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Yin J, Feng Z, Li Z, Hu J, Hu Y, Cai X, Zhou H, Wang K, Tang N, Huang A, Huang L. Synthesis and evaluation of N-sulfonylpiperidine-3-carboxamide derivatives as capsid assembly modulators inhibiting HBV in vitro and in HBV-transgenic mice. Eur J Med Chem 2023; 249:115141. [PMID: 36709646 DOI: 10.1016/j.ejmech.2023.115141] [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: 12/01/2022] [Revised: 01/13/2023] [Accepted: 01/18/2023] [Indexed: 01/24/2023]
Abstract
The hepatitis B virus (HBV) capsid assembly modulators (CAMs) have been developed as effective anti-HBV agents in the treatment of chronic HBV infection by targeting the HBV core protein and inducing the formation of aberrant or morphologically normal capsid. However, some CAMs have been observed adverse events such as ALT flares and rash. Therefore, finding new CAMs is of great importance. In this report, we synthesized N-sulfonylpiperidine-3-carboxamides (SPCs) derivatives and evaluated their anti-HBV activities. Among the SPC derivatives, compound C-49 notably suppressed HBV replication in HepAD38, HepG2-HBV1.3 and HepG2-NTCP cells. Moreover, treatment with C-49 for 12 days exhibited potent anti-HBV activity (100 mg/kg; 2.42 log reduction of serum HBV DNA) in HBV-transgenic mice without apparent hepatotoxicity. Our findings provided a new SPC derivative as HBV capsid assembly modulator for developing safe and efficient anti-HBV therapy.
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Affiliation(s)
- Jiaxin Yin
- Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Department of Infectious Diseases, Institute for Viral Hepatitis, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Zhongqi Feng
- Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Department of Infectious Diseases, Institute for Viral Hepatitis, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Zhi Li
- Department of Breast&thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, 400010, China
| | - Jieli Hu
- Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Department of Infectious Diseases, Institute for Viral Hepatitis, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yuan Hu
- Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Department of Infectious Diseases, Institute for Viral Hepatitis, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Xuefei Cai
- Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Department of Infectious Diseases, Institute for Viral Hepatitis, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Hui Zhou
- Chongqing Research Center for Pharmaceutical Engineering, College of Pharmacy, Chongqing Medical University, Chongqing, 400016, China
| | - Kai Wang
- Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Department of Infectious Diseases, Institute for Viral Hepatitis, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ni Tang
- Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Department of Infectious Diseases, Institute for Viral Hepatitis, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ailong Huang
- Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Department of Infectious Diseases, Institute for Viral Hepatitis, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Luyi Huang
- Key Laboratory of Molecular Biology for Infectious Diseases (Ministry of Education), Department of Infectious Diseases, Institute for Viral Hepatitis, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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Yang Y, Yan Y, Yin J, Hu J, Cai X, Hu J, Xia J, Wang K, Tang N, Huang L. Structure-Based Discovery of N-Sulfonylpiperidine-3-carboxamides as Novel Capsid Assembly Modulators for Potent Inhibition of HBV Replication. Viruses 2022; 14:v14020348. [PMID: 35215939 PMCID: PMC8876525 DOI: 10.3390/v14020348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/31/2022] [Accepted: 01/31/2022] [Indexed: 12/03/2022] Open
Abstract
As a key element during HBV replication, a nucleocapsid is considered a promising target for the treatment of chronic hepatitis B. The present study aimed to identify small molecules as novel capsid assembly modulators with antiviral activity. Structure-based virtual screening of an integrated compound library led to the identification of several types of HBV inhibitors. Among these inhibitors, N-sulfonylpiperidine-3-carboxamides (SPCs) potently reduced the amount of secreted HBV DNA. Through structure–activity relationship studies, we identified an SPC derivative, namely, C-39, which exhibited the highest antiviral activity without causing cytotoxicity. Mechanism studies showed that C-39 dose-dependently inhibited the formation of HBV capsid, synthesis of cccDNA, e antigen (HBeAg), viral pregenomic RNA (pgRNA), and HBV DNA levels, thereby restraining HBV replication. In summary, SPCs represent a new class of capsid assembly modulators. Further optimization of SPCs is expected to obtain new antiviral drugs against HBV infection.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ni Tang
- Correspondence: (N.T.); (L.H.)
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3
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Identification and Characterization of Besifovir-Resistant Hepatitis B Virus Isolated from a Chronic Hepatitis B Patient. Biomedicines 2022; 10:biomedicines10020282. [PMID: 35203489 PMCID: PMC8868672 DOI: 10.3390/biomedicines10020282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/17/2022] [Accepted: 01/23/2022] [Indexed: 01/05/2023] Open
Abstract
Hepatitis B virus (HBV) is known to cause severe liver diseases such as acute or chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. Chronic hepatitis B (CHB) infection is a major health problem with nearly 300 million individuals infected worldwide. Currently, nucleos(t)ide analogs (NAs) and interferon alpha are clinically approved treatments for HBV infection. NAs are potent antiviral agents that bind to HBV polymerase and block viral reverse transcription and replication. Besifovir dipivoxil maleate (BSV) is a newly developed NA against HBV in the form of acyclic nucleotide phosphonate that is available for oral administration similar to adefovir and tenofovir. Until now, resistance to BSV treatment has not been reported. In this study, we found a CHB patient who showed viral breakthrough after long-term treatment with BSV. The isolated HBV DNA from patient’s serum were cloned into the replication-competent HBV 1.2 mer and the sequence of reverse transcriptase (RT) domain of HBV polymerase were analyzed. We also examined the drug susceptibility of generated clones in vitro. Several mutations were identified in HBV RT domain. A particular mutant harboring ten RT mutations showed resistance to BSV treatment in vitro. The ten mutations include rtV23I (I), rtH55R (R), rtY124H (H), rtD134E (E), rtN139K (K), rtL180M (M), rtM204V (V), rtQ267L (L), rtL269I (I) and rtL336M (M). To further identify the responsible mutations for BSV resistance, we performed in vitro drug susceptibility assay on several artificial clones. As a result, our study revealed that rtL180M (M) and rtM204V (V) mutations, already known as lamivudine-resistant mutations, confer resistance to BSV in the CHB patient.
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Marlet J, Lier C, Roch E, Moreau A, Combe B, Handala L, Lefeuvre S, Maugey M, Elkrief L, d'Alteroche L, Potier P, Brand D, Gaudy-Graffin C. Evolution and phenotypic characterization of whole HBV genome in compliant patients experiencing unexplained entecavir treatment failure. Antiviral Res 2021; 192:105106. [PMID: 34214504 DOI: 10.1016/j.antiviral.2021.105106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/29/2021] [Accepted: 05/31/2021] [Indexed: 12/20/2022]
Abstract
Entecavir treatment failure can be observed in compliant patients despite an absence of detectable resistance mutations by Pol/RT Sanger sequencing. We hypothesized that these unexplained treatment failures could rely on other mechanisms of viral resistance, especially on mutations selected outside of the Pol/RT domain. Partial virological response to entecavir was observed in three patients treated with immunosuppressive drugs, without selection of Pol/RT resistance mutations. Mutations selected in the whole HBV genome during entecavir treatment and potentially associated with resistance were searched for using deep sequencing and characterized using a phenotypic resistance assay. Mutations Q206K (pre-core/core), Q120K (pre-S1/pre-S2, T-cell epitope) and A300E (spacer domain) were selected during entecavir treatment in patient #1 but were not associated with an increased level of resistance to entecavir or an increase in HBV replication capacity. Core promoter mutations T1753G, A1762T and G1764A were present as major mutations before and after treatment in patient #1. HBs Ag immune escape mutations were present as major mutations before and after treatment in patients #2 (sK122R, sT126I, sP127S and sG145R) and #3 (sM133I). We demonstrated that PVR to entecavir does not require selection of any resistance mutation in the whole HBV genome. Our results demonstrate that major mutations can be selected outside of the Pol/RT domain before or during entecavir treatment. These mutations could contribute to entecavir treatment failure by other mechanisms than an increased level of resistance.
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Affiliation(s)
- Julien Marlet
- INSERM U1259, Université de Tours et CHRU de Tours, France; Service de Bactériologie-Virologie-Hygiène, CHRU de Tours, France.
| | - Clément Lier
- INSERM U1259, Université de Tours et CHRU de Tours, France; Service de Bactériologie-Virologie-Hygiène, CHRU de Tours, France
| | | | - Alain Moreau
- INSERM U1259, Université de Tours et CHRU de Tours, France
| | - Benjamin Combe
- INSERM U1259, Université de Tours et CHRU de Tours, France
| | - Lynda Handala
- INSERM U1259, Université de Tours et CHRU de Tours, France
| | | | - Morgan Maugey
- INSERM U1259, Université de Tours et CHRU de Tours, France
| | - Laure Elkrief
- Service D'Hépato-gastroentérologie, CHRU de Tours, France
| | | | - Pascal Potier
- Service D'Hépato-gastroentérologie, CHR D'Orléans, France
| | - Denys Brand
- INSERM U1259, Université de Tours et CHRU de Tours, France; Service de Bactériologie-Virologie-Hygiène, CHRU de Tours, France
| | - Catherine Gaudy-Graffin
- INSERM U1259, Université de Tours et CHRU de Tours, France; Service de Bactériologie-Virologie-Hygiène, CHRU de Tours, France
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Fu Y, Wu S, Hu Y, Chen T, Zeng Y, Liu C, Ou Q. Mutational characterization of HBV reverse transcriptase gene and the genotype-phenotype correlation of antiviral resistance among Chinese chronic hepatitis B patients. Emerg Microbes Infect 2021; 9:2381-2393. [PMID: 33124952 PMCID: PMC7605321 DOI: 10.1080/22221751.2020.1835446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background and Aims: The drug resistance of hepatitis B virus (HBV) originates from mutations within HBV reverse transcriptase (RT) region during the prolonged antiviral therapy. So far, the characteristics of how these mutations distribute and evolve in the process of therapy have not been clarified yet. Thus we aimed to investigate these characteristics and discuss their contributing factors. Methods: HBV RT region was direct-sequenced in 285 treatment-naive and 214 post-treatment patients. Mutational frequency and Shannon entropy were calculated to identify the specific mutations differing between genotypes or treatment status. A typical putative resistance mutation rtL229V was further studied using in-vitro susceptibility assays and molecular modeling. Results: The classical resistance mutations were rarely detected among treatment-naive individuals, while the putative resistance mutations were observed at 8 AA sites. rtV191I and rtA181T/V were the only resistance mutations identified as genotype-specific mutation. Selective pressure of drug usage not only contributed to the classical resistance mutations, but also induced the changes at a putative resistance mutation site rt229. rtL229V was the major substitution at the site of rt229. It contributed to the most potent suppression of viral replication and reduced the in-vitro drug susceptibility to entecavir (ETV) when coexisting with rtM204V, consistent with the hypothesis based on the molecular modeling and clinical data analysis. Conclusions: The analysis of mutations in RT region under the different circumstances of genotypes and therapy status might pave the way for a better understanding of resistance evolution, thus providing the basis for a rational administration of antiviral therapy.
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Affiliation(s)
- Ya Fu
- Department of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Clinical Laboratory Diagnostics, The First Clinical College, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Gene Diagnosis Research Center, Fujian Medical University, Fuzhou, China
| | - Songhang Wu
- Department of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Clinical Laboratory Diagnostics, The First Clinical College, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Gene Diagnosis Research Center, Fujian Medical University, Fuzhou, China
| | - Yuhai Hu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Tianbin Chen
- Department of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Clinical Laboratory Diagnostics, The First Clinical College, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Gene Diagnosis Research Center, Fujian Medical University, Fuzhou, China
| | - Yongbin Zeng
- Department of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Clinical Laboratory Diagnostics, The First Clinical College, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Gene Diagnosis Research Center, Fujian Medical University, Fuzhou, China
| | - Can Liu
- Department of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Clinical Laboratory Diagnostics, The First Clinical College, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Gene Diagnosis Research Center, Fujian Medical University, Fuzhou, China
| | - Qishui Ou
- Department of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Clinical Laboratory Diagnostics, The First Clinical College, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Gene Diagnosis Research Center, Fujian Medical University, Fuzhou, China
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Li ZB, Li L, Niu XX, Chen SH, Fu YM, Wang CY, Liu Y, Shao Q, Chen G, Ji D. Switching from entecavir to tenofovir alafenamide for chronic hepatitis B patients with low-level viraemia. Liver Int 2021; 41:1254-1264. [PMID: 33404182 DOI: 10.1111/liv.14786] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/13/2020] [Accepted: 01/03/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS About 20% of patients receiving nucleos(t)ide analogues treatment experienced low-level viraemia (LLV), which is associated with progression of liver fibrosis and high risk of hepatocellular carcinoma. We aimed to evaluate the effectiveness and safety of switching from entecavir (ETV) to tenofovir alafenamide fumarate (TAF) in ETV-treated patients with LLV. METHODS In this prospective study, ETV-treated patients with LLV, presented to our hospital from December 2018 to October 2019, were enrolled. Switching to TAF or continuing ETV was given. The primary effectiveness endpoint was complete virological response (CVR) at 24 weeks, and the safety endpoint was the first occurrence of any clinical adverse event during the treatment. RESULTS Totally, 211 patients were recruited and propensity score matching (PSM) generated 75 patients in either TAF or ETV group. After PSM, baseline characteristics were balanced in two groups. After 24-week treatment, the CVR and ALT normalization in TAF group were 62.7% and 47.6%, which were higher than 9.3% and 10.5% in ETV group (OR 16.4, 95% CI 6.6-40.0, P < .001) respectively. Subgroup analysis showed that switching to TAF achieved favours CVR regardless of the status of sex, age, CHB family history, HBV DNA, HBeAg and cirrhosis, whereas alcohol consumption and diabetes mellitus might compromise the CVR of switching to TAF. Both therapies were well tolerated and had satisfying renal safety. CONCLUSIONS For ETV-treated patients with LLV, switching to TAF is safe enough and superior compared with continuing ETV monotherapy regarding both virological and biochemical benefits.
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Affiliation(s)
- Zhong-Bin Li
- Department of Liver Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Le Li
- Department of Infectious Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiao-Xia Niu
- Department of Liver Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Song-Hai Chen
- Department of Liver Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yi-Ming Fu
- Department of Liver Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Chun-Yan Wang
- Department of Liver Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yan Liu
- Department of Infectious Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qing Shao
- Department of Liver Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Guofeng Chen
- Department of Liver Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Dong Ji
- Department of Liver Diseases, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
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Liang J, Liang X, Ma H, Nie L, Tian Y, Chen G, Wang Y. Detection of Hepatitis B Virus M204V Mutation Quantitatively via Real-time PCR. J Clin Transl Hepatol 2021; 9:143-148. [PMID: 34007795 PMCID: PMC8111100 DOI: 10.14218/jcth.2020.00118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/25/2021] [Accepted: 01/30/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND AIMS Drug-resistant DNA mutations of the hepatitis B virus (HBV) affect treatment response in chronic hepatitis B patients. We have established a new, sensitive, specific, accurate and convenient real-time PCR method to detect HBV mutations quantitatively. METHODS Blood samples were collected from patients showing viral breakthrough, primary nonresponse, or poor response during treatment, and mutations were detected via direct sequencing to assess our method. A plasmid containing the M204V mutation was synthesized and standard curves plotted. RESULTS The determination coefficient for linear correlation between Ct and log plasmid copy numbers was 0.996, where Ct value was -3.723log (DNA concentration) +48.647. Coefficients of variation indicated good reproducibility. Correctness was within tolerable bias. Limit of detection was 103 copies/mL. Specificity, accuracy, positive predictive value and negative predictive value were 92.86%, 100%, 96.88%, 100% and 94.74%, respectively. CONCLUSIONS These results show that our method can be used to detect HBV M204V mutations with the advantages of sensitivity, specificity and efficiency, providing a new choice for monitoring drug resistance.
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Affiliation(s)
- Jingjing Liang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, Beijing, China
| | | | - Hong Ma
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, Beijing, China
| | - Leng Nie
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ying Tian
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Guang Chen
- Technical center of Beijing Customs District, Beijing, China
| | - Yu Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, Beijing, China
- Correspondence to: Guang Chen, Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, 95 Yong-an Road, Xicheng District, Beijing 100050, China. Tel: +86-131-4126-5625, E-mail: ; Yu Wang, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center of Digestive Diseases, 95 Yong-an Road, Xicheng District, Beijing 100050, China. Tel: +86-133-1110-0797, E-mail:
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8
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Liu Y, Chen R, Liu W, Si L, Li L, Li X, Yao Z, Liao H, Wang J, Li Y, Zhao J, Xu D. Investigation of multidrug-resistance mutations of hepatitis B virus (HBV) in a large cohort of chronic HBV-infected patients with treatment of nucleoside/nucleotide analogs. Antiviral Res 2021; 189:105058. [PMID: 33711338 DOI: 10.1016/j.antiviral.2021.105058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/22/2021] [Accepted: 03/04/2021] [Indexed: 12/19/2022]
Abstract
Multidrug-resistance hepatitis B virus (MDR HBV), defined as those with mutations resistant to both nucleoside analogs lamivudine/telbivudine/entecavir (LAM/LdT/ETV) and nucleotide analog adefovir (ADV), has potential to cause treatment difficulty. To clarify clinical prevalence and virological features of MDR HBV, we investigated serum samples from 28,236 chronic HBV-infected patients with treatment of nucleoside/nucleotide analogs. All patients underwent resistance testing in the Fifth Medical Center of Chinese PLA General Hospital between 2007 and 2019. MDR mutations were screened by direct sequencing; MDR strains (with mutations co-located on the same viral genome) were verified by clonal sequencing (≥20 clones/sample) and subjected to phenotypic analysis if necessary. MDR mutations were detected in 0.81% (229/28,236) patients. MDR strains were verified in 83.0% (190/229) of MDR mutation-positive patients. As ETV-resistance mutation (ETVr) had additional mutation(s) on LAMr conferring more resistance, MDR mutations fell into LAMr + ADVr and ETVr + ADVr subsets. Sixteen mutation patterns of MDR strains were verified, including eight with LAMr + ADVr and eight with ETVr + ADVr. Refractory to sequential therapies of LAM/LdT/ETV and ADV were closely linked with MDR HBV development. Ten representative MDR strains (five LAMr + ADVr and five ETVr + ADVr) tested all had decrease in replication capacity compared to wild-type strains and decrease extent was positively related with the number of primary resistance on viral genome. Compared to ADV + ETV, TDF/TDF + ETV showed higher inhibitory rates on MDR HBV, especially for the five ETVr + ADVr strains (74.5%-97.6% vs. 60.2%-79.5%, all P < 0.05). This study significantly extends the knowledge on MDR HBV and has clinical implications for resistance management.
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Affiliation(s)
- Yan Liu
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Rongjuan Chen
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Wenhui Liu
- Department of Gastroenterology, The Second Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Geriatric Diseases, Beijing, 100853, China
| | - Lanlan Si
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Le Li
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Xiaodong Li
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Zengtao Yao
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Hao Liao
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Jun Wang
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Yuanhua Li
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Jun Zhao
- Department of Liver Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China.
| | - Dongping Xu
- Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China.
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9
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Roade L, Riveiro-Barciela M, Esteban R, Buti M. Long-term efficacy and safety of nucleos(t)ides analogues in patients with chronic hepatitis B. Ther Adv Infect Dis 2021; 8:2049936120985954. [PMID: 33614029 PMCID: PMC7871062 DOI: 10.1177/2049936120985954] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/07/2020] [Indexed: 12/11/2022] Open
Abstract
Nucleos(t)ide analogues with high barrier to resistance are regarded as the principal therapeutic option for chronic hepatitis B (CHB). Treatment with entecavir (ETV), tenofovir disoproxil (TDF) and the later released tenofovir alafenamide (TAF) is highly effective at controlling hepatitis B virus (HBV) infection and, in the vast majority of patients, is well tolerated. No significant differences in viral suppression have been described among the different regimens, although an earlier achievement in biochemical response has been suggested first under TDF and recently under TAF. High barrier to resistance NAs rarely achieve hepatitis B surface antigen sero-clearance, and therefore should be maintained life-long in most cases. This has increased concerns about treatment-related toxicity, especially in patients under TDF with additional risk factors for kidney and bone impairment. TAF has shown a better bone and kidney safety profile than TDF, although it is not yet available worldwide due to its higher cost. Emergence of adverse events should be monitored since treatment-switch to ETV/TAF seems to be effective and safe in HBV mono-infected subjects. Finally, although an effective antiviral treatment leads to a clear improvement in clinical outcome of CHB patients; the risk of developing hepatocellular carcinoma (HCC) is not completely avoided with viral suppression. Whether tenofovir-based regimens provide any additional benefit over ETV in HCC prevention remains unclear and requires further investigation.
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Affiliation(s)
- Luisa Roade
- Liver Unit, Internal Medicine Department, Hospital Universitario Vall d'Hebrón, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain. Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Carlos III, Madrid, Spain
| | - Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitario Vall d'Hebrón, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain. Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Carlos III, Madrid, Spain
| | - Rafael Esteban
- Liver Unit, Internal Medicine Department, Hospital Universitario Vall d'Hebrón, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain. Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Carlos III, Madrid, Spain
| | - Maria Buti
- Liver Unit, Internal Medicine Department, Hospital Universitario Vall d'Hebrón, Vall d'Hebron Barcelona Hospital Campus, Barcelona, 119-129, Spain. Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Carlos III, Madrid, Spain
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10
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Huang BX, Liu Y, Fan ZP, Si LL, Chen RJ, Wang J, Luo D, Wang FS, Xu DP, Liu XG. Investigation of immune escape-associated mutations of hepatitis B virus in patients harboring hepatitis B virus drug-resistance mutations. World J Gastroenterol 2020; 26:5314-5327. [PMID: 32994690 PMCID: PMC7504243 DOI: 10.3748/wjg.v26.i35.5314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/27/2020] [Accepted: 08/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND It is unclear whether immune escape-associated mutations in the major hydrophilic region of hepatitis B virus surface antigen (HBsAg) are associated with nucleoside/nucleotide analog resistance.
AIM To evaluate the association between immune escape-associated mutations and nucleoside/nucleotide analog resistance mutations.
METHODS In total, 19440 patients with chronic hepatitis B virus infection, who underwent resistance testing at the Fifth Medical Center of Chinese PLA General Hospital between July 2007 and December 2017, were enrolled. As determined by sequence analysis, 6982 patients harbored a virus with resistance mutations and 12458 harbored a virus lacking resistance mutations. Phenotypic analyses were performed to evaluate HBsAg production, replication capacity, and drug-induced viral inhibition of patient-derived drug-resistant mutants with or without the coexistence of sA159V.
RESULTS The rate of immune escape-associated mutation was significantly higher in 9 of the 39 analyzed mutation sites in patients with resistance mutations than in patients without resistance mutations. In particular, these mutations were sQ101H/K/R, sS114A/L/T, sT118A/K/M/R/S/V, sP120A/L/Q/S/T, sT/I126A/N/P/S, sM133I/L/T, sC137W/Y, sG145A/R, and sA159G/V. Among these, sA159V was detected in 1.95% (136/6982) of patients with resistance mutations and 1.08% (134/12,458) of patients lacking resistance mutations (P < 0.05). The coexistence of sA159V with lamivudine (LAM) and entecavir (ETV)-resistance mutations in the same viral genome was identified during follow-up in some patients with drug resistance. HBsAg production was significantly lower and the replication capacity was significantly higher, without a significant difference in LAM/ETV susceptibility, in sA159V-containing LAM/ETV-resistant mutants than in their sA159V-lacking counterparts.
CONCLUSION In summary, we observed a close link between the increase in certain immune escape-associated mutations and the development of resistance mutations. sA159V might increase the fitness of LAM/ETV-resistant mutants under environmental pressure in some cases.
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Affiliation(s)
- Bi-Xia Huang
- Guangdong Provincial Key Laboratory of Medical Molecular Diagnostics/Institute of Biochemistry & Molecular Biology, Guangdong Medical University, Dongguan 523808, Guangdong Province, China
| | - Yan Liu
- Institute of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Zhen-Ping Fan
- Institute of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Lan-Lan Si
- Institute of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Rong-Juan Chen
- Institute of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Jun Wang
- Institute of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Dan Luo
- Department of Infectious Diseases, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Fu-Sheng Wang
- Institute of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Dong-Ping Xu
- Institute of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Xin-Guang Liu
- Guangdong Provincial Key Laboratory of Medical Molecular Diagnostics/Institute of Biochemistry & Molecular Biology, Guangdong Medical University, Dongguan 523808, Guangdong Province, China
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Revisiting HBV resistance to entecavir with a phenotypic approach. Antiviral Res 2020; 181:104869. [PMID: 32735901 DOI: 10.1016/j.antiviral.2020.104869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/30/2020] [Accepted: 07/01/2020] [Indexed: 12/16/2022]
Abstract
Treatment adaptation after hepatitis B virus (HBV) treatment failure relies on genotypic resistance testing. However, the results of such tests are not always consistent with treatment response. These discrepancies may be due to differences in resistance levels between isolates with the same genotypic resistance testing profiles. We explored this hypothesis by investigating six cases of entecavir treatment failure with an integrative strategy combining genotypic and phenotypic resistance testing, medical record review and therapeutic drug monitoring. Among isolates with genotypic reduced susceptibility to entecavir, one displayed a higher level of resistance to entecavir (mean fold change in entecavir IC50 of 1 508 ± 531 vs. 318 ± 53, p = 0.008). This isolate harbored a substitution (rt250L) at a position reported to be associated with resistance (rt250V). Reversion to wild-type amino acid at this position partially restored susceptibility to entecavir, confirming that the rt250L mutation was responsible for the high level of resistance to entecavir. This is the first description of entecavir treatment failure associated with selection of the rt250L mutation without other entecavir resistance mutations. One isolate with genotypic resistance to entecavir, harboring the rt173L mutation, displayed a lower level of resistance than the other, harboring the rt202G mutation (mean fold change of 323 ± 124 vs. 6 036 ± 2 100, p = 0.20). These results suggest that isolates harboring the rt250L mutations should be considered resistant to entecavir, whereas isolates harboring the rt173L mutations should be considered to display reduced susceptibility to entecavir. An integrative approach to antiviral drug resistance in HBV would provide a more accurate assessment of entecavir treatment failures and help to improve the accuracy of genotypic testing algorithms.
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Qian F, Zou W, Jin F, Li D, Shen Y. Prevalence of Potential Resistance Related Variants Among Chinese Chronic Hepatitis B Patients Not Receiving Nucleos(T)ide Analogues. Infect Drug Resist 2020; 13:2407-2416. [PMID: 32765014 PMCID: PMC7381783 DOI: 10.2147/idr.s249476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/24/2020] [Indexed: 12/15/2022] Open
Abstract
Background and Aims Potential drug resistance (DR) related variants in the hepatitis B virus (HBV) reverse transcriptase (RT) region may be associated with the effectiveness of antiviral drugs and disease progression. The aim of this study was to investigate the prevalence and clinical characteristics of potential DR-related variants in Chinese CHB patients not receiving nucleos(t)ide analogues (NAs). Patients and Methods Two hundred and six untreated CHB patients from Huzhou Central Hospital in eastern China were recruited for this study. The serum DNA was extracted and the HBV RT region was amplified using nest polymerase chain reaction (nest-PCR). The 42 potential DR-related variants were analyzed by direct sequencing. Results Among these CHB patients, HBV genotype B and genotype C were identified in 121 (58.7%) and 85 (41.3%) patients, respectively. Potential DR-related variants were detected in 42.7% (88/206) of patients. Primary and secondary DR variants were found in 7.3% (15/206) of patients, including rtL80I/V, rtI169T, rtV173L rtL180M, rtA181T/V, rtM204I/V, and rtN236T. The variants at rt53, rt82, rt221, rt233, rt237, and rt256 were specific for genotype B, and those at rt38, rt84, rt126, rt139, rt153, rt191, rt214, rt238, and rt242 were specific for genotype C. Moreover, the variation frequency in the A-B interdomain (3.96%) was significantly higher than that in the functional domains (1.17%) and non-A-B interdomains (1.11%). Multivariate logistic regression analysis showed that lower HBV-DNA load (<106 IU/mL) was an independent factor associated with potential DR-related variants in untreated CHB patients (P <0.05). Conclusion Potential DR-related variants were frequent and complex in untreated Chinese CHB patients. Furthermore, the variants may contribute to decreased serum HBV-DNA loads. However, the effects of potential DR-related variants on the antiviral therapy and liver disease progression require further study.
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Affiliation(s)
- Fuchu Qian
- Department of Precision Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, People's Republic of China.,Huzhou Key Laboratory of Molecular Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, People's Republic of China
| | - Weihua Zou
- Department of Laboratory Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, People's Republic of China
| | - Fang Jin
- Department of Precision Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, People's Republic of China.,Huzhou Key Laboratory of Molecular Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, People's Republic of China
| | - Dongli Li
- Department of Precision Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, People's Republic of China.,Huzhou Key Laboratory of Molecular Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, People's Republic of China
| | - Yujuan Shen
- Department of Infectious Diseases, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, People's Republic of China
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Chen R, Liu Y, Luo D, Si L, Huang B, Wang J, Li X, Cheng F, Xu D, Duan C. Hepatitis B virus mutation pattern rtA181S+T184I+M204I may contribute to multidrug resistance in clinical practice: Analysis of a large cohort of Chinese patients. Antiviral Res 2020; 180:104852. [PMID: 32569703 DOI: 10.1016/j.antiviral.2020.104852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 05/15/2020] [Accepted: 06/09/2020] [Indexed: 02/07/2023]
Abstract
The study aimed to characterize the prevalence and virological features of the rtA181S + T184I + M204I mutant in a large cohort of patients with chronic HBV infection. In total, 22,009 nucleoside/nucleotide analog-treated patients who underwent resistance testing at the Fifth Medical Center of Chinese PLA General Hospital between 2007 and 2016 were enrolled. Serum samples were collected for HBV reverse-transcriptase gene sequencing. Phenotypic analysis of the viral replication capacity and drug susceptibility was performed. The rtA181S mutation was detected in 0.82% (180/22,009) of samples. rtA181S-positive patients had significantly higher lamivudine (LAM), adefovir (ADV), and entecavir (ETV) exposure than rtA181S-negative patients. Of 180 rtA181S-positive patients, 42 had no coexistent resistance mutations, 34 had coexisting LAM-resistance mutation (LAMr), 17 had coexisting ADV-resistance mutation (ADVr), and 86 had coexisting ETV-resistance mutation (ETVr), and one had ADVr + ETVr. rtA181S + T184I + M204I occurred in 79.1% (68/86) of patients with rtA181S + ETVr and 37.8% (68/180) of all rtA181S-positive patients. Longitudinal analysis of the clinical course of resistant mutant evolution for four representative cases showed that rtA181S + T184I + M204I developed in all patients who had received LAM/telbivudine ± ADV and was receiving ETV or ADV + ETV. Compared with wild-type, the rtA181S + T184I + M204I mutant had 53.7% lower replication capacity and >1000-, 3.9-, and 383.3-fold greater LAM, ADV, and ETV resistance, respectively, but remained sensitive to tenofovir. Artificial elimination of rtA181S from the rtA181S + T184I + M204I mutant restored viral susceptibility to ADV but decreased viral replication capacity. Our study presented the first evidence that HBV rtA181S + T184I + M204I mutation had features of multidrug-resistance that contributed to resistance to both nucleoside and nucleotide analogs.
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Affiliation(s)
- Rongjuan Chen
- Department of Cell Biology and Genetics, Molecular Medicine and Cancer Research Center, Chongqing Medical University, Chongqing, 400016, China; Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Yan Liu
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Dan Luo
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Lanlan Si
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Bixia Huang
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Jun Wang
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Xiaodong Li
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Fengjuan Cheng
- Department of Cell Biology and Genetics, Molecular Medicine and Cancer Research Center, Chongqing Medical University, Chongqing, 400016, China
| | - Dongping Xu
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China.
| | - Changzhu Duan
- Department of Cell Biology and Genetics, Molecular Medicine and Cancer Research Center, Chongqing Medical University, Chongqing, 400016, China.
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Luo D, Liu Y, Chen R, Niu M, Liu L, Li X, Li Q, Huang B, Wang J, Xu D, Lin S. Investigation of hepatitis B virus (HBV) rtS78T/sC69* mutation in a large cohort of chronic HBV-infected patients with nucleoside/nucleotide analogue treatment. Antiviral Res 2019; 170:104579. [PMID: 31398372 DOI: 10.1016/j.antiviral.2019.104579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/29/2019] [Accepted: 08/05/2019] [Indexed: 02/07/2023]
Abstract
This study aimed to investigate clinical occurrence and significance of the rtS78T/sC69* mutation of hepatitis B virus (HBV). A total of 22,009 consecutive chronic HBV-infected patients who underwent resistance testing at the Fifth Medical Center of Chinese PLA General Hospital (Original name Beijing 302 Hospital) from 2007 to 2016 were enrolled. Serum samples were collected for sequence analysis of HBV reverse-transcriptase (RT) and S regions. Phenotypic analysis was performed to evaluate the viral replication capacity and drug susceptibility. The rtS78T mutation was detected in 0.83% (182/22,009) of the patients' samples. All mutations simultaneously created a stop codon at sC69 (sC69*). The prevalence of rtS78T/sC69* did not differ significantly between the patients with and without entecavir/tenofovir treatment. Of the 182 mutation-positive samples, 41 (22.5%) were detected with signature drug-resistance mutations to adefovir (n = 26), lamivudine (n = 11), entecavir (n = 3), and lamivudine plus adefovir (n = 1). The HBV DNA and RNA levels of the rtS78T/sC69* mutant were significantly increased compared to the wild-type; while the mutant had undetectable secreted and intracellular HBsAg, and its half maximal effective concentration to lamivudine, adefovir, entecavir, and tenofovir were 3.73-, 1.61-, 4.76-, and 3.71-fold of the wild-type, respectively. Artificial elimination of the rtS78T mutation had a limited effect on the drug susceptibilities. The data obtained in the present study suggested that the emergence of the rtS78T/sC69* mutation was not closely related to entecavir/tenofovir treatment and itself appeared insufficient to confer drug resistance unless it coexisted with signature drug-resistance mutations.
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Affiliation(s)
- Dan Luo
- Department of Infectious Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China; Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital (Beijing 302 Hospital), Beijing, 100039, China
| | - Yan Liu
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital (Beijing 302 Hospital), Beijing, 100039, China
| | - Rongjuan Chen
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital (Beijing 302 Hospital), Beijing, 100039, China
| | - Ming Niu
- Institute of Chinese Medicine, The Fifth Medical Center of Chinese PLA General Hospital (Beijing 302 Hospital), Beijing, 100039, China
| | - Lujie Liu
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital (Beijing 302 Hospital), Beijing, 100039, China
| | - Xiaodong Li
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital (Beijing 302 Hospital), Beijing, 100039, China
| | - Qi Li
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital (Beijing 302 Hospital), Beijing, 100039, China
| | - Bixia Huang
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital (Beijing 302 Hospital), Beijing, 100039, China
| | - Jun Wang
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital (Beijing 302 Hospital), Beijing, 100039, China
| | - Dongping Xu
- Institute of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital (Beijing 302 Hospital), Beijing, 100039, China.
| | - Shumei Lin
- Department of Infectious Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China.
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