Society: AASLD

Introduction:
Chronic hepatitis delta (CHD) typically leads to cirrhosis and hepatic decompensation. The only treatment option for CHD patients with decompensated cirrhosis is liver transplantation with associated short- and long-term complications. REP 2139-Mg is a nucleic acid polymer (NAP) that blocks the assembly and secretion of HBV subviral particles and hepatitis delta antigen function, providing multiple effects against both HBV and HDV infection. The objective of this study is to describe the safety and efficacy of REP 2139-Mg in CHD patients with decompensated cirrhosis.

Patients & Methods:
Compassionate use access in the first two European CHD patients with decompensated cirrhosis to receive REP 2139-Mg 250 mg QW subcutaneously (SC) and tenofovir disoproxil fumarate (TDF) 300 mg QD orally for a planned total duration of 48 weeks was approved in France by the ANSM. Clinical, biological, virological and imaging data were collected at baseline and every week for the first month, then every month. Safety and tolerance were continuously evaluated.

Results:
Patient #1 is a Caucasian, 56-year old female, HDV treatment-naïve, with CHD decompensated cirrhosis (Child Pugh B8, portal hypertension and ascites) with HDV RNA 7.04 log10 IU/mL and HBsAg 1177 IU/mL at baseline. At week 4 of therapy, reversal of ascites was confirmed by ultrasound (minimal diuretic dose was maintained due to mild bilateral leg edema). HBsAg loss occurred at week 10 with HBsAg seroconversion (27 mIU/mL) at week 14 increasing to 168 mIU/mL at week 18. HDV RNA has been undetectable since week 20.
Patient #2 is an African, 56-year old female with arterial hypertension awaiting liver transplant. She experienced HDV relapse 1 year after discontinuing bulevirtide 2mg and pegIFN 180ug and progressed to decompensated cirrhosis (Child Pugh C11, portal hypertension, ascites and hepatocellular carcinoma) with accompanying edema, and pronounced fatigue. Baseline HDV RNA was 3.64 log10 IU/mL and HBsAg 4270 IU/mL. At Week 4, abdominal CT confirmed significant reduction of clinical ascites and peripheral edema and fatigue were markedly reduced.

Both patients have no side effects and present a good tolerance to subcutaneous injections of REP 2139-Mg to date.

Conclusion:
REP 2139-Mg in association with TDF is safe and well tolerated in patients with CHD and decompensated cirrhosis. Liver function improvement with significant ascites reversal was rapid, occurring after only 4 weeks of treatment. HBV-HDV functional cure with HBsAg loss and HBs seroconversion appears achievable in this special population which could prevent the need for a future liver transplant.

Background & Aims: International treatment guidelines for hepatitis B infection (HBV) recommend initiating antiviral therapy based on viral replication with significant inflammation or fibrosis. However, HBV viral load and liver fibrosis measurements are not widely available in resource-limited countries. We aimed to develop a simple scoring system for selecting patients for treatment in these countries.

Methods: We examined 602 and 420 treatment-naive HBV mono-infected patients for derivation and validation cohorts, respectively. We performed logistic regression analysis to identify independent liver-related complication parameters associated with the initiation of antiviral treatment based on the European Association for the Study of the Liver clinical practice guideline. The scores in our system were based on these parameters and converted to integer points. The scoring system’s performance was validated and compared with the Treatment Eligibility in Africa for HBV (TREAT-B) system, World Health Organization (WHO) simplified criteria, and Risk Estimation for HCC in Chronic Hepatitis B (REACH-B) system.

Results: The novel scoring system (HePAA score) was based on HBeAg (0 point; negative, 1 point; positive), platelet count (0 point; ≥150,0000, 1 point; <150,0000 /mm³), alanine transaminase (0 point; <30, 1 point; 30 - 39, 2 points; 40 – 49, 3 points; ≥ 50 IU/L), and albumin (0 point ≥ 4, 1 points; < 4 g/dL). The system showed excellent performance, with an area under the receiver operating characteristic curve of 0.926 (95% CI, 0.901–0.950) for the derivation cohort and 0.872 (95% CI, 0.833–0.910) for the validation cohort. The optimal cutoff was ≥3 points (sensitivity, 84.9%; specificity, 92.6%). The HePAA scoring system performed better than the WHO criteria and REACH-B scoring system and performed similarly to the TREAT-B system. The HePAA system demonstrated similar performance when using all guidelines (AASLD; American Association for the Study of Liver Diseases, APASL; Asian-Pacific Association for the Study of Liver, and THASL; Thai Association for the Study of the Liver) as gold standards.

Conclusions: The HePAA scoring system is simple and accurate for chronic hepatitis B treatment eligibility in resource-limited countries.

Background: Human pluripotent stem cell (PSC) derived hepatocyte-like cells and primary human hepatocytes applications for clinical or research uses is dependent on the ability to generate phenotypically and functionally relevant hepatocytes or hepatocyte-containing constructs. We have developed a scalable multi-well platform that enables the rapid generation of three-dimensional (3D) multicellular spheroids composed of primary and stem cell derived human liver parenchymal cell types including hepatocytes, liver sinusoidal endothelial cells (LSEC), stellate cells (HSC), and Kupffer cells. This 3D system is able to maintain hepatocellular function long-term and can be used to model the complex interactions and host responses between hepatocytes and nonparenchymal cells (LSEC, HSC, and Kupffer cells) during HBV Infection.

Methods: Multicellular spheroids containing hepatocytes and nonparenchymal cells alone were generated from primary human liver tissue or from human PSCs. This robust human multicellular platform maintains hepatocellular and nonparenchymal cell differentiated function for greater that 6 weeks and allows for extended experiments. Given the longevity and stability of the platform we examined whether such a platform could be used to model the complex interactions and host responses between hepatocytes, LSEC, HSC, and Kupffer cells in vitro during HBV infection.

Results: We generated multicellular spheroids and examined the acute and chronic changes due to HBV infection in multicellular spheroids. We found that multicellular spheroids maintain long-term infection in contrast to traditional hepatocyte-culture systems. Moreover, we found that metabolic perturbations led to impaired higher viral loads, hepatocyte injury, and macrophage and stellate cell activation. We evaluated the cross-talk between these different cell types early and late after HBV infection and found that in unexpectedly the presence of macrophages led to higher viral loads than when they were not present in the multicellular spheroids. We identified that Kupffer cell cytokine production is responsible for increased viral loads and neutralizing antibodies against IL-6 were able to mitigate this effect.

Conclusion: Our work demonstrates that multicellular spheroids composed of primary and stem cell derived human liver parenchymal cell types including hepatocytes, LSEC, stellate cells, and Kupffer cells have stable function and can model complex disease phenotypes in vitro. Leveraging these technologies focused on HBV enabled studies of viral infection and can be leveraged in mechanistic studies of infection.

Introduction: Delta hepatitis (HDV) is the most severe form of viral hepatitis with rapid progression to cirrhosis and hepatocellular carcinoma. New York City (NYC) has previously been called a hot spot for hepatitis D virus (HDV), in part due to its large immigrant population. We evaluated a large regional database pooling data from four NYC hospital systems to determine the prevalence of HDV testing and positivity among patients with hepatitis B virus (HBV).

Methods: The INSIGHT Clinical Research Network (CRN), a member of the national Patient-Centered Outcomes Research Institute (PCORI) network, PCORnet®, is a centralized, robust electronic health record database of over 17 million diverse patients from NYC’s leading health systems, containing longitudinal data from 2010-2022. We performed a large retrospective analysis of patients with a record of hepatitis B diagnosis and HBsAg positive laboratory status to determine the prevalence of HDV testing (HDV Ab and HDV RNA).

Results: We identified a total of 125,626 patients with a diagnosis code for hepatitis B and 74,437 individuals with HBsAg positive laboratory tests. Among those, 2,250 (3.0%) had a record of an HDV antibody lab test, with 64% occurring after the year 2016. Among those tested, 114 (5%) had HDV positive tests. Only 213 individuals were ever tested for HDV RNA; the majority had qualitative HDV testing performed with 142 available results, and 1.4% reporting positive qualitative results. Only 9 patients had quantitative HDV RNA results reported with median HDV RNA 152,931 IU/ML (IQR 518, 499,000). Regarding the prevalence of HDV testing, compared to females, males were more likely to have testing (1.3% vs 0.67%, p=0.009), and Asians had higher prevalence of testing than other races (3.6% vs 0.70%, p=0.000); while Hispanics had lower prevalence than non-Hispanics (0.3% vs 1.24%, p=0.000). The median age at time of initial HDV test was 49 years (IQR 37, 60). Among those with reported death, the median time to death from initial HDV Ab testing was only one year (IQR 0.07, 2.89), with no significant difference between groups. Table 1 shows demographic characteristics of HDV Ab positive versus negative patients. Interestingly, HDV Ab positive patients were older at time of testing and more likely to be Caucasian (p<0.05) than HDV AB negative patients.

Conclusions: In this large regional database, HDV testing occurred in less than 5% of individuals with evidence of HBV infection by diagnosis code or HbsAg positive status. HDV RNA testing was infrequent, with the majority of available testing being qualitative. There were demographic differences in those who underwent testing, suggesting possible provider bias in ordering HDV testing. Efforts to increase education around HDV testing and availability of HDV RNA testing are needed to improve HDV detection and prognostication.

Background: Recent studies in predominantly Asian cohorts of patients with chronic hepatitis B (CHB) demonstrate significant variations in on-treatment risks of hepatocellular carcinoma (HCC) by baseline levels of hepatitis B virus (HBV) DNA. However, it is not clear whether similar variations in HCC risk are observed in non-Asian cohorts. We aim to evaluate on-treatment risks of cirrhosis and HCC by baseline HBV DNA among a national cohort of predominantly non-Asian patients with CHB.
Methods: Adult Veterans with CHB in the U.S. were identified using the 2010-2022 Veterans Affairs Corporate Data Warehouse, which comprehensively captures healthcare data on Veterans across the U.S. Patients with concurrent HIV, hepatitis C, hepatitis delta were excluded Patients with cirrhosis or HCC at baseline or within 12 months of starting antiviral therapy were excluded. On-treatment incidence of cirrhosis or HCC (per 100 person-years) among this non-cirrhotic cohort of CHB patients was stratified by baseline HBV DNA, which was categorized into 3 groups: < 100,000 IU/mL (Low-DNA), 100,000-10⁷ IU/mL (Intermediate-DNA), and > 10⁷ IU/mL (High-DNA). Subgroup analyses were performed in patients with e antigen (eAg) positive CHB. Comparisons of cirrhosis or HCC incidence between groups utilized the z-statistic using standard equations.
Results: A total of 2,510 non-cirrhotic CHB patients on antiviral therapy were identified, including 36.5% eAg positive, 94.2% men, 36.5% non-Hispanic white, 37.7% African American, 18.3% Asian, mean age 56.2 ± 13.4 years, and 38.8% had Low-DNA, 23.4% Intermediate-DNA, 37.9% High-DNA). Over a median follow up 6.3 years (IQR 3.5 – 10.0), 15.7% developed cirrhosis and 3.2% developed HCC. When stratified by baseline HBV DNA levels, incidence of cirrhosis was significantly higher in the High-DNA group compared to Low-DNA (3.18 vs. 2.26 per 100 person-years, p<0.05), but no significant difference was observed when compared to the Intermediate-DNA group. No significant difference in HCC incidence by baseline HBV DNA was observed (Figure 1). When focusing specifically on patients with eAg positive CHB, we observed similar risks of cirrhosis or HCC across the spectrum of baseline HBV DNA levels (Figure 2). For example, incidence of cirrhosis was 2.63 per 100 person-years in the Low-DNA group vs 3.08 per 100 person-years in the High-DNA group (p=0.49), and the incidence of HCC was 0.35 per 100 person-years in the Low-DNA group vs. 0.45 per 100 person-years in the High-DNA group (p=0.72).
Conclusion: In contrast to observations from Asian cohorts, we observed similar on-treatment risks of HCC when stratified by baseline HBV DNA among a predominantly non-Asian U.S CHB cohort. While risk of cirrhosis was greater in the High-DNA group, no significant difference was observed in the Intermediate-DNA group, or when stratified by eAg positive patients.

Joseph Lim

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