Clearing the Confusion: Lab Testing in the Diagnosis and Management of Viral Hepatitis

Transcription

1 Welcome Your Host: Karen Riba Clearing te Confusion: Lab Testing in te Diagnosis and Management of Viral Hepatitis April 12, 2011 Handout is available by clicking on te andout icon in te upper rigt and corner of your screen For tecnical difficulties please For questions you ave during te presentation use te Q & A link at te top of your screen Questions will be answered at te end of te presentation Welcome Your Host: Karen Riba P.A.C.E. credit may be obtained by submitting your completed evaluation form at te end of te webinar CE credit may be obtained by downloading te Certificate of Completion PAML employees will be able to receive one our of continuing education. Speaker Information Speaker Image Dr. Katerine Soreng, P.D. Dr. Soreng received er BSc. in Biology from te University of Wasington in Seattle. Se was awarded a P.D. in Immunology and Molecular Patogenesis from Emory University in Atlanta, GA, publising a tesis on protein syntesis and cytoskeletal elements in te Class II restricted processing of antigen. Learning Objectives At te end of tis presentation participants will be able to: Identify te appropriate tests involved in te differential diagnosis of viral epatitis (including acute vs cronic) Discuss te algoritms useful for bot epatitis B and C antibody test confirmation Discuss te clinical utility of viral load and genotype in bot epatitis B and C infection. Disclosures Full-time employee of Siemens Healtcare Sr. Manager of Clinical Education and Scientific Publications 1

2 Stages of Liver Damage Pysical Symptoms Of Liver Failure Normal Liver injury/ inflammation Liver fibrosis Liver failure/ Cirrosis liver cancer Nausea Loss of appetite Fatigue Jaundice Bleeding/bruising easily Swollen abdomen/legs Diarrea Intense skin itcing Clay stool, dark urine, tenderness Mental disorientation Early YEARS Late Common Causes of Hepatitis Introduction Te beginning of ealt is to know te disease Cinese proverb Viruses Metabolic Disease Bacteria Alcool Drugs Acute Hepatitis Symptoms Common Tests for Identifying Liver Disease Mout & Upper GI Tract Lower Digestive Tract Is tere liver injury? ALT AST Wat is causing te damage? Viral epatitis Arm & Leg Joints & Muscles Fever Jaundice Alkaline pospatase LDH Total bilirubin Alcool Fatty Liver 2

3 Common Types of Viral Hepatitis Viral Hepatitis - Overview Hepatitis E Hepatitis D Hepatitis A Hepatitis B Hepatitis C Type of Hepatitis A B C D E Genome RNA DNA RNA RNA RNA Source of virus feces Route of fecal-oral transmission infection Prevention blood/ blood/ blood/ feces blood-derived blood-derived blood-derived body fluids body fluids body fluids percutaneous permucosal percutaneous permucosal percutaneous permucosal no yes yes yes no pre/postexposure immunization pre/postexposure immunization blood donor screening; risk beavior modification pre/postexposure immunization; risk beavior modification fecal-oral ensure safe drinking water Acute vs. Viral Hepatitis Hepatitis A Liver damage Fulminant Acute Deat Progression HDV HAV HBV Stable disease HEV HCV Acute Recovery 6 monts Time HAV: Severity HAV Serological Course Usually mild, most recover Frequently symptomless, especially in cildren May be sick for several monts HAV Infection Fecal HAV sedding Symptoms Total anti-hav Can cause acute liver failure and deat ALT Patient populations wit te greatest risk for significant disease include: Resolution and immunity Persons 50 years of age or older anti-hav IgM Persons wit oter liver diseases, suc as epatitis B or C Monts after exposure 3

4 HAV Serological Tests Hepatitis B Anti-HAV IgM Anti-HAV-Total Indicates acute infection Detects bot IgM and IgG Can be detected in blood about 3-4 weeks after infection IgM antibodies not generally detectable witin 3-12 monts Positive in acute and recovered epatitis Present in infected and vaccinated populations HBV Transmission Risk Factors HBV Infection Outcomes in Adults Birt (spread from an infected moter to er baby during birt) Acute HBV Sex wit an infected partner Subclinical infection Clinical infection Fulminant epatitis Saring needles, syringes, or oter drug-injection equipment HBsAg carrier ~5% Recovery immunity ~95% Saring items suc as razors or tootbruses wit an infected person epatitis Asymptomatic HBsAg carrier Direct contact wit te blood or open sores of an infected person Exposure to blood from needlesticks or oter sarp instruments Andrew Magill, Creative Commons Attribution 2.0 License HBV infected maternal blood Liver injury Liver cirrosis Liver cancer Deat HBV Transmission HBV Infection Outcomes in Newborns Hig Viral Acute HBV Blood Serum Wound exudates Subclinical infection Clinical infection Fulminant epatitis Vertical transmission Semen Moderate Viral Vaginal fluid Saliva HBsAg carrier ~90% ~5% epatitis HBsAg Recovery carrier immunity ~10% ~95% Asymptomatic HBsAg carrier Low Viral Urine Feces Sweat Tears Breast milk Liver injury Liver cirrosis Liver cancer Deat 4

5 HBV Correlates Inversely wit Age Age at Infection ity (%) <6 monts >6 monts years >4 years 5-10 Immunopropylaxis to Prevent Perinatal Transmission Vaccine Dose and HBIG* Age Infant Born to Moter Known to be HBsAg Positive First Vaccine Dose HBIG Second Vaccine Dose Tird Vaccine Dose Birt (witin 12 ours) Birt (witin 12 ours) 1 2 monts 6 monts Infant Born to Moter Not Screened for HBsAg First Vaccine Dose HBIG Second Vaccine Dose Tird Vaccine Dose *Hepatitis B Immune Globulin Birt (witin 12 ours) Screen moter ASAP. If HBsAg positive, give ASAP but by no later tan 1 week of age 1 2 monts 6 monts Recommended Immunization Scedule for Persons Aged 0 Troug 6 Years United States 2009 ttp:// Hepatitis B Virus Structure Hepatitis B Testing Envelope Viral DNA Nucleocapsid (core antigen) Surface antigens HBe Antigen Serology Manual and automated metods are available to identify antibody to or antigen from te Hepatitis B virus Molecular Tests Detect viral load for terapeutic decision making Serological Tests For HBV HBV Serological Profile: Acute Infection wit Recovery Antibody detection Anti-HBs Anti-HBc IgM HBeAg Symptoms Anti-HBe Anti-HBe Anti-HBc total HBsAg anti-hbc IgM Total anti-hbc anti-hbs Antigen detection HBeAg HBsAg Weeks after exposure 5

6 Clearing te Confusion: HBV Serological Profile: Non-replicative Infection nonreplicative replicative state state HBeAg Anti-HBe 6 mont = cronic HBsAg anti-hbc IgM Total anti-hbc HBV Serological Profile: Replicative Infection Acute (6 monts) anti-hbc IgM HBeAg (Years) HBsAg Total anti-hbc anti-hbs rarely seen anti-hbs rarely seen Weeks after exposure Weeks after exposure Hepatitis B Testing Treating HBV Test Result Probable Diagnosis HBsAg ahbct ahbc IgM HBeAg ahbe ahbs Uninfected, unvaccinated Vaccinated (immune) + Acute infection Active infection: recovering + + Recovered (immune) replicative infection nonreplicative infection Treatment is often lifelong - few are cured Tenofovir Telbivudine Entecavir Treatment options include Adefovir Interferon Alpa Pegylated interferon Lamivudine Treatment Goals for HBV Guidelines for treatment replicative state HBeAg 6 mont = cronic IgM anti-hbc nonreplicative state Anti-HBe HBsAg Total anti-hbc anti-hbs rarely seen Weeks after exposure 6

7 Hepatitis C HCV Prevalence > 2.9% % % < 1.0% US 3 4M Americas 12 15M No data wwwnc.cdc.gov/.../yellowbook/2008/c4/epa.aspx Western Europe 5M Africa 30 40M Eastern Europe 10M 10,000 12,000 deats per year, US Leading cause of liver transplants, US No vaccine Souteast Asia 30 45M Far East Asia 60M Australia 0.2M 6 HCV Genotypes and > 50 Subtypes HCV Infection In Te US Japan & Taiwan f e d a 2(I) US & Western Europe c b 1c(E) 1(I) 4a(E) 1b 1c(0) 1(II) 4a(B) 1a Middle East 4c 4e 2 3c 3e 4g 4 3(III) 4 4f 1 3d 4d 3(VI) 3a 5a f TD3 10a a 3b Sout Africa 6a b 6b f g d c e 7c/NGII/VII i 9a 7b 7d 7a 11a n m k j 9b l Hong Kong & Souteast Asia NGI * 8a 8b 9c Australia & Sout Asia # Cases (millions) HCV HIV Source: Clin Gastroenterol Hepatol October; 4(10): Up to 2% of US population infected Estimated 35,000 new HCV cases per year in te US 80 % Infected for life HCV: Te Silent Epidemic HCV Transmission Early Stage Late Stage Symptoms rare (~20%) and generalized Symptoms still rare (nausea, jaundice, fatigue) Houseold 3% Occupational 3% Sexual 21% Liver Disease Presentation Often years post-exposure Transfusions* 3% Illegal drug abuse 60% Initial ID of Damage Transmission Elevated liver enzyme profiles (AST, ALT) Infected individuals may unknowingly spread virus No Identified risks 10% Disease ity >75%-80% * Reduced after implementation of routine blood screening 7

8 Altoug IV Drug Abuse Is Te Leading Risk, Oter Causes Of HCV Include: Anoter Risk - Going to a Clinic?! Manicure and pedicure 60,000 patients Tattoos Occupational azards Source: CDC press release Jan. 6, 2009 At risk of HBV, HCV, HIV after failure of medical personnel to follow proper practice Hepatitis C Virus (HCV) HCV RNA Genome Envelope Core 2 nd or 3 rd generation HCV IA detects antibody to 3 or more viral proteins 5 NTR Structural Proteins Non-structural Proteins 3 NTR First Generation Second Generation Tird Generation p22 p70 p8 p27 P56/58 p68 NS C E1 E2 NS1 NS2 NS3 4A NS4B NS5A NS5B Envelope glycoproteins Viral RNA (9400 nucleotides) Nucleocapsid Metalloprotease Serine Protease RNA Helicase Cofactors Interferon Resistance Protein RNA Polymerase RIBA for HCV antibody confirmation HCV Infection Testing Algoritm Interpretation Positive Positive IgG Control Level II c100(p) 5-1-1(p) c33c c22 (p) NS5 SOD IgG Control Level I Report Negative Positive (but < Index or S/CO) OR Index or S/CO Validated Report Positive Indeterminate RIBA for Anti-HCV Negative HCV RNA Testing Indeterminate Negative Negative Report Negative Negative PCR Normal ALT Indeterminate Additional Laboratory Evaluation (PCR, ALT) Positive PCR Elevated ALT Positive Medical Evaluation Positive 8

9 HCV Progression HCV Progression Symptoms ± Anti-HCV Symptoms ± Anti-HCV HCV RNA HCV RNA ALT AbHCV/ RIBA ALT/AST Oter ALT tests Genotype and Viral Load Liver Biopsy Normal Monts Time after exposure Years Normal Monts Time after exposure Years Testing of te HCV Infected Patient Tecnologies to detect HCV RNA include: Has te patient ever been infected? Anti-HCV serology HCV Virus HCV RNA How muc virus is present? Wat genotype is te patient infected wit? Is te patient responding to terapy? Is te patient relapsing? Viral Load Genotyping Assay Viral Load/Qualitative assay Viral Load/Qualitative assay TMA* Hig Sensitivity Qualitative Assay Add primers & enzymes Copies (RNA) One detection probe per copy TMA = Transcription Mediated Amplification RT-PCR Add primers & enzymes Target Amplification Quantitative Assay Copies (DNA) One detection probe per amplified copy bdna Add target probes and amplification probes Signal Amplification Quantitative Assay Multiple detection probes per target Tecnologies to detect HCV genotype include: Molecular Testing in Treatment of HCV Patients RT-PCR wit sequencing Line Probe Assay (LiPA) Genotype 1a, 1b Genotype 2, 3 Sensitive qualitative, quantitative viral load, and genotyping central to terapy Pegylated interferon Ribavirin Terapy response Current varies HCV wit genotype terapy and compliance 9

10 Treatment of HCV NIH Guidelines Gany, et al. 2009, Hepatology, Vol. 49; No. 4, page 1335 Strader, et al. 2004; Hepatology, Vol. 39. Siemens No. 4 page AG, All rigts reserved Side Effects of HCV Terapy HCV Treatment Nomenclature Pegylated interferon Neuropsyciatric Depression, anxiety, irritability, fatigue Bone marrow depression Neutropenia, trombocytopenia Anorexia / weigt loss Alopecia Exacerbation of autoimmune disorders Tyroid dysfunction Hasimoto s tyroiditis Grossman H et al.. 41st Interscience Conference on Antimicrobial Agents and Cemoterapy. December 16-19, Cicago. Abstract I-254. Ribavirin Coug and dyspnea Hemolytic anemia Teratogenicity Insomnia Ras / Puritus Nausea SVR : Sustained Virologic Response EVR : Early Virologic Response RVR : Rapid Virologic Response Stopping Rules Management of Hepatitis C: 2002 NIH Consensus Conference Statement Early viral response (EVR): HCV Terapy Algoritm Baseline: Quantitative & Genotype A minimum 2 log decrease in viral load during te first 12 weeks of treatment Predictive of SVR and sould be a routine part of monitoring patients 12 weeks treatment <2 log10 drop Consider terapy end Week 12: Quantitative 2 log10 drop Genotype 1 48 weeks End treatment: Qualitative 6 mont follow-up: Qualitative Genotype non-1 24 weeks HCV RNA (+) Non-responder 2002 NIH Consensus Conference HCV RNA (+) Relapser HCV RNA (-) Sustained responder 10

11 Viral Load Clearing te Confusion: SVR vs. Non-Response (NR) to te Anti-Viral Terapies * Terapy Response IFN mono 15% 85% IFN + RBV 41% 59% Peg + RBV 54% 46% Peg + RBV (80/80/80) 63% 37% 20% 80% 0% 40% 60% 100% SVR NR Viral load Terapy Cessation at 12 Weeks? EVR Predictive SVR Non-responder Initial load 2 log drop 80/80/80 = >80% dose of peg-interferon; >80% dose of ribavirin; >80% of prescribed treatment duration * McHutcison JG et al. Te effects of interferon alpa-2b in combination wit ribavirin on ealt related quality of life and work productivity. J Hepatol. 2001;34: McHutcison JG et al. Aderence to combination terapy enances sustained response in Genotype-1-infected patients wit cronic epatitis C. J Gastroenterology. 2002; 123: Terapy course (weeks) 2002 NIH Consensus Conference Outcome wit PEG-IFN 2a +R: 12 Week Stopping Rule Outcome wit PEG-IFN 2b +R: 12 Week Stopping Rule Week 12 (N = 453) Yes n = 390 (86%) SVR NR n = 253 (65%) n = 137 (35%) PPV Week 12 (N = 478) Yes n = 380 (79%) SVR No SVR n = 273 (72%) n = 107 (28%) PPV 2 log 10 drop or Neg HCV RNA 2 log 10 drop or Neg HCV RNA Fried et al NEJM 347(13): No n = 63 (14%) SVR NR n = 2 (3%) n = 61 (97%) NPV No Davis et al. Hepatology (2003) 38(3): n = 98 (21%) SVR No SVR n = 0 (0%) n = 98 (100%) NPV Terapeutic Response: RVR RVR in te 2009 AASLD HCV Treatment Update Rapid Viral Response Initial load Gany, et al. 2009, Hepatology, Vol. 49; No. 4, page 1335 RVR EVR Non-responder 2 log drop Predictive SVR Terapy course (weeks) 11

12 Patients wit SVR (%) Clearing te Confusion: Time to Undectability Predicts SVR Using RVR in patient management Ferenci, P, et al. J Hepatol 2005;43: % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Week 4 Negative 2 log < 2 log Week 12 Negative Negative Negative Week Guidelines 91% 72% 66% 48% 43% 2 log 2 log < 2 log 2 log Negative Negative Negative Negative Negative 2002 NIH Consensus Conference Baseline: Quantitative & genotype Week Week 12: 4: Quantitative and/or Qualitative qualitative <2 log10 drop Consider terapy end HCV RNA (+) Non-responder 2 log10 drop Genotype 1 48 weeks Genotype non-1 24 weeks End treatment: Qualitative 6 mont follow-up: Qualitative HCV RNA (+) Relapser HCV? HCV RNA (-) Sustained responder 6 HCV Genotypes and > 50 Subtypes HCV Genotypes can Predict Treatment Success Japan & 4d 4a(E) 4c 4g 5a 4a(B) 4e 4 6a Taiwan 4f 6b 2(I) 7c/NGII/VII a b f 7b f c b d 7d e c 7a d e 11a 5 g a 4 n NGI HCV genotype assessment 6 guides mterapy 2 l * and predicts likeliood 8a 1of 3SVR k 8b 1b j i 9c 1c(E) 9a 9b 1(I) 1c(0) 3c 1(II) 1a 3e 3d 3f 3b US & Western Europe Middle East 3(III) 3(VI) 3a TD3 10a Sout Africa Hong Kong & Souteast Asia Australia & Sout Asia Genotype 1 40% Effective Genotype Non-1 80% Effective Pegylated Interferon Ribavirin Treatment Success Treatment Success HCV Treatment: Genotypes Make a Difference Treatment Response (SVR) wit Pegylated Interferon and Ribavirin 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% All Patients Genotype 1 Genotype 2&3 0% All Patients Genotype 1 Genotype 2&3 Adapted from Ann Intern Med 2004; 140: & Lancet 2001; 358: Adapted from Hepatology. 2002;36:(5 suppl 1):S3-S20 12

13 Patients wit SVR (%) Clearing te Confusion: HCV Mono-infected vs HCV-HIV Co-infected Patients Patient Presentation Nausea, sligt fever, epatomegaly, jaundice 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Treatment wit Pegylated Interferon + Ribavirin 63% 40% 52% 29% 85% 62% All Patients Genotype 1 Genotype 2 & 3 HCV Only HCV + HIV Acute Viral Hepatitis Testing Panel HAV IgM HBsAg HBV Core IgM Interpretation Pos Neg Neg Neg Acute HAV Neg Neg Neg Neg Pos Neg Anti-HCV Pos Neg HCV-acute, cronic, resolved? HBV? Neg Pos Pos Neg Acute HBV? Resources Ann Robinson, P.D., DABMM, FAAM Director, Microbiology and Virology ann.robinson@providence.org Virginia Henderson, M,SV (ASCP) Tecnical Supervisor, Virology venders@paml.com American Association for te Study of Liver Disease (AASLD) Diagnosis, Management and Treatment of Hepatitis C: An Update Tank-you for Attending Tank-you for Attending P.A.C.E. credit may be obtained by submitting your completed evaluation form. You will find te form by clicking on te andouts icon in te upper rigt and corner of your screen CE credit may be obtained by downloading te Certificate of Completion under te andouts icon PAML employees will be able to receive one our of continuing education credit by submitting your attendance troug CE Manager. Tis webinar as been recorded and will be available by April 14 t, on under te Hospital Tab/Hospital Portal/Webinar Series eading 13