Pretreatment gamma-glutamyl transferase predicts mortality in patients with chronic hepatitis B treated with nucleotide/nucleoside analogs

Mortality; TreatmentMortalitat; TractamentMortalidad; TratamientoElevated serum gamma-glutamyl transferase (GGT) levels are associated with chronic hepatitis B (CHB)-related hepatocellular carcinoma. However, their role in predicting mortality in patients with CHB treated with nucleotide/nucleoside analogs (NAs) remains elusive. Altogether, 2843 patients with CHB treated with NAs were recruited from a multinational cohort. Serum GGT levels before and 6 months (Month-6) after initiating NAs were measured to explore their association with all-cause, liver-related, and non-liver-related mortality. The annual incidence of all-cause mortality was 0.9/100 person-years over a follow-up period of 17,436.3 person-years. Compared with patients who survived, those who died had a significantly higher pretreatment (89.3 vs. 67.4 U/L, p = 0.002) and Month-6-GGT levels (62.1 vs. 38.4 U/L, p 75 percentile of pretreatment GGT levels was observed with respect to the all-cause mortality (trend p < 0.001). Pretreatment serum GGT levels predicted all-cause, liver-related, and non-liver-related mortality in patients with CHB treated with NAs

Cost-effectiveness analysis of an active search to retrieve HCV patients lost to follow-up (RELINK-C strategy) and the impact of COVID-19

Acord transformatiu CRUE-CSICAltres ajuts: Gilead Science

Assessing the rate of non-linkage to care and identifying barriers in individuals living with hepatitis B. Results of the LINK-B study

Access to care; Barriers; Hepatitis BAccés a l'atenció; Barreres; Hepatitis BAcceso a la atención; Barreras; Hepatitis BBackground & Aims Hepatitis B infection is the most frequent cause of chronic hepatitis and liver cancer worldwide. Active searching for individuals with chronic hepatitis B has been proposed as a strategy to achieve the elimination of this virus. The primary aim of this study was to link to specialists HBsAg-positive individuals detected in a laboratory database and to characterize individuals who were not linked to care. Methods We performed a retrospective–prospective evaluation of all HBsAg-positive serum samples identified in the central laboratory of the Northern Barcelona area between January 2018 and June 2022. After reviewing the patients' clinical charts, all those not linked to care were given an appointment with a specialist. Results Medical records of 2765 different HBsAg-positive serum samples were reviewed and 2590 individuals were identified: 844 (32.6%) were not linked to a specialist, 653 were candidates for linkage, and 344 attended the specialist visit. The two main reasons why they were not under specialist care were administrative issues, such as living in another region (12.1%) and lacking contact details (4.1%), and low life expectancy (2.8%). Individuals who did not attend their scheduled visit were mainly young [38.1 ± 12.9 vs. 44.0 ± 14.0 (p < .001)], non-White European [75.3% vs. 58.1% (p < .001)] and men [70.7% vs. 56.4% (p < .001)]. Conclusions One in every three HBsAg-positive individuals in our setting was not currently under specialist care. Of particular note, half of them had never attended a specialist consultation, an essential step for evaluating the disease and starting therapy in some countries.This project was supported by Gilead Sciences through the competitive research ‘HBV Treat’ (protocol number IN-ES-320-6107)

LINK-B: study protocol of a retrospective and prospective project for identification and linkage to care of people living with hepatitis B in a large health area of Barcelona

Hepatology; Telemedicine; VirologiaHepatologia; Telemedicina; VirologiaHepatología; Telemedicina; VirologíaIntroduction An estimated 290 million people are living with hepatitis B virus (HBV) worldwide; in Spain, the prevalence of hepatitis B virus surface antigen (HBsAg) is 0.4%. In our setting, many HBsAg-positive individuals are not linked to care, which implies a barrier to receiving treatment and controlling the infection. The main objective of this project is to evaluate the performance of a programme designed to achieve appropriate linkage to specialist care of HBsAg-positive individuals, newly tested or previously tested and lost to follow-up. Methods and analysis This is a retrospective and prospective study in which all HBsAg-positive cases recorded in the microbiology database will be identified. The retrospective phase will include cases detected between 2018 and 2020, and the prospective phase will run from January 2021 to June 2022. The project will be carried out in a tertiary university hospital covering the northern health area of Barcelona with a catchment population of 450 000 inhabitants and 16 affiliated primary care centres. The central laboratory detects approximately 1200 HBsAg-positive individuals every year; therefore, we expect to identify around 4000 patients over the duration of the project. The medical records of HBsAg-positive individuals will be consulted to identify and retrieve those who have not been appropriately linked to care. Candidates will be contacted to offer specialist disease assessment and follow-up. A website will be created to provide HBV-related information to primary care physicians, and a mobile phone application will be available to patients to improve the linkage circuits and ensure follow-up continuity. Ethics and dissemination The Vall d’Hebrón Hospital Ethics Committee (PR(AG)201/2021) and the Spanish Agency of Medicines and Medical Devices approved this study. The findings will be disseminated through peer-reviewed publications and conference presentations. This programme could increase the number of HBsAg-positive individuals properly linked to care and achieve better HBV monitoring, which will have a positive impact on WHO’s viral hepatitis elimination goals.This project is supported by Gilead Sciences through the competitive research 'HBV Treat' (protocol number IN-ES-320-6107)

Partial restoration of immune response in Hepatitis C patients after viral clearance by direct-acting antiviral therapy

Fibrosi hepàtica; Cèl·lules T; Teràpia de citocinesFibrosis hepática; Células T; Terapia de citocinasLiver fibrosis; T cells; Cytokine therapyBackground & aims HCV CD4+ and CD8+ specific T cells responses are functionally impaired during chronic hepatitis C infection. DAAs therapies eradicate HCV infection in more than 95% of treated patients. However, the impact of HCV elimination on immune responses remain controversial. Here, we aimed to investigate whether HCV cure by DAAs could reverse the impaired immune response to HCV. Methods We analyzed 27 chronic HCV infected patients undergoing DAA treatment in tertiary care hospital, and we determined the phenotypical and functional changes in both HCV CD8+ and CD4+ specific T-cells before and after viral clearance. PD-1, TIM-3 and LAG-3 cell-surface expression was assessed by flow cytometry to determine CD4+ T cell exhaustion. Functional responses to HCV were analyzed by IFN-Ɣ ELISPOT, intracellular cytokine staining (IL-2 and IFN-Ɣ) and CFSE-based proliferation assays. Results We observed a significant decrease in the expression of PD-1 in CD4+ T-cells after 12 weeks of viral clearance in non-cirrhotic patients (p = 0.033) and in treatment-naive patients (p = 0.010), indicating a partial CD4 phenotype restoration. IFN-Ɣ and IL-2 cytokines production by HCV-specific CD4+ and CD8+ T cells remained impaired upon HCV eradication. Finally, a significant increase of the proliferation capacity of both HCV CD4+ and CD8+ specific T-cells was observed after HCV elimination by DAAs therapies. Conclusions Our results show that in chronically infected patients HCV elimination by DAA treatment lead to partial reversion of CD4+ T cell exhaustion. Moreover, proliferative capacity of HCV-specific CD4+ and CD8+ T cells is recovered after DAA’s therapies.This study was funded by Instituto de Salud Carlos III, cofinanced by the European Regional Development Fund (ERDF): grant numbers PI16/00337, PI18/00210 and PI19/00301. C.P. is supported by the Miguel Servet program of the Instituto de Salud Carlos III (CP14/00121 and CPII19/00001) cofinanced by the European Regional Development Fund (ERDF)

Partial restoration of immune response in Hepatitis C patients after viral clearance by direct-acting antiviral therapy

Background & aims: HCV CD4+ and CD8+ specific T cells responses are functionally impaired during chronic hepatitis C infection. DAAs therapies eradicate HCV infection in more than 95% of treated patients. However, the impact of HCV elimination on immune responses remain controversial. Here, we aimed to investigate whether HCV cure by DAAs could reverse the impaired immune response to HCV. Methods: We analyzed 27 chronic HCV infected patients undergoing DAA treatment in tertiary care hospital, and we determined the phenotypical and functional changes in both HCV CD8+ and CD4+ specific T-cells before and after viral clearance. PD-1, TIM-3 and LAG-3 cell-surface expression was assessed by flow cytometry to determine CD4+ T cell exhaustion. Functional responses to HCV were analyzed by IFN-Ɣ ELISPOT, intracellular cytokine staining (IL-2 and IFN-Ɣ) and CFSE-based proliferation assays. Results: We observed a significant decrease in the expression of PD-1 in CD4+ T-cells after 12 weeks of viral clearance in non-cirrhotic patients (p = 0.033) and in treatment-naive patients (p = 0.010), indicating a partial CD4 phenotype restoration. IFN-Ɣ and IL-2 cytokines production by HCV-specific CD4+ and CD8+ T cells remained impaired upon HCV eradication. Finally, a significant increase of the proliferation capacity of both HCV CD4+ and CD8+ specific T-cells was observed after HCV elimination by DAAs therapies. Conclusions: Our results show that in chronically infected patients HCV elimination by DAA treatment lead to partial reversion of CD4+ T cell exhaustion. Moreover, proliferative capacity of HCV-specific CD4+ and CD8+ T cells is recovered after DAA's therapies

ACE Score Identifies HBeAg-negative Inactive Carriers at a Single-point Evaluation, Regardless of HBV Genotype

HBV DNA; Hepatitis B virus; Inactive carrierADN del VHB; Virus de la hepatitis B; Portador inactivoADN del VHB; Virus de l'hepatitis B; Portador inactiuBackground and Aims Hepatitis B virus (HBV) biomarkers have been used for a better categorization of patients, even though the lack of simple algorithms and the impact of genotypes limit their application. Our aim was to assess the usefulness of noninvasive markers for the identification of HBV inactive carriers (ICs) in a single-point evaluation and to design a predictive model for their identification. Methods This retrospective-prospective study included 343 consecutive HBeAg-negative individuals. Clinical, analytical, and virological data were collected, and a liver biopsy was performed if needed. Subjects were classified at the end of follow-up as ICs, chronic hepatitis B and gray zone.A predictive model was constructed, and validated by 1000-bootstrap samples. Results After 39 months of follow-up, 298 subjects were ICs, 36 were chronic hepatitis B CHB, and nine were gray zone. Eighty-nine (25.9%) individuals required a liver biopsy. Baseline HBV DNA hazard ratio (HR) 6.0, p<0.001), HBV core-related antigen (HBcrAg) (HR 6.5, p<0.001), and elastography (HR 4.6, p<0.001) were independently associated with the IC stage. The ACE score (HBV DNA, HBcrAg, elastography), obtained by bootstrapping, yielded an area under the receiver operating characteristics (AUROC) of 0.925 (95% CI: 0.880–0.970, p<0.001) for identification of ICs. The AUROC for genotype D was 0.95, 0.96 for A, 0.90 for E, and 0.88 for H/F. An ACE score of <1 had a positive predictive value of 99.5%, and a score ≤12 points had a diagnostic accuracy of 93.8%. Conclusions Low baseline HBV DNA, HBcrAg, and liver stiffness were independently associated with the IC phase. A score including those variables identified ICs at a single-point evaluation, and might be applied to implement less intensive follow-up strategies.This study received partial financial support from Instituto de Salud Carlos III (PI17/02233 and PI20/01692)

Ultra Deep Sequencing of Circulating Cell-Free DNA as a Potential Tool for Hepatocellular Carcinoma Management

Biomarkers; cfDNA; Liquid biopsyBiomarcadores; cfDNA; Biopsia líquidaBiomarcadors; cfDNA; Biòpsia líquidaBackground: Cell-free DNA (cfDNA) concentrations have been described to be inversely correlated with prognosis in cancer. Mutations in HCC-associated driver genes in cfDNA have been reported, but their relation with patient’s outcome has not been described. Our aim was to elucidate whether mutations found in cfDNA could be representative from those present in HCC tissue, providing the rationale to use the cfDNA to monitor HCC. Methods: Tumoral tissue, paired nontumor adjacent tissue and blood samples were collected from 30 HCC patients undergoing curative therapies. Deep sequencing targeting HCC driver genes was performed. Results: Patients with more than 2 ng/µL of cfDNA at diagnosis had higher mortality (mean OS 24.6 vs. 31.87 months, p = 0.01) (AUC = 0.782). Subjects who died during follow-up, had a significantly higher number of mutated genes (p = 0.015) and number of mutations (p = 0.015) on cfDNA. Number of mutated genes (p = 0.001), detected mutations (p = 0.001) in cfDNA and ratio (number of mutations/cfDNA) (p = 0.003) were significantly associated with recurrence. However, patients with a ratio (number of mutations/cfDNA) above 6 (long-rank p = 0.0003) presented a higher risk of recurrence than those with a ratio under 6. Detection of more than four mutations in cfDNA correlated with higher risk of death (long-rank p = 0.042). Conclusions: In summary, cfDNA and detection of prevalent HCC mutations could have prognostic implications in early-stage HCC patientsThis research was funded by Instituto de Salud Carlos III (ISCIII) (PI18/00961) and (PI21/00714) to B.M. PI19/00301 by Instituto de Salud Carlos III (ISCIII) and Centro para el Desarrollo Tecnológico Industrial (CDTI) from the Spanish Ministry of Economy and Business, grant number IDI-20200297 to J.Q., E.V.-A. is a recipient of a predoctoral fellowship from Instituto de Salud Carlos III (ISCIII) (FI18/00027)

Real-world Effectiveness and Tolerability of Interferon-free Direct-acting Antiviral for 15,849 Patients with Chronic Hepatitis C: A Multinational Cohort Study

BACKGROUND AND AIMS: As practice patterns and hepatitis C virus (HCV) genotypes (GT) vary geographically, a global real-world study from both East and West covering all GTs can help inform practice policy toward the 2030 HCV elimination goal. This study aimed to assess the effectiveness and tolerability of DAA treatment in routine clinical practice in a multinational cohort for patients infected with all HCV GTs, focusing on GT3 and GT6. METHODS: We analyzed the sustained virological response (SVR12) of 15,849 chronic hepatitis C patients from 39 Real-World Evidence from the Asia Liver Consortium for HCV clinical sites in Asia Pacific, North America, and Europe between 07/01/2014-07/01/2021. RESULTS: The mean age was 62±13 years, with 49.6% male. The demographic breakdown was 91.1% Asian (52.9% Japanese, 25.7% Chinese/Taiwanese, 5.4% Korean, 3.3% Malaysian, and 2.9% Vietnamese), 6.4% White, 1.3% Hispanic/Latino, and 1% Black/African-American. Additionally, 34.8% had cirrhosis, 8.6% had hepatocellular carcinoma (HCC), and 24.9% were treatment-experienced (20.7% with interferon, 4.3% with direct-acting antivirals). The largest group was GT1 (10,246 [64.6%]), followed by GT2 (3,686 [23.2%]), GT3 (1,151 [7.2%]), GT6 (457 [2.8%]), GT4 (47 [0.3%]), GT5 (1 [0.006%]), and untyped GTs (261 [1.6%]). The overall SVR12 was 96.9%, with rates over 95% for GT1/2/3/6 but 91.5% for GT4. SVR12 for GT3 was 95.1% overall, 98.2% for GT3a, and 94.0% for GT3b. SVR12 was 98.3% overall for GT6, lower for patients with cirrhosis and treatment-experienced (TE) (93.8%) but ≥97.5% for treatment-naive patients regardless of cirrhosis status. On multivariable analysis, advanced age, prior treatment failure, cirrhosis, active HCC, and GT3/4 were independent predictors of lower SVR12, while being Asian was a significant predictor of achieving SVR12. CONCLUSIONS: In this diverse multinational real-world cohort of patients with various GTs, the overall cure rate was 96.9%, despite large numbers of patients with cirrhosis, HCC, TE, and GT3/6. SVR12 for GT3/6 with cirrhosis and TE was lower but still excellent (\u3e91%)

Liquid biopsy in hepatocellular carcinoma: Utility of circulating cell-free DNA profiling and cytokine levels in hepatocellular carcinoma management

El carcinoma hepatocel·lular és la segona causa de mort relacionada amb el càncer i la seva incidència està augmentant a tot el món. Els tractaments amb intenció curativa només són aplicables als pacients diagnosticats en estadis inicials, que són menys de la meitat dels pacients diagnosticats de CHC. En el cas de la resecció quirúrgica, la recidiva tumoral s’acosta al 70% als 5 anys; sent la seva detecció precoç o la seva estimació pronòstica una necessitat en pràctica clínica. Les teràpies sistèmiques, tractament d’elecció en els pacients amb CHC avançat, estan canviant ràpidament. La immunoteràpia, i en particular, els inhibidors de punt de control immunitari, han suposat un avenç rellevant, amb una clara traducció en l’increment de supervivència d’aquests pacients. Tot i això, la resposta radiològica objectiva a aquestes teràpies s’estima al voltant del 20% de pacients. La identificació precisa dels pacients que podrien beneficiar-se de cada teràpia seria desitjable per optimitzar l’ús racional de medicaments, evitant els seus potencials efectes secundaris a pacients que a priori no se’n beneficiaran, podent dissenyar d’una manera més racional les estratègies terapèutiques i refinant els actuals algorismes clínics. Al primer estudi es van recollir mostres de teixit tumoral, teixit adjacent no tumoral i de sang de 30 pacients amb CHC sotmesos a teràpies curatives, per analitzar les mutacions més prevalents al CHC (promotor de TERT, TP53, CTNNB1, AXIN1 i ARID1A) al cfDNA plasmàtic mitjançant seqüenciació de nova generació, amb l’objectiu de dilucidar-ne el valor com a biomarcadors pronòstics no invasius. Al nostre estudi, la quantitat total de cfDNA es va relacionar amb supervivència durant el seguiment. El nombre de gens mutats o el nombre de mutacions detectades al cfDNA es van correlacionar amb recurrència i supervivència. A més, es van detectar canvis dinàmics a les mutacions del cfDNA durant el seguiment, amb increment o aparició d’aquestes abans de la detecció radiològica de la recidiva del CHC. Al segon estudi es van recollir mostres de plasma d’una cohort prospectiva de 25 pacients tractats amb inhibidors de punt de control immunitari en iniciar el tractament i després de 3 mesos de tractament. Es van analitzar els nivells de 24 citocines inflamatòries mitjançant ELISA, així com els nivells de cfDNA, ctDNA i el percentatge de mutació de TERT mitjançant ddPCR, a l’inici i després de 3 mesos del tractament. El perfil de cfDNA basal de 21 d’aquests pacients es va analitzar mitjançant Onco-500 TruSight. Els resultats van mostrar que les diferències basals en la quantitat total de cfDNA, CTLA-4 i CNV eren significativament diferents entre els pacients amb i sense resposta radiològica al tractament amb ICIs. Els nivells de MCP-1 i de TNF-alfa i la quantitat total de cfDNA i ctDNA després de tres mesos de tractament amb ICIs van ser significativament diferents en els pacients que van presentar resposta radiològica comparat amb els que van presentar malaltia estable o progressió com a millor resposta radiològica.El carcinoma hepatocelular es la segunda causa de muerte relacionada con el cáncer y su incidencia está aumentando en todo el mundo. Los tratamientos con intención curativa solo son aplicables a los pacientes diagnosticados en estadios iniciales, que son menos de la mitad de los pacientes diagnosticados de CHC. En el caso de la resección quirúrgica, la recidiva tumoral se acerca al 70% a los 5 años; siendo su detección precoz o su estimación pronóstica una necesidad en práctica clínica. Las terapias sistémicas, tratamiento de elección en los pacientes con CHC avanzado, están cambiando rápidamente. La inmunoterapia, y en particular, los inhibidores de punto de control inmunitario, han supuesto un avance relevante, con una traducción clara en el incremento de supervivencia de estos pacientes. Sin embargo, la respuesta radiológica objetiva a estas terapias se estima en torno al 20% de pacientes. La identificación precisa de los pacientes que podrían beneficiarse de cada terapia sería deseable para optimizar el uso racional de medicamentos, evitando sus potenciales efectos secundarios a pacientes que a priori no se beneficiarán de ellos, pudiendo diseñar de un modo más racional las estrategias terapéuticas y refinando los actuales algoritmos clínicos. En el primer estudio se recogieron muestras de tejido tumoral, tejido adyacente no tumoral y de sangre de 30 pacientes con CHC sometidos a terapias curativas, para analizar las mutaciones más prevalentes en el CHC (promotor de TERT, TP53, CTNNB1, AXIN1 y ARID1A) en el cfDNA plasmático mediante secuenciación de nueva generación, con el objetivo de dilucidar su valor como biomarcadores pronósticos no invasivos. En nuestro estudio, la cantidad total de cfDNA se relacionó con supervivencia durante el seguimiento. El número de genes mutados o el número de mutaciones detectadas en el cfDNA se correlacionaron con recurrencia y supervivencia. Además, se detectaron cambios dinámicos en las mutaciones del cfDNA durante el seguimiento, con incremento o aparición de estas antes de la detección radiológica de la recidiva del CHC. En el segundo estudio se recogieron muestras de plasma de una cohorte prospectiva de 25 pacientes tratados con inhibidores de punto de control inmunitario al iniciar el tratamiento y después de 3 meses de tratamiento. Se analizaron los niveles de 24 citoquinas inflamatorias mediante ELISA, así como los niveles de cfDNA, ctDNA y el porcentaje de mutación de TERT mediante ddPCR, al inicio y después de 3 meses del tratamiento. El perfil de cfDNA basal de 21 de estos pacientes se analizó mediante Onco-500 TruSight. Los resultados mostraron que las diferencias basales en la cantidad total de cfDNA, CTLA-4 y CNV eran significativamente diferentes entre los pacientes con y sin respuesta radiológica al tratamiento con ICIs. Los niveles de MCP-1 y de TNF-alfa y la cantidad total de cfDNA y ctDNA después de tres meses de tratamiento con ICIs fueron significativamente diferentes en los pacientes que presentaron respuesta radiológica comparado con los que presentaron enfermedad estable o progresión como mejor respuesta radiológica.Hepatocellular carcinoma is the second leading cause of cancer-related death, and its incidence is increasing globally. Surgery remains as the first therapeutic option for patients with early HCC, but most patients are diagnosed at late clinical stages due to the lack of early symptoms. Curative treatments are only applicable to patients diagnosed at early stages, which are less than half of the patients diagnosed with HCC. In the case of surgical resection, tumor recurrence is close to 70% at 5 years; its prompt detection or a prognostic estimation would be necessary in clinical practice. Systemic therapies, that are treatment of choice for patients with advanced HCC, are rapidly changing. Immunotherapy, and in particular immune checkpoint inhibitors, have revolutionized the therapeutic landscape of advanced HCC, increasing the expected survival of these patients. However, objective radiological response to these therapies has been reported to occur in around 20% of patients. The precise identification of patients that could benefit from those therapies would optimize the rational use of these drugs, avoiding their potential side effects in patients who a priori will not benefit from them, and so allowing to design the therapeutic strategy in a more rational way, refining the current clinical algorithms. In the first study we collected tumoral tissue, paired nontumor adjacent tissue and blood samples from 30 HCC patients undergoing curative therapies, to analyze the most prevalent mutations in HCC (TERT promoter, TP53, CTNNB1, AXIN1 and ARID1A) in plasma cfDNA by next-generation sequencing, aiming to elucidate their value as prognostic noninvasive biomarkers. In our study, total amount of cfDNA was related to survival during follow-up. The number of mutated genes or the number of detectable mutations on cfDNA were correlated with recurrence and survival. Moreover, dynamic changes in cfDNA mutations were detected during the follow-up, with increase or appearance of these mutations before radiological detection of HCC recurrence. In the second study plasma samples from a prospective cohort of 25 advanced HCC patients treated with immune checkpoint inhibitors were collected at the beginning and after 3 months under treatment. Twenty-four inflammatory cytokine levels were analyzed by ELISA as well as the levels of cfDNA, ctDNA and percentage of TERT mutation by ddPCR, at baseline and after 3 months of treatment. Basal cfDNA profiling from 21 of these patients was analyzed by Onco-500 TruSight. Results showed that basal differences in total amount of cfDNA, CTLA-4 and CNV were significantly different between patients with and without radiological response to ICIs treatment. Levels of MCP-1 and TNF-alpha, and total amount cfDNA and ctDNA after three months of ICIs treatment were significantly different in patients presenting radiological response compared to those not presenting stable or progressive disease as best radiological response.Universitat Autònoma de Barcelona. Programa de Doctorat en Medicin