Treatment strategies for recurrent hepatitis C after living donor liver transplantation (from Kyushu University experience)

Korean Association of HBP Surgery President: Dong Wook Choi, MD, PhD, Samsung Medical Center Session : 09:50-10:50, 2 nd /3, Apr 27, 2013 Venue: Lotte Hotel, Jeju Island, Korea Session: Prevention of original disease recurrence after liver transplantation Treatment strategies for recurrent hepatitis C after living donor liver transplantation (from Kyushu University experience) Department of Surgery and Science, Kyushu University Toru Ikegami, MD

Today s topics 1. What determines IFN sensitivity for Hepatitis C after LT? (Viral factors vs. Host factors) 2. Telaprevir based new antiviral treatment for Hepatitis C after LT (Telaprevir will be available in Korea in 2015) 3. Diagnosis and treatment for cholestatic Hepatitis C after LT

Today s topics 1. What determines IFN sensitivity for Hepatitis C after LT? (Viral factors vs. Host factors) 2. Telaprevir based new antiviral treatment for Hepatitis C after LT (Telaprevir will be available in Korea in 2015) 3. Diagnosis and treatment for cholestatic Hepatitis C after LT

Case numbers The cases of living donor liver transplantation, Kyushu University 45 40 35 30 25 20 Total 454 cases HCV (-) n=294 (64.8%) 15 10 5 0 HCV (+) n=160 (35.2%) 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12(year)

The most significant problem: recurrent hepatitis C after LDLT F1 recurrence F3-4 recurrence (%) 100 80 58.1% 78.7% 97.8% 100 80 60 60 40 40 20 20 11.2% 0 0 0 1 2 3 4 5 6 Post-transplant years 7 0 1 2 3 4 5 6 Post-transplant years 7

Significance of IFN treatment for recurrent Hep C 1 year after LT 3 years after LT F1 F4 x40 2 years after LT 68y.o. female, LDLT for Hep C and HCC F2 x40 7 years after LT IFN treatment (SVR) F1 x40 x40 IFN treated fibrosis

Overall outcomes after IFN treatment for hepatitis C, Kyushu University Conventional IFN (n=6) Peg-IFN with ribavirin (n=111) NR (no response) (n=4,66.7%) NR (n=42 37.8%) VR (viral response) (n=69 62.3%) EVR (n=17, 24.6%) No-EVR (n=52, 75.4%) SVR (n=2 33.3%) Relapse (n=10 9.0%) (SVR:47.9%) SVR (n=54 48.6%) On treatment (n=5 4.5%) SVR: sustained viral response (no HCVRNA over 6 months after finishing IFN treatment)

SVR rate (%) SVR rate (%) SVR rate (%) SVR rate (%) Which factors are associated with IFN sensitivity? Vital genotype Elderly recipient ( 60) p=0.231 p=0.654 48.9% 64.7% 51.2% 46.2% Type 1 (n=90) Type 2 (n=17) No (n=86) Yes (n=26) HCVRNA ( 5LogIU/ml) p=0.985 Donor age 40 p=0.669 50.0% 50.5% 51.2% 46.7% No (n=4) Yes (n=107) No (n=30) Red characters: generally believed favorable factors Yes (n=82)

Does mutation in HCV genomic RNA impacts IFN sensitivity? Structural (viral structures) Non Structural (RNA replication) Favorable: wild Favorable: mutant Wild type amino acid 70 and 91 in the core portion, mutated ISDR and IRRDR in NS-5A have been identified for significant factors for increased IFN sensitivity in non-transplant cases.

SVR rate (%) Role of HCV mutations in IFN sensitivity after LDLT Known favorable factors: double wile core protein, mutant ISDR and IRRDR Double wild AA 70/91 (core protein) 39.7% p=0.055 (n.s.) 61.3% SVR rate (%) SVR rate (%) Mutated ISDR ( 2) p=0.080 (n.s.) 59.4% 40.0% No (n=55) Yes (n=32) Mutated IRRDR ( 6) p=0.067 (n.s.) 60.7% 39.7% No (n=53) Yes (n=31) No (n=58) Yes (n=27)

Genome-wide analysis for IFN sensitivity (host) Smaller p-value (Nat Genet 41: 1100-04, 2009) (Nat Genet 41: 1105-09, 2009) 19q3 IL28B (IFNλ3) rs12980275 AAAC[G/A]GAC G rs8099917 CAAT[G/T]TCAT Numerous SNPs on chromosomes Chromosome 19 IL28A (IFNλ2) Genome-wide analysis showed that single nuclear polymorphisms close to the IL28B (IFN λ3) gene were significantly associated with the sensitivity of IFN treatment for chronic hepatitis C. rs8099917: TT = high IFN sensitivity, TG or GG = low IFN sensitivity

Dual grafts LDLT from two donors with different IL28B genotypes Minor Major Donor for Rt lobe graft 42 y.o Female Recipient s spouse rs8099917 : T / G Donor for Lt lobe graft 21 y.o Male Recipient s son rs8099917 : T / T Minor Recipient 51y.o Male, Hep-C HCC rs8099917 : T / G Peg-IFN and Ribavirin

Intrahepatic HCV-RNA and IL28B genotype (4 years after LDLT) Rt lobe graft Lt lobe graft Donor rs8099917 T/G (Minor) Donor rs8099917 T/T (Major) A2F2 A1F0 HCV RNA quantitative RT-PCR 15.3 copies / µg undetectable Motomura T et al. Am J Transpl. 2011

Paraffin embedded specimen could be used for IL28B genotyping Sliced paraffin embedded specimen Hybridized and polymerized for luminescence DNA isolator PS TM Applied Biosystems StepOne TM Isolated DNA G/G rs8099917 T/G rs8099917 T/T rs8099917

Donor and Recipient IL28B genotype determines IFN sensitivity (SVR) Factors No (SVR rate) Yes (SVR rate) p-value Recipient age >60 years 38/68 (55.8) 18/44 (40.9) 0.121 Recipient gender, male 23/47 (48.9) 33/65 (50.8) 0.848 Donor age <40 years 14/30 (46.7) 42/82 (51.2) 0.669 Left lobe graft 18/42 (42.8) 38/70 (54.3) 0.241 Splenectomy 17/43 (39.5) 39/69 (56.5 0.080 Early IFN induction within 3 mo 42/82 (51.2) 13/28 (46.4) 0.661 Biliary stenosis 40/78 (51.3) 16/34 (47.1) 0.681 Acute rejection 51/101 (50.5) 5/11 (45.5) 0.751 FK use 26/45 (57.8) 30/67 (44.8) 0.177 Steroid use 9/21 (42.8) 47/91 (51.6) 0.467 Type 1 HCV 11/17 (64.7) 44/90 (48.9) 0.231 HCV-RNA 5 logiu/ml 2/4 (50.0) 54/107 (50.5) 0.985 R-IL28B-TT genotype (Major) 4/31 (12.9) 50/77 (64.9) <0.001 D-IL28B-TT genotype (Major) 5/27 (18.5) 47/74 (63.5) <0.001 Core AA (70/91:DW) 21/53 (39.7) 19/31 (61.3) 0.055 ISDR mutation 2 22/55 (40.0) 19/32 (59.4) 0.080 IRRDR mutation 6 23/58 (39.7) 17/28 (60.7) 0.066 IL-28B-genotypes determines SVR

Both donor and recipient IL28B determines IFN sensitivity after LDLT Genome-wide analysis Chromosome #19 IL28B (rs8099917) rs8099917 (%) 100 80 60 SVR rate p<0.001 70.1% rs8099917 genotype Major (M):TT Minor (m):tg GG 40 20 0 16.7% 14.3% 12.5% Donor IL28B m m M M Recipient IL28B m M m M N (%) 18 (16.7%) 7 (14.3%) 8 (12.5%) 65 (66.3%) Major: TT minor: TG or GG

Today s topics 1. What determines IFN sensitivity for Hepatitis C after LT? (Viral factors vs. Host factors) 2. Telaprevir based new antiviral treatment for Hepatitis C after LT (Telaprevir will be available in Korea in 2015) 3. Diagnosis and treatment for cholestatic Hepatitis C after LT

Telaprevir for hepatitis C after liver transplantation Telaprevir (will be available in Korea in 2015, has been available in Japan last year) : NS3-4A serine protease inhibitor, inhibits the release of proteins involved for RNA replication Structural (viral structures) Non Structural (RNA replication) NS3-4A protease release all the proteins involved for RNA replication Telaprevir inhibits master switch (NS3-4A) for RNA replication of HCV

Telaprevir and CNI (Cyclosporine, Taclorimus) Increase of Cyclosporine level X 4.6 Increase of Taclorimus level X 70 Garg, et al. Hepatology 2011

German team used full-dose Telaprevir for LT patients Case 58M 67M 71M 51M 70F 59F 53M 58M 61M Cr 1 1.2 1.1 1.2 0.7 0.7 1 0.8 1.4 IS Tac Tac Tac Tac Sir CyA CyA CyA CyA IL28B (CC:major) Pre-Tx CT CT CT CT CT TT CT CT CT Peg- IFN RBV FK: 1/22 dosage, CyA: 1/2.5 dosage - Peg-IFN Peg-IFN RBV Peg-IFN RBV Peg-IFN RBV Peg-IFN RBV Peg-IFN RBV Peg-IFN RBV NR - NR NR TR NR NR NR NR Peg-IFN 2b 2a 2a 2a 2a 2a 2a 2a 2a 80 180 180 180 180 180 180 180 180 RBV 800 600 1000 1000 1000 600 1000 1000 600 G-CSF Yes - - - - - - Yes - EPO Yes Yes - - - Yes Yes Yes Yes RCC Yes Yes - - - Yes Yes Yes Yes Effect RVR RVR RVR NR EVR EVR EVR RVR EVR EVR; 88.9% RBC was given for 6/9 (66.7%) Wemer, et al. Liver Transpl 2012

Reduced telaprevir for recurrent Hep-C after LDLT at Kyushu Univ. Indication:NR or TR by conventional Peg-IFN and Ribavirin treatment Exclusion:Cr>1.5 mg/dl, Hb<10g/dl Methods Peg-IFN α2b:1.0-1.5 μg/kg/week Ribavirin:start with 25-50% of regular dosage(200-600mg/day) Telaprevir:1500mg for 12 weeks (reduced from 2250 mg) Cyclosporine:start with 25% dosage(trough は :80-150ng/ml) Mycophenolate:continue Dose modification anemia:hb<8.5g/dl(2-6w) Ribavirin dose reduction rash:grade-ii(diffuse, 1-2w) stop Telaprevir renal:cr>2.0mg/d(1-2w) stop Telaprevir Skin problem Anemia, renal problem Increase Cyclosporine dosage Telaprevir Peg-IFN+RIbavirin 4w 12w 24w

Triple therapy including Telaprevir for rec. Hep-C after LDLT Case 52, M 63, M 70, M 59, M 64, F 56, M Previous IFN Yes Yes Yes Yes Yes Yes Outcome after prev.ifn TR NR NR NR TR NR HCV-genotype 1b 1b 1b 1b 1b 1b HCV-RNA (logiu/ml) 6.4 5.3 5.4 5.8 5.7 7 IL28B (Recipient) TT TG TT TT TG TT IL28B (Donor) TT TG TT TT TG TT AA70(R) R Q R R Q Q AA91(L) L L L L M M CNI CyA CyA CyA CyA CyA CyA MMF 1000 0 0 500 500 0 Peg-IFN 130 90 100 90 100 100 TPV 1500 1500 1500 1500 1500 1500 RBV 500 200 800 400 200 600 G-CSF No No No No No No EPO No No No No No No RBC Yes No No No No No Rash Grade 1 No No No No Grade 1 Inquantitiable HCVRNA 4 2 2 3 3 5 Undetectable HCVRNA 5 5 4 NA 4 11 Effect EVR EVR RVR NR RVR EVR EVR: 83%

HCV-RNA (log IU/ml) Triple therapy including Telaprevir for rec. Hep-C after LDLT (Changes in HCV-RNA titer) 8 7 6 5 4 3 RVR 33.3% EVR 83.3% 2 1 0 0 2 4 6 8 10 12 14 16 18 20 Undetectable 33.3% 83.3% (weeks) HCV-RNA (2/6) (5/6)

Hemoglobin (g/dl) Triple therapy including Telaprevir for rec. Hep-C after LDLT (Changes in Hemoglobin) 18 16 14 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Decrease in hemoglobin: 4.4 ± 0.9 g/dl (weeks)

Creatinine (mg/dl) Triple therapy including Telaprevir for rec. Hep-C after LDLT (Changes in creatinine) 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Increase in serum creatinine 0.4 ± 0.1 mg/dl (weeks)

Cyclosporine concentration (ng/dl) Triple therapy including Telaprevir for rec. Hep-C after LDLT (Changes in cyclosporine trough level) 200 180 160 140 105 ± 22 ng/dl 120 100 80 60 40 20 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 (weeks)

Today s topics 1. What determines IFN sensitivity for Hepatitis C after LT? (Viral factors vs. Host factors) 2. Telaprevir based new antiviral treatment for Hepatitis C after LT (Telaprevir will be available in Korea in 2015) 3. Diagnosis and treatment for cholestatic Hepatitis C after LT

T.Bil (mg/dl) HCVRNA (KIU/ml) ALT (IU/L) Cholestatic hepatitis after LDLT: Very serious condition! A1 cholestatic 18 9 万 Day 9 Day 36 1200 12 6 万 800 6 3 万 Dead at Day 87 400 0 0 0 5 10 15 20 25 30 35 40 0 Saraf N. Liver Transpl. 2007.

Cholestatic hepatitis C after liver transplantation 1. Later than 1 month after transplantation (usually <6 months) 2. Serum bilirubin level greater than 6 mg/dl 3. Serum ALP and GGT greater than 5x the upper limits of normal value 4. Ballooning of hepatocytes, paucity of inflammation, and variable degrees of cholangiolar proliferation 5. High serum HCV RNA levels 6. Absence of surgical biliary complications Mortality: over 50%? Difficult to diagnose (acute rejection, preservation injury, functional choestasis) Narang T, et al. 2010

Histologic findings of cholestatic hepatitis after LDLT Pt #2 Pt #4 x40 Minimal lymphocyte aggregation x40 Minimal lymphocyte aggregation Pt #3 Pt #6 x40 Minimal lymphocyte aggregation x40 Minimal lymphocyte aggregation No cholestasis, hepatocyte ballooning, high HCVRNA titer, hyperbilirubinemia

Which factors are associated with cholestatic hepatitis after LDLT? Factors Cholestatic hepatitis No (n=44) Yes (n=5) p-value Recipient age 57.4 ± 8.0 58.2 ± 7.7 0.839 Donor age 34.5 ± 10.9 29.2 ± 10.0 0.302 Graft standard liver volume ratio (%) 39.2 ± 5.9 45.0 ± 7.3 0.059 Splenectomy 42 (95.5) 5 (100.0) 0.626 Recipient IL28B genotype, T/T 23 (60.5) 4 (80.0) 0.393 Donor IL28B genotype, T/T 27 (64.3) 4 (80.0) 0.483 HCV genotype 1, yes 34 (80.9) 3 (60.0) 0.279 HCV-RNA titer (log 10 IU/ml) Before LDLT 5.4 ± 1.2 5.2 ± 0.7 0.813 2 weeks after LDLT 5.8 ± 1.3 7.7 ± 0.4 0.002 Peak value 6.8 ± 1.3 7.9 ± 0.1 0.089 VR (%) 22 (64.7) 5 (100.0) 0.110 Taclorimus use 22 (50.0) 1 (20.0) 0.202 Acute rejection 1 (2.3) 0 (0.0) 0.733 Biliary stenosis 8 (18.2) 2 (40.0) 0.251 CMV infection 12 (27.2) 4 (80.0) 0.017

HCV-RNA titer and cholestatic hepatitis Appropriate cut off for cholestatic hepatitis C ROC curve HCV-RNA=8.0 log/ml 2 weeks after LDLT Pt #5 Lobular hepatitis and hepatocyte ballooning

IFN treatment for cholestatic hepatitis after LDLT Recipient Donor genotype HCV RNA (log) Onset (months) T.Bil (mg/dl) Recipient IL2bB-SNP Donor IL28B-SNP IFN effect Follow-up (year)) 40, M 39, M 1b 5.4 2 19.0 Minor Minor IFNα NR 0.6 59 M 28 M 1b 5.3 1 16.2 Major Major Peg-α2b SVR 2.1 54 F 21 F 1b 5.7 0.5 17.4 Major Major Peg-α2b VR 3.7 62 F 36 M 2a 5.7 1 13.6 Minor Minor Peg-α2a SVR 2.8 52 M 20 M 1b 5.2 4 18.3 Major Major Peg-α2b SVR 2.1 53 F 27 M 2a 5.4 1 16.7 Major Major Peg-α2b VR 1.8 70 F 43 F 1b 3.9 1 9.0 Major Major Peg-α2a SVR 1.8 71.4% major combination VR: 85.7% The key is early recognition, diagnosis and initiation of treatment

Summary Combination of donor and recipient IL28B is a significant predictor for IFN sensitivity for recurrent hepatitis C after LDLT. Telaprevir based antiviral treatment is a feasible option for recurrent hepatitis C for selected patients after LDLT. Cholestatic recurrent hepatitis C after LDLT could be successfully treated by early pathological and virological diagnosis and early IFN installation.