Interferon-induced protein 10 (IP10) at discontinuation of effective entecavir (ETV) or tenofovir (TDF) therapy cannot predict subsequent relapses in non-cirrhotic HBeAgnegative chronic hepatitis B (CHBe-) patients. DARING-B: a prospective Greek study. Margarita Papatheodoridi 1, Emilia Hadziyannis 2, Eirini Rigopoulou 3, Kalliopi Zachou 3, Vasilis Xourafas 1, Aggeliki Lyberopoulou 3, Nikolaos Gatselis 3, Spilios Manolakopoulos 2, George Dalekos 3, George Papatheodoridis 1 1 Academic Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece; 2 2nd Department of Internal Medicine, Medical School of National and Kapodistrian University of Athens, Hippokratio General Hospital, Athens, Greece; 3 Department of Internal Medicine, Thessalia University Medical School, Larissa, Greece
Background ΝΑ therapy in CHBe- until HBsAg clearance. (EASL guidelines 2012) Virological relapses may occur in the majority of CHBe- patients who discontinue NAs. (Papatheodoridis et al. Hepatology 2016) Virological relapses are not always associated with biochemical relapses and/or may be transient leading to long-term remission and HBsAg clearance. (Papatheodoridis et al. Hepatology 2016; Hatziyannis et al. Gastroenterology 2012) Strong predictors of sustained off-nas remission have not yet been identified. (Papatheodoridis et al. Hepatology 2016)
IP-10 (IFN-inducible protein 10, CXCL10) Chemokine secreted from cells stimulated with IFNγ and TNFa or bacterial LPS Binds to CXCR3, G-protein coupled-receptor on TH1 T cells, NK cells and some CD4/CD8 T cells (Dufour et al., J Immunology 2002)
IP-10 Important role in generating and recruiting activated T cells into sites of IP-10 tissue expression: inflammation psoriasis, multiple sclerosis, atherosclerosis, rheumatoid arthritis, transplant rejection IBD, viral meningitis, pulm. sarcoidosis chronic active hepatitis Mostly in Th1-type inflammatory diseases
IP-10 in Chronic Hepatitis IP-10 mrna was expressed mainly in hepatocytes around intralobular focal and periportal necrosis in CHC patients. (Narumi et al., J Immunology 1997) A low IP-10 value was independently predictive of both RVR and SVR after Peg-IFNa and RBV therapy in HCV patients. (Lagging et al., Hepatology 2006) Higher IP-10 values have been associated with HBsAg decline during NAs and IFN therapy in HBV patients. (Jaroscewutz et al., Antiviral Ther 2011; Papatheodoridis et al. J Hepatol 2011; J Viral Hepat 2015) IP-10 can predict fibrosis progression in CHB patients. (Wang et al. Scientific Reports 2017)
Aim To assess rates of off-treatment relapse and retreatment in non-cirrhotic CHBe- patients after discontinuation of effective long-term ETV/TDF therapy To evaluate IP-10 serum levels at ETV/TDF discontinuation as a possible predictor of relapse
60 patients with CHBe- Patients Inclusion criteria Absence of cirrhosis at the onset of NA(s) therapy Duration of NA(s) therapy for 4 years Duration of serum HBV DNA undetectability under NA(s) for 3 years Exclusion criteria Coinfection with HCV, HDV, or HIV HCC or any other malignancy Liver transplantation Poor follow-up after NA(s) discontinuation
Management & Follow-up Physical examination and blood examination for ALT, AST, GGT, ALP and bilirubin, HBV DNA and storage serum samples for IP10 measurement BASELINE: Discontinuation of NAs MONTH 1 MONTH 2 MONTH 3 Detectable HBV DNA Undetectable HBV DNA Visit every 2 months Visit every 3 months Follow-up for 12 mo after NA(s) discontinuation OR until retreatment
Retreatment criteria ALT >10xULN ALT >5xULN & total bilirubin >2 mg/dl ALT >3xULN & HBV DNA >100,000 IU/mL ALT >ULN & HBV DNA >2,000 IU/mL on 3 sequential occasions
Table 1A. Patient main characteristics* Patients 60 Age at the onset of NA(s), years 58 ± 10.7 Gender, males 39 (65) Alcohol consumption, social use (<40/20g/24h, M/F) no 10 (16.7) 49 (81.7) Body mass index at the onset of NA(s), kg/m 2 26.8 ± 3.45 ALT at the onset of NA(s), IU/L 98.5 [111] AST at the onset of NA(s), IU/L 52 [56] Albumin at the onset of NA(s), g/dl 4.4 [0.7] Hb at the onset of NA(s), g/dl 14.1 ± 1.4 WBC at the onset of NA(s), g/dl 5880 [2445] Platelets at the onset of NA(s), x10 3 /mm 3 216 [71] Serum HBV DNA at the onset of NA(s), IU/Ml 351,786 [752,230] *Values are mean ± SD, count (%) or median [IQR]
Table 1B. Patient main characteristics Type of initial NA(s) therapy Entecavir Tenofovir disoproxil fumarate Other NA(s) Type of last NA(s) before discontinuation Entecavir Tenofovir disoproxil fumarate 13 (21.7) 14 (23.3) 33 (55) 18 (30) 44 (70) ALT at ETV/TDF discontinuation, IU/L 22 [10] Liver stiffness at ETV/TDF discontinuation, kpa 5.7 [2.2] IP-10 at ETV/TDF discontinuation, pg/ml 145 [83]
Off-NA(s) follow-up Median: 7 [2] months No patient experienced jaundice, liver decompensation, HCC or other serious adverse event No patient died
Cumulative rates of virological relapse based on three predetermined serum HBV DNA cut-off levels HBV DNA cut-off levels for definitions of relapse 80 74 Patients With virological relapse, % 70 60 50 40 30 20 10 35 25 10 63 53 25 62 29 IU/mL >200 >2,000 >20,000 0 Month 1 Month 3 Month 6
Table 2. Cumulative rates of combined virological and biochemical relapses based on several ALT and HBV DNA cut-off levels HBV DNA, IU/mL >200 >2,000 >20,000 ALT Any Any >ULN >2x ULN Any > ULN 1 mo 35% 25% 15% 2% 10% 2% 3 mos 63% 53% 34% 23% 25% 18% 6 mos 74% 62% 37% 29% 29% 24% 9 mos 74% 62% 37% 29% 35% 24%
Probability of no retreatment 85 80 76
Table 3. Baseline IP-10 levels as predictors of relapse. Univariable Cox regression analyses. Relapse definition HBV DNA, IU/mL ALT levels Hazard ratios (95% confidence intervals) Baseline IP-10 levels >200 Any 1.00 (0.99-1.00) P=0.712 >2,000 Any 1.00 (0.99-1.00) P=0.985 >ULN 0.99 (0.99-1.00) P=0.762 >2x ULN 0.99 (0.99-1.00) P=0.813 >20,000 Any 0.99 (0.99-1.00) P=0.872 Retreatment >ULN 0.99 (0.99-1.00) P=0.915 0.99 (0.99-1.00) P=0.742
Conclusions The majority of CHBe- patients who discontinue effective long-term ETV/TDF therapy can remain safely without retreatment, at least in the shortterm, despite common virological relapses. IP-10 levels at discontinuation of antiviral therapy do not seem to be helpful for predicting relapses and need for retreatment. Further research is required for reliable predictors of relapse in this setting.
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