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Wolfson-Stofko B, Hirode G, Vanderhoff A, Karkada J, Capraru C, Biondi MJ, Hansen B, Shah H, Janssen HLA, Feld JJ. Real-world hepatitis C prevalence and treatment uptake at opioid agonist therapy clinics in Ontario, Canada. J Viral Hepat 2024; 31:240-247. [PMID: 38385850 DOI: 10.1111/jvh.13931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/02/2024] [Accepted: 02/15/2024] [Indexed: 02/23/2024]
Abstract
Widespread screening for hepatitis C virus (HCV) is necessary for Canada to meet its HCV elimination goals by 2030. People who currently or previously injected drugs are at high risk for HCV. Opioid agonist therapy (OAT, such as methadone and buprenorphine) has been shown to help stabilize the lives of people who are opioid-dependent. The distribution of OAT in North America typically requires daily, weekly, or monthly clinic visits and presents an opportunity for engagement, screening and treatment for those at high-risk of HCV. In this study, HCV screening was conducted by staff at OAT clinics in Ontario from 2016 to 2020 and those with chronic infections were treated on-site with direct-acting antivirals. Point-of-care or dried blood spot (DBS) testing was used for antibodies, DBS or serum for HCV RNA and serum for HCV RNA at SVR12 (sustained virological response). Clinics screened 1954 people (mean age 40 years ±12, 63% male). Forty-five percent were antibody positive, of whom 64% were HCV RNA+. Eighty percent of those RNA+ set an appointment in which 99% attended. Ninety-six percent started treatment with 87% completing treatment. Sixty-eight percent of people who completed treatment submitted a sample for SVR12 testing of which 97% achieved a virological cure. Results suggest that HCV screening and treatment at OAT clinics is feasible, effective and warrants expansion. Data suggest strong treatment adherence due to high rates of SVR12 comparable with other OAT-based HCV treatment programs. The lack of SVR12 sampling could be addressed by either on-site phlebotomy or incentivizing SVR12 sampling.
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Affiliation(s)
- B Wolfson-Stofko
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Center for Drug Use and HIV/HCV Research (CDUHR), College of Global Public Health, New York University, New York, New York, USA
| | - G Hirode
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - A Vanderhoff
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - J Karkada
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - C Capraru
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - M J Biondi
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- School of Nursing, York University, Toronto, Ontario, Canada
| | - B Hansen
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Biostatistics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - H Shah
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - H L A Janssen
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J J Feld
- Viral Hepatitis Care Network (VIRCAN), Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
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2
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Hirode G, Hansen BE, Chen CH, Su TH, Wong GLH, Seto WK, d'Almeida AF, Papatheodoridi M, Brakenhoff SM, Lens S, Choi HSJ, Chien RN, Feld JJ, Forns X, Sonneveld MJ, Papatheodoridis GV, Vanwolleghem T, Yuen MF, Chan HLY, Kao JH, Hsu YC, Cornberg M, Jeng WJ, Janssen HLA. Limited Sustained Remission After Nucleos(t)ide Analog Withdrawal: Results From a Large, Global, Multiethnic Cohort of Patients With Chronic Hepatitis B (RETRACT-B Study). Am J Gastroenterol 2024:00000434-990000000-01070. [PMID: 38483300 DOI: 10.14309/ajg.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/14/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Complete viral suppression with nucleos(t)ide analogs (NAs) has led to a profound reduction in hepatocellular carcinoma and mortality among patients with chronic hepatitis B. Finite therapy yields higher rates of functional cure; however, initial hepatitis B virus (HBV) DNA and alanine aminotransferase (ALT) elevations are almost certain after treatment interruption. We aimed to analyze off-treatment outcomes beyond 12 months after NA cessation. METHODS Patients with well-suppressed chronic hepatitis B who were hepatitis B e antigen-negative at NA cessation and remained off treatment without hepatitis B surface antigen (HBsAg) loss at 12 months were included (n = 945). HBV DNA and ALT fluctuations were allowed within the first 12 months. We used Kaplan-Meier methods to analyze outcomes beyond 12 months. Sustained remission was defined as HBV DNA <2,000 IU/mL and ALT <2× upper limit of normal (ULN) and an ALT flare as ALT ≥5× ULN. RESULTS Cumulative probability of sustained remission was 29.7%, virological relapse was 65.2% with a mean peak HBV DNA of 5.0 ± 1.5 log 10 IU/mL, an ALT flare was 15.6% with a median peak ALT × ULN of 8.3 (5.7-11.3), HBsAg loss was 9.9% and retreatment was 34.9% at 48 months after NA cessation. A single occurrence of virological relapse or an ALT flare within the first 12 months off-treatment were associated with significantly lower rates of sustained remission beyond 12 months. DISCUSSION Despite allowing for HBV DNA and ALT fluctuations within the first 12 months off-treatment, most patients without HBsAg loss did not maintain a sustained response thereafter. The best candidates for NA withdrawal are patients with low HBsAg levels at NA cessation, and those without profound or recurrent virological and biochemical relapses in the first off-treatment year.
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Affiliation(s)
- Grishma Hirode
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Department of Epidemiology, Biostatistics, Erasmus Medical Center, Rotterdam, Netherlands
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Tung-Hung Su
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Grace L H Wong
- Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong, China
| | - Wai-Kay Seto
- Department of Medicine and State Key Laboratory of Liver Research, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China
| | - Arno Furquim d'Almeida
- Viral Hepatitis Research Group, Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
| | | | - Sylvia M Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sabela Lens
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Hannah S J Choi
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Rong-Nan Chien
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Linkou, Taiwan
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Xavier Forns
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Thomas Vanwolleghem
- Viral Hepatitis Research Group, Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Man-Fung Yuen
- Department of Medicine and State Key Laboratory of Liver Research, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China
| | - Henry L Y Chan
- Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong, China
| | - Jia-Horng Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Chun Hsu
- Center for Liver Diseases, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- Centre for Individualized Infection Medicine (CiiM), Hannover, Germany
| | - Wen-Juei Jeng
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Linkou, Taiwan
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
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3
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Farag MS, van Campenhout MJH, Sonneveld MJ, Fung S, van Erpecum KJ, Wong DK, Verhey E, de Man R, De Knegt RJ, Brouwer JT, Baak HC, Feld JJ, Liem KS, Boonstra A, Hansen BE, Janssen HLA. Addition of PEG-interferon to long-term nucleos(t)ide analogue therapy enhances HBsAg decline and clearance in HBeAg-negative chronic hepatitis B: Multicentre Randomized Trial (PAS Study). J Viral Hepat 2024; 31:197-207. [PMID: 38243144 DOI: 10.1111/jvh.13918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/21/2024]
Abstract
We studied whether 48 weeks of PEG-IFN alfa-2a add-on increases HBsAg-decline and clearance in HBeAg-negative patients on long-term nucleo(s)tide analogue (NA) therapy. In this investigator-initiated, randomized, controlled trial conducted in Europe and Canada, HBeAg-negative patients treated with NA > 12 months, with HBVDNA < 200 IU/mL, were enrolled. Patients were randomized 2:1 to 48 weeks of PEG-IFN alfa-2a add-on (180 μg per week) or continued NA-monotherapy with subsequent follow-up to Week 72. Endpoints were HBsAg decline (≥1 log10 IU/mL) and HBsAg clearance at Week 48. Of the 86 patients in the modified-intention-to-treat analysis, 58 patients received PEG-IFN add-on, and 28 continued NA monotherapy. At Week 48, 16(28%) patients achieved HBsAg decline ≥1 log10 in the add-on arm versus none on NA-monotherapy (p < .001), and HBsAg clearance was observed in 6 (10%) PEG-IFN add-on patients versus 0% NA-monotherapy (p = .01). HBVRNA was only detected in 2% after PEG-IFN treatment versus 19% in NA-monotherapy (p = .002) at Week 48. PEG-IFN add-on therapy was well tolerated in majority of patients. Low baseline HBsAg levels (<10 IU/mL) identified patients most likely to achieve HBsAg loss with PEG-IFN add-on, whereas an HBsAg level > 200 IU/mL at on-treatment Week 12 was highly predictive of non-response (NPV = 100%). Addition of PEG-IFN to long-term NA enhanced HBsAg decline and increased the chance of HBsAg clearance in HBeAg-negative patients on long-term NA. On-treatment HBsAg levels >200 IU/mL identify patients unlikely to benefit from PEG-IFN add-on and could be used as a potential stopping-rule for PEG-IFN therapy. Our findings support further exploration of immune modulation add-on to antiviral therapy, preferably using response-guided strategies, to increase functional cure rates in patients with CHB.
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Affiliation(s)
- Mina S Farag
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Margo J H van Campenhout
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Scott Fung
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Karel J van Erpecum
- Department of Gastroenterology, University Medical Center, Utrecht, The Netherlands
| | - David K Wong
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Elke Verhey
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert de Man
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert J De Knegt
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Johannes T Brouwer
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, The Netherlands
| | - Hubertus C Baak
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Kin Seng Liem
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - André Boonstra
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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4
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van Kleef LA, Francque SM, Prieto-Ortiz JE, Sonneveld MJ, Sanchez-Luque CB, Prieto-Ortiz RG, Kwanten WJ, Vonghia L, Verrijken A, De Block C, Gadi Z, Janssen HLA, de Knegt RJ, Brouwer WP. Metabolic Dysfunction-Associated Fibrosis Score Predicts Liver Fibrosis Risk and Outcome in the General Population With Metabolic Dysfunction. Gastroenterology 2024:S0016-5085(24)00300-7. [PMID: 38513745 DOI: 10.1053/j.gastro.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 03/10/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND & AIMS There is an unmet need for noninvasive tests to improve case-finding and aid primary care professionals in referring patients at high risk of liver disease. METHODS A metabolic dysfunction-associated fibrosis (MAF-5) score was developed and externally validated in a total of 21,797 individuals with metabolic dysfunction in population-based (National Health and Nutrition Examination Survey 2017-2020, National Health and Nutrition Examination Survey III, and Rotterdam Study) and hospital-based (from Antwerp and Bogota) cohorts. Fibrosis was defined as liver stiffness ≥8.0 kPa. Diagnostic accuracy was compared with FIB-4, nonalcoholic fatty liver disease fibrosis score, and steatosis-associated fibrosis estimator. MAF-5 was externally validated with liver stiffness measurement ≥8.0 kPa, with shear-wave elastography ≥7.5 kPa, and biopsy-proven steatotic liver disease according to Metavir and Nonalcoholic Steatohepatitis Clinical Research Network scores, and was tested for prognostic performance (all-cause mortality). RESULTS The MAF-5 score comprised waist circumference, body mass index (calculated as kg / m2), diabetes, aspartate aminotransferase, and platelets. With this score, 60.9% was predicted at low, 14.1% at intermediate, and 24.9% at high risk of fibrosis. The observed prevalence was 3.3%, 7.9%, and 28.1%, respectively. The area under the receiver operator curve of MAF-5 (0.81) was significantly higher than FIB-4 (0.61), and outperformed the FIB-4 among young people (negative predictive value [NPV], 99%; area under the curve [AUC], 0.86 vs NPV, 94%; AUC, 0.51) and older adults (NPV, 94%; AUC, 0.75 vs NPV, 88%; AUC, 0.55). MAF-5 showed excellent performance to detect liver stiffness measurement ≥12 kPa (AUC, 0.86 training; AUC, 0.85 validation) and good performance in detecting liver stiffness and biopsy-proven liver fibrosis among the external validation cohorts. MAF-5 score >1 was associated with increased risk of all-cause mortality in (un)adjusted models (adjusted hazard ratio, 1.59; 95% CI, 1.47-1.73). CONCLUSIONS The MAF-5 score is a validated, age-independent, inexpensive referral tool to identify individuals at high risk of liver fibrosis and all-cause mortality in primary care populations, using simple variables.
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Affiliation(s)
- Laurens A van Kleef
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Sven M Francque
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium; Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
| | | | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | | | | | - Wilhelmus J Kwanten
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium; Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
| | - Luisa Vonghia
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium; Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
| | - An Verrijken
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium; Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Antwerp, Belgium
| | - Christophe De Block
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium; Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Antwerp, Belgium
| | - Zouhir Gadi
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium; Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Canada
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Willem P Brouwer
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands.
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5
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Chua C, Mahamed D, Nkongolo S, Sanchez Vasquez JD, Mehrotra A, Wong DKH, Chung RT, Feld JJ, Janssen HLA, Gehring AJ. Liver-restricted Type I IFN Signature Precedes Liver Damage in Chronic Hepatitis B Patients Stopping Antiviral Therapy. J Immunol 2024; 212:1002-1011. [PMID: 38294274 DOI: 10.4049/jimmunol.2300569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 01/01/2024] [Indexed: 02/01/2024]
Abstract
Immune-mediated liver damage is the driver of disease progression in patients with chronic hepatitis B virus (HBV) infection. Liver damage is an Ag-independent process caused by bystander activation of CD8 T cells and NK cells. How bystander lymphocyte activation is initiated in chronic hepatitis B patients remains unclear. Periods of liver damage, called hepatic flares, occur unpredictably, making early events difficult to capture. To address this obstacle, we longitudinally sampled the liver of chronic hepatitis B patients stopping antiviral therapy and analyzed immune composition and activation using flow cytometry and single-cell RNA sequencing. At 4 wk after stopping therapy, HBV replication rebounded but no liver damage was detectable. There were no changes in cell frequencies at viral rebound. Single-cell RNA sequencing revealed upregulation of IFN-stimulated genes (ISGs) and proinflammatory cytokine migration inhibitory factor (MIF) at viral rebound in patients that go on to develop hepatic flares 6-18 wk after stopping therapy. The type I IFN signature was only detectable within the liver, and neither IFN-α/β or ISG induction could be detected in the peripheral blood. In vitro experiments confirmed the type I IFN-dependent ISG profile whereas MIF was induced primarily by IL-12. MIF exposure further amplified inflammatory cytokine production by myeloid cells. Our data show that innate immune activation is detectable in the liver before clinically significant liver damage is evident. The combination of type I IFN and enhanced cytokine production upon MIF exposure represent the earliest immunological triggers of lymphocyte bystander activation observed in hepatic flares associated with chronic HBV infection.
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Affiliation(s)
- Conan Chua
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Deeqa Mahamed
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Shirin Nkongolo
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Internal Medicine IV (Gastroenterology, Hepatology, Infectious Diseases), University Hospital Heidelberg, Heidelberg, Germany
| | - Juan Diego Sanchez Vasquez
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Aman Mehrotra
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - David K H Wong
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | | | - Jordan J Feld
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Division of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Adam J Gehring
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
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6
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Hirode G, Hansen BE, Chen CH, Su TH, Wong G, Seto WK, Van Hees S, Papatheodoridi M, Brakenhoff SM, Lens S, Choi HSJ, Chien RN, Feld JJ, Forns X, Sonneveld MJ, Papatheodoridis GV, Vanwolleghem T, Yuen MF, Chan HLY, Kao JH, Hsu YC, Cornberg M, Jeng WJ, Janssen HLA. Erratum: Incidence of Hepatic Decompensation After Nucleos(t)ide Analog Withdrawal: Results From a Large, International, Multiethnic Cohort of Patients With Chronic Hepatitis B (RETRACT-B Study). Am J Gastroenterol 2024:00000434-990000000-01058. [PMID: 38457250 DOI: 10.14309/ajg.0000000000002718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Affiliation(s)
- Grishma Hirode
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Ontario, Canada
| | - Bettina E Hansen
- Department of Epidemiology, Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Tung-Hung Su
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Grace Wong
- Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Wai-Kay Seto
- Department of Medicine and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, SAR, China
| | - Stijn Van Hees
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | | | - Sylvia M Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sabela Lens
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Hannah S J Choi
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rong-Nan Chien
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Ontario, Canada
| | - Xavier Forns
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Thomas Vanwolleghem
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Man-Fung Yuen
- Department of Medicine and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, SAR, China
| | - Henry L Y Chan
- The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Jia-Horng Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Chun Hsu
- E-DaHospital/I-Shou University, Kaohsiung, Taiwan
| | - Markus Cornberg
- Department of Gastroenterology, Hepatolology and Endocrinology, Hannover Medical School, Germany; Centre for Individualized Infection Medicine (CiiM), Hannover, Germany
| | - Wen-Juei Jeng
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Perrillo RP, Janssen HLA. Letter to the Editor: Provider preparedness for functional cure of chronic hepatitis B. Hepatology 2024:01515467-990000000-00779. [PMID: 38442001 DOI: 10.1097/hep.0000000000000810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 12/09/2023] [Indexed: 03/07/2024]
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Dongelmans EJ, Sonneveld MJ, Janssen HLA. Letter to the Editor: Benefits of stopping therapy in patients with cirrhotic hepatitis B, true effect or residual confounding? Hepatology 2024; 79:E95-E96. [PMID: 37862458 DOI: 10.1097/hep.0000000000000639] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 09/14/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Edo J Dongelmans
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
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9
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Patmore LA, van Eekhout KMA, Buti M, Koc ÖM, Agarwal K, de Knegt RJ, Janssen HLA, van der Valk M, Lieveld FI, Hansen BE, Kramer M, de Bruijne J, Claassen MAA, Smit C, de Man RA, Takkenberg B, Carey I, Sonneveld MJ. Hepatocellular carcinoma risk in sub-Saharan African and Afro-Surinamese individuals with chronic hepatitis B living in Europe. J Hepatol 2024; 80:243-250. [PMID: 37898348 DOI: 10.1016/j.jhep.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/20/2023] [Accepted: 10/16/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND & AIMS Sub-Saharan African (SSA) ethnicity has been associated with a higher risk of hepatocellular carcinoma (HCC) among individuals with chronic hepatitis B in cross-sectional studies. However, the incidence of HCC and performance of HCC risk scores in this population are unknown. METHODS We conducted an international multicenter retrospective cohort study of all consecutive HBV-monoinfected individuals of SSA or Afro-Surinamese (AS) ethnicity managed at sites in the Netherlands, the United Kingdom and Spain. We assessed the 5- and 10-year cumulative incidences of HCC in the overall study population, among different clinically relevant subgroups and across (m)PAGE-B subgroups. Next, we explored the different risk factors for HCC. RESULTS During a median follow-up of 8 years, we analyzed 1,473 individuals of whom 34 developed HCC. The 5- and 10-year cumulative incidences of HCC were 1% and 2.4%. The 10-year cumulative incidence of HCC was 0.7% among individuals without advanced fibrosis at baseline, compared to 12.1% among individuals with advanced fibrosis (p <0.001). Higher age (adjusted hazard ratio [aHR] 1.05), lower platelet count (aHR 0.98), lower albumin level (aHR 0.90) and higher HBV DNA log10 (aHR 1.21) were significantly associated with HCC development. The 10-year cumulative incidence of HCC was 0.5% among individuals with a low PAGE-B score, compared to 2.9% in the intermediate- and 15.9% in the high-risk groups (p <0.001). CONCLUSIONS In this unique international multicenter cohort of SSA and AS individuals with chronic hepatitis B, we observed 5- and 10-year cumulative HCC risks of 1% and 2.4%, respectively. The risk of HCC was negligible for individuals without advanced fibrosis at baseline, and among individuals with low baseline (m)PAGE-B scores. These findings can be used to guide HCC surveillance strategies. IMPACT AND IMPLICATIONS Sub-Saharan African ethnicity has been associated with a higher risk of hepatocellular carcinoma among individuals with chronic hepatitis B. In this international multicenter cohort study of sub-Saharan African and Afro-Surinamese individuals living with chronic hepatitis B in Europe, we observed 5- and 10-year cumulative incidences of hepatocellular carcinoma of 1% and 2.4%, respectively. The risk was negligible among individuals without advanced fibrosis and a low baseline (m)PAGE-B score. These findings can be used to guide HCC surveillance strategies in this population.
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Affiliation(s)
- Lesley A Patmore
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - Kirsi M A van Eekhout
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Maria Buti
- Liver Unit, Hospital University Valle d'Hebron, Barcelona, Spain
| | - Özgur M Koc
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Rob J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Marc van der Valk
- Amsterdam University Medical Centers, University of Amsterdam, Department of Infectious Disease, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands; Hiv Monitoring Foundation, Amsterdam, The Netherlands
| | - Faydra I Lieveld
- Department of Gastroenterology and Hepatology, Utrecht UMC, Utrecht, The Netherlands; Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bettina E Hansen
- Deperatment of Epidemiology & Biostatistics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; IHPME, University of Toronto & Toronto Centre for Liver disease, UHN, Toronto, Canada
| | - Matthijs Kramer
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joep de Bruijne
- Department of Gastroenterology and Hepatology, Utrecht UMC, Utrecht, The Netherlands
| | - Mark A A Claassen
- Department of Internal Medicine and Infectious Diseases, Rijnstate Hospital, Arnhem, The Netherlands
| | - Colette Smit
- Hiv Monitoring Foundation, Amsterdam, The Netherlands
| | - Rob A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bart Takkenberg
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Ivana Carey
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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10
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Krassenburg LAP, Maan R, Puenpatom A, Erler NS, Welsch C, van Hees S, Cerrhoci O, Vermehren J, de Knegt RJ, Hansen BE, Zeuzem S, Vanwolleghem T, Janssen HLA, de Man RA, Feld JJ, van der Meer AJ. Progression of the FIB-4 index among patients with chronic HCV infection and early liver disease. BMJ Open Gastroenterol 2023; 10:e001209. [PMID: 38637963 PMCID: PMC10711888 DOI: 10.1136/bmjgast-2023-001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/03/2023] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND AIMS Historical paired liver biopsy studies are likely to underestimate current progression of disease in patients with chronic hepatitis C virus (HCV) infection. We aimed to assess liver disease progression according to the non-invasive Fibrosis-4 (FIB-4) index in patients with chronic HCV and early disease. METHODS AND RESULTS Patients diagnosed with chronic HCV and FIB-4 <3.25 from four international liver clinics were included in a retrospective cohort study. Follow-up ended at start of antiviral therapy resulting in sustained virological response, at time of liver transplantation or death. Primary outcome of advanced liver disease was defined as FIB-4 >3.25 during follow-up. Survival analyses were used to assess time to FIB-4 >3.25.In total, 4286 patients were followed for a median of 5.0 (IQR 1.7-9.4) years, during which 41 071 FIB-4 measurements were collected. At baseline, median age was 47 (IQR 39-55) years, 2529 (59.0%) were male, and 2787 (65.0%) patients had a FIB-4 <1.45. Advanced liver disease developed in 821 patients. Overall, 10-year cumulative incidence of advanced disease was 32.1% (95% CI 29.9% to 34.3%). Patients who developed advanced disease showed an exponential FIB-4 increase. Among patients with a presumed date of HCV infection, cumulative incidence of advanced disease increased 7.7-fold from 20 to 40 years as opposed to the first 20 years after HCV infection. CONCLUSIONS The rate of advanced liver disease is high among chronic HCV-infected patients with early disease at time of diagnosis, among whom liver disease progression accelerated over time. These results emphasise the need to overcome any limitations with respect to diagnosing and treating all patients with chronic HCV across the globe.
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Affiliation(s)
- Lisette A P Krassenburg
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Francis Family Liver Clinic, Toronto Centre for Liver Disease, Toronto, Ontario, Canada
| | - Raoel Maan
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Nicole S Erler
- Department of Biostatistics, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christoph Welsch
- Department of Internal Medicine 1, Frankfurt Hospital Consortium, Frankfurt am Main, Germany
| | - Stijn van Hees
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Edegem, Belgium
| | - Orlando Cerrhoci
- Francis Family Liver Clinic, Toronto Centre for Liver Disease, Toronto, Ontario, Canada
| | - Johannes Vermehren
- Department of Internal Medicine 1, Frankfurt Hospital Consortium, Frankfurt am Main, Germany
| | - Robert J de Knegt
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Francis Family Liver Clinic, Toronto Centre for Liver Disease, Toronto, Ontario, Canada
| | - Stefan Zeuzem
- Department of Internal Medicine 1, Frankfurt Hospital Consortium, Frankfurt am Main, Germany
| | - Thomas Vanwolleghem
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Edegem, Belgium
| | - Harry L A Janssen
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Francis Family Liver Clinic, Toronto Centre for Liver Disease, Toronto, Ontario, Canada
| | - Robert A de Man
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jordan J Feld
- Francis Family Liver Clinic, Toronto Centre for Liver Disease, Toronto, Ontario, Canada
| | - Adriaan J van der Meer
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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11
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Patmore LA, van der Eijk AA, Janssen HLA, de Man RA, Sonneveld MJ. Increase in HDV replication during steroid therapy - potential implications for testing and treatment strategies. J Hepatol 2023:S0168-8278(23)05295-9. [PMID: 38036005 DOI: 10.1016/j.jhep.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/05/2023] [Accepted: 11/14/2023] [Indexed: 12/02/2023]
Affiliation(s)
- Lesley A Patmore
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - Annemiek A van der Eijk
- Department of Viroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Toronto Centre of Liver Disease, Toronto General Hospital, Toronto, Canada
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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12
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Sonneveld MJ, Brouwer WP, Janssen HLA. Treatment of diabetes mellitus in patients with chronic hepatitis B: Are SGLT2 inhibitors hitting the sweet spot? Hepatology 2023; 78:1334-1336. [PMID: 37185255 DOI: 10.1097/hep.0000000000000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Willem Pieter Brouwer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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13
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Ghany MG, King WC, Hinerman AS, Lok AS, Lisker-Melman M, Chung RT, Terrault N, Janssen HLA, Khalili M, Lee WM, Lau DTY, Cloherty GA, Sterling RK. Use of HBV RNA and to predict change in serological status and disease activity in CHB. Hepatology 2023; 78:1542-1557. [PMID: 37074026 DOI: 10.1097/hep.0000000000000413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/28/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND AND AIMS Predicting changes in disease activity and serological endpoints is necessary for the management of patients with chronic hepatitis B (CHB). We examined whether HBV RNA and hepatitis B core-related antigen (HBcrAg), two specialized virological markers proposed to reflect the activity of covalently closed circular DNA, may improve the ability to predict not sustained inactive carrier phase, spontaneous alanine aminotransferase (ALT) flare, HBeAg loss, and HBsAg loss. APPROACH AND RESULTS Among eligible participants enrolled in the North American Hepatitis B Research Network Adult Cohort Study, we evaluated demographic, clinical, and virologic characteristics, including HBV RNA and HBcrAg, to predict not sustained inactive carrier phase, ALT flare, HBeAg loss, and HBsAg loss through a series of Cox proportional hazard or logistic regression models, controlling for antiviral therapy use. Among the study population, 54/103 participants experienced not sustained inactive carrier phase, 41/1006 had a spontaneous ALT flare, 83/250 lost HBeAg, and 54/1127 lost HBsAg. HBV RNA or HBcrAg were predictive of all 4 events. However, their addition to models of the readily available host (age, sex, race/ethnicity), clinical (ALT, use of antiviral therapy), and viral factors (HBV DNA), which had acceptable-excellent accuracy (e.g., AUC = 0.72 for ALT flare, 0.92 for HBeAg loss, and 0.91 for HBsAg loss), provided only small improvements in predictive ability. CONCLUSION Given the high predictive ability of readily available markers, HBcrAg and HBV RNA have a limited role in improving the prediction of key serologic and clinical events in patients with CHB.
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Affiliation(s)
- Marc G Ghany
- Liver Diseases Branch, NIDDK, NIH, Bethesda, Maryland, USA
| | - Wendy C King
- Graduate School of Public Health University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amanda S Hinerman
- Department of Epidemiology, Graduate School of Public Health University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anna Sf Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mauricio Lisker-Melman
- Washington University School of Medicine and John Cochran VA Medical Center, St. Louis, Missouri, USA
| | | | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, Keck Medicine of University of Southern California, Los Angeles, California, USA
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University of Toronto, Toronto, Canada
| | - Mandana Khalili
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - William M Lee
- Meredith Mosle Chair in Liver Disease, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Daryl T Y Lau
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Gavin A Cloherty
- Head of Infectious Disease Research, Abbott Diagnostics, Abbott Park, Illinois, USA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
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14
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Perrillo R, Lok AS, Leonard K, Ghany MG, Terrault N, Belle SH, Janssen HLA. Association of Alanine Aminotransferase Flares to Hepatitis B Surface Decline During Tenofovir Alone or With Pegylated Interferon Alfa. Am J Gastroenterol 2023; 118:2075-2079. [PMID: 37307571 DOI: 10.14309/ajg.0000000000002355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/25/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION We aimed to determine whether the intensity of alanine aminotransferase (ALT) flares during antiviral therapy is associated with the level of hepatitis B surface antigen (HBsAg) decline. METHODS Quantitative HBsAg was determined during tenofovir monotherapy or tenofovir plus peginterferon alfa-2a in 201 participants with hepatitis B e antigen-positive or -negative chronic hepatitis B. A multivariable analysis identified factors associated with a shorter time to reduction in HBsAg. RESULTS Fifty flares occurred during treatment of which 74% were moderate (ALT >5-10 × upper limit of normal) or severe (ALT >10 × upper limit of normal). These flares were associated with greater HBsAg decline compared with no flares. Significantly faster times to HBsAg decline >1 log 10 IU ( P = 0.04) and to HBsAg level <100 IU/mL ( P = 0.01) were observed with severe flares. DISCUSSIONS Flare severity is a potentially important factor associated with shorter time to HBsAg reduction. These findings can be useful when evaluating HBsAg response to evolving hepatitis B virus therapies.
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Affiliation(s)
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kelsey Leonard
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marc G Ghany
- Liver Diseases Branch, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Norah Terrault
- Gastrointestinal and Liver Diseases Division, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Steven H Belle
- Departments of Epidemiology and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Harry L A Janssen
- Toronto Centre for Liver Diseases, University Health Network, Toronto, Ontario, Canada
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15
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Genshaft AS, Subudhi S, Keo A, Sanchez Vasquez JD, Conceição-Neto N, Mahamed D, Boeijen LL, Alatrakchi N, Oetheimer C, Vilme M, Drake R, Fleming I, Tran N, Tzouanas C, Joseph-Chazan J, Arreola Villanueva M, van de Werken HJG, van Oord GW, Groothuismink ZMA, Beudeker BJ, Osmani Z, Nkongolo S, Mehrotra A, Spittaels K, Feld J, Chung RT, de Knegt RJ, Janssen HLA, Aerssens J, Bollekens J, Hacohen N, Lauer GM, Boonstra A, Shalek AK, Gehring AJ. Single-cell RNA sequencing of liver fine-needle aspirates captures immune diversity in the blood and liver in chronic hepatitis B patients. Hepatology 2023; 78:1525-1541. [PMID: 37158243 PMCID: PMC10581444 DOI: 10.1097/hep.0000000000000438] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 03/07/2023] [Accepted: 03/20/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND AND AIMS HBV infection is restricted to the liver, where it drives exhaustion of virus-specific T and B cells and pathogenesis through dysregulation of intrahepatic immunity. Our understanding of liver-specific events related to viral control and liver damage has relied almost solely on animal models, and we lack useable peripheral biomarkers to quantify intrahepatic immune activation beyond cytokine measurement. Our objective was to overcome the practical obstacles of liver sampling using fine-needle aspiration and develop an optimized workflow to comprehensively compare the blood and liver compartments within patients with chronic hepatitis B using single-cell RNA sequencing. APPROACH AND RESULTS We developed a workflow that enabled multi-site international studies and centralized single-cell RNA sequencing. Blood and liver fine-needle aspirations were collected, and cellular and molecular captures were compared between the Seq-Well S 3 picowell-based and the 10× Chromium reverse-emulsion droplet-based single-cell RNA sequencing technologies. Both technologies captured the cellular diversity of the liver, but Seq-Well S 3 effectively captured neutrophils, which were absent in the 10× dataset. CD8 T cells and neutrophils displayed distinct transcriptional profiles between blood and liver. In addition, liver fine-needle aspirations captured a heterogeneous liver macrophage population. Comparison between untreated patients with chronic hepatitis B and patients treated with nucleoside analogs showed that myeloid cells were highly sensitive to environmental changes while lymphocytes displayed minimal differences. CONCLUSIONS The ability to electively sample and intensively profile the immune landscape of the liver, and generate high-resolution data, will enable multi-site clinical studies to identify biomarkers for intrahepatic immune activity in HBV and beyond.
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Affiliation(s)
- Alex S. Genshaft
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Massachusetts, USA
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, 400 Technology Square, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Sonu Subudhi
- Liver Center, Division of Gastroenterology and Liver Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Arlin Keo
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Cancer Computational Biology Center, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Juan Diego Sanchez Vasquez
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Nádia Conceição-Neto
- Infectious Diseases Biomarkers, Janssen Research and Development, Beerse, Belgium
| | - Deeqa Mahamed
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Lauke L. Boeijen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nadia Alatrakchi
- Liver Center, Division of Gastroenterology and Liver Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Chris Oetheimer
- Liver Center, Division of Gastroenterology and Liver Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mike Vilme
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Massachusetts, USA
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, 400 Technology Square, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Riley Drake
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Massachusetts, USA
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, 400 Technology Square, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Ira Fleming
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Massachusetts, USA
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, 400 Technology Square, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Nancy Tran
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Massachusetts, USA
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, 400 Technology Square, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Constantine Tzouanas
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Massachusetts, USA
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, 400 Technology Square, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Jasmin Joseph-Chazan
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Massachusetts, USA
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, 400 Technology Square, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Immunology, Harvard Medical School, Boston, Massachusetts, USA
| | - Martin Arreola Villanueva
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Massachusetts, USA
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, 400 Technology Square, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Harmen J. G. van de Werken
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Cancer Computational Biology Center, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
- Department of Immunology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands
| | - Gertine W. van Oord
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Zwier M. A. Groothuismink
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Boris J. Beudeker
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Zgjim Osmani
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Shirin Nkongolo
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Aman Mehrotra
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Kurt Spittaels
- Infectious Diseases Biomarkers, Janssen Research and Development, Beerse, Belgium
| | - Jordan Feld
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Raymond T. Chung
- Liver Center, Division of Gastroenterology and Liver Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J. de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Harry L. A. Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Jeroen Aerssens
- Infectious Diseases Biomarkers, Janssen Research and Development, Beerse, Belgium
| | - Jacques Bollekens
- Infectious Diseases Biomarkers, Janssen Research and Development, Beerse, Belgium
| | - Nir Hacohen
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Immunology, Harvard Medical School, Boston, Massachusetts, USA
| | - Georg M. Lauer
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, 400 Technology Square, Cambridge, Massachusetts, USA
| | - Andre Boonstra
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Alex K. Shalek
- Institute for Medical Engineering and Science (IMES), Department of Chemistry, and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Massachusetts, USA
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, 400 Technology Square, Cambridge, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Adam J. Gehring
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada
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16
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Patmore LA, Katwaroe WK, van der Spek D, Choi HSJ, Patel K, Brakenhoff S, van der Meer AJ, Brouwer WP, van Kleef LA, de Knegt RJ, Hansen BE, de Man RA, Feld JJ, Janssen HLA, Sonneveld MJ. Association Between the Presence of Metabolic Comorbidities and Liver-Related Events in Patients With Chronic Hepatitis B. Clin Gastroenterol Hepatol 2023; 21:3089-3096.e1. [PMID: 37004973 DOI: 10.1016/j.cgh.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/09/2023] [Accepted: 03/17/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND & AIMS Patients with chronic hepatitis B (CHB) are at increased risk of hepatocellular carcinoma and (liver-related) mortality. In addition to hepatitis B-related factors, metabolic comorbidities may contribute to the progression of fibrosis. Therefore, we studied the association between metabolic comorbidities and adverse clinical outcomes in patients with CHB. METHODS We conducted a retrospective cohort study of CHB patients attending the Erasmus MC University Medical Center (Rotterdam, The Netherlands) and CHB patients who underwent liver biopsy at the Toronto General Hospital (Toronto, Canada). The presence of metabolic comorbidities (ie, overweight, diabetes mellitus, hypertension, and dyslipidemia) was assessed based on chart review. The primary end point was liver-related events, defined as the first composite of hepatocellular carcinoma, liver transplantation, or liver-related mortality. RESULTS We analyzed 1850 patients, of whom 926 (50.1%) were overweight, 161 (8.7%) had hypertension, 116 (6.3%) had dyslipidemia, and 82 (4.4%) had diabetes. During a median follow-up period of 7.3 years (interquartile range, 2.9-11.5 y), a total of 111 first events were recorded. Hypertension (hazard ratio [HR], 8.3; 95% CI, 5.5-12.7), diabetes (HR, 5.4; 95% CI, 3.2-9.1), dyslipidemia (HR, 2.8; 95% CI, 1.6-4.8), and overweight (HR, 1.7; 95% CI, 1.1-2.5) were associated with an increased risk for liver-related events. The presence of multiple comorbidities further increased the risk. Findings were consistent for patients with and without cirrhosis, among noncirrhotic hepatitis B e antigen-negative patients with hepatitis B virus DNA less than 2000 IU/mL and in multivariable analysis adjusting for age, sex, ethnicity, hepatitis B e antigen status, hepatitis B virus DNA, use of antiviral therapy, and the presence of cirrhosis. CONCLUSIONS Metabolic comorbidities in CHB patients are associated with an increased risk for liver-related events, with the highest risk observed in patients with multiple comorbidities. Findings were consistent in various clinically relevant subgroups, underscoring the need for thorough metabolic assessment in patients with CHB.
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Affiliation(s)
- Lesley A Patmore
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Warshan K Katwaroe
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Daniel van der Spek
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hannah S J Choi
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
| | - Keyur Patel
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
| | - Sylvia Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Willem P Brouwer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Laurens A van Kleef
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rob J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Epidemiology and Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rob A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jordan J Feld
- Department of Epidemiology and Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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17
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Hirode G, Hansen BE, Chen CH, Su TH, Wong G, Seto WK, Van Hees S, Papatheodoridi M, Brakenhoff SM, Lens S, Choi HSJ, Chien RN, Feld JJ, Forns X, Sonneveld MJ, Papatheodoridis GV, Vanwolleghem T, Yuen MF, Chan HLY, Kao JH, Hsu YC, Cornberg M, Jeng WJ, Janssen HLA. Incidence of Hepatic Decompensation After Nucleos(t)ide Analog Withdrawal: Results From a Large, International, Multiethnic Cohort of Patients With Chronic Hepatitis B (RETRACT-B Study). Am J Gastroenterol 2023; 118:1601-1608. [PMID: 36719174 DOI: 10.14309/ajg.0000000000002203] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/27/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Despite improvements in the management of chronic hepatitis B (CHB), risk of cirrhosis and hepatocellular carcinoma remains. While hepatitis B surface antigen loss is the optimal end point, safe discontinuation of nucleos(t)ide analog (NA) therapy is controversial because of the possibility of severe or fatal reactivation flares. METHODS This is a multicenter cohort study of virally suppressed, end-of-therapy (EOT) hepatitis B e antigen (HBeAg)-negative CHB patients who stopped NA therapy (n = 1,557). Survival analysis techniques were used to analyze off-therapy rates of hepatic decompensation and differences by patient characteristics. We also examined a subgroup of noncirrhotic patients with consolidation therapy of ≥12 months before cessation (n = 1,289). Hepatic decompensation was considered related to therapy cessation if diagnosed off therapy or within 6 months of starting retreatment. RESULTS Among the total cohort (11.8% diagnosed with cirrhosis, 84.2% start-of-therapy HBeAg-negative), 20 developed hepatic decompensation after NA cessation; 10 events were among the subgroup. The cumulative incidence of hepatic decompensation at 60 months off therapy among the total cohort and subgroup was 1.8% and 1.1%, respectively. The hepatic decompensation rate was higher among patients with cirrhosis (hazard ratio [HR] 5.08, P < 0.001) and start-of-therapy HBeAg-positive patients (HR 5.23, P < 0.001). This association between start-of-therapy HBeAg status and hepatic decompensation remained significant even among the subgroup (HR 10.5, P < 0.001). DISCUSSION Patients with cirrhosis and start-of-therapy HBeAg-positive patients should be carefully assessed before stopping NAs to prevent hepatic decompensation. Frequent monitoring of viral and host kinetics after cessation is crucial to determine patient outcome.
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Affiliation(s)
- Grishma Hirode
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Ontario, Canada
| | - Bettina E Hansen
- Department of Epidemiology, Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Tung-Hung Su
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Grace Wong
- Medical Data Analytics Centre (MDAC), The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Wai-Kay Seto
- Department of Medicine and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, SAR, China
| | - Stijn Van Hees
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | | | - Sylvia M Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sabela Lens
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Hannah S J Choi
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rong-Nan Chien
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Ontario, Canada
| | - Xavier Forns
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Thomas Vanwolleghem
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Man-Fung Yuen
- Department of Medicine and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, SAR, China
| | - Henry L Y Chan
- The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Jia-Horng Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Chun Hsu
- E-DaHospital/I-Shou University, Kaohsiung, Taiwan
| | - Markus Cornberg
- Department of Gastroenterology, Hepatolology and Endocrinology, Hannover Medical School, Germany; Centre for Individualized Infection Medicine (CiiM), Hannover, Germany
| | - Wen-Juei Jeng
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Taoyuan, Taiwan
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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18
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Yuen MF, Asselah T, Jacobson IM, Brunetto MR, Janssen HLA, Takehara T, Hou JL, Kakuda TN, Lambrecht T, Beumont M, Kalmeijer R, Guinard-Azadian C, Mayer C, Jezorwski J, Verbinnen T, Lenz O, Shukla U, Biermer M. Efficacy and safety of the siRNA JNJ-73763989 and the capsid assembly modulator JNJ-56136379 (bersacapavir) with nucleos(t)ide analogues for the treatment of chronic hepatitis B virus infection (REEF-1): a multicentre, double-blind, active-controlled, randomised, phase 2b trial. Lancet Gastroenterol Hepatol 2023; 8:790-802. [PMID: 37442152 DOI: 10.1016/s2468-1253(23)00148-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND JNJ-73763989 (JNJ-3989), a small interfering RNA, targets all hepatitis B virus (HBV) RNAs, reducing all HBV proteins. JNJ-56136379 (JNJ-6379; also known as bersacapavir), a capsid assembly modulator, inhibits HBV replication. We aimed to evaluate the efficacy (ie, antiviral activity) and safety of these therapeutics in combination with nucleos(t)ide analogues in patients with chronic hepatitis B. METHODS The REEF-1 multicentre, double-blind, active-controlled, randomised, phase 2b study was done at 108 hospitals or outpatient centres across 19 countries in Asia, Europe, and North and South America. We included patients aged 18-65 years with chronic hepatitis B (defined as HBsAg positivity at screening and at least 6 months before screening or alternative markers of chronicity [eg, HBV DNA]), including those not currently treated, virologically suppressed, HBeAg positive, and HBeAg negative. Patients were randomly assigned (1:1:2:2:2:2) via permuted block randomisation according to a computer-generated schedule to receive oral nucleos(t)ide analogues once per day plus placebo (control group); oral JNJ-6379 250 mg daily plus nucleos(t)ide analogues (JNJ-6379 dual group); nucleos(t)ide analogues plus subcutaneously injected JNJ-3989 at doses of 40 mg (JNJ-3989 dual 40 mg group), 100 mg (JNJ-3989 dual 100 mg group), or 200 mg (JNJ-3989 dual 200 mg group) every 4 weeks; or JNJ-6379 250 mg plus JNJ-3989 100 mg every 4 weeks plus nucleos(t)ide analogues (triple group) for 48 weeks followed by a follow-up phase. An interactive web response system provided concealed treatment allocation, and investigators remained masked to the intervention groups until the primary analysis at week 48. The primary endpoint was the proportion of patients meeting predefined nucleos(t)ide analogue-stopping criteria (alanine aminotransferase <3 × upper limit of normal, HBV DNA below the lower limit of quantitation, HBeAg negative, and HBsAg <10 IU/mL) at week 48. All patients who received at least one dose of study drug were included in the analysis population used for primary efficacy assessment, excluding those who withdrew because of COVID-19-related reasons, withdrew before week 44, or had no efficacy data (ie, the modified intention-to-treat population). Safety was assessed in all participants who received at least one dose of study drugs. This trial is registered with ClinicalTrials.gov, NCT03982186. The study has been completed. FINDINGS Between Aug 1, 2019, and April 26, 2022, 470 patients (310 [66%] male and 244 [52%] White) were randomly assigned: 45 to the control group, 48 to the JNJ-6379 dual group, 93 to the JNJ-3989 dual 40 mg group, 93 to the JNJ-3989 dual 100 mg group, 96 to the JNJ-3989 dual 200 mg group, and 95 to the triple group. At week 48, five (5%; 90% CI 2-11) of 91 patients in the JNJ-3989 dual 40 mg group, 15 (16%; 10-24) of 92 in the JNJ-3989 dual 100 mg group, 18 (19%; 13-27) of 94 in the JNJ-3989 dual 200 mg group, eight (9%; 4-15) of 94 in the triple group, and one (2%; 0-10) of 45 in the control group met nucleos(t)ide analogue stopping criteria. No patients in the JNJ-6379 dual group met stopping criteria. 38 (81%) patients who met nucleos(t)ide analogue-stopping criteria at week 48 were virologically suppressed and HBeAg negative at baseline. Ten (2%) of 470 patients had serious adverse events during the treatment phase, and two patients (one each from the JNJ-3989 dual 200 mg group [exercise-related rhabdomyolysis] and the triple group [increase in ALT or AST]) had serious adverse events related to study treatment. During follow-up, 12 (3%) of 460 patients had a serious adverse event; one (<1%), a gastric ulcer, was considered to be related to nucleos(t)ide analogues and occurred in a patient from the JNJ-3989 dual 200 mg group. 29 (6%) of 460 patients in the treatment phase and in ten (2%) of 460 patients in the follow-up phase had grade 3 or 4 adverse events. Five (1%) of 470 patients discontinued treatment due to adverse events, and there were no deaths. INTERPRETATION Although treatment with JNJ-3989 led to a dose-dependent response for meeting nucleos(t)ide analogue-stopping criteria, it rarely led to HBsAg seroclearance. However, most patients treated with JNJ-3989 had clinically meaningful reductions in HBsAg that might contribute to a liver environment conducive to better immune control and, in turn, might improve the response to immune-modulating therapies. FUNDING Janssen Research and Development.
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Affiliation(s)
- Man-Fung Yuen
- Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China.
| | - Tarik Asselah
- Université de Paris-Cité, Department of Hepatology, AP-HP Hôpital Beaujon, Clichy, INSERM UMR1148, France
| | - Ira M Jacobson
- Division of Gastroenterology and Hepatology, New York University Langone Health, New York, NY, USA
| | - Maurizia Rossana Brunetto
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, ON, Canada; Erasmus Medical Center, Rotterdam, Netherlands
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Jin Lin Hou
- Department of Infectious Diseases, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | | | | | - Maria Beumont
- Janssen Research and Development, Titusville, NJ, USA
| | | | | | | | | | | | | | - Umesh Shukla
- Janssen Research and Development, Titusville, NJ, USA
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19
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Chan HLY, Buti M, Lim YS, Agarwal K, Marcellin P, Brunetto M, Chuang WL, Janssen HLA, Fung S, Izumi N, Abdurakhmanov D, Jabłkowski M, Celen MK, Ma X, Caruntu F, Flaherty JF, Abramov F, Wang H, Camus G, Osinusi A, Pan CQ, Shalimar D, Seto WK, Gane E. Long-term Treatment With Tenofovir Alafenamide for Chronic Hepatitis B Results in High Rates of Viral Suppression and Favorable Renal and Bone Safety. Am J Gastroenterol 2023:00000434-990000000-00837. [PMID: 37561058 PMCID: PMC10903997 DOI: 10.14309/ajg.0000000000002468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/08/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVES Results from two Phase 3 studies, through 2 years, in chronic hepatitis B infection (CHB) showed tenofovir alafenamide (TAF) had similar efficacy to tenofovir disoproxil fumarate (TDF) with superior renal and bone safety. Here, we report updated results through 5 years. METHODS Patients with HBeAg-negative or -positive CHB with or without compensated cirrhosis were randomized (2:1) to TAF 25 mg or TDF 300 mg once daily in double-blind (DB) fashion for up to 3 years, followed by open-label (OL) TAF up to 8 years. Efficacy (antiviral, biochemical, serologic), resistance (deep sequencing of polymerase/reverse transcriptase and phenotyping), and safety, including renal and bone parameters, were evaluated by pooled analyses. RESULTS Of 1298 randomized and treated patients, 866 receiving TAF (DB and OL) and 432 receiving TDF with rollover to OL TAF at year 2 (n = 180; TDF→TAF3y) or year 3 (n = 202; TDF→TAF2y) were included. Fifty (4%) TDF patients who discontinued during DB were excluded. At year 5, 85%, 83%, and 90% achieved HBV DNA < 29 IU/mL (missing = failure) in the TAF, TDF→TAF3y, and TDF→TAF2y groups, respectively; no patient developed TAF or TDF resistance. Median eGFR (by Cockcroft-Gault) declined < 2.5 mL/min, and mean declines of < 1% in hip and spine bone mineral density were seen at year 5 in the TAF group; patients in the TDF→TAF groups had improvements in these parameters at year 5 after switching to OL TAF. CONCLUSIONS Long-term TAF treatment resulted in high rates of viral suppression, no resistance, and favorable renal and bone safety.
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Affiliation(s)
- Henry L Y Chan
- Faculty of Medicine, the Chinese University of Hong Kong, People's Republic of China
| | - Maria Buti
- Hospital Universitario Vall d'Hebron and CIBEREHD del Instituto Carlos III, Barcelona, Spain
| | - Young-Suk Lim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Patrick Marcellin
- Hepatology Department, Hôpital Beaujon, APHP, INSERM, University of Paris, France
| | | | - Wan-Long Chuang
- Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
- Erasmus Medical Center, Rotterdam, Netherlands
| | - Scott Fung
- University of Toronto, Toronto, Ontario, Canada
| | - Namiki Izumi
- Department of Gastroenterology and Hepatology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | | | | | - Mustafa K Celen
- Dicle Üniversitesi Medical School Hospitals, Diyarbakir, Turkey
| | - Xiaoli Ma
- Hahnemann University Hospital, Philadelphia, PA, USA
| | - Florin Caruntu
- National Institute for Infectious Diseases "Matei Bals", Bucharest, Romania
| | | | | | | | | | | | - Calvin Q Pan
- NYU Langone Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Dr Shalimar
- All India Institute of Medical Sciences, New Delhi, India
| | - Wai-Kay Seto
- Department of Medicine and School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Edward Gane
- Auckland Clinical Studies, Auckland, New Zealand
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20
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Murillo Perez CF, Ioannou S, Hassanally I, Trivedi PJ, Corpechot C, van der Meer AJ, Lammers WJ, Battezzati PM, Lindor KD, Nevens F, Kowdley KV, Bruns T, Cazzagon N, Floreani A, Mason AL, Gulamhusein A, Ponsioen CY, Carbone M, Lleo A, Mayo MJ, Dalekos GN, Gatselis NK, Thorburn D, Verhelst X, Parés A, Londoño MC, Janssen HLA, Invernizzi P, Vuppalanchi R, Hirschfield GM, Hansen BE, Levy C. Optimizing therapy in primary biliary cholangitis: Alkaline phosphatase at six months identifies one-year non-responders and predicts survival. Liver Int 2023; 43:1497-1506. [PMID: 37157905 DOI: 10.1111/liv.15592] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/05/2023] [Accepted: 04/16/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND AND AIMS Patients with primary biliary cholangitis (PBC) and insufficient response to ursodeoxycholic acid (UDCA), currently assessed after 1 year, are candidates for second-line therapy. The aims of this study are to assess biochemical response pattern and determine the utility of alkaline phosphatase (ALP) at six months as a predictor of insufficient response. METHODS UDCA-treated patients in the GLOBAL PBC database with available liver biochemistries at one year were included. POISE criteria were used to assess response to treatment, defined as ALP <1.67 × upper limit of normal (ULN) and normal total bilirubin at one year. Various thresholds of ALP at six months were evaluated to predict insufficient response based on negative predictive value (NPV) and that with nearest to 90% NPV was selected. RESULTS For the study, 1362 patients were included, 1232 (90.5%) female, mean age of 54 years. The POISE criteria were met by 56.4% (n = 768) of patients at one year. The median ALP (IQR) of those who met POISE criteria compared to those who did not was 1.05 × ULN (0.82-1.33) vs. 2.37 × ULN (1.72-3.69) at six months (p < .001). Of 235 patients with serum ALP >1.9 × ULN at six months, 89% did not achieve POISE criteria (NPV) after one year of UDCA. Of those with insufficient response by POISE criteria at one year, 210 (67%) had an ALP >1.9 × ULN at six months and thus would have been identified early. CONCLUSIONS We can identify patients for second-line therapy at six months using an ALP threshold of 1.9 × ULN, given that approximately 90% of these patients are non-responders according to POISE criteria.
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Affiliation(s)
- C Fiorella Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Stephanie Ioannou
- Schiff Center for Liver Diseases, Division of Digestive Health and Liver Diseases, University of Miami, Miami, Florida, USA
| | | | - Palak J Trivedi
- National Institute for Health Research Birmingham Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, Paris, France
| | | | - Willem J Lammers
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | | | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Nora Cazzagon
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- IRCCS Negrar, Verona, Italy
| | - Andrew L Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza, Italy
| | - Ana Lleo
- Division of Internal Medicine and Hepatology, IRCCS Humanitas Research Hospital, Department of Biomedical Sciences, Humanitas University, Rozzano (Milan), Italy
| | - Marlyn J Mayo
- Digestive and Liver diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, Full Member of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, Full Member of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, UK
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Albert Parés
- Liver Unit, Hospital Clínic de Barcelona, Health Care Provider of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER) CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maria-Carlota Londoño
- Liver Unit, Hospital Clínic de Barcelona, Health Care Provider of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER) CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza, Italy
| | - Raj Vuppalanchi
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Cynthia Levy
- Schiff Center for Liver Diseases, Division of Digestive Health and Liver Diseases, University of Miami, Miami, Florida, USA
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21
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Verbinnen T, Talloen W, Janssen HLA, Zoulim F, Shukla U, Vandenbossche JJ, Biermer M, De Meyer S, Lenz O. Viral sequence analysis of chronic hepatitis B patients treated with the capsid assembly modulator JNJ-56136379 in the JADE phase 2a study. Antiviral Res 2023:105660. [PMID: 37385475 DOI: 10.1016/j.antiviral.2023.105660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/30/2023] [Accepted: 06/26/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND & AIMS In the monotherapy arms of the phase 2 JADE study (ClinicalTrials.gov Identifier: NCT03361956) evaluating the safety and efficacy of JNJ-56136379 (capsid assembly modulator-class E) with/without nucleos(t)ide analogue (NA), viral breakthroughs (VBT) were observed, leading to JNJ-56136379 monotherapy discontinuation. We present the viral sequencing analysis of JNJ-56136379±NA-treated hepatitis B virus (HBV)-infected patients. METHODS The HBV full genome was sequenced using next generation sequencing. Baseline amino acid (aa) polymorphisms were defined as changes versus the universal HBV reference sequence (sequence read frequency >15%). Emerging mutations were defined as aa changes versus baseline sequence (frequency <1% at baseline and ≥15% post-baseline). RESULTS 6/28 JNJ-56136379 75 mg monotherapy arm patients experienced VBT; all 6 had emerging JNJ-56136379-resistant variants T33N (n = 5; fold change [FC] = 85) or F23Y (n = 1; FC = 5.2). 1/32 JNJ-56136379 250 mg arm patients (genotype-E) had <1 log10 IU/mL decline in HBV DNA at Week 4, experienced VBT at Week 8, and carried the I105T baseline polymorphism (FC = 7.9), but had no emerging variants. Eight additional monotherapy-treated patients had shallow second phases of their HBV DNA profile and emerging T33N (n = 7) or F23Y (n = 1) variants. NA initiation (switch [75 mg arm]; add-on [250 mg arm]) in all monotherapy patients with VBT resulted in HBV DNA decline in all patients. No VBT was observed during JNJ-56136379+NA combination therapy. CONCLUSIONS JNJ-56136379 monotherapy resulted in VBT and was associated with the selection of JNJ-56136379-resistant variants. Efficacy of NA treatment (de novo combination or rescue therapy for VBT) was not impacted, confirming the lack of cross-resistance between these drug classes. CLINICAL TRIAL NUMBER NCT03361956.
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Affiliation(s)
| | - Willem Talloen
- Janssen Pharmaceutica NV, Turnhoutseweg 30, 2340, Beerse, Belgium
| | - Harry L A Janssen
- Toronto General Hospital, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada; Erasmus MC University Hospital Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Fabien Zoulim
- INSERM Unit 1052-Cancer Research Institute of Lyon, Hospices Civils de Lyon, Lyon University, 69008, Lyon, France
| | - Umesh Shukla
- Janssen Pharmaceuticals Research & Development, LLC 1125 Trenton Harbourton Rd, Titusville, NJ, 08560, USA
| | | | - Michael Biermer
- Janssen Pharmaceutica NV, Turnhoutseweg 30, 2340, Beerse, Belgium
| | - Sandra De Meyer
- Janssen Pharmaceutica NV, Turnhoutseweg 30, 2340, Beerse, Belgium
| | - Oliver Lenz
- Janssen Pharmaceutica NV, Turnhoutseweg 30, 2340, Beerse, Belgium
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22
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Li Y, Zhang R, Wang Y, Li P, Li Y, Janssen HLA, de Man RA, Peppelenbosch MP, Ou X, Pan Q. Hepatitis E virus infection remodels the mature tRNAome in macrophages to orchestrate NLRP3 inflammasome response. Proc Natl Acad Sci U S A 2023; 120:e2304445120. [PMID: 37307479 DOI: 10.1073/pnas.2304445120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/10/2023] [Indexed: 06/14/2023] Open
Abstract
Hepatitis E virus (HEV) infection has been shown to activate NOD-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome in macrophages, a key mechanism of causing pathological inflammation, but the mechanisms regulating this response remain poorly understood. Here, we report that the mature tRNAome dynamically responds to HEV infection in macrophages. This directs IL-1β expression, the hallmark of NLRP3 inflammasome activation, at mRNA and protein levels. Conversely, pharmacological inhibition of inflammasome activation abrogates HEV-provoked tRNAome remodeling, revealing a reciprocal interaction between the mature tRNAome and the NLRP3 inflammasome response. Remodeling the tRNAome results in improved decoding of codons directing leucine- and proline synthesis, which are the major amino acid constituents of IL-1β protein, whereas genetic or functional interference with tRNAome-mediated leucine decoding impairs inflammasome activation. Finally, we demonstrated that the mature tRNAome also actively responds to lipopolysaccharide (a key component of gram-negative bacteria)-triggered inflammasome activation, but the response dynamics and mode of actions are distinct from that induced by HEV infection. Our findings thus reveal the mature tRNAome as a previously unrecognized but essential mediator of host response to pathogens and represent a unique target for developing anti-inflammatory therapeutics.
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Affiliation(s)
- Yunlong Li
- Medical Faculty, Kunming University of Science and Technology, 450500 Kunming, Yunnan, China
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, 3015GD Rotterdam, The Netherlands
| | - Ruyi Zhang
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, 3015GD Rotterdam, The Netherlands
| | - Yining Wang
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, 3015GD Rotterdam, The Netherlands
| | - Pengfei Li
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, 3015GD Rotterdam, The Netherlands
| | - Yang Li
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, 3015GD Rotterdam, The Netherlands
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, 3015GD Rotterdam, The Netherlands
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, M5G 2C4 ON, Canada
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, 3015GD Rotterdam, The Netherlands
| | - Maikel P Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, 3015GD Rotterdam, The Netherlands
| | - Xumin Ou
- Engineering Research Center of Southwest Animal Disease Prevention and Control Technology, Ministry of Education of the People's Republic of China, 611130 Chengdu, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Sichuan Agricultural University, Wenjiang, 611830 Chengdu, Sichuan, China
| | - Qiuwei Pan
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, 3015GD Rotterdam, The Netherlands
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23
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Majeed NA, Alawad AS, Liem KS, Takyar V, Alter H, Feld JJ, Janssen HLA, Ghany MG. Low Rate of Hepatitis B Reactivation Among Patients with Chronic Hepatitis C During Direct Acting Antiviral Therapy. Dig Dis Sci 2023:10.1007/s10620-023-07916-2. [PMID: 37022602 DOI: 10.1007/s10620-023-07916-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/04/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND AND AIMS Hepatitis B virus (HBV) reactivation has been reported in patients co-infected with hepatitis C virus (HCV) during direct acting antiviral (DAA) therapy, leading the United States Food and Drug Administration (U.S. FDA) to issue a black box warning on all DAA drug labels recommending monitoring for HBV reactivation. We conducted a comprehensive evaluation to assess the rate of HBV reactivation among patients with chronic hepatitis C (CHC) during DAA therapy. METHODS Patients with CHC and recovered HBV infection (hepatitis B surface antigen negative (HBsAg)/anti-hepatitis B core positive), treated with DAAs were included if stored sera were available. Samples were tested for HBV DNA, HBsAg, and ALT. HBV reactivation was considered if (1) HBV DNA was undetectable pre-DAA therapy and became detectable post-therapy, or (2) HBV DNA was detectable pre-treatment, but not quantifiable (< 20 IU/mL) and became quantifiable post-treatment. RESULT 79 patients with median age of 62 years were included. 68% were male and Caucasian. Various DAA regimens were administered for 12-24 weeks. Reactivation occurred in 8/79 (10%) of patients and occurred more frequently in men compared to women: 6 during treatment and 2 after treatment. Neither an ALT flare nor HBsAg seroreversion were observed. Detectable HBV DNA was transient in 5/8 and could not be determined in 3/8 but ALT flares were not observed in follow-up of these patients. CONCLUSION The risk of HBV reactivation was low in CHC patients with resolved HBV during DAA therapy. Our data support testing for HBV DNA only in selected patients with ALT flares or failure of ALT normalization during DAA treatment.
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Affiliation(s)
- Nehna Abdul Majeed
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Ahmad Samer Alawad
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Kin Seng Liem
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Canada
| | - Varun Takyar
- Department of Gastroenterology, Alta Bates Summit Medical Center, Oakland, CA, USA
| | - Harvey Alter
- Transfusion Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
- The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Canada
- Liver Disease & Transplantation, Erasmus MC, Rotterdam, Netherlands
| | - Marc G Ghany
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
- Liver Diseases Branch, NIDDK, NIH, Bldg 10, Room 9B-16, 10 Center Drive, MSC 1800, Bethesda, MD, 20892-1800, USA.
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24
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Wagner J, Yuen L, Littlejohn M, Sozzi V, Jackson K, Martin R, Aeschbacher T, Suri V, Tan SK, Feierbach B, Gaggar A, Marcellin P, Buti Ferret M, Janssen HLA, Gane E, Meagher N, Price DJ, Wong D, Thompson AT, Revill PA. Hepatitis B virus haplotype number at baseline is a predictive marker of functional cure during antiviral therapy for patients with genotypes A and D HBeAg-positive chronic hepatitis B. Aliment Pharmacol Ther 2023; 57:509-523. [PMID: 36427857 DOI: 10.1111/apt.17299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/03/2022] [Accepted: 10/28/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUNDS AND AIMS We investigated associations between hepatitis B virus (HBV) genome-length haplotype number (HN) at baseline in subjects with HBeAg-positive chronic hepatitis B (CHB), and the likelihood of achieving functional cure during direct-acting antiviral therapy METHOD: We analysed 86 HBeAg-positive baseline samples from patients with HBV genotypes A and D who were enrolled in a Phase II trial of tenofovir disoproxil fumarate (TDF) to determine if HN was a biomarker of HBsAg loss during therapy. Findings were validated using baseline samples from 181 patients with HBV genotypes A and D from an independent clinical trial utilising TDF or tenofovir alafenamide therapy in HBeAg-positive CHB. RESULTS In the HBeAg-positive test cohort, patients with genotypes A or D and ≤2 haplotypes had a minimum of 21-fold higher likelihood of achieving HBsAg loss on TDF. Baseline HN (p < 0.0001) was a stronger predictor of HBsAg loss on therapy than HBsAg titre (p = 0.03), HBeAg titre (p = 0.0002), or the presence of HBV basal core promoter (A1762T, p = 0.0379 and G1764A, p = 0.0176) or G1896A precore mutations (p = 0.0218). This finding was validated in the independent validation cohort. HN was statistically higher in patients with HBV genotypes B or C infection compared to genotypes A and D. CONCLUSION Baseline HN ≤2 predicts which patients with HBV genotypes A or D will more likely progress to functional cure on current direct-acting antiviral therapy, with greater accuracy than current biomarkers including baseline HBsAg and HBeAg titre.
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Affiliation(s)
- Josef Wagner
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Lilly Yuen
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Margaret Littlejohn
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Vitina Sozzi
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Kathy Jackson
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Ross Martin
- Gilead Sciences, Foster City, California, USA
| | | | | | | | | | - Anuj Gaggar
- Gilead Sciences, Foster City, California, USA
| | | | - Maria Buti Ferret
- Liver Unit, Valle d'Hebron (Ciberehd) University Hospital, Barcelona, Spain
| | - Harry L A Janssen
- Toronto Center for Liver Diseases, Toronto General Hospital, University: Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ed Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - Niamh Meagher
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - David J Price
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Darren Wong
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Alexander T Thompson
- Department of Gastroenterology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Peter A Revill
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.,Department of Microbiology and Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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25
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Wedemeyer H, Tergast TL, Lazarus JV, Razavi H, Bakoyannis K, Baptista-Leite R, Bartoli M, Bruggmann P, Buşoi CS, Buti M, Carballo M, Castera L, Colombo M, Coutinho RS, Dadon Y, Esmat G, Esteban R, Farran JC, Gillyon-Powell M, Goldberg D, Hutchinson S, Janssen HLA, Kalamitsis G, Kondili LA, Lambert JS, Marinho RT, Maticic M, Patricello A, Peck-Radosavljevic M, Pol S, Poljak M, Pop C, Sokol T, Sypsa V, Tözün N, Younossi Z, Aghemo A, Papatheodoridis GV, Hatzakis A. Securing wider EU commitment to the elimination of hepatitis C virus. Liver Int 2023; 43:276-291. [PMID: 36196744 DOI: 10.1111/liv.15446] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/04/2022] [Accepted: 09/29/2022] [Indexed: 01/25/2023]
Abstract
In 2016, the Hepatitis B and C Public Policy Association (HepBCPPA), gathered all the main stakeholders in the field of hepatitis C virus (HCV) to launch the now landmark HCV Elimination Manifesto, calling for the elimination of HCV in the EU by 2030. Since then, many European countries have made progress towards HCV elimination. Multiple programmes-from the municipality level to the EU level-were launched, resulting in an overall decrease in viremic HCV infections and liver-related mortality. However, as of 2021, most countries are not on track to reach the 2030 HCV elimination targets set by the WHO. Moreover, the COVID-19 pandemic has resulted in a decrease in HCV diagnoses and fewer direct-acting antiviral treatment initiations in 2020. Diagnostic and therapeutic tools to easily diagnose and treat chronic HCV infection are now well established. Treating all patients with chronic HCV infection is more cost-saving than treating and caring for patients with liver-related complications, decompensated cirrhosis or hepatocellular carcinoma. It is more important than ever to reinforce and scale-up action towards HCV elimination. Yet, efforts urgently need the dedicated commitment of policymakers at all governmental and policy levels. Therefore, the third EU Policy Summit, held in March 2021, featured EU parliamentarians and other key decision makers to promote dialogue and take strides towards securing wider EU commitment to advance and achieve HCV elimination by 2030. We have summarized the key action points and reported the 'Call-to-Action' statement supported by all the major relevant European associations in the field.
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Affiliation(s)
- Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Tammo L Tergast
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Homie Razavi
- Center for Disease Analysis Foundation, Lafayette, Colorado, USA
| | | | - Ricardo Baptista-Leite
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Institute of Health Sciences, Católica University of Portugal, Lisbon, Portugal
| | | | | | | | - Maria Buti
- Liver Unit, Hospital Universitari Vall d'Hebron and CIBERHED del Instituto Carlos III, Barcelona, Spain
| | - Manuel Carballo
- International Centre for Migration, Health and Development, Geneva, Switzerland
| | - Laurent Castera
- Department of Hepatology, Hôpital Beaujon AP-HP-University of Paris-VII, Clichy, France
| | | | | | | | - Gamal Esmat
- Endemic Medicine and Department of HepatoGastroenterology Faculty of Medicine, Cairo University Hospital, Cairo, Egypt
| | - Rafael Esteban
- Liver Unit, Hospital Universitari Vall d'Hebron and CIBERHED del Instituto Carlos III, Barcelona, Spain
| | | | | | | | - Sharon Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | | | - John S Lambert
- Mater Misericordiae University Hospital, and UCD School of Medicine, Dublin, Ireland
| | - Rui Tato Marinho
- Serviço de Gastrenterologia e Hepatologia, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Mojca Maticic
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Markus Peck-Radosavljevic
- Department of Internal Medicine and Gastroenterology (IMuG) Hepatology, Endocrinology, Rheumatology and Nephrology with Centralized Emergency Department (ZAE), Klagenfurt, Austria
| | - Stanislas Pol
- Department of Hepatology, Université de Paris, APHP, Hopital Cochin, Paris, France
| | - Mario Poljak
- Faculty of Medicine, Institute of Microbiology and Immunology, University of Ljubljana, Ljubljana, Slovenia
| | - Cora Pop
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Vana Sypsa
- Epidemiology and Preventive Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Nurdan Tözün
- Department of Gastroenterology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Zobair Younossi
- Department of Medicine, Inova Health Fairfax Medical Campus, Fairfax, Virginia, USA
| | - Alessio Aghemo
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Clinical and Research Hospital, Milan, Italy
| | - George V Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Athens, Greece
| | - Angelos Hatzakis
- Epidemiology and Preventive Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
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26
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Janssen HLA, Hou J, Asselah T, Chan HLY, Zoulim F, Tanaka Y, Janczewska E, Nahass RG, Bourgeois S, Buti M, Lampertico P, Lenz O, Verbinnen T, Vandenbossche J, Talloen W, Kalmeijer R, Beumont M, Biermer M, Shukla U. Randomised phase 2 study (JADE) of the HBV capsid assembly modulator JNJ-56136379 with or without a nucleos(t)ide analogue in patients with chronic hepatitis B infection. Gut 2023:gutjnl-2022-328041. [PMID: 36697207 DOI: 10.1136/gutjnl-2022-328041] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 12/22/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVE We present the final analysis results of the phase 2 JADE study (ClinicalTrials.gov Identifier: NCT03361956). DESIGN 232 patients with chronic hepatitis B (CHB) not currently treated at study start (NCT) at study start or virologically suppressed were randomised to receive 75 mg (part 1) or 250 mg (part 2) JNJ-56136379, a hepatitis B virus (HBV)-capsid assembly modulator, one time per day or placebo with nucleos(t)ide analogue (NA) (tenofovir disoproxil fumarate/entecavir) or JNJ-56136379 alone (NCT-only) for ≥24 and ≤48 weeks. RESULTS In patients who are NCT hepatitis B e-antigen (HBeAg) positive, JNJ-56136379 75 mg+NA and 250 mg+NA showed limited mean (SE) hepatitis B surface antigen (HBsAg) declines (0.14 (0.10) and 0.41 (0.15), respectively) from baseline at Week 24 (primary endpoint; placebo+NA: 0.25 (0.11) log10 international unit (IU)/mL).In patients who are NCT HBeAg positive, mean (SE) HBV DNA declines at Week 24 were 5.53 (0.23) and 5.88 (0.34) for JNJ-56136379 75 mg+NA and 250 mg+NA, respectively, versus 5.21 (0.42) log10 IU/mL for placebo+NA. In NCT patients, mean (SE) HBV RNA declines were 2.96 (0.23) and 3.15 (0.33) versus 1.33 (0.32) log10 copies/mL, respectively.Patients with HBsAg declines had HBeAg and hepatitis B core-related antigen (HBcrAg) declines and some early on-treatment isolated alanine aminotransferase flares. Viral breakthrough occurred with JNJ-56136379 monotherapy with the emerging resistant-variant T33N, but not with JNJ-56136379+NA. JNJ-56136379 treatment beyond Week 24 had a generally small additional effect on viral markers.No study treatment-related serious adverse events or clinically significant changes in laboratory parameters occurred. CONCLUSIONS In patients with non-cirrhotic CHB, JNJ-56136379+NA showed pronounced reductions in HBV DNA and HBV RNA, limited HBsAg or HBeAg declines in patients who are NCT HBeAg positive, and was well tolerated, but no clear benefit with regards to efficacy of JNJ-56136379 over NA was observed.
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Affiliation(s)
- Harry L A Janssen
- Toronto General Hospital, Toronto, Ontario, Canada.,Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Jinlin Hou
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tarik Asselah
- Université de Paris Cité, INSERM UMR1149, Hôpital Beaujon AP-HP, Clichy, France
| | - Henry L Y Chan
- The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Fabien Zoulim
- Hospices Civils de Lyon and Lyon University & INSERM U1052-Cancer Research Institute of Lyon, Lyon, France
| | - Yasuhito Tanaka
- Department of Gastroenterology and Hepatology, Kumamoto University, Kumamoto, Japan
| | - Ewa Janczewska
- Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice, Poland
| | | | | | - Maria Buti
- Hospital Universitario Vall d'Hebrón and CIBERHED del Instituto Carlos III, Barcelona, Spain
| | - Pietro Lampertico
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, CRC 'A. M. and A. Migliavacca' Center for Liver Disease, University of Milan, Milan, Italy
| | | | | | | | | | | | - Maria Beumont
- Janssen Pharmaceuticals R&D, Titusville, New Jersey, USA
| | | | - Umesh Shukla
- Janssen Pharmaceuticals R&D, Titusville, New Jersey, USA
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27
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Biondi MJ, Estes C, Razavi-Shearer D, Sahdra K, Lipton N, Shah H, Capraru C, Janssen HLA, Razavi H, Feld JJ. Cost-effectiveness modelling of birth and infant dose vaccination against hepatitis B virus in Ontario from 2020 to 2050. CMAJ Open 2023; 11:E24-E32. [PMID: 36627129 PMCID: PMC9842099 DOI: 10.9778/cmajo.20210284] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The World Health Organization recommends universal birth dose vaccination for hepatitis B virus (HBV), yet only 3 provinces and territories in Canada provide birth dose vaccination, and Canadian-born children in Ontario are acquiring HBV before adolescent vaccination. We sought to determine whether birth and/or infant HBV vaccination is cost-effective. METHODS We used a dynamic HBV model that incorporates population by year, disease stage, sex and the influence of immigration to quantify the disease and economic burden of chronic HBV infection in Ontario from 2020 to 2050. We compared 4 vaccination scenarios, which included a birth dose vaccine and variations of the 2 subsequent doses (either alone or as a part of the hexavalent vaccine) and a hexavalent-only strategy in infancy with the current adolescent vaccination strategy. Our costing estimates were based on values from 2020. RESULTS All 4 infant vaccination approaches prevented an additional 550-560 acute and 160 chronic pediatric HBV infections from 2020 to 2050 compared with adolescent vaccination. Whereas birth dose could be cost-effective, incorporating vaccination into a hexavalent vaccine was cost saving. By 2050, the hexavalent approach led to $428 000 in cost savings per disability-adjusted life years averted. INTERPRETATION At the current prevalence in Ontario, a switch to birth dose or infant dose will be cost-effective or even cost saving. Introducing any form of infant HBV immunization in Ontario will prevent acute and chronic pediatric HBV infections.
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Affiliation(s)
- Mia J Biondi
- Viral Hepatitis Care Network (VIRCAN) Study Group (Biondi, Sahdra, Lipton, Shah, Capraru, Janssen, Feld), Toronto Centre for Liver Disease; Institute of Medical Sciences (Feld), University of Toronto; School of Nursing (Biondi), York University, Toronto, Ont.; Arthur Labatt Family School of Nursing (Biondi), Western University, London, Ont.; Center for Disease Analysis Foundation (Estes, Razavi-Shearer, Razavi), Lafayette, Colo
| | - Chris Estes
- Viral Hepatitis Care Network (VIRCAN) Study Group (Biondi, Sahdra, Lipton, Shah, Capraru, Janssen, Feld), Toronto Centre for Liver Disease; Institute of Medical Sciences (Feld), University of Toronto; School of Nursing (Biondi), York University, Toronto, Ont.; Arthur Labatt Family School of Nursing (Biondi), Western University, London, Ont.; Center for Disease Analysis Foundation (Estes, Razavi-Shearer, Razavi), Lafayette, Colo
| | - Devin Razavi-Shearer
- Viral Hepatitis Care Network (VIRCAN) Study Group (Biondi, Sahdra, Lipton, Shah, Capraru, Janssen, Feld), Toronto Centre for Liver Disease; Institute of Medical Sciences (Feld), University of Toronto; School of Nursing (Biondi), York University, Toronto, Ont.; Arthur Labatt Family School of Nursing (Biondi), Western University, London, Ont.; Center for Disease Analysis Foundation (Estes, Razavi-Shearer, Razavi), Lafayette, Colo
| | - Kanwar Sahdra
- Viral Hepatitis Care Network (VIRCAN) Study Group (Biondi, Sahdra, Lipton, Shah, Capraru, Janssen, Feld), Toronto Centre for Liver Disease; Institute of Medical Sciences (Feld), University of Toronto; School of Nursing (Biondi), York University, Toronto, Ont.; Arthur Labatt Family School of Nursing (Biondi), Western University, London, Ont.; Center for Disease Analysis Foundation (Estes, Razavi-Shearer, Razavi), Lafayette, Colo
| | - Nechama Lipton
- Viral Hepatitis Care Network (VIRCAN) Study Group (Biondi, Sahdra, Lipton, Shah, Capraru, Janssen, Feld), Toronto Centre for Liver Disease; Institute of Medical Sciences (Feld), University of Toronto; School of Nursing (Biondi), York University, Toronto, Ont.; Arthur Labatt Family School of Nursing (Biondi), Western University, London, Ont.; Center for Disease Analysis Foundation (Estes, Razavi-Shearer, Razavi), Lafayette, Colo
| | - Hemant Shah
- Viral Hepatitis Care Network (VIRCAN) Study Group (Biondi, Sahdra, Lipton, Shah, Capraru, Janssen, Feld), Toronto Centre for Liver Disease; Institute of Medical Sciences (Feld), University of Toronto; School of Nursing (Biondi), York University, Toronto, Ont.; Arthur Labatt Family School of Nursing (Biondi), Western University, London, Ont.; Center for Disease Analysis Foundation (Estes, Razavi-Shearer, Razavi), Lafayette, Colo
| | - Camelia Capraru
- Viral Hepatitis Care Network (VIRCAN) Study Group (Biondi, Sahdra, Lipton, Shah, Capraru, Janssen, Feld), Toronto Centre for Liver Disease; Institute of Medical Sciences (Feld), University of Toronto; School of Nursing (Biondi), York University, Toronto, Ont.; Arthur Labatt Family School of Nursing (Biondi), Western University, London, Ont.; Center for Disease Analysis Foundation (Estes, Razavi-Shearer, Razavi), Lafayette, Colo
| | - Harry L A Janssen
- Viral Hepatitis Care Network (VIRCAN) Study Group (Biondi, Sahdra, Lipton, Shah, Capraru, Janssen, Feld), Toronto Centre for Liver Disease; Institute of Medical Sciences (Feld), University of Toronto; School of Nursing (Biondi), York University, Toronto, Ont.; Arthur Labatt Family School of Nursing (Biondi), Western University, London, Ont.; Center for Disease Analysis Foundation (Estes, Razavi-Shearer, Razavi), Lafayette, Colo
| | - Homie Razavi
- Viral Hepatitis Care Network (VIRCAN) Study Group (Biondi, Sahdra, Lipton, Shah, Capraru, Janssen, Feld), Toronto Centre for Liver Disease; Institute of Medical Sciences (Feld), University of Toronto; School of Nursing (Biondi), York University, Toronto, Ont.; Arthur Labatt Family School of Nursing (Biondi), Western University, London, Ont.; Center for Disease Analysis Foundation (Estes, Razavi-Shearer, Razavi), Lafayette, Colo
| | - Jordan J Feld
- Viral Hepatitis Care Network (VIRCAN) Study Group (Biondi, Sahdra, Lipton, Shah, Capraru, Janssen, Feld), Toronto Centre for Liver Disease; Institute of Medical Sciences (Feld), University of Toronto; School of Nursing (Biondi), York University, Toronto, Ont.; Arthur Labatt Family School of Nursing (Biondi), Western University, London, Ont.; Center for Disease Analysis Foundation (Estes, Razavi-Shearer, Razavi), Lafayette, Colo.
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Casey JL, Dore GJ, Grebely J, Matthews GV, Cherepanov V, Martinello M, Marks P, Janssen HLA, Hansen BE, Kaul R, MacParland SA, Gehring AJ, Feld JJ. Hepatitis C virus-specific immune responses following direct-acting antivirals administered during recent hepatitis C virus infection. J Viral Hepat 2023; 30:64-72. [PMID: 36302162 DOI: 10.1111/jvh.13761] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 12/09/2022]
Abstract
Individuals who spontaneously clear hepatitis C virus (HCV) infection have demonstrated evidence of partial protective immunity, whereas treatment-induced clearance provides little or no protection against reinfection. We aimed to investigate whether treatment of acute HCV infection with direct-acting antivirals (DAA) prevents establishment of, or reverses, T-cell exhaustion, leading to a virus-specific T-cell immune profile more similar to that seen in spontaneous clearance. The magnitude and breadth of HCV-specific T-cell responses before and after DAA or interferon-based therapy in acute or chronic HCV were compared to those of participants with spontaneous clearance of infection, using Enzyme-linked Immunospot (ELISPOT). PBMCs were available for 55 patients comprising 4 groups: spontaneous clearance (n = 17), acute interferon (n = 14), acute DAA (n = 13) and chronic DAA (n = 11). After controlling for sex, the magnitude of post-treatment HCV-specific responses after acute DAA treatment was greater than after chronic DAA or acute IFN treatment and similar to those found in spontaneous clearers. However, spontaneous clearers responded to more HCV peptide pools indicating greater breadth of response. In conclusion, early treatment with DAAs may prevent or reverse some degree of immune exhaustion and result in stronger HCV-specific responses post-treatment. However, individuals with spontaneous clearance had broader HCV-specific responses.
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Affiliation(s)
- Julia L Casey
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Gail V Matthews
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Vera Cherepanov
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Philippa Marks
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rupert Kaul
- Department of Immunology, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Sonya A MacParland
- Departments of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Adam J Gehring
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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29
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Murillo Perez CF, Fisher H, Hiu S, Kareithi D, Adekunle F, Mayne T, Malecha E, Ness E, van der Meer AJ, Lammers WJ, Trivedi PJ, Battezzati PM, Nevens F, Kowdley KV, Bruns T, Cazzagon N, Floreani A, Mason AL, Parés A, Londoño MC, Invernizzi P, Carbone M, Lleo A, Mayo MJ, Dalekos GN, Gatselis NK, Thorburn D, Verhelst X, Gulamhusein A, Janssen HLA, Smith R, Flack S, Mulcahy V, Trauner M, Bowlus CL, Lindor KD, Corpechot C, Jones D, Mells G, Hirschfield GM, Wason J, Hansen BE. Greater Transplant-Free Survival in Patients Receiving Obeticholic Acid for Primary Biliary Cholangitis in a Clinical Trial Setting Compared to Real-World External Controls. Gastroenterology 2022; 163:1630-1642.e3. [PMID: 36150526 DOI: 10.1053/j.gastro.2022.08.054] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/19/2022] [Accepted: 08/30/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS The Primary Biliary Cholangitis (PBC) Obeticholic Acid (OCA) International Study of Efficacy (POISE) randomized, double-blind, placebo-controlled trial demonstrated that OCA reduced biomarkers associated with adverse clinical outcomes (ie, alkaline phosphatase, bilirubin, aspartate aminotransferase, and alanine aminotransferase) in patients with PBC. The objective of this study was to evaluate time to first occurrence of liver transplantation or death in patients with OCA in the POISE trial and open-label extension vs comparable non-OCA-treated external controls. METHODS Propensity scores were generated for external control patients meeting POISE eligibility criteria from 2 registry studies (Global PBC and UK-PBC) using an index date selected randomly between the first and last date (inclusive) on which eligibility criteria were met. Cox proportional hazards models weighted by inverse probability of treatment assessed time to death or liver transplantation. Additional analyses (Global PBC only) added hepatic decompensation to the composite end point and assessed efficacy in patients with or without cirrhosis. RESULTS During the 6-year follow-up, there were 5 deaths or liver transplantations in 209 subjects in the POISE cohort (2.4%), 135 of 1381 patients in the Global PBC control (10.0%), and 281 of 2135 patients in the UK-PBC control (13.2%). The hazard ratios (HRs) for the primary outcome were 0.29 (95% CI, 0.10-0.83) for POISE vs Global PBC and 0.30 (95% CI, 0.12-0.75) for POISE vs UK-PBC. In the Global PBC study, HR was 0.20 (95% CI, 0.03-1.22) for patients with cirrhosis and 0.31 (95% CI, 0.09-1.04) for those without cirrhosis; HR was 0.42 (95% CI, 0.21-0.85) including hepatic decompensation. CONCLUSIONS Patients treated with OCA in a trial setting had significantly greater transplant-free survival than comparable external control patients.
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Affiliation(s)
- C Fiorella Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Holly Fisher
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Shaun Hiu
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | | | - Tracy Mayne
- Intercept Pharmaceuticals, Morristown, New Jersey
| | | | - Erik Ness
- Intercept Pharmaceuticals, Morristown, New Jersey
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | | - Frederik Nevens
- University Hospital Katholieke Universiteit Leuven, Leuven, Belgium
| | | | - Tony Bruns
- Department of Gastroenterology and Hepatology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
| | | | | | - Andrew L Mason
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Albert Parés
- Department of Medicine, Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain; European Reference Network on Hepatological Diseases, Barcelona, Spain
| | - Maria-Carlota Londoño
- Department of Medicine, Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain; European Reference Network on Hepatological Diseases, Barcelona, Spain
| | - Pietro Invernizzi
- European Reference Network on Hepatological Diseases, Barcelona, Spain; Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; San Gerardo Hospital, Monza, Italy
| | | | - Ana Lleo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marlyn J Mayo
- Department of Medicine, Division of Digestive and Liver Disease, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - George N Dalekos
- European Reference Network on Hepatological Diseases, Barcelona, Spain; Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Nikolaos K Gatselis
- European Reference Network on Hepatological Diseases, Barcelona, Spain; Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Douglas Thorburn
- Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Xavier Verhelst
- Department of Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rachel Smith
- Cambridge Liver Unit, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Steve Flack
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | - Victoria Mulcahy
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | | | | | | | | | - David Jones
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - George Mells
- Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James Wason
- Department of Biostatistics, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Epidemiology & Biostatistics, Erasmus MC, Rotterdam, the Netherlands, Toronto, Ontario, Canada; IHPME, University of Toronto, Toronto, Ontario, Canada.
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30
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Zoulim F, Zlotnick A, Buchholz S, Donaldson E, Fry J, Gaggar A, Hu J, Kann M, Lenz O, Lin K, Mani N, Nassal M, Delaney W, Wang S, Westman G, Miller V, Janssen HLA. Nomenclature of HBV core protein-targeting antivirals. Nat Rev Gastroenterol Hepatol 2022; 19:748-750. [PMID: 36207612 PMCID: PMC10442071 DOI: 10.1038/s41575-022-00700-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- Fabien Zoulim
- Hepatology Department, INSERM Unit 1052, Hospices Civils de Lyon, Lyon University, Lyon, France.
| | - Adam Zlotnick
- Molecular and Cellular Biochemistry Department, Indiana University, Bloomington, IN, USA
| | | | | | - John Fry
- Aligos Therapeutics, San Francisco, CA, USA
| | | | - Jianming Hu
- Department of Microbiology and Immunology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Michael Kann
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Microbiology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Kai Lin
- Aerium Therapeutics, Boston, MA, USA
| | - Nagraj Mani
- Arbutus Biopharma Inc., Department of Biology, Warminster, PA, USA
| | - Michael Nassal
- Department of Medicine II, Freiburg University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Su Wang
- Cooperman Barnabas Medical Center, RWJBarnabas-Rutgers Medical Group, Livingston, NJ, USA
| | - Gabriel Westman
- Swedish Medical Products Agency, Uppsala University, Uppsala, Sweden
| | | | - Harry L A Janssen
- Department of Gastroenterology & Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
- Toronto Centre for Liver Disease, University of Toronto, Ontario, Canada
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31
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Yuen MF, Lim SG, Plesniak R, Tsuji K, Janssen HLA, Pojoga C, Gadano A, Popescu CP, Stepanova T, Asselah T, Diaconescu G, Yim HJ, Heo J, Janczewska E, Wong A, Idriz N, Imamura M, Rizzardini G, Takaguchi K, Andreone P, Arbune M, Hou J, Park SJ, Vata A, Cremer J, Elston R, Lukić T, Quinn G, Maynard L, Kendrick S, Plein H, Campbell F, Paff M, Theodore D. Efficacy and Safety of Bepirovirsen in Chronic Hepatitis B Infection. N Engl J Med 2022; 387:1957-1968. [PMID: 36346079 DOI: 10.1056/nejmoa2210027] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Bepirovirsen is an antisense oligonucleotide that targets all hepatitis B virus (HBV) messenger RNAs and acts to decrease levels of viral proteins. METHODS We conducted a phase 2b, randomized, investigator-unblinded trial involving participants with chronic HBV infection who were receiving or not receiving nucleoside or nucleotide analogue (NA) therapy. Participants were randomly assigned (in a 3:3:3:1 ratio) to receive weekly subcutaneous injections of bepirovirsen at a dose of 300 mg for 24 weeks (group 1), bepirovirsen at a dose of 300 mg for 12 weeks then 150 mg for 12 weeks (group 2), bepirovirsen at a dose of 300 mg for 12 weeks then placebo for 12 weeks (group 3), or placebo for 12 weeks then bepirovirsen at a dose of 300 mg for 12 weeks (group 4). Groups 1, 2, and 3 received loading doses of bepirovirsen. The composite primary outcome was a hepatitis B surface antigen (HBsAg) level below the limit of detection and an HBV DNA level below the limit of quantification maintained for 24 weeks after the planned end of bepirovirsen treatment, without newly initiated antiviral medication. RESULTS The intention-to-treat population comprised 457 participants (227 receiving NA therapy and 230 not receiving NA therapy). Among those receiving NA therapy, a primary-outcome event occurred in 6 participants (9%; 95% credible interval, 0 to 31) in group 1, in 6 (9%; 95% credible interval, 0 to 43) in group 2, in 2 (3%; 95% credible interval, 0 to 16) in group 3, and 0 (0%; post hoc credible interval, 0 to 8) in group 4. Among participants not receiving NA therapy, a primary-outcome event occurred in 7 participants (10%; 95% credible interval, 0 to 38), 4 (6%; 95% credible interval, 0 to 25), 1 (1%; post hoc credible interval, 0 to 6), and 0 (0%; post hoc credible interval, 0 to 8), respectively. During weeks 1 through 12, adverse events, including injection-site reactions, pyrexia, fatigue, and increased alanine aminotransferase levels, were more common with bepirovirsen (groups 1, 2, and 3) than with placebo (group 4). CONCLUSIONS In this phase 2b trial, bepirovirsen at a dose of 300 mg per week for 24 weeks resulted in sustained HBsAg and HBV DNA loss in 9 to 10% of participants with chronic HBV infection. Larger and longer trials are required to assess the efficacy and safety of bepirovirsen. (Funded by GSK; B-Clear ClinicalTrials.gov number, NCT04449029.).
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Affiliation(s)
- Man-Fung Yuen
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Seng-Gee Lim
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Robert Plesniak
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Keiji Tsuji
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Harry L A Janssen
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Cristina Pojoga
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Adrian Gadano
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Corneliu P Popescu
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Tatyana Stepanova
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Tarik Asselah
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Gheorghe Diaconescu
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Hyung Joon Yim
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Jeong Heo
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Ewa Janczewska
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Alexander Wong
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Nevin Idriz
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Michio Imamura
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Giuliano Rizzardini
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Koichi Takaguchi
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Pietro Andreone
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Manuela Arbune
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Jinlin Hou
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Sung Jae Park
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Andrei Vata
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Jennifer Cremer
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Robert Elston
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Tamara Lukić
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Geoff Quinn
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Lauren Maynard
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Stuart Kendrick
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Helene Plein
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Fiona Campbell
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Melanie Paff
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
| | - Dickens Theodore
- From the Department of Medicine, Queen Mary Hospital, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, and the State Key Laboratory of Liver Research, University of Hong Kong, Hong Kong (M.-F.Y.), and Nanfang Hospital, Southern Medical University, Guangzhou (J. Hou) - all in China; National University Health System, Singapore (S.-G.L.); the University of Rzeszow, College of Medical Sciences, Centrum Medyczne w Lancucie, Lancut (R.P.), and the Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice (E.J.) - both in Poland; the Department of Gastroenterology, Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital (K. Tsuji), and Hiroshima University Hospital (M.I.), Hiroshima, and Kagawa Prefectural Central Hospital, Takamatsu (K. Takaguchi) - all in Japan; Toronto General Hospital, Toronto (H.L.A.J.), and the Department of Medicine, University of Saskatchewan, Regina (A.W.) - both in Canada; Erasmus Medical Center, Rotterdam, the Netherlands (H.L.A.J.); Regional Institute of Gastroenterology and Hepatology and Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj-Napoca (C.P.), Dr. Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest (C.P.P.), Spitalul Clinic de Boli Infectioase si Pneumoftiziologie, Craiova (G.D.), Sfanta Cuvioasa Parascheva Infectious Diseases Clinical Hospital, Galati (M.A.), and "Grigore T. Popa" University of Medicine and Pharmacy, Iasi (A.V.) - all in Romania; Hospital Italiano de Buenos Aires, Buenos Aires (A.G.); Modern Medicine Clinic, Moscow (T.S.); Université de Paris-Cité and INSERM Unité Mixte de Recherche 1149, Department of Hepatology, Assistance Publique-Hôpitaux de Paris Hôpital Beaujon, Clichy, France (T.A.); Korea University Ansan Hospital, Ansan (H.J.Y.), and the College of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital (J. Heo), and Inje University Busan Paik Hospital (S.-J.P.), Busan - all in South Korea; the University of Medicine and Hospital for Active Treatment Sofiamed, Sofia, Bulgaria (N.I.); Luigi Sacco Hospital, Milan (G.R.), and Azienda Ospedaliero-Universitaria di Modena, Baggiovara Hospital, Modena (P.A.) - both in Italy; GSK, Durham, NC (J.C., D.T.); GSK, Stevenage (R.E., G.Q., L.M., S.K., F.C.), and GSK, Brentford (H.P.) - both in the United Kingdom; GSK, Dubai, United Arab Emirates (T.L.); and GSK, Collegeville, PA (M.P.)
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Liem KS, Chi H, Fung S, Wong DK, Yim C, Noureldin S, Chen J, de Man RA, Sarowar A, Feld JJ, Hansen BE, Hou J, Peng J, Janssen HLA. Early virologic relapse predicts alanine aminotransferase flares after nucleos(t)ide analogue withdrawal in patients with chronic hepatitis B. J Viral Hepat 2022; 29:986-993. [PMID: 36048970 DOI: 10.1111/jvh.13742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/28/2022] [Accepted: 07/06/2022] [Indexed: 12/09/2022]
Abstract
When patients with chronic hepatitis B (CHB) stop nucleos(t)ide analogue (NA) therapy before achieving HBsAg loss, flares often ensue which are challenging to predict early. We determined the incidence, severity, outcome and predictors of flares after NA withdrawal. Forty-five patients enrolled in an RCT were included; 107 patients from an external, prospective cohort were used for validation. Retreatment criteria were pre-defined. Pre- and post-treatment predictors of alanine aminotransferase (ALT) flare (>5× ULN) were evaluated by Cox proportional-hazards regression. Seventy-two weeks after NA withdrawal, 23/45 (51%) patients had developed >5× ULN and 14 (31%) >20× ULN. Median time to develop ALT >5× ULN was 12 weeks after NA withdrawal. Independent predictors of ALT >5× ULN were male sex (HR [95% CI] 3.2 [1.2-8.9]; p = 0.03) and serum HBV DNA (1.2 [1.0-1.8]; p = 0.03) at Week 6 off-therapy. Specifically, week 6 HBV DNA >10,000 IU/ml predicted ALT >5× ULN (3.4 [1.4-8.4]; p = 0.01), which was externally validated. In conclusion, this study on post-treatment flares revealed a high cumulative incidence in CHB. Week 6 HBV DNA >10,000 IU/ml independently predicted flares. The proposed threshold enables prediction of imminent flares in patients who may benefit from closer monitoring and earlier retreatment.
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Affiliation(s)
- Kin Seng Liem
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Heng Chi
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Scott Fung
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - David K Wong
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Colina Yim
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Seham Noureldin
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Jiayun Chen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Arif Sarowar
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada.,McLaughlin-Rotman Centre for Global Health, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jinlin Hou
- Department of Infectious Diseases, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jie Peng
- Department of Infectious Diseases, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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33
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Kramvis A, Chang KM, Dandri M, Farci P, Glebe D, Hu J, Janssen HLA, Lau DTY, Penicaud C, Pollicino T, Testoni B, Van Bömmel F, Andrisani O, Beumont-Mauviel M, Block TM, Chan HLY, Cloherty GA, Delaney WE, Geretti AM, Gehring A, Jackson K, Lenz O, Maini MK, Miller V, Protzer U, Yang JC, Yuen MF, Zoulim F, Revill PA. A roadmap for serum biomarkers for hepatitis B virus: current status and future outlook. Nat Rev Gastroenterol Hepatol 2022; 19:727-745. [PMID: 35859026 PMCID: PMC9298709 DOI: 10.1038/s41575-022-00649-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 12/13/2022]
Abstract
Globally, 296 million people are infected with hepatitis B virus (HBV), and approximately one million people die annually from HBV-related causes, including liver cancer. Although there is a preventative vaccine and antiviral therapies suppressing HBV replication, there is no cure. Intensive efforts are under way to develop curative HBV therapies. Currently, only a few biomarkers are available for monitoring or predicting HBV disease progression and treatment response. As new therapies become available, new biomarkers to monitor viral and host responses are urgently needed. In October 2020, the International Coalition to Eliminate Hepatitis B Virus (ICE-HBV) held a virtual and interactive workshop on HBV biomarkers endorsed by the International HBV Meeting. Various stakeholders from academia, clinical practice and the pharmaceutical industry, with complementary expertise, presented and participated in panel discussions. The clinical utility of both classic and emerging viral and immunological serum biomarkers with respect to the course of infection, disease progression, and response to current and emerging treatments was appraised. The latest advances were discussed, and knowledge gaps in understanding and interpretation of HBV biomarkers were identified. This Roadmap summarizes the strengths, weaknesses, opportunities and challenges of HBV biomarkers.
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Affiliation(s)
- Anna Kramvis
- Hepatitis Virus Diversity Research Unit, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.
| | - Kyong-Mi Chang
- The Corporal Michael J. Crescenz Veterans Affairs Medical Center and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maura Dandri
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Infection Research (DZIF), Hamburg-Lübeck-Borstel-Riems partner site, Hamburg, Germany
| | - Patrizia Farci
- Hepatic Pathogenesis Section, Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Dieter Glebe
- National Reference Center for Hepatitis B Viruses and Hepatitis D Viruses, Institute of Medical Virology, Justus Liebig University Giessen, Giessen, Germany
- German Center for Infection Research (DZIF), Partner Site Giessen-Marburg-Langen, Giessen, Germany
| | - Jianming Hu
- Department of Microbiology and Immunology, The Pennsylvania State University College of Medicine, Philadelphia, PA, USA
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University of Toronto, Toronto, Canada
| | - Daryl T Y Lau
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Capucine Penicaud
- Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Teresa Pollicino
- Laboratory of Molecular Hepatology, Department of Human Pathology, University Hospital "G. Martino" of Messina, Messina, Italy
| | - Barbara Testoni
- INSERM U1052, CNRS UMR-5286, Cancer Research Center of Lyon (CRCL), Lyon, France
- University of Lyon, Université Claude-Bernard (UCBL), Lyon, France
| | - Florian Van Bömmel
- Department of Hepatology, Leipzig University Medical Center, Leipzig, Germany
| | - Ourania Andrisani
- Basic Medical Sciences, Purdue University, West Lafayette, Indiana, USA
| | | | | | - Henry L Y Chan
- Chinese University of Hong Kong, Shatin, Hong Kong
- Union Hospital, Shatin, Hong Kong
| | | | | | - Anna Maria Geretti
- Roche Pharma Research & Early Development, Basel, Switzerland
- Department of Infectious Diseases, Fondazione PTV, Faculty of Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Infectious Diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Adam Gehring
- Toronto Centre for Liver Disease, University Health Network, Toronto, Canada
| | - Kathy Jackson
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | | | - Mala K Maini
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Veronica Miller
- Forum for Collaborative Research, University of California Berkeley School of Public Health, Washington DC Campus, Washington, DC, USA
| | - Ulrike Protzer
- Institute of Virology, School of Medicine, Technical University of Munich, Helmholtz Zentrum München, Munich, Germany
| | | | - Man-Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Fabien Zoulim
- INSERM Unit 1052 - Cancer Research Center of Lyon, Hospices Civils de Lyon, Lyon University, Lyon, France
| | - Peter A Revill
- Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.
- Department of Microbiology and Immunology, University of Melbourne, Parkville, Victoria, Australia.
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34
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de Veer RC, Harms MH, Corpechot C, Thorburn D, Invernizzi P, Janssen HLA, Battezzati PM, Nevens F, Lindor KD, Floreani A, Ponsioen CY, Mayo MJ, Parés A, Mason AL, Kowdley KV, Trivedi PJ, Hirschfield GM, Bruns T, Dalekos GN, Gatselis NK, Verhelst X, Lammers WJ, Hansen BE, van Buuren HR, van der Meer AJ. Liver transplant-free survival according to alkaline phosphatase and GLOBE score in patients with primary biliary cholangitis treated with ursodeoxycholic acid. Aliment Pharmacol Ther 2022; 56:1408-1418. [PMID: 36138566 PMCID: PMC9826062 DOI: 10.1111/apt.17226] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/23/2022] [Accepted: 09/05/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND After 1 year of ursodeoxycholic acid (UDCA), patients with primary biliary cholangitis (PBC) may have a normal GLOBE score despite high alkaline phosphatase (ALP) levels. AIM To assess the association between ALP and liver transplantation (LT)-free survival according to the GLOBE score METHODS: Among patients with a normal or elevated GLOBE score in the Global PBC cohort, the association between ALP after 1 year of UDCA and the risk of LT/death was assessed. The LT-free survival was compared with that of a matched general population. RESULTS After 1 year of UDCA, ALP was associated with the risk of LT/death (aHR 1.31, 95% CI 1.003-1.72, p = 0.048) among 2729 patients with a normal GLOBE score. The 10-year LT-free survival among these patients with an ALP >2.0 × ULN was 94.0% (95% CI 90.1-97.9) for those <50 years, and 82.6% (95% CI 76.5-88.7) for those ≥50 years, which was significantly lower (p = 0.040) and similar (p = 0.736) to that of the matched population, respectively. The 10-year LT-free survival in patients ≥50 years with normal GLOBE score and normal ALP (90.8%, 95% CI 87.7-93.9) was significantly higher (p = 0.022) than the matched population. Among 1045 patients with an elevated GLOBE score, ALP was associated with LT/death only in those <50 years (aHR 1.38, 95% CI 1.06-1.81, p = 0.016). CONCLUSION The LT-free survival of patients with PBC with a normal GLOBE score is optimal in case of normal ALP levels, also in relation to the general population. Despite their generally favourable prognosis, an elevated ALP level may still indicate a need for add-on therapy.
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Affiliation(s)
- Rozanne C. de Veer
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Maren H. Harms
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Christophe Corpechot
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, European Reference Network on Hepatological Diseases (ERN Rare‐Liver)Saint‐Antoine Hospital, Assistance Publique ‐ Hôpitaux de Paris; Inserm UMR_S938, Saint‐Antoine Research Center, Sorbonne UniversityParisFrance
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, and UCL Institute of Liver and Digestive HealthThe Royal Free HospitalLondonUK
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Harry L. A. Janssen
- Toronto Centre for Liver disease, Toronto General HospitalUniversity Health NetworkTorontoCanada
| | | | - Frederik Nevens
- Department of HepatologyUniversity Hospitals LeuvenKU LeuvenLeuvenBelgium
| | - Keith D. Lindor
- Department of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA,Arizona State UniversityCollege of Health SolutionsPhoenixArizonaUSA
| | - Annarosa Floreani
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly,Scientific Institute for ResearchHospitalization and HealthcareNegrarVeronaItaly
| | - Cyriel Y. Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centreslocation Academic Medical CenterAmsterdamThe Netherlands
| | - Marlyn J. Mayo
- Digestive and Liver diseases, UT Southwestern Medical CenterDallasTexasUSA
| | - Albert Parés
- Liver UnitHospital Clínic, CIBERehd, IDIBAPS, University of BarcelonaBarcelonaSpain
| | - Andrew L. Mason
- Division of Gastroenterology and HepatologyUniversity of AlbertaEdmontonAlbertaCanada
| | - Kris V. Kowdley
- Liver Care Network and Organ Care ResearchSwedish Medical CenterSeattleWAUSA
| | - Palak J. Trivedi
- Birmingham NIHR Biomedical Research Centre, and Centre for Liver ResearchUniversity of BirminghamBirminghamUK
| | - Gideon M. Hirschfield
- Toronto Centre for Liver disease, Toronto General HospitalUniversity Health NetworkTorontoCanada,Birmingham NIHR Biomedical Research Centre, and Centre for Liver ResearchUniversity of BirminghamBirminghamUK
| | - Tony Bruns
- Department of Internal Medicine IVJena University Hospital, Friedrich Schiller UniversityJenaGermany,Department of Internal Medicine IIIUniversity Hospital RWTH AachenAachenGermany
| | - George N. Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver DiseasesGeneral University Hospital of LarissaLarissaGreece,European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)General University Hospital of LarissaLarissaGreece
| | - Nikolaos K. Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver DiseasesGeneral University Hospital of LarissaLarissaGreece,European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)General University Hospital of LarissaLarissaGreece
| | - Xavier Verhelst
- Department of Gastroenterology and HepatologyGhent University HospitalBelgium
| | - Willem J. Lammers
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Bettina E. Hansen
- Toronto Centre for Liver disease, Toronto General HospitalUniversity Health NetworkTorontoCanada,Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
| | - Henk R. van Buuren
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Adriaan J. van der Meer
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
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35
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Hirode G, Janssen HLA. Reply. Gastroenterology 2022; 163:779-780. [PMID: 35598630 DOI: 10.1053/j.gastro.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/09/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Grishma Hirode
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada, and, Institute of Medical Science, University of Toronto, Toronto, Canada, and, The Toronto Viral Hepatitis Care Network (VIRCAN), Toronto, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada, and, Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
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36
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Martin P, Nguyen MH, Dieterich DT, Lau DTY, Janssen HLA, Peters MG, Jacobson IM. Treatment Algorithm for Managing Chronic Hepatitis B Virus Infection in the United States: 2021 Update. Clin Gastroenterol Hepatol 2022; 20:1766-1775. [PMID: 34329775 DOI: 10.1016/j.cgh.2021.07.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic hepatitis B (CHB) infection remains the most frequent etiology of hepatocellular carcinoma globally as well as a major cause of cirrhosis. Despite vaccination, substantial numbers of persons have already been infected with hepatitis B virus and remain at risk of progressive liver disease. METHODS In 2004, a CHB management algorithm was developed by a panel of North American hepatologists, which was subsequently updated in 2006, 2008, and 2015. Since the most recent version, several developments have altered the management of CHB. Tenofovir alafenamide, with a more favorable safety profile than tenofovir disoproxil fumarate, has been introduced as an initial antiviral choice as well as an alternative for long-term therapy. Quantitation of hepatitis B surface antigen is becoming more widely available in clinical practice, with implications for monitoring response to treatment. Additionally, there has been a shift in how the natural history of CHB is perceived, as newer evidence has challenged the concept that during the immunotolerant phase of infection disease progression is not a concern. Finally, recent analyses indicate that in the United States, the average age of patients with CHB has increased, implying that the presence of comorbidities, including metabolic liver disease, increasing use of biologics associated with aging will increasingly affect disease management. RESULTS This updated algorithm is intended to serve as a guide to manage CHB while new antiviral strategies are developed. CONCLUSIONS Recommendations have been based on evidence from the scientific literature, when possible, as well as clinical experience and consensus expert opinion. Points of continued debate and areas of research need are also described.
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Affiliation(s)
- Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami School of Medicine, Miami, Florida.
| | - Mindie H Nguyen
- Department of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California; Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, California
| | | | - Daryl T-Y Lau
- Liver Center, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Harry L A Janssen
- Toronto Centre for Liver Diseases, University Health Network, Toronto, Canada
| | - Marion G Peters
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California
| | - Ira M Jacobson
- Division of Gastroenterology, NYU Langone Health, New York, New York
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37
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Roberts SB, Hirschfield GM, Worobetz LJ, Vincent C, Flemming JA, Cheung A, Qumosani K, Swain M, Grbic D, Ko HH, Peltekian K, Selzner N, Abrahamyan L, Aziz B, Lytvyak E, Tirona K, Gulamhusein AF, Janssen HLA, Montano-Loza AJ, Mason AL, Hansen BE. Ethnicity, disease severity, and survival in Canadian patients with primary biliary cholangitis. Hepatology 2022; 76:303-316. [PMID: 35220609 DOI: 10.1002/hep.32426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/21/2022] [Accepted: 02/16/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS We investigated associations between ethnicity, survival, and disease severity in a diverse Canadian cohort of patients with primary biliary cholangitis (PBC). APPROACH AND RESULTS Patients with PBC were included from the Canadian Network for Autoimmune Liver Disease. Ethnicity was defined using a modified list adopted from Statistics Canada, and ethnicities with small samples were grouped. Clinical events were defined as liver decompensation, HCC, liver transplantation, or death. Clinical event-free and liver transplantation-free survival were analyzed using Cox regression. Trajectories of serum liver function tests were assessed over time using mixed-effects regression. Health-related quality of life was assessed using the Short Form 36, the PBC-40 questionnaire, and the 5-D Itch scale and analyzed using mixed-effects regression. The cohort included 1538 patients with PBC from six sites and was comprised of 82% White, 4.7% Indigenous, 5.5% East Asian, 2.6% South Asian, and 5.1% miscellaneous ethnicities. Indigenous patients were the only ethnic group with impaired liver transplant-free and event-free survival compared to White patients (HR, 3.66; 95% CI, 2.23-6.01; HR, 3.09; 95% CI, 1.94-4.92). Indigenous patients were more likely to have a clinical event before diagnosis (10%) than all other ethnic groups despite similar age at diagnosis. Indigenous patients presented with higher alkaline phosphatase, total bilirubin, and GLOBE scores than White patients; and these relative elevations persisted during follow-up. CONCLUSIONS Indigenous Canadians with PBC present with advanced disease and have worse long-term outcomes compared to White patients.
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Affiliation(s)
- Surain B Roberts
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence J Worobetz
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Catherine Vincent
- Département de Médecine, Université de Montréal, Montréal, Quebec, Canada
| | | | - Angela Cheung
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Karim Qumosani
- Department of Medicine, Western University, London, Ontario, Canada
| | - Mark Swain
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dusanka Grbic
- Department de Médecine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Hin Hin Ko
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevork Peltekian
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Nazia Selzner
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Bishoi Aziz
- Department of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ellina Lytvyak
- Department of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Kattleya Tirona
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Aliya F Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Aldo J Montano-Loza
- Department of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew L Mason
- Department of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Choi HSJ, Hirode G, Chen CH, Su TH, Seto WK, Van Hees S, Papatheodoridi M, Lens S, Wong GLH, Brakenhoff SM, Chien RN, Feld JJ, Sonneveld MJ, Chan HLY, Forns X, Papatheodoridis GV, Vanwolleghem T, Yuen MF, Hsu YC, Kao JH, Cornberg M, Hansen BE, Jeng WJ, Janssen HLA. Differential Relapse Patterns After Discontinuation of Entecavir vs Tenofovir Disoproxil Fumarate in Chronic Hepatitis B. Clin Gastroenterol Hepatol 2022; 21:1513-1522.e4. [PMID: 35863683 DOI: 10.1016/j.cgh.2022.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/27/2022] [Accepted: 07/03/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Whether entecavir (ETV) and tenofovir disoproxil fumarate (TDF) differentially affect relapse and outcomes following treatment discontinuation across different patient subpopulations remains unclear. We aimed to compare rates of off-therapy hepatitis B surface antigen (HBsAg) loss, virological and clinical relapse, and retreatment between chronic hepatitis B (CHB) patients who discontinued TDF or ETV therapy. METHODS This study included 1402 virally suppressed CHB patients who stopped either ETV (n = 981) or TDF (n = 421) therapy between 2001 and 2020 from 13 participating centers across North America, Europe, and Asia. All patients were hepatitis B e antigen-negative at treatment discontinuation. Inverse probability of treatment weighting was used to balance the treatment groups. Outcomes were analyzed using survival methods. RESULTS During a median off-treatment follow-up of 18 months, HBsAg loss occurred in 96 (6.8%) patients overall. Compared with ETV, TDF was associated with a higher rate of HBsAg loss (P = .03); however, the association was no longer significant after statistical adjustment (P = .61). Virological relapse occurred earlier among TDF-treated patients (P < .01); nonetheless, rates became comparable after the first year off therapy (P = .49). TDF was significantly associated with a higher clinical relapse rate than ETV throughout follow-up (P < .01). The development of a virological or clinical relapse did not affect the rate of HBsAg loss. Retreatment rates were not significantly different between the treatment groups. CONCLUSIONS TDF and ETV have differential relapse patterns but are associated with similar rates of HBsAg loss and retreatment following discontinuation. Finite therapy can be considered for CHB patients on either TDF or ETV therapy.
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Affiliation(s)
- Hannah S J Choi
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ontario, Canada
| | - Grishma Hirode
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Toronto Viral Hepatitis Care Network, University Health Network, Toronto, Ontario, Canada
| | - Chien-Hung Chen
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan
| | - Tung-Hung Su
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Stijn Van Hees
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Margarita Papatheodoridi
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Sabela Lens
- Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Grace L H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Sylvia M Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rong-Nan Chien
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Linkou, Taiwan
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Toronto Viral Hepatitis Care Network, University Health Network, Toronto, Ontario, Canada
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henry L Y Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Xavier Forns
- Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - George V Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Thomas Vanwolleghem
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Yao-Chun Hsu
- Division of Gastroenterology and Hepatology, E-Da Hospital, Kaohsiung, Taiwan
| | - Jia-Horng Kao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany; Centre for Individualized Infection Medicine, Helmholtz Centre for Infection Research and Hannover Medical School, Hannover, Germany
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ontario, Canada; Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wen-Juei Jeng
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Linkou, Taiwan
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ontario, Canada; Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
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King WC, Sterling RK, Hinerman AS, Lok ASF, Cloherty GA, Ghany MG, Wahed AS, Chung RT, Janssen HLA, Khalili M, Lau DTY, Lee WM, Lisker-Melman M, Terrault N. Hepatitis B RNA and Core-Related Antigen Provide Value Beyond DNA in Evaluating e But Not Surface Antigen Clearance. Clin Gastroenterol Hepatol 2022:S1542-3565(22)00660-7. [PMID: 35850413 PMCID: PMC9841061 DOI: 10.1016/j.cgh.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 02/07/2023]
Abstract
In chronic hepatitis B virus (HBV) infection, hepatitis B e antigen (HBeAg) and hepatitis B surface antigen (HBsAg) clearance are important milestones toward immune control.1 A drop in HBV DNA is an established correlate of both HBeAg and HBsAg clearance.2 We evaluated changes in HBV RNA and hepatitis B core-related antigen (HBcrAg) levels, markers of transcriptional activity of covalently closed circular DNA (cccDNA),3,4 with HBeAg and HBsAg clearance, and compared them with changes in HBV DNA level among adult participants in the Hepatitis B Research Network (HBRN).
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Affiliation(s)
- Wendy C King
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, Virginia
| | - Amanda S Hinerman
- Epidemiology Department, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Gavin A Cloherty
- Infectious Disease Research, Abbott Diagnostics, Abbott Park, Illinois
| | - Marc G Ghany
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Abdus S Wahed
- Biostatistics Department, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raymond T Chung
- Hepatology and Liver Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University of Toronto, Toronto, Canada
| | - Mandana Khalili
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Daryl T Y Lau
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - William M Lee
- Liver Disease, UT Southwestern Medical Center, Dallas, Texas
| | - Mauricio Lisker-Melman
- Washington University School of Medicine; John Cochran VA Medical Center, St. Louis, Missouri
| | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, Keck Medicine of University of Southern California, Los Angeles, California
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40
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Fung S, Choi HSJ, Gehring A, Janssen HLA. Getting to HBV cure: The promising paths forward. Hepatology 2022; 76:233-250. [PMID: 34990029 DOI: 10.1002/hep.32314] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/17/2021] [Accepted: 12/19/2021] [Indexed: 12/18/2022]
Abstract
Chronic HBV infection is a global public health burden estimated to impact nearly 300 million persons worldwide. Despite the advent of potent antiviral agents that effectively suppress viral replication, HBV cure remains difficult to achieve because of the persistence of covalently closed circular DNA (cccDNA), HBV-DNA integration into the host genome, and impaired immune response. Indefinite treatment is necessary for most patients to maintain level of viral suppression. The success of direct-acting antivirals (DAAs) for hepatitis C treatment has rejuvenated the search for a cure for chronic hepatitis B (CHB), though an HBV cure likely requires an additional layer: immunomodulators for restoration of robust immune responses. DAAs such as entry inhibitors, capsid assembly modulators, inhibitors of subviral particle release, cccDNA silencers, and RNA interference molecules have reached clinical development. Immunomodulators, namely innate immunomodulators (Toll-like receptor agonists), therapeutic vaccines, checkpoint inhibitors, and monoclonal antibodies, are also progressing toward clinical development. The future of the HBV cure possibly lies in triple combination therapies with concerted action on replication inhibition, antigen reduction, and immune stimulation. Many obstacles remain, such as overcoming translational failures, choosing the right endpoint using the right biomarkers, and leveraging current treatments in combination regimens to enhance response rates. This review gives an overview of the current therapies for CHB, HBV biomarkers used to evaluate treatment response, and development of DAAs and immune-targeting drugs and discusses the limitations and unanswered questions on the journey to an HBV cure.
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Affiliation(s)
- Scott Fung
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ontario, Canada
| | - Hannah S J Choi
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ontario, Canada
| | - Adam Gehring
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ontario, Canada
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41
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Kuipery A, Sanchez Vasquez JD, Mehrotra A, Feld JJ, Janssen HLA, Gehring AJ. Immunomodulation and RNA interference alter hepatitis B virus-specific CD8 T-cell recognition of infected HepG2-NTCP. Hepatology 2022; 75:1539-1550. [PMID: 34743340 DOI: 10.1002/hep.32230] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 10/13/2021] [Accepted: 11/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS CD8 T cells are essential in controlling HBV infection. Viral control is dependent on efficient recognition of HBV-infected hepatocytes by CD8 T cells, which can induce direct lysis of infected hepatocytes. In addition, CD8 T cells produce interferon (IFN)-γ, which mediates noncytopathic viral clearance. Innate immunomodulators and HBV-targeted RNA interference (RNAi) are being developed to treat chronic hepatitis B (CHB), but may modify HBV antigen presentation and impact CD8 T-cell recognition, in addition to their primary mechanisms of action. APPROACH AND RESULTS HBV-infected HepG2-NTCP cells were treated with tenofovir disoproxil fumarate (TDF), Toll-like receptor (TLR) 7/8 agonists, TLR7/8 conditioned media (CM) collected from immune cells, or RNAi using short interfering RNAs. The effect of these treatments on antigen presentation was measured through coculture with CD8 T cells recognizing human leukocyte antigen-A0201 restricted epitopes, HBc18-27 or HBs183-191. Cytokine profiles of TLR7/8 CM were measured using a cytometric bead array. TDF reduced viral replication, but not CD8 T-cell recognition, of infected cells. Direct exposure of infected HepG2-NTCP to TLR7/8 agonists had no impact on T-cell recognition. Exposure of infected HepG2-NTCP to TLR7/8 CM enhanced HBV-specific CD8 T-cell recognition through type 1 interferon (IFN) and IFN-γ-dependent mechanisms. RNAi rapidly suppressed HBV-DNA, HBcAg, and HBsAg expression, impairing recognition by HBV-specific CD8 T cells. CONCLUSIONS Immunomodulation and RNAi, but not nucleos(t)ide analogues, alter the recognition of infected HepG2-NTCP by HBV-specific CD8 T cells. Understanding these changes will inform combination treatments for CHB.
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Affiliation(s)
- Adrian Kuipery
- Department of ImmunologyUniversity of TorontoTorontoOntarioCanada
- Toronto Center for Liver DiseaseToronto General Hospital Research InstituteUniversity Health NetworkTorontoOntarioCanada
| | - Juan Diego Sanchez Vasquez
- Department of ImmunologyUniversity of TorontoTorontoOntarioCanada
- Toronto Center for Liver DiseaseToronto General Hospital Research InstituteUniversity Health NetworkTorontoOntarioCanada
| | - Aman Mehrotra
- Toronto Center for Liver DiseaseToronto General Hospital Research InstituteUniversity Health NetworkTorontoOntarioCanada
| | - Jordan J Feld
- Toronto Center for Liver DiseaseToronto General Hospital Research InstituteUniversity Health NetworkTorontoOntarioCanada
| | - Harry L A Janssen
- Toronto Center for Liver DiseaseToronto General Hospital Research InstituteUniversity Health NetworkTorontoOntarioCanada
| | - Adam J Gehring
- Department of ImmunologyUniversity of TorontoTorontoOntarioCanada
- Toronto Center for Liver DiseaseToronto General Hospital Research InstituteUniversity Health NetworkTorontoOntarioCanada
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42
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Brakenhoff SM, de Knegt RJ, Oliveira J, van der Eijk AA, van Vuuren AJ, Hansen BE, Janssen HLA, de Man RA, Boonstra A, Sonneveld MJ. Levels of Antibodies to Hepatitis B Core Antigen Are Associated With Liver Inflammation and Response to Peginterferon in Patients With Chronic Hepatitis B. J Infect Dis 2022; 227:113-122. [PMID: 35599306 PMCID: PMC9796168 DOI: 10.1093/infdis/jiac210] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 03/11/2022] [Accepted: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Emerging evidence suggests a pivotal role for B-cell responses in the natural history of chronic hepatitis B. Serum levels of antibodies to hepatitis B core antigen (anti-HBc) vary across infection stages, but their role in predicting response to antiviral therapy is uncertain. METHODS Anti-HBc levels were assessed before peginterferon (PEG-IFN) therapy in patients with chronic hepatitis B who either started de novo PEG-IFN (n = 299; 195 hepatitis B e antigen [HBeAg] positive) or started PEG-IFN as add-on to an existing nucleo(s)tide analogue backbone (n = 91; all HBeAg-positive). Associations were explored between anti-HBc and (1) serum biomarkers, (2) liver histological findings, and (3) treatment response. RESULTS We studied 390 patients. The hepatitis B virus (HBV) genotype were A, B, C, and D in 24%, 9%, 16%, and 49%, respectively; 72% of patients were Caucasian. Among currently untreated HBeAg-positive patients, anti-HBc was correlated with HBV DNA, hepatitis B core-related antigen (HBcrAg), hepatitis B surface antigen (HBsAg), and HBV RNA, but not with alanine aminotransferase (ALT). Higher anti-HBc was associated with more severe histological inflammatory activity (P < .001), irrespective of HBeAg status. After de novo PEG-IFN, higher anti-HBc levels were associated with HBeAg loss, sustained response, HBsAg decline, and HBsAg clearance (P < .050). Among patients treated with add-on PEG-IFN, higher anti-HBc was associated with HBeAg loss (P = .01). CONCLUSIONS Serum anti-HBc levels correlate with histological inflammatory activity. Higher anti-HBc levels were associated with favorable treatment outcomes. These findings suggest that anti-HBc could be used to select patients most likely to respond to immunomodulatory therapy. CLINICAL TRIALS REGISTRATION NCT00114361, NCT00146705, NCT00877760, and NCT01532843.
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Affiliation(s)
- Sylvia M Brakenhoff
- Correspondence: Sylvia M. Brakenhoff, Erasmus MC, Department of Gastroenterology and Hepatology, internal postal address Na-606, Dr.Molewaterplein 40, 3015 GD Rotterdam, the Netherlands ()
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Jeffrey Oliveira
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Annemiek A van der Eijk
- Department of Viroscience, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Anneke J van Vuuren
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - André Boonstra
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Kuipery A, Mahamed D, Nkongolo S, D’Angelo JA, Johnson Valiente A, Mehrotra A, Chapman WC, Horton P, McGilvray I, Janssen HLA, Gehring AJ. The Human Male Liver Is Predisposed to Inflammation Via Enhanced Myeloid Responses to Inflammatory Triggers. Front Immunol 2022; 13:818612. [PMID: 35493503 PMCID: PMC9046993 DOI: 10.3389/fimmu.2022.818612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background & Aim Men have a higher prevalence of liver disease. Liver myeloid cells can regulate tissue inflammation, which drives progression of liver disease. We hypothesized that sex alters the responsiveness of liver myeloid cells, predisposing men to severe liver inflammation. Methods Luminex was done on plasma from Hepatitis B Virus infected patients undergoing nucleoside analogue cessation in 45 male and female patients. We collected immune cells from the sinusoids of uninfected livers of 53 male and female donors. Multiparametric flow cytometry was used to phenotype and characterize immune composition. Isolated monocytes were stimulated with TLR ligands to measure the inflammatory potential and the expression of regulators of TLR signaling. Results We confirmed that men experienced more frequent and severe liver damage upon Hepatitis B Virus reactivation, which was associated with inflammatory markers of myeloid activation. No differences were observed in the frequency or phenotype of sinusoidal myeloid cells between male and female livers. However, monocytes from male livers produced more inflammatory cytokines and chemokines in response to TLR stimulation than female monocytes. We investigated negative regulators of TLR signaling and found that TOLLIP was elevated in female liver-derived monocytes Conclusions Our data show that enhanced responsiveness of myeloid cells from the male liver predisposes men to inflammation, which was associated with altered expression of negative regulators of TLR signaling.
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Affiliation(s)
- Adrian Kuipery
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Department of Immunology, University of Toronto, Toronto, ON, Canada
| | - Deeqa Mahamed
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Department of Immunology, University of Toronto, Toronto, ON, Canada
| | - Shirin Nkongolo
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - June Ann D’Angelo
- Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Alexandra Johnson Valiente
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Department of Immunology, University of Toronto, Toronto, ON, Canada
| | - Aman Mehrotra
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - William C. Chapman
- Division of Abdominal Transplant, Washington University School of Medicine, St. Louis, MO, United States
| | - Peter Horton
- Methodist University Hospital Transplant Institute, Memphis, TN, United States
- Division of Abdominal Transplant, Saint Louis University School of Medicine, St. Louis, MO, United States
- The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ian McGilvray
- Multi-Organ Transplant Program, Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Harry L. A. Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Adam J. Gehring
- Toronto Centre for Liver Disease, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Department of Immunology, University of Toronto, Toronto, ON, Canada
- *Correspondence: Adam J. Gehring,
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Ghany MG, King WC, Lisker-Melman M, Lok ASF, Terrault N, Janssen HLA, Khalili M, Chung RT, Lee WM, Lau DTY, Cloherty GA, Sterling RK. Reply. Hepatology 2022; 75:761-763. [PMID: 34800047 DOI: 10.1002/hep.32251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/24/2021] [Indexed: 12/08/2022]
Affiliation(s)
- Marc G Ghany
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Wendy C King
- Graduate School of Public Health University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mauricio Lisker-Melman
- Washington University School of Medicine and John Cochran VA Medical Center, St. Louis, Missouri, USA
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, Keck Medicine of University of Southern California, Los Angeles, California, USA
| | - Harry L A Janssen
- Toronto Center for Liver Disease, University of Toronto, Toronto, Ontario, Canada
| | - Mandana Khalili
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Raymond T Chung
- Hepatology and Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William M Lee
- Meredith Mosle Chair in Liver Disease, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Daryl T Y Lau
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Gavin A Cloherty
- Head of Infectious Disease Research, Abbott Diagnostics, Abbott Park, Illinois, USA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
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45
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Hirode G, Choi HSJ, Chen CH, Su TH, Seto WK, Van Hees S, Papatheodoridi M, Lens S, Wong G, Brakenhoff SM, Chien RN, Feld J, Sonneveld MJ, Chan HLY, Forns X, Papatheodoridis GV, Vanwolleghem T, Yuen MF, Hsu YC, Kao JH, Cornberg M, Hansen BE, Jeng WJ, Janssen HLA. Off-Therapy Response After Nucleos(t)ide Analogue Withdrawal in Patients With Chronic Hepatitis B: An International, Multicenter, Multiethnic Cohort (RETRACT-B Study). Gastroenterology 2022; 162:757-771.e4. [PMID: 34762906 DOI: 10.1053/j.gastro.2021.11.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 10/28/2021] [Accepted: 11/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Functional cure, defined based on hepatitis B surface antigen (HBsAg) loss, is rare during nucleos(t)ide analogue (NA) therapy and guidelines on finite NA therapy have not been well established. We aim to analyze off-therapy outcomes after NA cessation in a large, international, multicenter, multiethnic cohort of patients with chronic hepatitis B (CHB). METHODS This cohort study included patients with virally suppressed CHB who were hepatitis B e antigen (HBeAg)-negative and stopped NA therapy. Primary outcome was HBsAg loss after NA cessation, and secondary outcomes included virologic, biochemical, and clinical relapse, alanine aminotransferase flare, retreatment, and liver-related events after NA cessation. RESULTS Among 1552 patients with CHB, cumulative probability of HBsAg loss was 3.2% at 12 months and 13.0% at 48 months of follow-up. HBsAg loss was higher among Whites (vs Asians: subdistribution hazard ratio, 6.8; 95% confidence interval, 2.7-16.8; P < .001) and among patients with HBsAg levels <100 IU/mL at end of therapy (vs ≥100 IU/mL: subdistribution hazard ratio, 22.5; 95% confidence interval, 13.1-38.7; P < .001). At 48 months of follow-up, Whites with HBsAg levels <1000 IU/mL and Asians with HBsAg levels <100 IU/mL at end of therapy had a high predicted probability of HBsAg loss (>30%). Incidence rate of hepatic decompensation and hepatocellular carcinoma was 0.48 per 1000 person-years and 0.29 per 1000 person-years, respectively. Death occurred in 7/19 decompensated patients and 2/14 patients with hepatocellular carcinoma. CONCLUSIONS The best candidates for NA withdrawal are virally suppressed, HBeAg- negative, noncirrhotic patients with CHB with low HBsAg levels, particularly Whites with <1000 IU/mL and Asians with <100 IU/mL. However, strict surveillance is recommended to prevent deterioration.
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Affiliation(s)
- Grishma Hirode
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; The Toronto Viral Hepatitis Care Network, Toronto, Canada
| | - Hannah S J Choi
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | | | - Tung-Hung Su
- National Taiwan University Hospital, Taipei, Taiwan
| | - Wai-Kay Seto
- Department of Medicine and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Special administrative regions of China
| | - Stijn Van Hees
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | | | - Sabela Lens
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Grace Wong
- The Chinese University of Hong Kong, Hong Kong, Special administrative regions of China
| | - Sylvia M Brakenhoff
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Rong-Nan Chien
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Linkou, Taiwan
| | - Jordan Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; The Toronto Viral Hepatitis Care Network, Toronto, Canada
| | - Milan J Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Henry L Y Chan
- The Chinese University of Hong Kong, Hong Kong, Special administrative regions of China
| | - Xavier Forns
- Hospital Clinic Barcelona, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | | | - Thomas Vanwolleghem
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Man-Fung Yuen
- Department of Medicine and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Special administrative regions of China
| | - Yao-Chun Hsu
- E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | | | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Germany Centre for Individualized Infection Medicine, Hannover, Germany
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada; The Toronto Viral Hepatitis Care Network, Toronto, Canada
| | - Wen-Juei Jeng
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Medical Center, Chang Gung University, Linkou, Taiwan
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; The Toronto Viral Hepatitis Care Network, Toronto, Canada.
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Terrault NA, Wahed AS, Feld JJ, Cooper SL, Ghany MG, Lisker-Melman M, Perrillo R, Sterling RK, Khalili M, Chung RT, Rosenthal P, Fontana RJ, Sarowar A, Lau DTY, Wang J, Lok AS, Janssen HLA. Incidence and prediction of HBsAg seroclearance in a prospective multi-ethnic HBeAg-negative chronic hepatitis B cohort. Hepatology 2022; 75:709-723. [PMID: 34743343 PMCID: PMC8943823 DOI: 10.1002/hep.32231] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 10/20/2021] [Accepted: 10/24/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Achieving HBsAg loss is an important landmark in the natural history of chronic hepatitis B (CHB). A more personalized approach to prediction of HBsAg loss is relevant in counseling patients. This study sought to develop and validate a prediction model for HBsAg loss based on quantitative HBsAg levels (qHBsAg) and other baseline characteristics. METHODS The Hepatitis B Research Network (HBRN) is a prospective cohort including 1240 untreated HBeAg-negative patients (1150 adults, 90 children) with median follow-up of 5.5 years. Incidence rates of HBsAg loss and hepatitis B surface antibody (anti-HBs) acquisition were determined, and a predictor score of HBsAg loss using readily available variables was developed and externally validated. RESULTS Crude incidence rates of HBsAg loss and anti-HBs acquisition were 1.6 and 1.1 per 100 person-years (PY); 67 achieved sustained HBsAg loss for an incidence rate of 1.2 per 100 PY. Increased HBsAg loss was significantly associated with older age, non-Asian race, HBV phenotype (inactive CHB vs. others), HBV genotype A, lower HBV-DNA levels, and lower and greater change in qHBsAg. The HBRN-SQuARe (sex,∆quantHBsAg, age, race) score predicted HBsAg loss over time with area under the receiver operating characteristic curve (AUROC) (95% CIs) at 1 and 3 years of 0.99 (95% CI: 0.987-1.00) and 0.95 (95% CI 0.91-1.00), respectively. In validation in another cohort of 1253 HBeAg-negative patients with median follow-up of 3.1 years, HBRN SQuARe predicted HBsAg loss at 1 and 3 years with AUROC values of 0.99 (0.98-1.00) and 0.88 (0.77-0.99), respectively. CONCLUSION HBsAg loss in predominantly untreated patients with HBeAg-negative CHB can be accurately predicted over a 3-year horizon using a simple validated score (HBRN SQuARe). This prognostication tool can be used to support patient care and counseling.
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Affiliation(s)
- NA Terrault
- Gastrointestinal and Liver Diseases Division, Keck Medicine of University of Southern California, Los Angeles, California, USA
| | - AS Wahed
- Department of Biostatistics and Epidemiology Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - JJ Feld
- Toronto Center for Liver Disease, University of Toronto, Toronto, Ontario, Canada
| | - SL Cooper
- San Francisco Center for Liver Disease, California Pacific Medical & Research Institute, San Francisco, California, USA
| | - MG Ghany
- Liver Diseases Branch, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - M Lisker-Melman
- Washington University School of Medicine and John Cochran VA Medical Center, St. Louis, Missouri, USA
| | - R Perrillo
- Baylor University Medical Center, Dallas, Texas, USA
| | - RK Sterling
- Section of Hepatology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - M Khalili
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - RT Chung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - P Rosenthal
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - RJ Fontana
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - A Sarowar
- Toronto Center for Liver Disease, University of Toronto, Toronto, Ontario, Canada
| | - DTY Lau
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts, USA
| | - J Wang
- Department of Biostatistics and Epidemiology Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - AS Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - HLA Janssen
- Toronto Center for Liver Disease, University of Toronto, Toronto, Ontario, Canada
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47
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Mandel E, Peci A, Cronin K, Capraru CI, Shah H, Janssen HLA, Tran V, Biondi MJ, Feld JJ. The impact of the first, second and third waves of covid-19 on hepatitis B and C testing in Ontario, Canada. J Viral Hepat 2022; 29:205-208. [PMID: 34820967 DOI: 10.1111/jvh.13637] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/05/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022]
Abstract
The COVID-19 pandemic interrupted routine healthcare services. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are often asymptomatic, and therefore, screening and on/post-treatment monitoring are required. Our aim was to determine the effect of the first, second and third waves of the pandemic on HBV and HCV testing in Ontario, Canada. We extracted data from Public Health Ontario for HBV and HCV specimens from 1 January 2019 to 31 May 2021. Testing volumes were evaluated and stratified by age, sex and region. Changes in testing volumes were analysed by per cent and absolute change. Testing volumes decreased in April 2020 with the first wave of the pandemic and recovered to 72%-75% of prepandemic volumes by the end of the first wave. HBsAg testing decreased by 33%, 18% and 15%, and HBV DNA testing decreased by 37%, 27% and 20%, in each consecutive wave. Anti-HCV testing decreased by 35%, 21% and 19%, and HCV RNA testing decreased by 44%, 30% and 36% in each consecutive wave. These trends were consistent by age, region and sex. Prenatal HBV testing volumes were stable. In conclusion, significant decreases in HBV and HCV testing occurred during the first three waves of the pandemic and have not recovered. In addition to direct consequences on viral hepatitis elimination efforts, these data provide insight into the impacts of the pandemic on chronic disease screening and management. Strategies to make up for missed testing will be critical to avoid additional consequences of COVID-19 long after the pandemic has resolved.
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Affiliation(s)
- Erin Mandel
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Adriana Peci
- Public Health Ontario Laboratory, Toronto, Ontario, Canada
| | - Kirby Cronin
- Public Health Ontario Laboratory, Toronto, Ontario, Canada
| | - Camelia I Capraru
- Viral Hepatitis Care Network (VIRCAN) Study Group, Toronto Centre for Liver Disease, Toronto, Ontario, Canada
| | - Hemant Shah
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada.,Viral Hepatitis Care Network (VIRCAN) Study Group, Toronto Centre for Liver Disease, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada.,Viral Hepatitis Care Network (VIRCAN) Study Group, Toronto Centre for Liver Disease, Toronto, Ontario, Canada
| | - Vanessa Tran
- Public Health Ontario Laboratory, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Mia J Biondi
- Viral Hepatitis Care Network (VIRCAN) Study Group, Toronto Centre for Liver Disease, Toronto, Ontario, Canada.,Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada.,Viral Hepatitis Care Network (VIRCAN) Study Group, Toronto Centre for Liver Disease, Toronto, Ontario, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
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48
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Kim HY, Lampertico P, Nam JY, Lee HC, Kim SU, Sinn DH, Seo YS, Lee HA, Park SY, Lim YS, Jang ES, Yoon EL, Kim HS, Kim SE, Ahn SB, Shim JJ, Jeong SW, Jung YJ, Sohn JH, Cho YK, Jun DW, Dalekos GN, Idilman R, Sypsa V, Berg T, Buti M, Calleja JL, Goulis J, Manolakopoulos S, Janssen HLA, Jang MJ, Lee YB, Kim YJ, Yoon JH, Papatheodoridis GV, Lee JH. An artificial intelligence model to predict hepatocellular carcinoma risk in Korean and Caucasian patients with chronic hepatitis B. J Hepatol 2022; 76:311-318. [PMID: 34606915 DOI: 10.1016/j.jhep.2021.09.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/13/2021] [Accepted: 09/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Several models have recently been developed to predict risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B (CHB). Our aims were to develop and validate an artificial intelligence-assisted prediction model of HCC risk. METHODS Using a gradient-boosting machine (GBM) algorithm, a model was developed using 6,051 patients with CHB who received entecavir or tenofovir therapy from 4 hospitals in Korea. Two external validation cohorts were independently established: Korean (5,817 patients from 14 Korean centers) and Caucasian (1,640 from 11 Western centers) PAGE-B cohorts. The primary outcome was HCC development. RESULTS In the derivation cohort and the 2 validation cohorts, cirrhosis was present in 26.9%-50.2% of patients at baseline. A model using 10 parameters at baseline was derived and showed good predictive performance (c-index 0.79). This model showed significantly better discrimination than previous models (PAGE-B, modified PAGE-B, REACH-B, and CU-HCC) in both the Korean (c-index 0.79 vs. 0.64-0.74; all p <0.001) and Caucasian validation cohorts (c-index 0.81 vs. 0.57-0.79; all p <0.05 except modified PAGE-B, p = 0.42). A calibration plot showed a satisfactory calibration function. When the patients were grouped into 4 risk groups, the minimal-risk group (11.2% of the Korean cohort and 8.8% of the Caucasian cohort) had a less than 0.5% risk of HCC during 8 years of follow-up. CONCLUSIONS This GBM-based model provides the best predictive power for HCC risk in Korean and Caucasian patients with CHB treated with entecavir or tenofovir. LAY SUMMARY Risk scores have been developed to predict the risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis B. We developed and validated a new risk prediction model using machine learning algorithms in 13,508 antiviral-treated patients with chronic hepatitis B. Our new model, based on 10 common baseline characteristics, demonstrated superior performance in risk stratification compared with previous risk scores. This model also identified a group of patients at minimal risk of developing HCC, who could be indicated for less intensive HCC surveillance.
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Affiliation(s)
- Hwi Young Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Pietro Lampertico
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy; CRC "A. M. and A. Migliavacca" Center for Liver Disease, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Joon Yeul Nam
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Up Kim
- Department of Internal Medicine and Yonsei Liver Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yeon Seok Seo
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College, Republic of Korea; Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Soo Young Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Young-Suk Lim
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Eun Sun Jang
- Departments of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Eileen L Yoon
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea; Department of Internal Medicine, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hyoung Su Kim
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Republic of Korea
| | - Sang Bong Ahn
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Republic of Korea
| | - Jae-Jun Shim
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Yong Jin Jung
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Republic of Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si, Republic of Korea
| | - Yong Kyun Cho
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Ramazan Idilman
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Vana Sypsa
- Department of Hygiene, Epidemiology & Medical Statistics, Medical School of National and Kapodistrian University of Athens, Athens, Greece
| | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Maria Buti
- Hospital General Universitario Vall Hebron and Ciberehd, Barcelona, Spain
| | | | - John Goulis
- 4th Department of Internal Medicine, Aristotle University of Thessaloniki Medical School, General Hospital of Thessaloniki "Hippokratio", Thessaloniki, Greece
| | - Spilios Manolakopoulos
- 2nd Department of Internal Medicine, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Hippokratio", Athens, Greece
| | - Harry L A Janssen
- Liver Clinic, Toronto Western & General Hospital, University Health Network, Toronto, ON, Canada
| | - Myoung-Jin Jang
- Medical Research Collaboration Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yun Bin Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoon Jun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - George V Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece.
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
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49
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Choi HSJ, Sonneveld MJ, Farag MS, Brouwer WP, Brakenhoff SM, Hirode G, Gehring AJ, de Man RA, Hansen BE, Janssen HLA. Effects of on-treatment ALT flares on serum HBsAg and HBV RNA in patients with chronic HBV infection. J Viral Hepat 2021; 28:1729-1737. [PMID: 34514678 DOI: 10.1111/jvh.13613] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 12/15/2022]
Abstract
As pegylated interferon alpha (PEG-IFN-α) is increasingly used in combination regimens of novel drugs, we aimed to characterize ALT flares and their relationship with serum HBsAg and HBV RNA kinetics in a large combined cohort of chronic hepatitis B (CHB) patients on PEG-IFN-α-based therapy. In this post hoc analysis of four international randomized trials, 269/130/124/128 patients on PEG-IFN-α monotherapy, PEG-IFN-α plus nucleos(t)ide analogue (NA) de novo combination, PEG-IFN-α add-on to NA or NA monotherapy were included, respectively. A flare was defined as an episode of ALT ≥5 × ULN. The association between flares and HBsAg and HBV RNA changes were examined. On-treatment flares occurred in 83/651 (13%) patients (median timing/magnitude: week 8 [IQR 4-12], 7.6 × ULN [IQR 6.2-10.5]). Flare patients were more often Caucasians with genotype A/D and had higher baseline ALT, HBV DNA, HBV RNA and HBsAg levels than the no-flare group. More flares were observed on PEG-IFN-α monotherapy (18%) and PEG-IFN+NA de novo combination (24%) vs. PEG-IFN-α add-on (2%) or NA monotherapy (1%) (p < .001). On-treatment flares were significantly and independently associated with HBsAg and HBV RNA decline ≥1 log10 at the final visit declines started shortly before the flare, progressing towards 24 weeks thereafter. On-treatment flares were seen in 16/22 (73%) patients who achieved HBsAg loss. In conclusion, ALT flares during PEG-IFN-α treatment are associated with subsequent HBsAg and HBV RNA decline and predict subsequent HBsAg loss. Flares rarely occurred during PEG-IFN-α add-on therapy and associated with low HBsAg loss rates. Combination regimens targeting the window of heightened response could be promising.
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Affiliation(s)
- Hannah S J Choi
- Toronto Centre for Liver Disease, University Health Network, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Milan J Sonneveld
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mina S Farag
- Toronto Centre for Liver Disease, University Health Network, Toronto, ON, Canada
| | - Willem P Brouwer
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sylvia M Brakenhoff
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Grishma Hirode
- Toronto Centre for Liver Disease, University Health Network, Toronto, ON, Canada
| | - Adam J Gehring
- Toronto Centre for Liver Disease, University Health Network, Toronto, ON, Canada
| | - Rob A de Man
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, University Health Network, Toronto, ON, Canada
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50
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Kuriry H, Casey J, Krassenburg L, La D, Kuczynski M, Shah H, Janssen HLA, Hansen BE, Feld JJ. Spontaneous Clearance After Relapse Following Direct-Acting Antiviral Treatment for Chronic HCV Infection. Clin Gastroenterol Hepatol 2021; 19:2398-2406.e1. [PMID: 32629131 DOI: 10.1016/j.cgh.2020.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/11/2020] [Accepted: 06/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Direct-acting antivirals (DAAs) cure most cases of chronic hepatitis C virus (HCV) infection. However, a small percentage of patients relapse with reappearance of viremia after a full course of therapy. Although most who relapse require retreatment, some patients spontaneously clear HCV without additional therapy. We studied patients who relapsed with detectable HCV RNA after a full course of DAA therapy and then spontaneously cleared the HCV infection without retreatment. METHODS We performed a case-control study of patients who spontaneously cleared chronic HCV infection following a documented relapse after DAA therapy at the Toronto Centre for Liver Disease, from January 2014 through December 2017. We collected clinical information at baseline, 12 weeks after treatment, and 6 months after relapse and compared data among spontaneous clearers, patients with persistent relapse, and patients who achieved a sustained virologic response to therapy 12 weeks after treatment (SVR12). The strength and breadth of interferon gamma cytokine secretion by HCV-specific T cells from peripheral blood were quantified using the ELISPOT assay. RESULTS Of the 1032 individuals with chronic HCV infection who were treated with DAAs, 93 patients had a documented relapse. Of these patients, 12 patients (13%) spontaneously cleared HCV within 6 months after the documented relapse without additional therapy. The spontaneous clearers had low levels of HCV RNA (<4 log IU/mL in 11 of 12) and normal levels of alanine aminotransferase at the time of relapse, much like patients with an SVR12. There was no significant difference between the spontaneous clearance group and the SVR12 group in magnitude and breadth of HCV-specific T cell responses. CONCLUSIONS In a case-control study of patients who spontaneously cleared chronic HCV infection following a relapse after DAA therapy, we found that it is important to confirm viremia prior to retreatment after the relapse-particularly for individuals with low levels of HCV RNA and normal or near-normal levels of alanine aminotransferase after treatment.
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Affiliation(s)
- Hadi Kuriry
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Julia Casey
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Lisette Krassenburg
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Danie La
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Magdalena Kuczynski
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Toronto Viral Hepatitis Care Network, Toronto, Ontario, Canada
| | - Hemant Shah
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Toronto Viral Hepatitis Care Network, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Toronto Viral Hepatitis Care Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Toronto Viral Hepatitis Care Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Toronto Viral Hepatitis Care Network, Toronto, Ontario, Canada.
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