Paestum, 18 maggio 2006
Il portatore di HBV: inattivo o malato ?
Giovanni Battista Gaeta
Unità Epatiti Virali Acute e Croniche
Seconda Università di Napoli
Il progresso nella definizione
della malattia da HBV
ALT
(epatite post-trasfusionale a lunga
incubazione, evoluzione in cronicità)
HBsAg
(Antigene Australia)
Istologia
(Desmet, 1973)
Biologia Molecolare
Alta sensibilità
Anni
’50-’60
’60
’70
‘90
2000
The “healthy carrier”: the histology era
de Franchis et al. Ann Intern Med 1993; 118:191-194
Baseline: 92 pts, HBsAg positive blood donors,
normal ALT
Follow-up: mean 130 mo., 68 pts; 21 with biopsy
HBV-DNA: spot-dot hybridization
Characteristics
at the baseline
No Caption Found
HBV-DNA :
10/60
End of follow-up
Limits of a healthy carrier definition based on liver
histology and low sensitivity DNA testing
–Dependent upon:
•Length of biopsy – 20mm optimal
•Number of biopsies performed
•Type of biopsy needle used
•Pathologist experience
–HBV-DNA testing:
•Spot-dot hybridizazion reveals pg of DNA
•Subjective lecture
Available HBV DNA Assays
1
Artus
Biotech
10 102 103 104 105 106 107 108 109 1010
HBVDNA cp/mL
Real Art HBV LC PCR
HBV Digene Hybrid-Capture I
HBV Digene Hybrid-Capture II
Digene Corp.
Ultra-Sensitive Digene
Hybrid-Capture II
Roche
Molecular
Systems
Amplicor HBV Monitor
Cobas Amplicor HBV Monitor
Cobas Taqman 48 HBV
Bayer Corp.
Versant HBV DNA 1.0 NA
Versant HBV DNA 3.0
1
10 102 103 104 105 106 107 108 109 1010
HBV DNA IU/mL
Locarnini et al., Antiv.Therapy 2004
 The era of molecular biology
Few copies of HBV-DNA can be detected
(10 –102)
What the clinical significance ?
infection/disease
Standardisation of Nomenclature for Hepatitis B
(EASL consensus conference September 2002)
Inactive HBsAg carrier




Presence of HBsAg and anti-HBe in serum
Serum HBV DNA < 105 copies/ml
Persistently normal serum ALT > 6 months
Liver histology (not essential) HAI grade < 3
Available HBV DNA Assays
1
Artus
Biotech
10 102 103 104 105 106 107 108 109 1010
HBVDNA cp/mL
Real Art HBV LC PCR
HBV Digene Hybrid-Capture I
HBV Digene Hybrid-Capture II
Digene Corp.
Ultra-Sensitive Digene
Hybrid-Capture II
Roche
Molecular
Systems
Amplicor HBV Monitor
Cobas Amplicor HBV Monitor
Cobas Taqman 48 HBV
Bayer Corp.
Versant HBV DNA 1.0 NA
Versant HBV DNA 3.0
1
10 102 103 104 105 106 107 108 109 1010
HBV DNA IU/mL
Locarnini et al., Antiv.Therapy 2004
Serum HBV DNA and Liver Inflammation in Chronic
Hepatitis B Review of 26 prospective studies
Histology Activity Index (HAI)
Correlation between HAI and HBV DNA
in untreated patients (r=0.78; P=0.0001)
HBV DNA level (log10 c/mL)
Mommeja-Marin H, et al. Hepatology. 2003:37:1309-1319.
Median improvement in HAI
Correlation between change in HBV DNA
and HAI with treatment Review of 26 prospective studies
(r=0.96; P<0.0000)
Median log10 HBV DNA decrease
Mommeja-Marin H, et al. Hepatology. 2003:37:1309-1319.
Natural history of inactive HBsAg carriers
Incidence per 100 person years of major events
De
Franchis
1993
Bellentani
2002
Manno
2004
Hsu
2002
Europe
Europe
Europe
Asia
● N° patients
68
46
296
189
● Median follow-up (yrs)
10
9
29
8
0.15
NR
NR
0.06
● HCC
0
0
0.02
0.19
● Liver-related death
0
0
0.01
0
1.0
0.9
1.0
0.6
● area
● Histologic
deterioration
● HBsAg loss
NR = not reported
Survival in HBsAg carriers and controls
patients= 296
controls = 157
Manno et al., Gastroenterology 2004;127:756-763
Percentage of patients who cleared HBsAg
Manno et al., Gastroenterology 2004;127:756-763
Serum HBV DNA (copies/mL)
Chronic HBsAg carriers: HBV DNA level
1010
109
108
107
106
CHB
HBeAg +
CHB
HBeAg –
105
104
103
102
Inactive
Patients
Villeneuve JP et al. Gastroenterology 1994. Martinot –Peignoux M et al. J.Hepatol 2002. Hsu et al
Hepatology 2002. Mommeja-Marin H et al. Hepatology 2003; Manno,Gastroenterology 2004.
The R.E.V.E.A.L. – HBV STUDY
Risk Evaluation of Viral Load Elevation and Associated Liver Disease
23,820
enrolled
in 1991-1992
4,155 HBsAg positive
19,665 HBsAg negative
3,851 HBV-DNA tested
3,774 included in the analysis
395 with cirrhosis
Chen CJ, EASL Meeting 2005, Abs.#476
Cumulative incidence of cirrhosis
N = 3582
P <0.001
Log rank test
Iloeje et al, Gastroenterology 2006; 130:678-686
Cumulative incidence of hepatocellular carcinoma
HBeAg negative with normal ALT at Baseline n= 2925
Chen CJ, JAMA 2006; 295:65-73
ALT flares in chronic hepatitis B
ALT IU/l
400
300
200
100
0
months
HBV-DNA, ALT and IgM anti-HBc
in 40 hepatitis exacerbations in 23 HBV carriers
HBV-DNA
ALT
IgM anti-HBc
HBV-DNA increments preceded or were simultaneous to
ALT elevations in 96.2% of cases. The ALT flares preceded or
were simultaneous to IgM anti-HBc increments in 96.2% of cases
Colloredo Mels G., 1994
Classification of inactive carrier vs. chronic hepatitis
Correct
Sensitivity
classification
Specificity
HBV DNA
>vs < 30.000 cp
94.3
80.0
100.0
HBV DNA
>vs < 100.000 cp
90.8
68.0
100.0
>vs < 0.200
81.6
56.0
91.6
DNA + IgM
92.0
92.0
91.9
anti-HBc IgM
Manesis, Am J Gastro 2003
Inactive HBV carriers in Central Italy
705 HBsAg positive subjects in 18 Centers
202 inactive carriers (29%)
84 follow-up (6 mo.)
12% DNA increase >1 log
6.6% ALT elevation
1 anti-HBs seroconversion
Piccolo et al, EASL 2006, abs. # 469
Outcome of anti-HBe pos chronic hepatitis B
102 Patients with chronic hepatitis at histology
Median follow-up
6 years (2-12)
Progression to cirrhosis
•2-5%/yr in
HBeAg positive patients
cirrhosis
• 8-10% in HBeAg
6.2% neg
•Predictors: older age, alcohol, coinfections,
•recurrent flares, bridging necrosis,
•fibrosis stage, genotype(?)
cirrhosis
49.2%
From: Brunetto, 2002
Outcome of HBsAg/anti-HBe pos cirrhosis
no. = 62
Median follow-up
6 years (2-12)
Hepatic decompensation
• 3%/yr
47% with ascites
12% jaundice
9% variceal bleeding
30% more than one
cirrhosis
at
Hepatocellular
carcinoma
baseline
without cirrhosis < 0.2%/yr (Western areas)
0.6% in Asia
worsened
with cirrhosis > 2.0%/yr
22%
Predictors: older age, male gender, alcohol,
environmental factors, coinfections, genotype
10 HCC
9 terminal
events
From: Brunetto, 2002
Cofactors influencing the outcome
of inactive HBV carriers
• HCV coinfection
• HDV coinfection
• HIV coinfection
• Alcohol abuse,
steroids,
immunosuppression
The “healthy” carrier ( inactive with chronic HBV; PNAL with
chronic HCV)
viraemia
liver histology
outcome
HBV
HCV
<104 cp/ml
wide range
minimal,
inactive fibrosis
20%
significant
stable
20-30%
progression
case-definition sensitive
 A new type of HBV carrier:
The occult carrier
Occult HBV infection
HBV-DNA detectable in liver tissue (± serum) by PCR
based methods following disappearance of HBsAg in
serum
30% in HCV chronic infections
60% in HBsAg negative hepatocellular carcinoma
Torberson & Thomas, Lancet Infect Dis, 2002
Pollicino et al, Gastroenterology, 2004
Il portatore di HBV: inattivo o malato ?
Paziente HBsAg positivo con ALT normali:
HBV-DNA>10,000 cp/ml = area rischio
(2000 IU/ml)
Seguire per un anno ad intervalli di
3 mesi ALT, anti-HBc IgM, HBV-DNA
 Biopsia epatica nei casi dubbi