22 bound specifically to hepatoma cell line HepG2.2.15 that expresses HBsAg but did not bind to HBsAg-devoid HepG2 cells. This is the first reported RNA aptamer which could bind to a HBV specific antigen. This newly isolated aptamer could be modified to deliver imaging, diagnostic, and therapeutic agents targeted at HBV-infected cells.

Advanced MRI methods for assessment of chronic liver disease

OBJECTIVE

With recent advances in technology, advanced MRI methods such as diffusion-weighted and perfusion-weighted MRI, MR elastography, chemical shift-based fat-water separation, and MR spectroscopy can now be applied to liver imaging. We will review the respective roles of these techniques for assessment of chronic liver disease.

CONCLUSION

MRI plays an increasingly important role in assessment of patients with chronic liver disease because of the lack of ionizing radiation and the possibility of performing multiparametric imaging.

Recent advancements for the evaluation of anti-viral activities of natural products

Significant progress has been achieved for the development of novel anti-viral drugs in the recent years. Large numbers of these newly developed drugs belong to three groups of compounds, nucleoside analogues, thymidine kinase-dependent nucleotide analogues and specific viral enzyme inhibitors. It has been found that the natural products, like plant extract, plant-derived compounds (phytochemicals) and so on, as well as traditional medicines, like Ayurvedic, traditional Chinese medicine (TCM), Chakma medicines and so on, are the potential sources for potential and novel anti-viral drugs based on different in vitro and in vivo approaches. In this chapter some of these important approaches utilised in the drug discovery process of potential candidate(s) for anti-viral agents are being discussed. The key conclusion is that natural products are one of the most important sources of novel anti-viral agents.

Chronic hepatitis: role of diffusion-weighted imaging and diffusion tensor imaging for the diagnosis of liver fibrosis and inflammation

PURPOSE

To determine the diagnostic performance of liver apparent diffusion coefficient (ADC) measured with conventional diffusion-weighted imaging (CDI) and diffusion tensor imaging (DTI) for the diagnosis of liver fibrosis and inflammation.

MATERIALS AND METHODS

Breathhold single-shot echo-planar imaging CDI and DTI with b-values of 0 and 500 second/mm(2) was performed in 31 patients with chronic liver disease and 13 normal volunteers. Liver biopsy was performed in all patients with liver disease with a median delay of two days from MRI. Fibrosis and inflammation were scored on a 5-point scale (0-4). Liver ADCs obtained with CDI and DTI were compared between patients stratified by fibrosis stage and inflammation grade. Receiver operating characteristic (ROC) curve analyses were conducted to evaluate the utility of the ADC measures for prediction of fibrosis and inflammation.

RESULTS

Patients with liver fibrosis and inflammation had significantly lower liver ADC than subjects without fibrosis or inflammation with CDI and DTI. For prediction of fibrosis stage > or = 1 and stage > or = 2, area under the ROC curve (AUC) of 0.848 and 0.783, sensitivity of 88.5% to 73.7%, and specificity of 73.3% to 72.7% were obtained, for ADC < or =1.40 x 10(-3) mm(2)/second and < or =1.30 x 10(-3) mm(2)/second (using CDI), respectively. For prediction of inflammation grade > or = 1, AUC of 0.825, sensitivity of 75.0%, and specificity of 78.6% were obtained using ADC < or = 1.30 x 10(-3) mm(2)/second (using CDI). CDI performed better than DTI for diagnosis of fibrosis and inflammation.

CONCLUSION

Liver ADC can be used to predict liver fibrosis and inflammation with acceptable sensitivity and specificity.

Role and support for hepatologists at liver transplant programs in the United States

Liver transplantation has evolved into a successful option for patients with end-stage liver disease. Transplant hepatologists are involved in the management of patients with end-stage liver disease both before and after liver transplantation. The goals of this study were to evaluate the roles that transplant hepatologists play at liver transplantation programs in the United States and the demand for and institutional support provided for these physicians. A web-based questionnaire was sent via e-mail to the medical directors of all 108 United Network for Organ Sharing-recognized liver transplant programs during the fall of 2006. Follow-up e-mails were sent and phone calls were made to those not completing the survey within 4 weeks. The survey was completed by 72 (67%) medical directors. The average number of liver transplants performed per center was 62, and a broad range of program sizes were represented. The number of transplant hepatologists increased in proportion to the number of transplants performed on an annual basis but lagged behind the number of surgeons and transplant coordinators. On average, 33 liver transplants were performed per year per transplant hepatologist. Transplant hepatologists were involved in all aspects of pretransplant and posttransplant care at all but 10% of these institutions; they provided virtually all pretransplant care at all of these programs and all long-term posttransplant care at 45% of these programs. Overall, 94% of liver transplant programs provided direct salary support and/or ancillary personnel for their transplant hepatologists. Despite this, over half of transplant hepatologists and 75% of those that received no direct salary support performed endoscopic procedures on a regular basis. Eighty-one percent of programs were recruiting additional transplant hepatologists. In conclusion, although the vast majority of transplant hepatologists receive institutional support, this support appears to be inadequate. The current shortage of transplant hepatologists is likely to increase if appropriate support mechanisms are not implemented.

Advances of candidate binding protein to envelope protein of hepatitis B virus

There are at least 4 initial coding positions in S gene of hepatitis B virus (HBV), encoding pre-pre-S, pre-S1, pre-S2 as well as major protein. There are no definite evidences to prove that envelope protein will interact with human cellular protein. This review focused on research approaches to the existing protein - protein interaction and summarized proteins of liver cells that may interact with current HBV envelope protein. However, most of currently available results need further verification.

Advanced liver fibrosis: diagnosis with 3D whole-liver perfusion MR imaging--initial experience

Institutional review board approval and informed consent were obtained for this HIPAA-compliant study. The purpose of this study was to prospectively evaluate sensitivity and specificity of various estimated perfusion parameters at three-dimensional (3D) perfusion magnetic resonance (MR) imaging of the liver in the diagnosis of advanced liver fibrosis (stage >or= 3), with histologic analysis, liver function tests, or MR imaging as the reference standard. Whole-liver 3D perfusion MR imaging was performed in 27 patients (17 men, 10 women; mean age, 55 years) after dynamic injection of 8-10 mL of gadopentetate dimeglumine. The following estimated perfusion parameters were measured with a dual-input single-compartment model: absolute arterial blood flow (F(a)), absolute portal venous blood flow (F(p)), absolute total liver blood flow (F(t)) (F(t) = F(a) + F(p)), arterial fraction (ART), portal venous fraction (PV), distribution volume (DV), and mean transit time (MTT) of gadopentetate dimeglumine. Patients were assigned to two groups (those with fibrosis stage <or= 2 and those with fibrosis stage >or= 3), and the nonparametric Mann-Whitney test was used to compare F(a), F(p), F(t), ART, PV, DV, and MTT between groups. Receiver operating characteristic curve analysis was used to assess the utility of perfusion estimates as predictors of advanced liver fibrosis. There were significant differences for all perfusion MR imaging-estimated parameters except F(p) and F(t). There was an increase in F(a), ART, DV, and MTT and a decrease in PV in patients with advanced fibrosis compared with those without advanced fibrosis. DV had the best performance, with an area under the receiver operating characteristic curve of 0.824, a sensitivity of 76.9% (95% confidence interval: 46.2%, 94.7%), and a specificity of 78.5% (95% confidence interval: 49.2%, 95.1%) in the prediction of advanced fibrosis.

Diffusion-weighted MRI for quantification of liver fibrosis: preliminary experience

OBJECTIVE

The purpose of this study was to evaluate our preliminary experience using diffusion-weighted MRI for quantification of liver fibrosis.

SUBJECTS AND METHODS

Diffusion-weighted MRI with single-shot echo-planar technique at b values of 50, 300, 500, 700, and 1,000 s/mm2 was prospectively performed on 23 patients with chronic hepatitis and on seven healthy volunteers. The apparent diffusion coefficient (ADC) was measured in four locations in the liver. Liver biopsy results (n = 19) were retrospectively reviewed by two hepatopathologists in consensus to determine stage of fibrosis and grade of inflammation. A Mann-Whitney test was used to compare the ADCs between patients classified with respect to having stage 2 or greater versus stage 1 or less fibrosis and stage 3 or greater versus stage or less 2 fibrosis. Receiver operating characteristics analysis was used to assess the performance of ADC in prediction of the presence of stage 2 or greater and stage 3 or greater fibrosis.

RESULTS

Using a b value of 500 s/mm2 and all combined b values, we found significantly lower hepatic ADCs in stage 2 or greater versus stage 1 or less fibrosis and stage 3 or greater versus stage 2 or less fibrosis. The mean ADCs (x 10(-3) mm2/s) with all b values were 1.47 +/- 0.11 (SD) versus 1.65 +/- 0.10 for stage 2 or greater versus stage 1 or less fibrosis (p < 0.001) and 1.44 +/- 0.07 versus 1.66 +/- 0.10 for stage 3 or greater versus stage 2 or less fibrosis (p <0.001). Hepatic ADC was a significant predictor of stage 2 or greater and stage 3 or greater fibrosis, with areas under the curve of 0.896 and 0.896, sensitivity of 83.3% and 88.9%, and specificity of 83.3% and 80.0% (ADC with all b values, 1.54-1.53 x 10(-3) mm2/s or less).

CONCLUSION

Diffusion-weighted MRI can be used for prediction of the presence of moderate and advanced liver fibrosis.

An hepatitis B virus surface antigen specific single chain of variable fragment derived from a natural immune antigen binding fragment phage display library is specifically internalized by HepG2.2.15 cells

Hepatitis B virus surface antigen (HBsAg), a specific antigen on the membrane of hepatitis B virus (HBV)-infected cells, provides a perfect target for therapeutic drugs. In order to mediate successful targeted delivery of these therapies, it is essential to have antibodies that recognize HBsAg with high specificity and affinity. In this report, we constructed a natural immune antigen binding fragments (Fab) antibody phage display library against HBsAg and after three rounds of panning, five Fab fragments with significant HBsAg binding ability were selected and analysed. DNA sequencing revealed that all the light chains had the same sequence, while all the Fd genes exhibited different sequences. For further application, all of the Fab antibodies were reconstructed into single chain antibodies (scFvs) and expressed in Escherichia coli BL21 cells. Indirect enzyme-linked immunosorbent assay analysis demonstrated that all five scFvs maintained a high affinity for HBsAg and could bind HBsAg on the membrane of HBV-infected cells. Indirect fluorescent staining analysis revealed that one of the scFvs (scFv15) could be internalized into HBsAg-positive HepG2.2.15 cells through clathrin-mediated endocytosis pathway. The internalizing scFv15 antibody would have great potential for the targeted delivery of therapeutics to HBV-infected cells.

Synergistic effect of a novel oxymatrine-baicalin combination against hepatitis B virus replication, α smooth muscle actin expression and type I collagen synthesis in vitro

AIM: To study the effect of oxymatrine-baicalin combination (OB) against HBV replication in 2.2.15 cells and α smooth muscle actin (α SMA) expression, type I, collagen synthesis in HSC-T6 cells.

METHODS: The 2.2.15 cells and HSC-T6 cells were cultured and treated respectively. HBsAg and HBeAg in the culture supernatants were detected by ELISA and HBV DNA levels were determined by fluorescence quantitative PCR. Total RNA was extracted from HSC-T6 cells and reverse transcribed into cDNA. The cDNAs were amplified by PCR and the quantities were expressed in proportion to β actin. The total cellular proteins extracted from HSC-T6 cells were separated by electrophoresis. Resolved proteins were electrophoretically transferred to nitrocellulose membrane. Protein bands were revealed and the quantities were corrected by β actin.

RESULTS: In the 2.2.15 cell culture system, the inhibitory rate against secretion of HBsAg and HBeAg in the OB group was significantly stronger than that in the oxymatrine group (HBsAg, P = 0.043; HBeAg, P = 0.026; respectively); HBV DNA level in the OB group was significantly lower than that in the oxymatrine group (P = 0.041). In HSC-T6 cells the mRNA and protein expression levels of α SMA in the OB group were significantly lower as compared with those in the oxymatrine group (mRNA, P = 0.013; protein, P = 0.042; respectively); The mRNA and protein expression levels of type I collagen in the OB group were significantly lower as compared with those in the oxymatrine group (mRNA, P < 0.01; protein, P < 0.01; respectively).

CONCLUSION: OB combination has a better effect against HBV replication in 2.2.15 cells and is more effective against α SMA expression and typeI collagen synthesis in HSC-T6 cells than oxymatrine in vitro.

Chronic hepatitis B: current testing strategies

The worldwide burden of hepatitis B mandates accurate and timely diagnosis of patients infected with the hepatitis B virus (HBV) and the use of treatment strategies derived from evidence-based guidelines. HBV is a DNA virus that produces a series of viral protein products circulating HBV DNA. Serologic and nucleic acid testing are critical to disease prevention and treatment objectives. Information from such testing helps determine patients' infectivity and immune status, appropriate monitoring strategies, and the efficacy of treatment, as well as providing data that contributes to a better understanding of the natural history and epidemiology of the disease. This article reviews the clinical use of state-of-the-art serologic and nucleic acid tests, including the relevance of hepatitis B e antigen and antibody and HBV DNA measurements as markers of disease activity. Viral load can be used to distinguish between active and inactive disease, define response to therapy, and detect the development of antiviral resistance. Some recent reports have suggested that high viral load is associated with poorer patient outcomes (eg, more rapid progression to cirrhosis and a higher incidence of hepatocellular carcinoma). Durable suppression of HBV DNA is evolving to become the primary goal of therapy, although all currently licensed medications have used histology as the primary end point of therapy. Suggested frequencies for HBV DNA monitoring are presented.