Hepatitis D:
A Case Presentation
GI Research
& Hepatitis
Support
Canadian Association of Hepatology Nurses
March 1, 2013
Daphne Meyer

Small defective RNA virus
Requires HBsAg to complete
it’s life cycle, enter
hepatocytes & propogate
infection

Aggressive
most severe form of viral
hepatitis in humans
 risk of cirrhosis + HCC

Co-Infection or super infection

8 genotypes, geography, distinct clinical
course
 Est. 15-20 million infected (~ 5% of B’s)
How do we measure for Hepatitis D?????
Antibody
RNA
CLINICAL CLUE:
 HBV DNA 
 ALT 
 **Immigrant
Patient Profile
 53 yr-old married caucasian woman
 Homemaker
What brought her to doctor?
Diagnosis Hep B GP
Diagnosed Hep D at Liver Centre
From Afghanistan,
Moved to Canada in 2006
History, Etc.
 Med Hx:
Stable depression, hyperlipidemia,
headaches, osteopenia, esophagitis,
hysterectomy/oopherectomy),
Obese (BMI: 30.7)
 Meds:
Zoloft, simvastatin, omeprazole,
risedronate

Ø previous hepatitis tx
DIAGNOSTIC PROCEDURES
Abdominal U/S:
Fibrotest:
Fibroscan:
Biopsy:
CT Abdomen:
Suggested Cirrhosis, echogenic
nodule
0.29 mild fibrosis
6.1 KPa mild disease
A2, F2, no steatosis
No HCC, tiny focal lesions
Treatment ???
Pre-Tx Lab Values
HBsAg
Positive
Ant-HBs
Negative
Anti HDV/ HDV RNA
Positive
HBeAg
Negative
HBeAb
Positive
HBV DNA
3.44 x 103
HCV Ab
Negative
ALT
45-62 U/L
AST
34-43 U/L
Hgb
131-135 g/L
Total WBC
4.4-5.6 x 09/L
Neutrophils
2.5-3.0 x109/L
PLT’s
227-257 x109/L
Pre-Tx Considerations
Mental Status
Hx depression during transition to Canada
Hx insomnia, fatigue, anxiety (PTSD conflict in Afghanistan)
Pre tx: stable on anti-depressant
Referred to psychiatrist
Depression in remission
PTSD in remission
• Anti-depressant dose increased
• Monitor with PHQ-9 and GAD-7
• Monthly psych f/u x 12 wks then
prn
• Pt education re-self assessment
of mood
Other Pre-Tx Considerations

Drug Coverage
Pegassist - Ontario doesn’t cover

Family Support
Married 30 years
Husband attends appointments
25 year old son at home

Language Barrier
Speaks and understands Persian
Attending English classes
Husband interprets

Willingness
Patient wanted treatment
Good Candidate
Tx Guidelines
 Peg-IFN x 48 wks
RNA

20-30% sustained reduction in HDV
1° endpoint – get rid of Hep D, 2° endpoint – get rid of
HBsAg
 Other oral agents not effective
 Ø difference in efficacy b/w Peg-IFN alone and Peg-IFN
plus Adefovir
 Some studies reveal comb. Therapy with Peg-
IFN/Tenofovir reveal marked reduction in HBsAg which
correlates with HDV RNA reduction
Treatment Labs
Wk
Date
ALT
AST
ALP
BILI
INR
CREAT
HB
WBC
PLT
NEUT
0
10Jul09
45
40
102
55
133
4.7
232
2.6
4
4Aug09
137
109
99
1.03
57
126
2.6
145
0.8
8
1Sep09
114
99
111
1.01
51
111
2.5
143
1.0
12
2Oct09
74
71
103
56
112
2.1
135
0.9
16
29Oct09
46
49
86
52
110
2.2
151
0.9
20
25Nov09
59
50
101
2.6
139
1.3
24
16Dec09
48
48
91
0.95
103
2.5
151
1.1
28
20Jan10
53
56
98
1.04
109
3.0
133
1.3
32
18Feb10
52
54
89
1.11
111
2.4
122
1.1
36
19Mar10
53
50
85
109
2.1
134
0.8
40
14Apr10
56
58
107
3.5
129
2.0
44
12May10
65
58
48
9Jun10
62
53
1.04
1.03
10
1.11
51
56
1.05
91
1.01
52
103
1.9
118
0.7
1.02
54
104
2.0
135
0.9
Hepatitis Labs During Tx
Week
Date
Hbe Ab
Hbe Ag
36
19Mar10
Positive
Negative
48
09Jun10
Positive
Negative
HBs Ab
HBs Ag
Hep D
RNA
Negative
Date
02Oct09
16Dec09
HBV DNA
< 12 (1.2x101 IU/ml)
< 12 (1.2x101 IU/ml)
19Mar10
09Jun10
< 12 (1.2x10 IU/ml)
< 13 (1.3x101 IU/ml)
1
Treatment Side Effects
 Generally Tolerated Well
 Mood Disturbance
POST TREATMENT
Post-Tx Labs
Date
ALT
AST
ALP
INR
Creat
HB
WBC
PLT
NEUT
3 mth
Post
08Sep10
36
31
81
0.98
60
131
3.6
185
1.8
6 mth
post
08Dec10
275
163
1.12
60
123
5.1
237
2.89
7 mth
post
13Jan10
198
130
1 yr
post
09Aug11
164
95
57
132
4.8
226
2.14
1.5 yr
post
23Feb12
104
75
130
4.9
193
2.36
2 yr
post
30Aug12
60
48
134
5.0
188
2.54
87
84
1.05
54
Flared after stopping tx
Hepatitis Testing Post-Tx
Date
Hbe Ab
Hbe Ag
HBs Ab
HBs Ag
Hep D
RNA
08Sep2010
Positive
Negative Negative
Positive
Positive
08Dec2010
Positive
Negative
09Aug2011
Positive
30Aug2012
Positive
Date
HBV DNA
08Sep2010
30200 3.02x104 IU/ml
08Dec2010
46.3
4.63x101 IU/ml
20Jan2011
34.3
3.43x101 IU/ml
30Aug2012
3440
3.44x103 IU/ml
Fibroscans Post-Treatment
Feb 2011
Feb 2012
3.5 KPa
3.1 KPa
Abdominal Ultrasounds
Jan 20/11: Stable, Fatty, No HCC
Feb 23/12: Stable, NO HCC
Aug 30/12: Stable, slightly nodular, NO HCC
Current Status

Patient Feels Well
Lost 3kg wt. in past year

Continue to Assess q 6 mths

? Treat Hep B
Key Points
 HBV DNA , ALT , immigrant ?? HEP D
 Treat with Peg-IFN x 48 weeks
 Drug Coverage
 Success rate is low
 Treatment generally tolerated well
References
 Coffin, C., et al.
Management of Chronic
Hepatitis B: CASL Consensus Guidelines,
December, 2012.
 Pascarella, S., et al. Hepatitis D Virus: An
Update. Liver International. 2010.
 Rizzetto, M. Current Management of Delta
Hepatitis. Liver International. 2013.
 Samiellah, S., et al. World Journal of
Gastroenterology, October 28, 2012
THANK YOU!