HBV-DNA detection by hybridization assay in the serum of anti-HBe positive HBV carriers

HBV-DNA + Chronic Hepatitis

11/19 58% 11/14 79% Bonino 1980 7/13 54% - Scotto 198316/32 50% - Liebermann 198314/24 58% 14/18 78% Hadziyannis 198328/106 26% 28/46 65% Bonino 1984 8/30 27% 8/21 38% Lok 198410/153 7% 1/5 20% Tur Kaspa 198414/78 18% 10/38 26% Wu 1986

116/455 25% 72/139 52%

Chronic anti-HBe positive hepatitis B was born in 1980 in the Mediterranean area

< 2% - Low 2-7% - Intermediate > 8% - High

Chronic anti-HBe positive hepatitis B

FeaturesFeatures

Virological :Virological : mean viremia levels lower than those observed in HBeAg positive patients

Clinical:Clinical: progressive liver disease with low rate of spontaneous resolutions, in spite of temporary remissions

high relapse rate after the end of IFN, in spite of the response obtained during treatment

Brunetto MR, Hepatology 1989

HBeAg positive infection

Anti-HBe positive infection

Identification of 1896 G to A switch as causative agent of

anti-HBe positive chronic hepatitis B

Brunetto MR et al, Ital. J Gastro 1989Carman A et al, Lancet 1989Santantonio T et al, Virology 1991

NUCLEOCAPSID PROTEINS: HBeAg

PRE-C CORE

183 aa

E.R.

29 aa

149 (154) aa10 aa

17 kDa non particulate, secreted HBeAg

Substitution of 7cys restores particle formation and HBcAg antigenicity

Hepatitis B Virus

Li J-S et al, J Virol 1993

Sequence ofpre-core codon 15 Genotype

Size of gene(nucleotides)

core Pre-S

CCC

CCU

CCC/U

CCU

CCU

CCC/U

A

B

C

D

E

F

555

549

549

549

549

549

519

519

519

486

486

486

BestBestmatchingmatchingwithwithcodon 28codon 28

Genotype D is the prevailing HBV genotype inthe Mediterranean area where Chronic anti-

HBe positive hepatitis B was originally described

< 2% - Low 2-7% - Intermediate > 8% - High

Reports from South Europe on the various features, the outcome and response to IFN of HBeAg negative/anti-HBe positive CHB, mainly concern 1896 GtoA ,genotype D CHB and do not necessarily apply to other geographical areas where other virologicform of HBeAg-negative CHB may prevail

Hadziyannis SJ, J Hep 2002

Modulation of HBeAg expression

Transcriptional

Translational

Basic core promoter mutants

HDV super/co-infections

Pre-core mutants:1896 G to A Stop at codon 281817 C to T Stop at codon 21897 G to A Stop at codon 281816 G to T Elimination of1815 T to C start codon 1

Anti-HBe positive chronic hepatitis B: 1896 G to A switch by oligohybridization

assay

All patients were of Italian origin

52 (31.7%)52 (31.7%)

99 (60.4%)99 (60.4%)

13 (7.9 %)13 (7.9 %)

161 / 164 (98.2%)

Brunetto MR,1999

Anti-HBe positive chronic hepatitis B: pre-core heterogeneity by direct sequencing in 18 patients from Tuscany

1762 1764 1896 1899 A - T G - A G - A G - A

12/18 12/18 11/18 6/18

66.6% 66.6% 61.1% 33.3%

+ + - - in 5 patients

- - - - in 2 patients

Moscato G, 2001

HBeAg+ 9%

anti-HCV+ 6%

anti-D+/ anti-HCV+

1%

anti-HBe+ 77%

anti-D+ 7%

Gaeta et al. Year of analisys:1997

Chronic HBsAg Hepatitis in ItalyChronic HBsAg Hepatitis in Italy834 cases in 14 centres834 cases in 14 centres

89%

11%

42%58%

HBeAg pos.veHBeAg pos.ve anti-HBe pos.veanti-HBe pos.veCases = 538Cases = 538 Cases = 718Cases = 718

Giusti et al.Giusti et al.1975-851975-85

Gaeta et al.Gaeta et al.19971997

Change of HBeAg and anti-HBe Distribution in positive HBsAg Carriers in Italy

Chronic anti-HBe positive hepatitis B

Reasons for the increase of its prevalence in Italy:Reasons for the increase of its prevalence in Italy:

- reduction of HBeAg positive cases

- long lasting unresolving disease inducing a progressive accumulation of cases in the population

- increase in the diagnostic accuracy (more sensitive assays, more diagnostic accuracy by the clinicians)

Geographic Distribution of HBsAg Carriers

< 2% - Low 2-7% - Intermediate > 8% - High

Chronic anti-HBe positive hepatitis B

Reasons for the increase of its prevalence in Italy:Reasons for the increase of its prevalence in Italy:

- reduction of HBeAg positive cases

- long lasting unresolving disease inducing a - long lasting unresolving disease inducing a progressive accumulation of cases in the populationprogressive accumulation of cases in the population

- increase in the diagnostic accuracy (more sensitive assays, more diagnostic accuracy by the clinicians)

Outcome of Chronic Anti-HBe Positive Hepatitis B

0 10 20 30 40 50 60 70 80

INFECTION

36 - 40 y.Age (years)

45 y.

CIRRHOSIS

asymptomatic

HBeAg minus selection

High intrafamiliar infection (43.9%) Low parenteral exposure (13.4%)Small number of patients with history of acute hepatitis (4.8%) or HBeAg pos. (2.4%)

High rate of asymptomaticcarriers among relativesHigh rate of acute hepatitis in sexual partners

DIAGNOSIS

Outcome of chronic anti-HBe positive hepatitis B

Steadyness

Amelioration

Cirrhosis

4 Signs of portal hypertension2 Died1 OLT

Worsening

Cirrhosis

Steadyness

2nd Biopsy 63/8772.4%

102 patients (mean age 36 y) with chronic hepatitis at histology Median follow-up 6y. (mean 5.9y.; range 2-12y.)

Biochemicaland ClinicalOutcome

85.3%

7.8% 6.9%

38.1%

49.2%

12.7%

50 50

Hepatitis Healthy

80

20

Hepatitis Healthy

80

20

Hepatitis Healthy

Gaeta et al. 2000

20 years old 50 years old

Prevalence of Chronic anti-HBe positive

Hepatitis B by Age

% %

Chronic anti-HBe positive hepatitis B

Reasons for the increase of its prevalence in Italy:Reasons for the increase of its prevalence in Italy:

- reduction of HBeAg positive cases

- long lasting unresolving disease inducing a progressive accumulation of cases in the population

- increase in the diagnostic accuracy - increase in the diagnostic accuracy (more sensitive assays, more diagnostic(more sensitive assays, more diagnostic accuracy by the clinicians) accuracy by the clinicians)

Outcome of Chronic Anti-HBe Positive Hepatitis B

0

100

200

300

400

0

100

200

300

400

0

100

200

300

400

Biochemical patterns in 164 untreated patientsafter 23 months (range 12-36) monthly monitoring

0 12 24months

With flares and normalization

Without flares

With flares and without normalization

73 pts ( 44.5% )

59 pts ( 36.0% )

32 pts ( 19.5% )

Asymptomatic flare-up:

90% of cases

ALT Flare-up yearly

frequency:once 57.1%twice 20%

< once 22.8%

Viremia profilepersistently > 106 gen/ml 15 ( 9.1%)occasionally < 106 gen/ml 52 (31.7%)frequently < 106 gen/ml 87 (53.1%)persistently < 106 gen/ml 10 ( 6.3%)

IgM anti-HBc profile

persistently > 7 PEI I.U. 110 (67.1%) 57.9% 82.2%fluctuations < 7 PEI I.U. 54 (32.9%) 42.1% 17.8% fluctuations < 4 PEI I.U. 5 ( 3.0%)

ALL ChronicHepatitis Cirrhosis

2 9.332, p = 0.002

Anti-HBe positive chronic hepatitis B: virological patterns in 164 patients 23 months (range 12-36) monthly monitoring

Brunetto MR,1999

A favoring condition due to the changed HBV epidemiology in Italy

A better understanding of what we are looking for and how to do it

Are the major factors responsible for the increased prevalence of anti-HBe positive CHB in Italy

AKNOWLEDGEMENT

Anna Maria Maina Giovanna Moscato

Filippo Oliveri Barbara Coco

Piero Colombatto Ferruccio Bonino