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Liu Q, Li J, Zong Q, Duan Z, Liu F, Duan W, Ruan M, Zhang H, Liu Y, Zhou Q, Wang Q. Interferon-induced polarization of M1 macrophages mediates antiviral activity against the hepatitis B virus via the hepcidin-ferroportin axis. Int Immunopharmacol 2024; 134:112219. [PMID: 38733823 DOI: 10.1016/j.intimp.2024.112219] [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: 11/30/2023] [Revised: 04/13/2024] [Accepted: 05/05/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUNDS & AIMS Given its ability to inhibit HBV replication, Interferon alpha (IFN-α) treatment has been confirmed to be effective in managing Chronic Hepatitis B (CHB). However, its underlying mechanisms are incompletely understood. METHODS Herein, we investigated the antiviral properties of IFN-α by introducing IFN-α expression plasmids into a well-established HBV Hydrodynamic Injection (HDI) mouse model and examined the impact of IFN-α or hepcidin treatment on macrophages derived from THP-1 cells. The cytokine profiles were analyzed using the cytometry microsphere microarray technology, and flow cytometry was used to analyze the polarization of macrophages. Additionally, the IL-6/JAK2/STAT3 signaling pathway and the hepcidin-ferroportin axis were analyzed to better understand the macrophage polarization mechanism. RESULTS As evidenced by the suppression of HBV replication, injection of an IFN-α expression plasmid and supernatants of IFN-α-treated macrophages exerted anti-HBV effects. The IFN-α treatment up-regulated IL-6 in mice with HBV replication, as well as in IFN-α-treated HepG2 cells and macrophages. Furthermore, JAK2/STAT3 signaling and hepcidin expression was promoted, inducing iron accumulation via the hepcidin-ferroportin axis, which caused the polarization of M1 macrophages. Furthermore, under the effect of IFN-α, IL-6 silencing or blockade downregulated the JAK2/STAT3 signaling pathway and hepcidin, implying that increased hepcidin expression under IFN-α treatment was dependent on the IL-6/JAK2/STAT3 pathway. CONCLUSION The IL-6/JAK2/STAT3 signaling pathway is activated by IFN-α which induces hepcidin expression. The resulting iron accumulation then induces the polarization of M1 macrophages via the hepcidin-ferroportin axis, yielding an immune response which exerts antiviral effects against HBV replication.
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Affiliation(s)
- Qian Liu
- Department of Clinical Laboratory, the Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Jianfei Li
- Department of Clinical Laboratory, the Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Qiyin Zong
- Department of Clinical Laboratory, the Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Zhi Duan
- Department of Clinical Laboratory, the Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Futing Liu
- Department of Clinical Laboratory, the Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Wanlu Duan
- Department of Clinical Laboratory, the Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Mengqi Ruan
- Department of Clinical Laboratory, the Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Hao Zhang
- Department of Clinical Laboratory, the Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China
| | - Yan Liu
- Department of Microbiology, School of Basic Medical, Anhui Medical University, Hefei, China
| | - Qiang Zhou
- Department of Clinical Laboratory, the Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China.
| | - Qin Wang
- Department of Clinical Laboratory, the Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China.
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Yu X, Gao Y, Zhang X, Ji L, Fang M, Li M, Gao Y. Hepatitis B: Model Systems and Therapeutic Approaches. J Immunol Res 2024; 2024:4722047. [PMID: 38745751 PMCID: PMC11093688 DOI: 10.1155/2024/4722047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 05/16/2024] Open
Abstract
Hepatitis B virus (HBV) infection is a major global health issue and ranks among the top causes of liver cirrhosis and hepatocellular carcinoma. Although current antiviral medications, including nucleot(s)ide analogs and interferons, could inhibit the replication of HBV and alleviate the disease, HBV cannot be fully eradicated. The development of cellular and animal models for HBV infection plays an important role in exploring effective anti-HBV medicine. During the past decades, advancements in several cell culture systems, such as HepG2.2.15, HepAD38, HepaRG, hepatocyte-like cells, and primary human hepatocytes, have propelled the research in inhibiting HBV replication and expression and thus enriched our comprehension of the viral life cycle and enhancing antiviral drug evaluation efficacy. Mouse models, in particular, have emerged as the most extensively studied HBV animal models. Additionally, the present landscape of HBV therapeutics research now encompasses a comprehensive assessment of the virus's life cycle, targeting numerous facets and employing a variety of immunomodulatory approaches, including entry inhibitors, strategies aimed at cccDNA, RNA interference technologies, toll-like receptor agonists, and, notably, traditional Chinese medicine (TCM). This review describes the attributes and limitations of existing HBV model systems and surveys novel advancements in HBV treatment modalities, which will offer deeper insights toward discovering potentially efficacious pharmaceutical interventions.
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Affiliation(s)
- Xiaoxiao Yu
- Laboratory of Cellular Immunity, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yating Gao
- Laboratory of Cellular Immunity, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xin Zhang
- Laboratory of Cellular Immunity, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Longshan Ji
- Laboratory of Cellular Immunity, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Miao Fang
- Laboratory of Cellular Immunity, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Man Li
- Laboratory of Cellular Immunity, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yueqiu Gao
- Laboratory of Cellular Immunity, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Hepatopathy, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Institute of Infectious Diseases of Integrated Traditional Chinese and Western Medicine, Shanghai, China
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3
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Farnesoid X Receptor Activation Decreases Toll-like Receptor 2 Expression by Upregulating HBeAg Production. HEPATITIS MONTHLY 2023. [DOI: 10.5812/hepatmon-129128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Background: Previous investigations have demonstrated that hepatitis B virus (HBV) infection leads to elevated serum bile acid levels, which is considered to cause liver damage. Thus, we suppose that bile acids may be of considerable significance in inducing immune tolerance. Methods: In this investigation, we explored the functions of the farnesoid X receptor (FXR), a nuclear receptor activated by bile acids, in modulating hepatitis B e antigen (HBeAg) production and toll-like receptor (TLR) expression in vitro and in vivo. Results: The results showed that FXR activation promoted secreted and intracellular HBeAg expression in HepG2 and HEK293T cells. However, FXR antagonist Z-guggulsterone (Z-g) decreased the bile acid-mediated HBeAg production. Meanwhile, TLR2 expression significantly reduced in HepG2 cells transfected with pAAV/HBV1.2 plasmid comprising whole HBV genome and treated with bile acids, but not with mutant pAAV/HBV1.2 plasmid with defected HBeAg product. In the hydrodynamic injection HBV mouse model, the level of serum HBeAg was decreased, but intrahepatic TLR2 expression was elevated in FXR-/- mice. Conclusions: In conclusion, FXR activation inhibits TLR2-mediated innate immunity by upregulating HBeAg production. Our data indicate that a mild elevation of serum bile acids may cause immune tolerance and lead to virus persistence in HBV-infected patients.
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Jia J, Zhang Y, Zhang H, Chen Z, Chen L, Zhou Q, Lv X, Wang Q. Hepcidin expression levels involve efficacy of pegylated interferon-α treatment in hepatitis B-infected liver. Int Immunopharmacol 2022; 107:108641. [PMID: 35217337 DOI: 10.1016/j.intimp.2022.108641] [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: 10/15/2021] [Revised: 02/10/2022] [Accepted: 02/17/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hepcidin is the master iron regulator hormone produced by the liver. The association of serum hepcidin with pegylated interferon therapy in patients with chronic hepatitis C infection has been studied. However, the role of serum hepcidin level in predicting the effect of pegylated interferon treatment in patients with chronic hepatitis B (CHB) infection is yet to be elucidated. Our study aims to investigate the correlation between hepcidin expression levels and the curative effect of interferon-alpha therapy in patients with CHB. METHODS A total of 47 patients with CHB who accepted pegylated interferon-α (PEG-IFN- α) treatment were recruited. The serum level of hepcidin was estimated by ELISA. The alternation in the gene expression level of hepcidin was detected by RT-PCR, and immunofluorescence cell staining was performed to detect hepcidin peptide. The induction of antiviral proteins was analyzed by Western blotting. The predictive value of early on-treatment variation in serum hepcidin during treatment progress was assessed by receiver operating characteristic analysis. RESULTS High levels of early on-treatment serum hepcidin were observed in patients who achieved a decline in HBsAg > 1 log10 IU/mL or HBV DNA > 1 log10 IU/mL. In vitro, an elevation of the hepcidin expression in HepG2.2.15 cells induced by PEG-IFN-α treatment was noted. Furthermore, combined treatment with hepcidin and PEG-IFN-α increased the levels of antiviral proteins. The predictive cut-off value of hepcidin for HBsAg decline > 1 log10 IU/mL was 239 pg/mL, and the sensitivity and specificity were 72.73% and 70.97%, respectively. The predictive cut-off value of hepcidin for the decline in HBV DNA > 1 log10 IU/mL was 190.4 pg/mL, and the sensitivity and specificity were 72.73% and 61.11%, respectively. Early-on treatment changes in the hepcidin level signified the predictive value of the PEG-IFN-α curative effect. CONCLUSIONS A higher early-on treatment hepcidin level indicates a higher possibility of HBsAg and HBV DNA decline in patients with CHB during PEG-IFN-α treatment. A high early-on treatment serum hepcidin level is significant in predicting the PEG-IFN-α therapeutic effect in patients with CHB.
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Affiliation(s)
- Jia Jia
- Department of Clinical Laboratory, the Second Hospital of Anhui Medical University, Hefei 230601, China
| | - Yunyun Zhang
- Department of Clinical Laboratory, the Second Hospital of Anhui Medical University, Hefei 230601, China
| | - Hao Zhang
- Department of Clinical Laboratory, the Second Hospital of Anhui Medical University, Hefei 230601, China
| | - Zhidong Chen
- Department of Clinical Laboratory, the Second Hospital of Anhui Medical University, Hefei 230601, China
| | - Liwen Chen
- Department of Clinical Laboratory, the Second Hospital of Anhui Medical University, Hefei 230601, China
| | - Qiang Zhou
- Department of Clinical Laboratory, the Second Hospital of Anhui Medical University, Hefei 230601, China
| | - Xiongwen Lv
- School of Pharmacy, Institute for Liver Diseases of Anhui Medical University, Anhui Key Laboratory of Bioactivity of Natural Products, Anhui Medical University, Mei Shan Road, Hefei, Anhui Province 230032, China.
| | - Qin Wang
- Department of Clinical Laboratory, the Second Hospital of Anhui Medical University, Hefei 230601, China.
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Simultaneous or prior activation of intrahepatic type I interferon signaling leads to hepatitis B virus persistence in a mouse model. J Virol 2021; 95:e0003421. [PMID: 34550772 DOI: 10.1128/jvi.00034-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
It remains controversial how interferon (IFN) response contributes to hepatitis B virus (HBV) control and pathogenesis. A previous study identified that hydrodynamic injection (HI) of type I IFN (IFN-I) inducer polyinosinic-polycytidylic acid (poly(I:C)) leads to HBV clearance in a chronic HBV mouse model. However, recent studies have suggested that premature IFN-I activation in the liver may facilitate HBV persistence. In the present study, we investigated how the early IFN-I response induces an immunosuppressive signaling cascade and thus causes HBV persistence. We performed HI of the plasmid adeno-associated virus (pAAV)/HBV 1.2 into adult BALB/c mice to establish an adult acute HBV replication model. Activation of the IFN-I signaling pathway following poly(I:C) stimulation or murine cytomegalovirus (MCMV) infection resulted in subsequent HBV persistence. HI of poly(I:C) with the pAAV/HBV 1.2 plasmid resulted in not only the production of IFN-I and the anti-inflammatory cytokine interleukin (IL)-10 but also the expansion of intrahepatic regulatory T cells (Tregs), Kupffer cells (KCs) and myeloid-derived suppressor cells (MDSCs), all of which impaired the T cell response. However, when poly(I:C) was injected at day 14 after the HBV plasmid injection, it significantly enhanced HBV specific T cell responses. In addition, interferon-alpha/beta receptor (IFNAR) blockade rescued T cell response by downregulating of IL-10 expression and decreasing Treg and KC expansion. Consistently, Treg depletion or IL-10 blockade also controlled HBV replication. Importance: IFN-I plays a double-edged sword role during chronic HBV infection. Here, we identified that application of IFN-I at different time points causes contrast outcome. Activation of the IFN-I pathway before HBV replication induces an immunosuppressive signaling cascade in the liver, and consequently caused HBV persistence while IFN-I activation post HBV infection enhances HBV-specific T cell responses and thus promote HBV clearance. This result provided an important clue to the mechanism of HBV persistence in adult individuals.
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Fox LE, Locke MC, Lenschow DJ. Context Is Key: Delineating the Unique Functions of IFNα and IFNβ in Disease. Front Immunol 2020; 11:606874. [PMID: 33408718 PMCID: PMC7779635 DOI: 10.3389/fimmu.2020.606874] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/11/2020] [Indexed: 12/15/2022] Open
Abstract
Type I interferons (IFNs) are critical effector cytokines of the immune system and were originally known for their important role in protecting against viral infections; however, they have more recently been shown to play protective or detrimental roles in many disease states. Type I IFNs consist of IFNα, IFNβ, IFNϵ, IFNκ, IFNω, and a few others, and they all signal through a shared receptor to exert a wide range of biological activities, including antiviral, antiproliferative, proapoptotic, and immunomodulatory effects. Though the individual type I IFN subtypes possess overlapping functions, there is growing appreciation that they also have unique properties. In this review, we summarize some of the mechanisms underlying differential expression of and signaling by type I IFNs, and we discuss examples of differential functions of IFNα and IFNβ in models of infectious disease, cancer, and autoimmunity.
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Affiliation(s)
- Lindsey E Fox
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO, United States
| | - Marissa C Locke
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO, United States
| | - Deborah J Lenschow
- Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO, United States.,Department of Medicine, Washington University School of Medicine, Saint Louis, MO, United States
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Miyasaka A, Yoshida Y, Suzuki A, Masuda T, Okamoto H, Takikawa Y. Hepatitis B virus reactivation after successful treatment of hepatitis C virus with sofosbuvir and ribavirin: A case report and literature review. Medicine (Baltimore) 2020; 99:e22650. [PMID: 33031326 PMCID: PMC7544429 DOI: 10.1097/md.0000000000022650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
RATIONALE Hepatitis B virus (HBV) reactivation caused by immunosuppressive therapy or chemotherapy is well known. The administration of direct-acting antiviral agents (DAAs) to treat hepatitis C virus (HCV) infection has also been reported to cause HBV reactivation. We report a rare case of HBV reactivation in a patient with HCV infection after DAA therapy. PATIENT CONCERNS In 1996, a 53-year-old female was identified as infected with HCV at a medical check-up, following which she visited our hospital. She was infected with HCV genotype 2b, and at follow up in 1997, was found to be hepatitis B surface antigen (HBsAg) and antibody against HBsAg negative, antibody against HBV core positive. She then experienced malignant lymphoma in 2001 at 58 years of age. Complete remission was achieved following chemotherapy and autologous peripheral blood stem cell transplantation. In 2014, she remained negative for HBsAg and antibody against HBsAg but positive for antibody against HBV core. In 2015, 12 weeks of sofosbuvir and ribavirin treatment for HCV was started. Serum HCV RNA levels rapidly decreased, and HCV elimination was confirmed at 24 weeks after cessation of DAA treatment. Acute hepatitis B developed at 15 weeks post- sustained virological response without any symptoms and physical examination findings. DIAGNOSES This case is speculated to represent HBV reactivation induced by DAA treatment in a patient with previously resolved HBV, based on virologic and clinical status. Genome sequencing revealed the HBV genotype as A2. INTERVENTIONS The patient was treated with nucleotide analog for HBV reactivation once a day. OUTCOMES Serum HBV-DNA levels decreased, and serum liver enzymes improved following initiation of nucleotide analog treatment. Also, adverse events of nucleotide analog treatment were not observed. LESSONS Although the risk may be very low, DAA therapy can cause HBV reactivation in chronic hepatitis C patients with prior HBV infection. Thus, those patients must be closely monitored for serum HBV DNA levels during and after DAA treatment.
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Affiliation(s)
- Akio Miyasaka
- Division of Hepatology, Department of Internal Medicine
| | | | - Akiko Suzuki
- Division of Hepatology, Department of Internal Medicine
| | - Tomoyuki Masuda
- Department of Pathology, Iwate Medical University School of Medicine, Yahaba-cho, Shiwa-gun, Iwate
| | - Hiroaki Okamoto
- Division of Virology, Department of Infection and Immunity, Jichi Medical University School of Medicine, Shimozuke, Tochigi, Japan
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Broering R, Luo X, Liu J, Lu M. Controversial: Early Innate Responses to Hepatitis B Virus Infection, an Explanation for Viral Persistence? Virol Sin 2020; 36:163-166. [PMID: 32632817 PMCID: PMC7973328 DOI: 10.1007/s12250-020-00235-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/03/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- Ruth Broering
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, 45147, Essen, Germany.
| | - Xufeng Luo
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, 45147, Essen, Germany
| | - Jia Liu
- Department of Infectious Diseases, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Mengji Lu
- Institute of Virology, University Hospital Essen, University of Duisburg-Essen, 45147, Essen, Germany
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Yang K, Guan S, Zhang H, Chen Z. Induction of interleukin 6 impairs the anti-HBV efficiency of IFN-α in human hepatocytes through upregulation of SOCS3. J Med Virol 2019; 91:803-812. [PMID: 30570770 DOI: 10.1002/jmv.25382] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 12/14/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Kai Yang
- Department of Pharmacology; Anhui Medical University; Hefei China
- Department of Clinical Laboratory; The Second Hospital of Anhui Medical University; Hefei China
| | - Shihe Guan
- Department of Clinical Laboratory; The Second Hospital of Anhui Medical University; Hefei China
| | - Hao Zhang
- Department of Clinical Laboratory; The Second Hospital of Anhui Medical University; Hefei China
| | - Zhiwu Chen
- Department of Pharmacology; Anhui Medical University; Hefei China
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10
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Sato K, Kobayashi T, Yamazaki Y, Takakusagi S, Horiguchi N, Kakizaki S, Kusano M, Yamada M. Spontaneous remission of hepatitis B virus reactivation during direct-acting antiviral agent-based therapy for chronic hepatitis C. Hepatol Res 2017; 47:1346-1353. [PMID: 28422376 DOI: 10.1111/hepr.12905] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/06/2017] [Accepted: 04/13/2017] [Indexed: 02/08/2023]
Abstract
The administration of direct-acting antiviral agents (DAAs) to treat hepatitis C virus (HCV) infection has been reported to cause hepatitis B virus (HBV) reactivation. However, the actual conditions of HBV reactivation and the ideal timing of medical intervention have not been fully evaluated. We report the cases of two female patients dually infected with HBV and HCV. Both patients were inactive HBV carriers. Although the serum HCV RNA levels promptly decreased after the initiation of DAA-based therapy, the serum HBV DNA levels gradually increased during DAA-based therapy, with the peak serum HBV DNA levels observed at 16 weeks after the initiation of DAA-based therapy in both cases. Subsequently, we checked the serum HBV DNA levels closely every week several times. Fortunately, the serum HBV DNA levels gradually decreased without medical intervention. Neither case developed an alanine aminotransferase flare-up. The HCV genotypes were 2a and 1b, and the DAA-based therapies of Cases 1 and 2 were 12 weeks of sofosbuvir/ribavirin and ombitasvir/paritaprevir/ritonavir, respectively. The significance of our case reports is the demonstration of the existence of spontaneous remission of HBV reactivation that developed during DAA-based therapy, the avoidance of intervention of nucleot(s)ide analogs by frequent monitoring of serum HBV DNA levels, and development of HBV reactivation regardless of the viral genotype or class of DAA. In conclusion, the close monitoring of serum HBV DNA levels during and after DAA-based therapy is essential and medical intervention for HBV reactivation should be carefully considered on an individual basis.
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Affiliation(s)
- Ken Sato
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Japan.,Department of Hepatology, Heisei Hidaka Clinic, Takasaki, Japan
| | - Takeshi Kobayashi
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Japan.,Department of Hepatology, Heisei Hidaka Clinic, Takasaki, Japan
| | - Yuichi Yamazaki
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Japan.,Department of Hepatology, Heisei Hidaka Clinic, Takasaki, Japan
| | - Satoshi Takakusagi
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Norio Horiguchi
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Japan.,Department of Hepatology, Heisei Hidaka Clinic, Takasaki, Japan
| | - Satoru Kakizaki
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Japan.,Department of Hepatology, Heisei Hidaka Clinic, Takasaki, Japan
| | - Motoyasu Kusano
- Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Maebashi, Japan
| | - Masanobu Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Japan
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