1. Hépatite B
Fabien Zoulim
Département d’hépatologie
& INSERM U871, Lyon

2. Natural history of hepatitis B
Acute infection
Resolved infection
5% neonates Chronic infection: 400 million carriers !
90% adults
Chronic hepatitis
Wild type virus HBeAg+
Pre-core mutant HBeAg- Inactive carrier
Immune tolerance
Reactivation
Cirrhosis
30-50 years Hepatocellular carcinoma
Seeger, Zoulim, Mason; Fields Virology; 2007

3. EPIDEMIOLOGIE DE L’HÉPATITE B

5. EPIDEMIOLOGIE DE L'INFECTION A VHB
AUX USA
• Hépatites aigues
– VHA : 40%
– VHB : 30%
– VHC : 20%
• incidence : 300 000 infections à VHB / an
• 30 000 nouveaux porteurs chroniques / an
• 3 000 décès / an

6. MODES DE TRANSMISSION DU VIRUS DE L'HÉPATITE B EN EUROPE
transfusions
contact avec 2%
porteur du VHB
personnels de santé
sexuelle 4%
2%
homo hémodialysés
34% 11% 8%
hétéro
23%
inconnue
31%
Asie drogue IV
Transmission verticale 26%

7. Déclaration obligatoire
de l’hépatite B en France :
résultats des 12 premiers mois de notification
Denise Antona, E Delarocque-Astagneau, D Lévy-Bruhl
département des maladies infectieuses

8. Results
158 acute hepatitis cases
• Hospital doctor in 64% cases
• Sex ratio M/F : 2,95 (118/40)
• Median age: 37 yrs for males, 36yrs for females
• Jaundice : 69%
• Hospitalisation : 46%
• Fulminant hepatitis : 3 (2 death)

9. Risk exposure within 6 months preceding the acute case
Source : obligatory declaration 2003-04
• Source: obligatory declaration march 03- february 2004 N=145
– Sexual 59 40,6% No factor 43 29,6%
– IVDU 9 6,2% >1 factor 38 26,3%
– Invasive treatment 15 10,3%
– Tatoo, piercing 5 3,4%
• Sentinel networks 91-96
– Familial 14 9,7% N=195
– Perinatal 2 1,4% –sexual 35%
– Live in instiution 11 7,6% –IVDU 19%
–« percutaneous » 15%
– Travel in endemic 21 14,5% –No factor 35%
areas
91/145 patients (63 %) had a vaccine indication (2 vaccinated ≥ 3 doses)

10. Surveillance épidémiologique de
l’infection HBV
• 14 446 adultes testés
• Prévalence de l’AgHBs 0,65% (280 000 porteurs
chroniques du VHB)
• Homme 1,1% versus 0,2% femme
• Naissance en zone d’endémie 4% versus 0,5%
• Précarité, séjour en institution, homosexualité,
usage de drogues
Meffre et al, J. Med Virol 2004

11. Hépatites virales B: épidémiologie
- Vaccin mais 400 millions de porteurs chroniques
dans le monde
- 280 000 porteurs chroniques en France (INVS)
- 45% ignorent leur statut
- 1 300 décès par an en France
- 60 000 avec hépatite chronique active
- Environ 15 000 patients traités

12. VIROLOGIE

13. LE VIRUS DE L ’HEPATITE B
• FAMILLE : Hepadnaviridae, seul représentant
humain
•VIRUS RESISTANT :
- 7 jours dans l’environnement
- pendant 5 mn à 100°C, 10 h à 60°C
- à la congélation.

14. HBsAg
filament S small surface protein
sphere
Dane particle
M middle surface protein
v v
L large surface protein
core capsid protein
HBeAg HBeAg secreted e antigen
v pol polymerase
HBx X protein (non-secreted)

15. The HBV genome
déterminant a
vaccin/IgHBs
8 génotypes
A to H Gène pol
antiviraux
Mt du core
Réponse CTL
Mt pre-core
Réponse anti-HBe ? Tiollais, Nature 1985

16. The viral replication cycle
Zoulim & Locarnini, Gastroenterology 2009

17. The animal models of HBV infection
Transgenic mice
Humanized mice
Human
Chimpanzee
Gibbon
baboons
Tupaïa
Woolley monkey
Ground squirrel
American woodchuck
Summers PNAS 1978, Mason J Virol
Pekin Duck
1981, Chisari Science 1985,
Grey Heron
Petersen PNAS 1998, Lanford PNAS
1998

18. Modèles in vitro
• Polymerase virale • Culture cellulaire
– DHBV : lysat réticulocytaire – Transfection : lignées d’hépatome
– HBV : baculovirus – Infection : hépatocytes primaires, HepaRG
– Baculovirus ou adenovirus recombinant
RC -
L-
U
Polymerase VHB
SS -
DNA(-)
ELONGATION
CCC -
Sells PNAS 1987, Wang Cell 1992, Zoulim J Virol 1994,
Lanford J Virol 1995, Gripon PNAS 2002, Sprinzl J Virol 2001

19. Comparative dynamics among three viruses
(Tsiang et al. Hepatology 1999)

20. Infection à VHB et risque de CHC
• Etude de Beasley à Taiwan
– risque relatif = 100 chez les porteurs de l'AgHBs
• Etude de Tsukuma
– risque cumumatif de CHC à 3 ans
• 12,5% chez 240 patients avec cirrhose
• 3,8% chez 677 patients avec hépatite chronique
– risque x 7 si AgHBs +
– risque X 4 si anti-HCV +
• Facteurs associés : alcool, tabac, aflatoxine
• Diminution incidence avec la vaccination de masse (Chen,
NEJM 1995)

21. CARCINOME HEPATOCELLULAIRE ET VIRUS DE
L'HEPATITE B
• Co-incidence de répartition géographique
VHB / CHC
• Porteurs AgHBs : RR x 100 pour le CHC
• CHC dans les modèles animaux de l'hépatite B :
– marmotte
– écureuil
• Présence d'ADN viral intégré dans les tumeurs

22. HBV replication and its role in HCC development
Wands, NEJM 2004

23. Role du VHB dans l’oncogénèse hépatique
REACTION INFLAMMATOIRE CHRONIQUE
REGENERATION HEPATIQUE
VHB CARCINOGENES
INFECTION CHRONIQUE CHC CO-FACTEURS
MUTAGENESE INSERTIONNELE
TRANSACTIVATION DE GENES CELLULAIRES
INTERACTIONS PROTEIQUES
INACTIVATION DE GENES SUPPRESSEURS DE TUMEUR

24. PHYSIOPATHOLOGIE /
IMMUNOPATHOLOGIE

25. Ganem and Prince, NEJM 2004

26. IMMUNOPATHOGÉNIE
DES HÉPATITES B CHRONIQUES
RÉPONSE IMMUNITAIRE
HÉPATOCYTE
CYTOKINES
NON INFECTÉ
CTL cytokines
perforine
Fas
ANTICORPS NEUTRALISANTS AgHBc/e
VHB HLAI
ANTIVIRAUX
HÉPATOCYTE INFECTÉ

27. IMMUNOPATHOLOGY OF HBV INFECTION
CD8+
HBV
Immune tolerance
CD8+ HBV
Clearance phase
Chronic hepatitis
HBV
Seroconversion CD8+
Remission

28. Immunopathology
Fulminant hepatitis
HBV
CD8+

29. MECHANISMS OF VIRAL CLEARANCE
Non cytolytic processes Turn-over of infected cells
TH1 cytokines with direct antiviral Immune mediated lysis of infected cells
effect
Transgenic mice Ducks
Chimpanzees Woodchucks
(Guidotti Science 1999, (Guo J Virol 1999
Thimme J Virol 2003) Summers PNAS 2003&2004)
Antivirals
Inhibition of viral DNA synthesis
-> inhibition of intracellular recycling of cccDNA
(Werle Gastroenterology 2004)
Restoration of anti-HBV immune response
(Boni Hepatology 2000)

30. Non cytolytic clearance of acute
Wieland S et al, PNAS 2004

31. Hepatocyte turn-over is required for clearance of
Summers et al, PNAS 2003 & 2004

32. Phase de tolérance immunitaire
Marqueurs
Hépatocyte
non infecté
AgHBe +
HBV DNA +++
ALAT = N
Foie = N
HBc/e Ag
HBV
Hépatocyte infecté

33. Phase de clairance immune
(hépatite chronique)
Marqueurs
AgHBe+
Hépatocyte
non infecté
HBV DNA > 2000 IU/mL
ALAT +++
CD8 Foie: Hépatite chronique
cytokines
perforine
Fas
HBc/e Ag
HBV
HLAI
Hépatocyte infecté

34. Phase de rémission
portage inactif de l’AgHBs
Marqueurs
Hépatocyte
non infecté CD8 AgHBe-
CD4 anti-HBe +
HBV DNA < 2000 IU/mL
ALAT = N
Foie = rémission
HBs Ag
Hépatocyte infecté Réactivation
Virus sauvage
Oncogénèse ou mt pre-core

35. Clairance de l’AgHBs
Marqueurs
Hépatocytes HBsAg -
non infectés CD8
CD4 anti-HBc +
Anti-HBs +/-
B
PCR sérum (-) / foie (+)
Hépatocytes infectés Mutants d’échappement
Oncogénèse
Infections occultes

36. cccDNA levels in the different phases of
chronic HBV infection
Total HBV DNA
cccDNA (copies/cell)
(copies/cell)
3 ) 8 ) ) 7 ) ) ) 0 ) )
(6 - (1 (10 -( (6
3
(1
8
(1 -(
7
g
g+ Ag r s
SA g+ g- r s Ag
A e rie A A rie BS
Be HB ar H B
Be Be r
H . C H H . Ca H
ct t
a ac
In In
• HBeAg+ patients had significantly higher cccDNA (90-fold) and total HBV
DNA (147- fold) levels compared to HBeAg- patients. (p<0.001, Wilcoxon
tests)
Werle et al, Gastroenterology 2004

37. Inactive HBV carrier
● Not virologically inactive:
– low levels of viremia
– episomal HBV DNA in the liver
Low-replicative or latent infection
Epigenetic control
Pollicino et al., Gastroenterology 2006
Sirt1 PCAF CBP p300 CBP
HDAC1HDAC1 Sirt1 p300 PCAF
Histones Histones
LOW-REPLICATIVE STATE HIGH-REPLICATIVE STATE
– spontaneously
– during immunosuppression
Pollicino et al. Gastroenteroplogy 2006
Levrero et al. J Hepatol, 2009

38. HISTOIRE NATURELLE ET
VIROLOGIE CLINIQUE

39. Histoire Naturelle de l’hépatite B
Infection aigue Seeger, Zoulim, Mason;
Guérison Fields Virology; 2007
5% nx-nés Infection chronique
90% adultes
Hépatite chronique
Virus sauvage (HBeAg+)
Mutant pre-core (HBeAg-) Portage inactif
Tolérance immunitaire
Réactivation
Cirrhose
30-50 ans Carcinome hépatocellulaire
Seeger, Zoulim, Mason – Fields Virology 2007

40. HEPATITE B AIGUE
• Incubation 1 à 6 mois
• Le plus souvent asymptomatique
– Évolution plus fréquente vers la chronicité
• Prodromes:
– Maladie sérique : arthralgies, urticaire,
acrodermatite etc. ..
• Formes ictériques : + graves que VHA et VHC
– Durée de l’ictère : jusqu’à 4 mois
• Evolution : chronicité 5 à 10%
• Hépatites fulminantes

41. Laboratory Diagnosis of Acute Hepatitis B
HBsAg Anti-HBs Ab
1000 HBeAg
Anti-HBe Ab
IU/L and million copies/ml
ALT
750 Total anti-HBc
ALT and HBV DNA
Symptoms
500
HBV DNA IgM anti-HBc
250
0 Normal
0 1 2 3 4 5 6 12 24 36 48 60
Months After Exposure
Seeger, Zoulim, Mason, Fields Virology 2007

42. HEPATITE B PROLONGEE
• Définition
– Persistance réplication virale à la 8ème
semaine d’évolution :
– AgHBe + ou ADN-VHB +
• Evolution
– Chronicité : 8 cas / 10
• Traitement : IFN
– Guérison : 7 à 8 cas / 10

43. INFECTIONS CHRONIQUES A VHB
FORMES CLINIQUES
• virus sauvage
– tolérance immunitaire
– rupture de tolérance -> lésions hépatocytaires : HCA
– séroconversion anti-HBe spontanée (portage inactif) :
5-10% /an
– > diminution significative réplication virale
– > amélioration signes histologiques
• virus muté pré-C (-)
– sélection au moment de la séroconversion anti-HBe
– dépend du génotype viral
– immunopathologie ?
– sévérité de l'hépatopathie : controversée
– association au CHC

44. Laboratory Diagnosis of Chronic Hepatitis B
associated with wild type virus infection
HBsAg
700 HBeAg
IU/L or million copies/ml
525
ALT and HBV DNA
HBV DNA
350
175 ALT
0 Normal
0 1 2 3 4 5 6 12 24 36 48 60
Months After Exposure
Seeger, Zoulim, Mason, Fields Virology 2007

45. Laboratory Diagnosis of Transition of Chronic
Hepatitis B to The inactive Carrier State
800
HBsAg ``
IU/L and million copies/ml
700
HBeAg Anti-HBe
600
ALT and HBV DNA
500
400 HBV DNA
300
200 ALT
100
Normal
0
0 1 2 3 4 5 6 12 24 36 48 60 72 80 92 104
Months After Exposure
Seeger, Zoulim, Mason, Fields Virology 2007

46. Laboratory Diagnosis of HBeAg negative
Chronic Hepatitis B
HBsAg
HBeAg Anti-HBe
IU/L and million copies/ml
500
ALT
ALT and HBV DNA
375
250
HBV DNA
125
0 Normal ALT levels
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48
Months
Seeger, Zoulim, Mason, Fields Virology 2007

47. UI/ml
AgHBs
pg/ml
AgHBe + anti-HBe +
1000
9 log ALAT
ADN-
8 log
100 VHB
7 log
10
6 log
5 log1 hybridation
4 log
0,1
3 log
0,01
2 log
PCR
1 0,001
log
Tolérance hép chronique p. inactif mt pré-core
VHB occulte

48. Dynamic ranges of quantification
of HBV DNA assays
10 102 103 104 105 106 107 108 109
Amplicor HBV Monitor
v2.0 (Roche)
HBV Hybrid-Capture II
(Digene)
Ultra-sensitive HBV
Hybrid-Capture II
Versant HBV DNA
3.0 (bDNA, Siemens)
Cobas Taqman HBV
(Roche)
RealArt HBV LC PCR
(Artus Biotech)
Abbot Real-time HBV
(Abbott)
Versant HBV DNA 1.0
(kPCR, Siemens)*
*in development

49. Formes cliniques

50. MANIFESTATIONS
EXTRAHEPATIQUES DU VHB
• PAN
– Complexes immuns circulants HBs/anti-HBs
– Dépots artères moyens et petit calibre
– Traitement : plasmaphéreses, corticoides, antiviraux
(vidarabine / IFN / famciclovir / lamivudine)
• Glomérulonéphrites
• Cryoglobulinémies
• Guillain-Barré
• Myocardite

51. TRANSMISSION VERTICALE DU VHB
• mère AgHBe +
– transmission : 90%
• mère anti-HBe +
– transmission : 10-20%
– VHB muté pré-C (-) : hépatites fulminantes
• chronicité chez l’enfant : 90%

52. PRESENTATION CLINIQUE
• INFECTION PERI-NATALE
– ALT normales ou subnormales
– ADN-VHB > 1000 pg/ml
– histologie : lésions minimes
• INFECTION POST-NATALE
– ALT élevées
– ADN-VHB < 1000 pg/ml
– histologie : hépatite modérée à sévère

53. Pathophysiologic Cascade of
HBV Replication
Liver
(Measured by
Inflammation
Serum HBV DNA)
ALT
Elevation
Worsening Histology Disease Progression
• Necroinflammation • Liver Failure
• Fibrosis • Liver Cancer
• Cirrhosis • Transplant
• Death
Adapted from: Lavanchy D. Journal of Viral Hepatitis, 2004, 11, 97–107. Chen JC, et al. JAMA. 2006;295:65-73. Iloeje U. H, et al.
Gastroenterology. 2006;130:678-86.

54. Charge virale et incidence de la cirrhose
.4
P <0.001
37.1%
Incidence cumulative de cirrhose
1.0 x 106 n=627
1.0-9.9x105 n=344
n=3774
1.0-9.9x104 n=649
.3 300-9.9x103 n=1210
<300 n=944
23.0%
.2
.1 10.0%
6.3%
5.2%
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Année de suivi
R.E.V.E.A.L. – HBV Study Iloeje UH et al. Gastroenterology 2006; 130: 678-686

55. Survie chez les patients au stade cirrhose
100
Patients Surviving, %
80
60 Cirrhosis1 55%
(n = 130)
40
20 Decompensated cirrhosis2 14%
(n = 21)
0
0 1 2 3 4 5
Years
1. Weissberg et al. Ann Intern Med. 1984;101:613.
2. De Jongh et al. Gastroenterology. 1992;103:1630.

56. Charge virale et incidence du CHC
Chen et al; JAMA 2006

57. REVEAL-Incidence of HCC
20%
% cumulative incidence of HCC
14.9%
15%
12.2%
10%
5% 3.6%
1.3% 1.4%
0%
<300 >300 - 103 > 103 - 104 >104 - 106 ≥106
Baseline HBV DNA (copies/mL)
Chen JC, et al. JAMA. 2006;295:65-73.

58. High Baseline Serum HBV DNA Levels are
Associated with Increased Risk of HCC Mortality
in HBsAg-Positive Patients
HBV DNA Negative
100 %
98 % HBV DNA Low
Survival distribution function
< 105 copies/mL
96 % RR = 1.7 (0.5-5.7)
94 %
92 %
90 %
88 % HBV DNA High
≥ 105 copies/mL
86 % p < 0.001 across viral RR = 11.2 (3.6-35.0)
84 % categories
82 %
80 %
0 1,0 2,0 3,0 4,0 5,0 6,0 7,0 8,0 9,0 10,0 11,0 12,0
Survival time (Years)
http://www.fccc.edu/docs/sci_report/Evans.pdf#search=%22haimen. Accessed 1/23/07.
Chen G, et al. J Hepatology 2005; 42 (suppl 2):477A.
Chen G, et al. Hepatology 2005; 40 (suppl 1):594A.

59. Relationship Between Persistent Viremia and HCC:
Argument For Antiviral Therapy
• Persistent replication associated with greater risk of HCC
• Decreased risk when viral replication declines
Rate Per 100,000
HCC Incidence
1.2x104 10,108
1.0x104 8730
8.0x103 5882
6.0x103
4.0x103 1473
2.0x103
0
Baseline HBV DNA, < 104 ≥105 ≥105 ≥105
(copies/mL)
Follow-up HBVDNA,
--- < 104 104 to <105 ≥105
copies/mL
Adjusted RR 1.0 3.6 6.9 9.1
(95% CI) (ref) (1.7-7.6) (3.4-13.8) (5.8-14.1)
P Value -- < 0.001 < 0.001 < .001
Chen, et al. JAMA 2006

60. Impact Clinique de la Variabilité du

61. VARIABILITE GENETIQUE DU VHB
• Multiplication virale
» taux d'erreur de la transcriptase inverse
• Pression de sélection
» réponse immunitaire cellulaire / humorale
» antiviraux
-> possibilité de variants d'échappement
• Conséquences cliniques
» diagnostic sérologique
» traitements antiviraux

62. 8 genotypes, numerous sub-genotypes, and
recombinant forms
B6
D1
World J Gastroenterol 2007; 13: 14-21

63. Génotypes VHB chez les patients atteints d’hépatite
chronique en France
37.4%
100
90
30.2%
80
Number of subjects
70
60
50
40 12.5%
11.3%
30
7.9%
20
10 1.1%
0.4 %
0
A B C D E F G
Zoulim et al J Viral Hepatitis 2006

64. Impact du génotype sur la
séroconversion Hbe/HBs
PEG-IFN a-2b PEG-IFN a-2b
HBeAg Loss 1 HBsAg Loss 2
47%
50 21
44%
Percentage of patients (%)
Percentage of patients (%)
18
40
15%
15
28%
30
25% 12
20 9 8%
6 5%
10
3
0%
0 0
A B C D A B C D
n=90 n=23 n=39 n=103 n=90 n=23 n=39 n=103
HBV genotype HBV genotype
1 Janssen, Lancet 2005; 2 Flink, Am J Gastro 2006

65. LES MUTANTS DU GÉNOME DU VHB
déterminant a
vaccin/HBIg
polymérase
antiviraux
Mt core
Réponse CTL
Mt pré-core
Réponse anti-e ?

66. ROLE DE LA RÉGION PRÉ-C ET DE L’AgHBe
• Non nécessaire à la réplication du VHB
– Culture cellulaire
– Modèles in vivo
• Marmotte
• Canard
• Modulation de la réponse immune
– Tolérogène : souris transgéniques
– Cible de la réponse anti-capside
Chang et al, J. Virol 1987; Schlicht et al J. Virol 1987; Chen J. Virol 1992; Millich et al PNAS

67. LES MUTANTS PRÉ-C (-)
• codon stop / région pré-C
TGG -> TAG en pos. 1896
– génotypes B à E (A : exceptionnel)
– arrêt traduction protéine pré-C/C
– AgHBe négatif
• mutation dans promoteur pré-C
TTAAAGG -> TTAATGA en pos. 1762 /1764
– génotypes A à E
– transcrits pré-C/C :
– synthèse d'AgHBe :
Carman et al Lancet 1989, Okamoto et al J Virol 1990/1994, Tong et al Virology 1990

68. HBeAg and Precore Mutation
G 1896A = stop codon, TAG
ATG ATG
Core gene
1814 1901
Precore Core
region region
HBcAg Virion
HBeAg Serum

69. HBeAg and Precore Mutation
ATG ATG
Core gene
1814 1901
Precore Core
region region
HBcAg Virion
HBeAg Serum

70. VARIANTS NÉGATIFS POUR L ’AgHBe
1762-1764 1896
PROMOTEUR PRE-C C
* * *
TAG
mRNA
Protéine
pré-C/C
arrêt des synthèses protéiques
Diminution de l’expression de l ’AgHBe

71. Sélection des mutants pré-core au cours de
l’histoire naturelle de l’hépatite B chronique
2500
AgHBe Anti-HBe
1875
ALAT
ADN-VHB 1250
625
100
75
50
0
sauvage
25
Mt pré-C
0

72. Outcome of Chronic Anti-HBe Positive Hepatitis B
400
Biochemical patterns in 164 untreated patients
300 after 23 months (range 12-36) monthly monitoring
200
With flares and normalization 73 pts
100 ( 44.5% )
400 0 Asymptomatic
flare-up:
300
90% of cases
200
A Without flares 59 pts
L 100
123456789112 156 19 223 26 29 32 35 38 41 44 47 50 53 56 59 62 65
10 13 117 20 2 25 28 31 34 37 40 43 46 49 52 55 58 61 64
1 14 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 ( 36.0% )
T 0 Flare-up yearly
frequency:
once 57.1%
400
twice 20%
300 < once 22.8%
200
With flares and without normalization
32 pts
12345678911134 178 222 25 28 31 34 338 41 44 47 50 53 56 560 63 5
100 10 2 15 119 1 24 27 30 33 367 40 43 46 49 52 55 589 62 6
1 16 20 23 26 29 32 35 39 42 45 48 51 54 57 61 64 ( 19.5% )
0
0 12 24
months
123456789 11111111122222222223333333333444444444455555555556666665 et al, J Hepatol 2002
10 2345678901 3456789012 4567890123 5678901234 Brunetto MR
678901234

73. Augmentation de prévalence des hépatites
chroniques avec AgHBe négatif en France
58 % 42% HBeAg(+)
N=119 HBeAg(-)
N=164
Zoulim et al, J Viral Hepatitis 2006

74. Pre-core mutations
Both mutations No pre-core mutation
(n = 95; 33.6%) (n = 42; 14.8%)
Data unavailable
(n = 12; 4.2%)
Stop codon mutation
(n = 55; 19.4%)
Promoter mutation
(n = 99; 27.9%)
Lamivir cohort, Zoulim et al, J Viral Hepatitis 2006

75. MUTANTS PRÉ-C ET SÉVÉRITÉ HISTOLOGIQUE
LA CONTROVERSE
• Italie
– Cirrhose plus fréquente
• Bonino Gastroenterology 1986, Fattovich Hepatology 1988
• France
– Activité idem / cirrhose plus fréquente
• Zarski et al, J Hepatol 1993
• Grandjacques et al, J Hepatol 2000
• Zoulim et al, J Viral Hepatitis 2006
• Asie
– Mt promoteur : activité histologique et fibrose plus importante
– Mt pré-C : activité histologique moins importante
• Lindh et al, J Infect Dis 1999
– Rémission histologique
• Chan et al, Hepatology 1999
• Afrique
– Mt promoteur : plus fréquents dans le CHC
• Baptista et al, Hepatology 1999

76. HBe serotype and liver pathology
HBe-positive
HBe-negative
70 70
Number of subjects
60 60
50 50
40 40
30 30
20 20
10 10
0 0
0-4 5-9 10-14 15-22 ≤ F2 F3 F4
Knodell score Metavir score
Lamivir cohort, Zoulim et al, J Viral Hepatitis 2006

77. HÉPATITES FULMINANTES ET MUTANTS PRE-C
• Lien de causalité :
– Épidémies hépatites fulminantes
– Transmission souche mutée pré-C (-)
– Rôle immunomodulateur de l ’AgHBe
• Pas de lien de causalité
– Séquençage génome complet
– Pas de profil commun de mutation
Stuyver et al, Hepatology 1999, Sternbeck et al Hepatology 1996, Liang et al, NEJM 1991

78. DIAGNOSTICS DIFFICILES

79. Diagnosis of inactive carrier versus
HBeAg negative chronic hepatitis
• Inactive Carrier
– Persistently normal ALT levels
– Persistently low levels of serum HBV DNA
• Threshold : 2,000 IU/ mL (see EASL CPG J Hepatol 2009)
• HBeAg negative chronic hepatitis
– Fluctuation / exacerbation of ALT
– Fluctuations of HBV DNA levels usually > 2000 IU/ mL
– Presence of pre-core / core promoter mutations

80. DIAGNOSTIC D'UNE EXACERBATION AIGUE
SUR HEPATITE B CHRONIQUE
• Définition : poussée cytolytique
≠ réactivation virale
• Ag HBe + initialement
– rupture de tolérance immunitaire
– séroconversion anti-HBe
– très fréquent chez patients asiatiques
• Anti-HBe + initialement
– réactivation virus sauvage : -> AgHBe +
– réactivation virus muté pré-C (-)
– Corticothérapie, biothérapie, chimiothérapie
– surinfection delta / VHC

81. PreS2
PreS1
HBs Ag
Pol S
0/3221
GR
E
Brin(-) 3,2kb
Brin(+) 2,4kb
SHBs (S) TATAA
« a » determinant
U5-like
MHBs (preS2+S) DR1
Enh2 Enh1
C DR2
LHBs (preS2+preS2+S) S-S
sP120T Pré-C
X
137
S- S
138 149
107 S-S S-S 147
139 sG145R
sD144H/A/E
99 NH2 S-S
COOH
« a » determinant induces the synthesis of
anti-HBs neutralizing antibodies
Tiollais P. et al., Nature 1985. Torresi J., J. Clin Virol 2002; Dryden KA. et al., Mol Cell 2006

82. Variants de l'Ag HBs
• échappement à la réponse humorale anti-HBs
– naturelle
– vaccination (transmission mère-enfant)
– immunoprophylaxie (transplantation hépatique)
• infection active malgré Ac anti-HBs
• sérologie AgHBs faussement négative
 Risques : transmission virale + infections occultes

83. VARIANTS DE L'AgHBs
• Mutations ponctuelles dans le déterminant a de
l'AgHBs (124-147)
– aa 145 : Gly -> Arg
– aa 126 : Ile -> Ser / Thr -> Asn
• transmission mère-enfant malgré la serovaccination
(3%)
• infection du greffon hépatique malgré
Immunoglobulines anti-HBs
• hépatites chroniques avec anti-HBc et anti-HBs +

84. Occult HBV Infection (OBI)
Presence of HBV DNA in the liver (± serum) of
individuals testing HBsAg negative by currently
available assays
Raimondo et al, J Hepatol 2008

85. How to Detect Occult HBV Infection
Currently there is no standardized
diagnostic assay for occult HBV infection

86. Reported Prevalence of Occult HBV Infection in HIV Positive Patients
Occult HBV
Study Country N° of N° (%) Methods
patients
Hofer, 1998 Switzerland 57 51 (89%) “nested” PCR
(serial evaluation)
Torres-Baranda, 2006 Mexico 35
7 (20%) “nested” PCR
Filippini, 2006 Italy 86 17 (20%) single step PCR
Mphahlele, 2006 South Africa 140 31 (22.%) “nested” PCR
Pogany, 2005 Netherlands 93 4 (4%) single step PCR
Neau, 2005 France 160 1 (0.6%) Cobas Amplicor HBV
Monitor (Roche)
Santos, 2003 Brazil 101 16 (16%) single step PCR
Wagner, 2004 France 30 11 (37%) “nested” PCR
Goncales, 2003 Brazil 159 8 (5%) “nested” PCR
Nunez, 2002 Spain 85 0 Cobas Amplicor HBV
Monitor (Roche)
Piroth, 2000 France 37 13 (35%) single step PCR
Raffa, 2007 Italy 101 42 (41%) “nested” PCR (liver)
Raimondo et al, J Hepaol 2007, modified

87. Cause(s) for the
failure of HBsAg detection
OBI “false” OBI
Suppression of
Infection by
HBV replication and
S gene Variants
gene expression

88. HBV replication
HBV cccDNA Integrated HBV DNA
HBV mutants Epigenetic control
Immune surveillance
Viral co-infections
Occult HBV infection

89. Schematic representation of HBV serum marker profile in OBI and
“false” OBI
OBI „false“ OBI
HBV DNA levels
< 200 UI/ml
Seropositive S gene
Seronegative escape mutants
Primary occult HBV DNA levels
HBsAg lost comparable to
after AH overt infection
HBsAg lost Progressive antibody
during CH disappearence

90. Occult hepatitis B
Torbenson M. & Thomas D.L., Lancet Inf Dis, 2002

91. Occult HBV infections: unresolved issues
Specific Diagnostic To be
treatments ? improved
High
prevalence
Tools ?
Co-infections ?
Therapy?
Worsen ROLE
HCV in
infection ? HCC Not fully
understood ?

92. Antiviraux
Persistance virale
Resistance aux antiviraux
Monitoring des traitements

93. HBsAg
Immuno-active Inactive phase Occult infection
Immunotolerant Reactivation phase
phase Low replication
phase
HBeAg(+) HBeAg(-) / anti-HBe(+)
HBV DNA
109-1012 IU/mL >2000-<109 IU/mL <2000 IU/mL >2000 IU/mL
ALAT
Minimal CH Moderate to severe CH Remission Moderate to severe CH
Cirrhosis Inactive cirrhosis Cirrhosis
Treatment indicated Treatment indicated
Adapted from Fattovich G. Sem Liver Dis. 2003

94. Antivirals approved for hepatitis B
Drug Type Approved Phase 3 Phase 2
Nucleoside analogs • Lamivudine* • Emtricitabine*
• Entecavir • Clevudine**
• Telbivudine
Nucleotide analogs • Adefovir dipivoxil
Cytokines • Tenofovir* alfa
• Interferon • IL7
• Pegylated Interferon •IFN Lambda
alfa-2a •Vaccine therapy
*Currently approved for HIV
**development on hold

95. Endpoints of therapy
Persistence of high viral load is associated with a significant risk of progression of
the liver disease and of HCC
Aim of antiviral therapy:
HBV DNA < 10-15 IU/mL by real-time PCR assays
Viral suppression No replication
=
Histological and clinical No resistance
improvement
Chen CJ, et al. JAMA 2006. Iloeje UH, et al. Gastroenterology 2006. Chen C, et al.
Am J Gastroenterol 2006. Zoulim & Perrillo J Hepatol 2008. Zoulim & Locarnini Gastroenterology 2009

96. Treatment failure
Primary non response Secondary treatment failure
Partial response Antiviral drug resistance
Host factors Drug factors
Drug metabolism Barrier to resistance
Patient’s compliance
Viral factors
Drug factors Resistant mutants
Antiviral potency
Zoulim et al Hepatol 2008; EASL CPG J Hepatol 2009; Lancet Infect Dis 2012

97. Clinical definition of resistance
• Virologic Breakthrough: Rebound in serum HBV DNA levels
(e.g. 1 log10 above nadir)
• Genotypic Resistance: Detection of mutations known to confer
resistance while on therapy
• Virologic Breakthrough with Genotypic Resistance: Viral
rebound associated with a mutation(s) known to cause
resistance.
• Primary non response: <1log10 decrease of viral load after 3
months
• Partial response: detectable HBV DNA levels during therapy
Zoulim & Perrillo, J Hepatol 2008; EASL CPG, J Hepatol 2009

98. Laboratory Definition of HBV Resistance to Antivirals
Laboratory Investigations
• Phenotypic Resistance: Decreased susceptibility (in vitro
testing) to inhibition by anti-viral drugs associated with
genotypic resistance.
• Cross Resistance: Mutants selected by one agent that also
confer resistance to other antiviral agents
Zoulim et al; Future Virology 2006

99. The main differences between HIV,
HBV and HCV
HIV1 HBV1,2 HCV1,3
Host cell Host cell Host cell HCV RNA
cccDNA
Host DNA
Host DNA H Host DNA H H
Proviral DNA Integrated DNA
Nucleus Nucleus Nucleus
Life-long suppression Long-term suppression Definitive viral clearance
of viral replication of viral replication and SVR
Adapted from 1. Sorriano V, et al. J Antimicrob Chemother 2008;62:1-4. 2. Locarnini S and Zoulim F. Antiviral Therapy 2010;15 (suppl 3):3-14. 3.
Sarrazin C and Zeuzem S. Gastroenterology 2010;138:447-462.

100. Kinetics of emergence of HBV drug resistant mutants
Si Ahmed et al. Hepatology. 2000; Yuen et al Hepatology 2001; Locarnini et al Antiviral Therapy 2004;
Villet et al Gastroenterology 2006 J Hepatol 2007 & 2008; Pallier et al J Virol 2007; Yim et al Hepatology 2006.

101. Lamivudine Resistance Accelerates
Progression of Liver Disease
Placebo (N=215)
YMDDm (N=209) (49%)
Wild Type (N=221) Placebo 21%
% With disease progression
25
YMDDm 13%
19
13
WT 5%
6
0
0 9 18 27 36
Time after randomization (Months)
Liaw YF et al. N Engl J Med. 2004;351:1521-1531

102. Biochemical and Histologic
Correlates of HBV Resistance
• Rise in ALT levels
– Mild ALT elevations in most cases
– ALT flares with acute exacerbations and liver failure:
especially patients with liver cirrhosis and/or pre-core
mutant infection
• Progression of liver disease
– Progressive worsening of liver histology
– Clinical deterioration, liver decompensation, HCC
development
Lai et al Clin Infect Dis 2003; 36: 687-696; Dienstag et al Gastroenterology 2003;124:105-117 ; Lok et al Gastroenterology 2003;
125 : 1714-1722; Hadziyannis et al Hepatology 2000;32:847-851; Si Ahmed et al Hepatology 2000; Zoulim et al J Viral Hepatitis
2006;13:278-288 ; Fung et al J Hepatol 2005;43:937-943; Liaw et al NEJM 2004;351:1521-1531.

103. ALT flares in patients with lamivudine
resistance over time
Lok et al Gastroenterology 2003; 125 : 1714-1722

104. Incidence of drug resistance over time
Resistance at year of therapy expressed as percentage of
patients
Drug and patient population 1 2 3 4 5 6
Lamivudine 23 46 55 71 80 -
Telbivudine HBeAg-Pos 4.4 21 - - - -
Telbivudine HBeAg-Neg 2.7 8.6 - - - -
Adefovir HBeAg-Neg 0 3 6 18 29 -
Adefovir (LAM-resistant) Up to 20% - - - - -
Tenofovir 0 0 0 0 0 -
Entecavir (naïve) 0.2 0.5 1.2 1.2 1.2 1.2
Entecavir (LAM resistant) 6 15 36 46 51 57
CL Lai Clin Infect Dis 2003; CL Lai NEJM 2007; Hadzyiannis Gastroenterology 2006;
Marcellin NEJM 2008; CL Lai & Chang NEJM 2006; Zoulim & Locarnini Gastroenterology 2009

105. Rates of resistance with lamivudine (LVD), adefovir (ADV), telbivudine (LdT),
entecavir (ETV) and tenofovir (TDF) among NA-naïve patients
80 80
71 High barrier to resistance
70
Proportion of patients (%)
60
55
50 46
40
30 29
25 Option to add
23 emtricitabine at
20 18 week 72*
11
10
5 1.2
3 0 0 0 0
0 0.2 0.5
0 1 2 3 4 5 1 2 3 4 5 1 2 1 2 3 4 5 6 1 2 3 4
LVD ADV LdT ETV TDF
*Patients confirmed to be viraemic at Week 72 or beyond could add emtricitabine to TDF at the discretion of the investigator. Clinical
data on the safety and efficacy of emtricitabine and TDF in CHB are pending
Adapted from Gish, Jia, Locarnini & Zoulim, Lancet Infect Dis 2012

106. Zoulim & Locarnini, Gastroenterology, 2009

107. Determinants of viral persistence & resistance
Zoulim & Locarnini, Gastroenterology, 2009

108. Multiple factors are associated with the
barrier of resistance & drug efficacy
• Antiviral potency
• Number of mutations needed
to overcome drug suppression
• Level of exposure to drug
• Chemical structure Antiviral Virus
Drug
• Adherence
Patient • Replication fitness and space
• Immune status • Persistence of archived
mutations as cccDNA
• Prior antiviral exposure
• Metabolism • Pre-existing mutations
• Body mass
Locarnini S, et al. Antivir Ther. 2004;9:679–93. Locarnini S, et al. Antivir Ther. 2007;12:H15-H23. 3. Ghany M & Liang TJ. Gastroenterology 2007;132:1574-85. Zoulim F, et al.
Antiviral Res. 2004;64:1-15. Locarnini S, et al. J Hepatol. 2003;39:S124-S132.; Zoulim & Locarnini Gastroenterology 2009

109. L(-)-SddU
mitochondria deaminase
L(-)-SddC, 3TC
Mt DNA L(-)-SddC-TP
L(-)-SddC Lamivudine
kinase
L(-)-SddC-TP HBV DNA
nucleus
L(-)-SddC-TP
cytoplasm
Nuclear DNA
Bridges; Progress in Liver Disease 1995

110. The HBV life cycle
Nucleos(t)ide analogs
Zoulim & Locarnini, Gastroenterology 2009

111. Formation of the recalcitrant cccDNA: a difficult
target for antiviral therapy
uncoating CCC DNA supercoiled DNA
minichromosome
Topoisomerase (TDP2) ?
removal of protein primer Acetyl transferase ?
Histones
removal of RNA primer
completion of viral (+) strand DNA
ligation of DNA strands extremities
Antivirals ? Tuttleman et al Cell 1986
viral polymerase? Le Guerhier et al AAC 2000
DNA repair protein? Delmas et al AAC 2002
other cellular enzymes? Kock et al Hepatology 2003
Cortes Ledesma et al Nature 2009
Boeck et al Plos Pathogen 2010

112. Can we prevent cccDNA formation ?
Nucleoside analogs in monotherapy or

113. Kinetics of Viral Loss During Antiviral Therapy with L-
FMAU (clevudine) in the woodchuck model
Zhu et al, J Virol 2001

114. ADV Associated Serum HBsAg Reductions are
Similar in Magnitude to cccDNA Reductions
Serum Total
HBV Intracellular cccDNA Serum
DNA DNA HBsAg
§ 48 weeks of ADV resulted in significant reductions in :
serum HBV DNA > total intrahepatic HBV DNA > cccDNA
§ Changes in HBsAg levels correlated with cccDNA changes
-> 14 years of therapy to clear completely viral cccDNA
Werle et al, Gastroenterology 2004

115. Immunohistochemical Staining of Patient Biopsies at
Baseline and After 48 Weeks ADV Therapy
Baseline Week 48
• 0.8 log10 (84%) decline in cccDNA, not paralleled by a similar decline in the number of
HBcAg+ cells
• Suggests cccDNA depleted primarily by non-cytopathic mechanisms or that cell turn-over
occurred but was associated with infection of new cells during therapy

116. Persistence of cccDNA after HBs seroconversion
Maynard et al, J Hepatol 2005

117. Clearance of viral infection versus selection of
escape mutants
The most important factors to consider:
§ The rate of immune killing of infected hepatocytes
§ The rate of replication and spread of mutant virus in the
chronically infected liver (I.e. fitness of the virus: the rate of
spread to uninfected hepatocytes)
§ Small changes in these factors may have profound effect on
whether treatment response is durable or subject to rapid
rebound (Litwin et al J Clin Virol 2005)
§ These factors may be subject to therapeutic intervention

118. Kinetics of spread and emergence of drug
resistant virus during antiviral therapy
antiviral
wt
mt Ò Ò Ò
Ò Free liver space
Mutant fitness
Ò ni = non-infected
wt = wild type
Ò mt = mutant type
Ò
ni
I II III IV
INHIBITION OF WILD TYPE VIRUS REPLICATIONS DELAYED EMERGENCE OF
DRUG RESISTANT VIRUS
Zhou T, et al. Antimicrobial Agents and Chemotherapy 1999; 43: 1947-1954.

119. Kinetics of HBV drug resistance emergence
Drug-susceptible virus
Treatment begins
Naturally—occurring viral variants
Drug-resistant variant
Secondary resistance mutations
/ compensatory resistance mutations
HBV replication
Primary resistance
mutations
Time
Si Ahmed et al. Hepatology. 2000; Yuen et al Hepatology 2001; Locarnini et al Antiviral Therapy 2004; Villet et al Gastroenterology 2006 J
Hepatol 2007 & 2008; Pallier et al J Virol 2007; Yim et al Hepatology 2006.

120. Partial response to adefovir dipivoxil is not due to the
selection of DR mutants
• The top 25% patients (quartile 1): > 4.91 log10 reduction in serum HBV DNA at week 48.
• In Q2: 3.52 to 4.90 log10 reduction of viral load.
• In Q3: 2.22 to 3.51 log10 reduction in viral load.
• The bottom 25% of patients (Q4):< 2.22 log10 reduction in HBV DNA levels at week
48.
• Phenotypic analysis of viral strains: Q4 as sensitive to ADV as Q1 strains
• Documented Drug Compliance (% of days without taking ADV)
Virological Response Virological Response Virological Response Virological Response
Q1 (best response) Q2 Q3 Q4 (worse response)
Median 99%
(n=38) 99%
(n=38) 99%
(n=38) 97% a
(n=38)
range 86-100% 41*-100% 91-100% 70-100%
• Wilcoxon rank sum test, P=0.01 Durantel et al, Antiviral Therapy, 2008

121. Amino acid substitutions result in conformation
changes of the polymerase catalytic site
Wild-type M204/L180 LVDr M204V/L180M
L180 L180M
M204 M204V
LVD-TP LVD-TP
LVDr M204V/L180M
M204V reduces pocket size
L180M Steric clash between lamivudine and V204
M204V
Minimal steric clash between entecavir and
ETV-TP V204
Langley DR, et al. J Virol. 2007;81:3992-4001.

122. Definition of fitness
• A parameter that quantifies the adaptation of an
organism or a virus to a given environment
• For a virus, ability to produce infectious progeny
relative to a reference viral clone, in a defined
environment
Esteban Domingo, In Fields Virology 2007

123. Cross-resistance data for the main mutants
and the commercially available drugs
Pathway Amino acid Lamivudine Telbivudine Entecavir Adefovir Tenofovir
substitutions in the
rt domain
Wild type S S S S S
L-nucleoside M204I R R I S S
L-nucleoside L180M+M204V R R I S S
Alkyl N236T S S S R I
phosphonate
Shared A181T/V I/R I/R S R I
D-Cyclopentane L180M+M204V/I R R R S S
(ETV) ±I169T±V173L
±M250V
D-Cyclopentane L180M+M204V/I R R R S S
(ETV) ±T184G±S202I/G
MDR V173L+L180M R R S R S
+A181V+N36T
Zoulim & Locarnini Gastroenterology 2009

124. Archiving of viral variants
Viral quasispecies
Liver
Majority population
Minority variants
Resistant variants
cccDNA variants
• cccDNA in the liver:
– Is propagated during the normal
replication cycle of HBV
– Can serve as a template for the production
of new virus
Blood circulation
Zhou et al, AAC 1999; Zoulim F. Antivir Res. 2004. Zoulim F & Perillo R. J Hepatol. 2008

125. Archiving of viral variants
Viral quasispecies
Liver
Majority population
Minority variants
Resistant variants
cccDNA variants
• cccDNA in the liver:
– Is propagated during the normal replication
cycle of HBV
– Can serve as a template for the production of
new virus
• It is believed that viral variants with antiviral
resistance may be archived in this way
Blood circulation
Zhou et al, AAC 1999; Zoulim F. Antivir Res. 2004. Zoulim F & Perillo R. J Hepatol. 2008

126. Archiving of viral variants
Viral quasispecies
Liver
Majority population
Minority variants
Resistant variants
cccDNA variants
• cccDNA in the liver:
– Is propagated during the normal replication
cycle of HBV
– Can serve as a template for the production of
new virus
• It is believed that viral variants with antiviral
resistance may be archived in this way
Blood circulation
Zhou et al, AAC 1999; Zoulim F. Antivir Res. 2004. Zoulim F & Perillo R. J Hepatol. 2008

127. Phenotyping of HBV clinical isolates
Cl ne A in
Southern blot
o ra
Cl e D
Cl e C
eE
Cl A
Cl b St
analysis
e
on
on
on
on
Whole genome
La
HBV clones
PCR Transfection
cloning
Patient HepG2
serum Huh7
lamivudine adefovir
Cell culture plate
RC -
Wild-type virus
SS -
Patient’s
virus Fold resistance =
IC50 mutant
IC50 reference strain
Increasing antiviral concentration
1. Durantel D, et al., Hepatology, 2004;40:855-64. 2. Yang H, et al., Antiv Ther, 2005;10:625-33.

133. Maximising the barrier to resistance
Wild-type virus
LAM rtM204V/I ± rtL180M
LAM-resistant virus
ADV-resistant virus
ETV-resistant virus
ADV rtN236T +/or rtA181V
rtT184 or rtS202 or rtM250
ETV
rtM204V/I +/-
rtL180M
LAM + TDF – what
do we see?
LAM rtT184 or rtS202 or rtM250
then ETV rtM204V/I +/- rtL180M
TDF: what can
we expect?
TDF

134. Can we detect low frequency mutants prior to or
during therapy ?
Use of pyrosequencing to detect low
frequency mutants
•May detect mutants representing as
low as 0.1% of the viral population
•The clinical significance for
treatment choice or adaptation needs
to be determined by prospective
studies

135. Important factors involved in selection of
MDR mutants
• Use of inadequate sequential monotherapies and inadequate treatment
adaptation
• Incomplete viral suppression
– > Persistent replication in the presence of antiviral pressure
• Use of drugs sharing cross-resistance characteristics
– One mutation may confer resistance to several drugs
– > Persistent replication
• Accumulation of mutations
• Wide replication space (liver transplantation)

136. The problem of sequential therapy with
nucleoside analogues
?
Drug A Drug B
Multiple drug
resistant mutants
+ one mutation + one mutation with complex
pattern of
Risk of selection of MDR mutants by sequential therapy mutations
- drugs sharing cross-resistance characteristics
- incomplete viral suppression
- liver transplantation
Yim et al, Hepatology al. J Hepatol. 2008;48:S2-19.
Zoulim F, et
2006; Villet et al Gastroenterology 2006 & 2009

137. Drugs sharing cross-resistance characteristics:
Switching strategy  emergence of MDR mutant
adefovir
IFN
Genotype H entecavir
lamivudine lamivudine
109
108
HBV DNA (copies/ml)
107
106
L180M+M204V
105
104
L180M+S202G+M204V
103
0 20 40 60 80 100 120
Treatment (months)
Villet et al, J Hepatol 2007

138. A single a.a. substitution at position rt181 may be
responsible for multidrug resistance
LVD ADV LVD+ADV
Patient #1 Patient #3 Patient #4 Patient #8
(67 months) (37 months) (31 months) (47 months)
Patient #7 Patient #5 Patient #6 Patient #9
(30 months) (44 months) (36 months) (19 months)
LVD+TDF Patient #2 LVD+ADV+TDF Patient #10
(23 months) (7 months) wt N236T + N238T
A181V M204V
A181T M204I
A181V + N236T L80V
A181T + N236T L80V + M204I
N236T
Villet S, et al. J Hepatol. 2008;48:747-55.

139. Impact of rtA181 and rtN236 mutations on antiviral
drug efficacy and cross-resistance
Villet et al, J Hepatol 2008

141. Impact on virus infectivity and fitness
Impact on virion release (intracellular
retention) and virologic monitoring of
breakthrough
Impact on vaccine prophylaxis efficacy
Warner et al Hepatology 2009
Kamili et al Hepatology 2009
Villet et al Gastroenterology 2009

142. Potential risk of transmission of HBV DR mutants
Clements et al, Bull WHO 2009

143. Management algorithm
Antiviral treatment
Viral load asssessment
Treatment failure
Check compliance
Viral genome sequence analysis
Wild type virus HBV drug resistant mutant
Check compliance Primary non response
Add-on therapy
based on cross-resistance data
Switch to more potent drug
Zoulim and Perrillo, J Hepatol, 2008; EASL CPG J Hepatol 2009

144. Management algorithm
Antiviral treatment
Viral load asssessment
Treatment response
Check for HBe/HBs seroconversion on a regular
basis (6 monthly)
Zoulim and Perrillo, J Hepatol, 2008; EASL CPG J Hepatol 2009

145. Virologic Consequences of Persistent Viremia
§ Infection of new hepatocytes
"  slower kinetics of clearance infected cells and cccDNA
§ Increases the risk of occurrence and subsequent selection
of HBV mutations responsible for drug resistance
§ On-treatment prediction of HBV drug resistance
Le Guerhier et al Antimicrob Agents Chemoter 2000;44:111-122; Delmas et al Antimicrob Agents
Chemother 2002; 46:425-433; Kock et al Hepatology2003; 38:1410-1418; Richman Hepatology
2000;32:866-867

146. Rescue therapy in patients with clinical breakthrough
Drug A
Serum HBV DNA (Log10 copies/mL)
Drug B 8
and ALT (x ULN)
6
4
2
Month of therapy
M0 M6
M3 M9 12 0
M M15 M21
M18 M24
M27 M33
M30 M36
HBV DNA ALT
HBV DNA

147. Rescue therapy in patients at the time of virologic breakthrough
Drug A 8
Drug B
Serum HBV DNA (Log10 copies/mL)
6
and ALT (x ULN)
4
2
Month of therapy
M0M3M6 0
M9 M15
HBV DNA
M12 M18
M21 M27
M24 M30
ALT M33
M36
HBV DNA