Faculty Bibliography

Despite the high global prevalence of chronic hepatitis B (CHB) infection, datasets covering the whole hepatitis B viral genome from large patient cohorts are lacking, greatly limiting our understanding of the viral genetic factors involved in this deadly disease. We performed deep sequencing of viral samples from patients chronically infected with HBV to investigate the association between viral genome variation and patients' clinical characteristics. We discovered novel viral variants strongly associated with viral load and HBeAg status. Patients with viral variants C1817T and A1838G had viral loads nearly three orders of magnitude lower than patients without those variants. These patients consequently experienced earlier viral suppression while on treatment. Furthermore, we identified novel variants that either independently or in combination with precore mutation G1896A were associated with the transition from HBeAg positive to the negative phase of infection. These observations are consistent with the hypothesis that mutation of the HBeAg open reading frame is an important factor driving CHB patient's HBeAg status. This analysis provides a detailed picture of HBV genetic variation in the largest patient cohort to date and highlights the diversity of plausible molecular mechanisms through which viral variation affects clinical phenotype.

Background: Limited data exist evaluating the treatment outcomes with direct-acting antivirals (DAAs) in patients with drug use in the community setting. We aim to assess the treatment response of DAAs in this subset of patients with or without the opioid agonist therapy (OAT). Methods: All the hepatitis C virus (HCV) infected patients treated with DAAs were retrospectively analyzed. Patients were stratified into two groups by the presence or absence of abusing alcohol, cocaine and heroin. All the patients who were assigned to the abuser group had positive urine toxicology with one of the drugs during the DAA treatment. The primary assessment was the sustained virologic response (SVR12) at 12 weeks post-treatment (SVR12). Results: Among the 314 patients, 152, 128 and 58 were patients with drug use, non-drug use and receiving OAT. Among the patients with injectable or non-injectable drug use treatment, completion rate was 99% (151/152) and SVR12 was 93.4%. Among the patients with no drug use treatment, completion rate was 95% (122/128) and SVR12 was 88.3%. Among patients receiving OAT alone, SVR12 was 100%, and in patients with OAT + other drug use, SVR12 was 96.5%. None of the patients included in this study discontinued the treatment due to adverse events associated with treatment medications. Conclusions: In this community-based study, DAAs are safe, effective with high overall SVR12 in patients with active drug use (injectable and non-injectable) and OAT enrolled patients. These results support the removal of drug use as a barrier to DAA therapy.

Background and aims: TAF provides similar efficacy to tenofovir disoproxil fumarate (TDF) but with an improved safety profile particularly for renal injury. Here, we assess clinical experience with TAF for patients with HBV in US Clinical Practice.
Method(s): The TRIO HBV Registry, consisting of 1078 enrolled patients from 6 academic and 4 community-based centers serving 17 US States, was created to understand real-world HBV treatment. Data presented here are limited to 250 registry patients who initiated TAF between Nov 2016 and Apr 2018, received >= 6 months of TAF therapy, and were followed up to 18 months. Baseline measures were closest to but between -30 to +60 days from regimen start. Measures in other time periods were those with the maximum date while on TAF. Comparisons to baseline were made using paired 2-tailed T-Tests. eGFR was calculated using the CKD-EPI equation.
Result(s): Characteristics of the study population: median age 52 years, BMI 24.3 kg/m2, male (147/250, 59%), Asian ethnicity (220/250, 88%), HBeAg positive (54/250, 22%), osteopenia/osteoporosis (47/250, 19%), and FIB-4 >3.25 (17/250, 7%). Mean and median TAF duration was 13 months as of data collection. 233/250 (93%) of patients receiving TAF switched from TDF (214/233, 92%), entecavir (16/233, 7%), or other therapies (3/233, 1%). At TAF initiation, 17/250 (7%) patients had baseline HBV DNA >= 2000 IU/ml. Of the 17, 16 patients had controlled HBV (< 2000 IU/ml) after 6 or 12 months of TAF therapy. One patient had a 50% viral reduction to 30, 000 IU/ml after 6 months of therapy but did not achieve suppression. 233/250 (93%) patients had baseline HBV DNA<2000 IU/ml; of these, 226 were assessed after 6 or 12 months of therapy and all had maintained HBV suppression (< 2000 IU/ml). 224/250 (90%) patients had baseline eGFR >= 60 ml/min and 26/250 (10%) < 60 ml/min with minimum 28 ml/min. In paired comparisons, mean eGFR increased 5% from baseline 85.7 to 90.1 ml/min (p < 0.001) after 6 months of TAF therapy (n = 213). Of 158 patients with eGFR measures after 12 months of TAF, the mean eGFR increase was 4% from baseline 86.9 to 90.5 ml/min (p = 0.001). For patients with baseline eGFR < 60 ml/min, mean eGFR increased 16% from 48.4 to 56.0 ml/min after 6 months (n = 24, p < 0.001). In the eGFR < 60 ml/min subset with 12+ months of TAF, the change in eGFR was 14% from baseline 54.0 to 61.4 ml/min though this change did not reach significance (n = 11, p = 0.066).
Conclusion(s): In US, clinical practice experience with TAF indicates effective HBV suppression after switching and improved renal function in real-world application. Continued long-term monitoring is critical to assess potential effects of prolonged treatment with lower dose tenofovir. (HBsAg). Currently approved drugs, nucleos (t)ide analogues, effectively reduce HBV DNA but only rarely result in a functional cure (defined as sustained HBsAg loss). Therefore, a critical need arises for novel therapies that reduce HBsAg levels and restore virus-specific immune responsiveness in patients. We have found that two subregions in 3' untranslated region of 2.1/2.4 kb HBV RNAs, here referred as "region X" and "region Y," regulate HBsAg production (unpublished data). Here, focusing on region X and Y, we aimed to screen host proteins to identify novel therapeutic targets reducing HBsAg.
Method(s): Host proteins binding to region X and Y were determined by following two methods. (1) The lysate of HepG2.2.15 hepatoblastoma cells was incubated with in vitro-transcribed RNA corresponding to above two regions, and binding proteins were pulled-down. The proteins pulled-down were identified by SDS-PAGE and LC-MS/MS. (2) Host proteins binding to region X and Y were presented by searching an RNA-binding protein database. siRNAs specific to the proteins determined by above two methods were transfected into HepG2.2.15 cells, and the effects on the HBsAg production were analyzed.
Result(s): Among those proteins either identified by pull-down assays or presented by database search, knockdown of 7 proteins showed potent anti-HBsAg effects, more than 90% reduction in HBsAg, without affecting cell viability. Interestingly, these were all nuclear-localizing proteins. Some of them were reported to regulate RNA splicing, stability or nuclear export of mRNA while the others were functionally unknown. Then, expression levels of 2.1/2.4 kb HBV RNAs were quantified, and silencing of these proteins showed less than 80% reduction in those RNAs, that was slightly milder reduction compared with that in HBsAg protein. These data suggested that the proteins identified here could regulate HBsAg production by affecting RNA processing or dynamics.
Conclusion(s): Host proteins binding to region X and Y in 2.1/2.4 kb HBV RNAs were shown to be attractive therapeutic targets to reduce HBsAg, suggesting novel insights for better understanding of HBV virology.
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Introduction: TAF is a new prodrug of tenofovir with improved safety profile compared to tenofovir disoproxil fumarate (TDF).
Objective(s): To assess real-world experience with TAF for HBV patients of Asian race in US Clinical Practice. Methodology: This study includes 212 of 1078 TRIO HBV registry patients in care at 10 centers and representing 17 US states. Patients were self-reported Asian race, initiated TAF after Nov 2016, and received >= 6 months TAF with follow up to 18 months.
Result(s): Population characteristics. Country of origin 49% China, 27% South Korea, 7% Viet Nam, 17% from 13 other Asian countries, median age 53 years, BMI 24.0 kg/m2, 58% male, 23% HBeAg positive, 18% osteopenia/osteoporosis, and 6% FIB-4>3.25. 200/212 (94%) TAF patients switched from TDF (182/200, 91%), entecavir (15/200, 8%), or other therapies (3/200, 2%). Median TAF duration was 12 months as of data collection. Paired comparisons. HBV DNA suppression (<2000 IU/ml) increased from 94% patients at baseline to 99% after 6 or 12 months TAF (n = 206, p = 0.006). Mean eGFR increased 4% from baseline 86.5 to 90.1 ml/min after 6 months TAF (n = 179, p<0.001) and 5% from 86.2 to 90.6 ml/min after 12 months TAF (n = 120, p<0.001). Normal ALT (<=29 U/L females, <= 35 U/L males) increased from 73% patients at baseline to 86% after 6 months TAF (n = 185, p = 0.002) and from 70% at baseline to 87% after 12 months TAF (n = 126, p = 0.001).
Conclusion(s): In US, clinical experience with TAF for Asian patients indicates effective HBV suppression and improved renal function and ALT normalization

Background: Chronic hepatitis B (CHB) is an important cause of chronic liver disease worldwide. It negatively impacts both clinical and patient-reported outcomes (PROs).
Aim(s): To assess long-term trends in PROs in CHB patients receiving anti-viral treatment in a registry.
Method(s): Patients with CHB without significant fibrosis or cirrhosis (Metavir stages 0-2) who had completed treatment with an approved or investigational agent in a clinical trial were prospectively enrolled in a long-term registry (clinicaltrials.gov #NCT02258581). PROs were collected every 24 weeks using Short Form-36 (SF-36), Chronic Liver Disease Questionnaire (CLDQ), and Work Productivity and Activity Impairment (WPAI:SHP).
Result(s): There were 229 CHB patients with viral suppression (48.6 +/- 10.4 years old, 71% male, 75% Asian, 62% enrolled in the U.S, HBV DNA<5,000 IU/mL); the patients were followed for 2 years. Baseline registry PROs were similar or higher than general population norms: mean Physical Component Summary 53.0 vs. 50.0, mean Mental Component Summary 52.7 vs. 50.0 (p<0.05 for all but one domains of SF-36), mean total CLDQ: 6.0 vs. 6.0 (p>0.05). Despite this, CHB patients still had a statistically significant work productivity impairment due to presenteeism: mean 0.07 (p<0.0001). Over the duration of registry, there were no significant changes in PROs of patients with CHB up to 96 weeks from enrollment (p>0.05).
Conclusion(s): Patients with CHB and early liver disease and viral suppression maintain good PROs with some impairment of work productivity. Patient-reported outcomes should complement other clinical outcomes to provide a comprehensive assessment of the impact of CHB on patients' well-being

Background and Aims: In 2 identically-designed double-blind, randomized (2:1), Phase 3 studies, the safety and efficacy of TAF vs TDF was evaluated in subjects treated for 3 years.
Method(s): 1298 HBeAg-negative and HBeAg-positive CHB patients were randomized and treated with TAF 25 mg or TDF 300 mg QD. Included in this analysis, were 1118 patients (759 HBeAg-positive and 359 HBeAg-negative); 866 of whom received TAF and 252 who received TDF for 3 years. Efficacy analyses included virologic, biochemical, and serologic responses, and pooled safety assessments included changes in bone mineral density (BMD), serum creatinine, and estimated GFR by Cockcroft- Gault method (eGFRCG).
Result(s): Baseline characteristics were similar between groups; mean age 39 years, 63% males, 78% Asian, mostly genotypes C (48%) and D (26%); mean HBV DNA was 7.0 log10 IU/mL (34% had HBV DNA >= 8 log10 IU/mL), and 25% previously treated with nucleos(- t)ides. At Week 144, high rates of virologic control were maintained in TAF vs. TDF subjects; a greater proportion of TAF vs TDF patients achieved ALT normalization (Table). Overall, adverse events (AEs) and serious AEs were similar between groups. At Week 144, greater median declines in eGFRCG were observed with TDF treatment; similarly, hip and spine BMD declines in the TDF group were larger than in the TAF group (Table).
Conclusion(s): After three years of treatment, high and similar rates of virologic suppression were achieved and maintained, and continued improvements in renal and bone safety were observed in patients receiving TAF compared to TDF