CURSO DE ACTUALIZACIÓN EN HEPATITIS VIRALES
SoMaMFyC
Madrid, 20-21 de octubre de 2011
HEPATITIS B Y C (PERSPECTIVA DEL
HEPATÓLOGO)
Javier García-Samaniego
Unidad de Hepatología
Hospital Carlos III. CIBERehd
Madrid
Hepatitis B
Hepatitis B virus (HBV)
• Hepadnaviridae member that primarily infects liver cells
• 100 times more infective than HIV
• Found in blood and body fluids
–
Able to survive in dried blood for > 1 week
Ott MJ et al. J Pediatr Health Care 1999; 13(5):211–216
Ribeiro RM et al. Microbes Infect 2002; 4:829–835
CDC. MMWR 2003; 52:1–33
IN MEMORIAM
Doctor Baruch Blumberg
(1925-2011)
• Descubridor del Ag de
superficie del VHB
• Premio Nobel de Medicina en
1976
• Presidente de la American
Philosophical Society
Geographic prevalence of
chronic hepatitis B
8% – High
2–8% – Intermediate
<2% – Low
World Health Organisation. Geographical Prevalence of HBsAg. Data 1996 (unpublished)
http://www.who.int/vaccines-surveilllance/graphics/htmls/hepbprev.htm
http://www.who/cds/csr/lyo/2002.2
Changing prevalence of hepatitis B
PORTUGAL
SPAIN
CDC data: prevalence 2–8%
WHO estimate: 1–2% HBsAg+
CDC data: prevalence 2–8%
WHO estimate: 1.2% HBsAg+
Current estimate: ~1.5% with some
regional variation. 0.9% HBsAg+ in
central Portugal in 1993. Overall
decreasing prevalence apart from
areas with high levels of immigration
Current estimate: ~1.25%
1993 ~1.2% prevalence (blood
donors) reduced to 0.7%
in 2003 (general public)
Hepatitis B nomenclature
Name
Abbreviation
Definition/Comment
Hepatitis B Surface Antigen
HBsAg
Protein indicating infection
Hepatitis B e Antigen
HBeAg
Antigen correlating with HBV
replication and infectivity; levels lower
in patients with precore and core
mutations
Hepatitis B Core Antigen
HBcAg
Detected in liver tissue
Chronic Hepatitis B
CHB
Defined as the persistence of HBsAg
for > 6 months
HBV deoxyribonucleic acid
HBV DNA
Indicates active viral replication
HBeAg-negative CHB
e-CHB
Chronic hepatitis B with active viral
replication, but low or undetectable
HBeAg
CDC. MMWR 2003; 52:1–33
Mahoney FJ Clin Microbiol Rev 1999; 12:351–366
Funk ML et al. J Viral Hepat 2002; 9:52–61
Phases of chronic hepatitis B
HBeAg
Status
Immune Tolerant Phase
HBeAg
Immune Active Phase
(Chronic Hepatitis B)
HBeAg or
anti-HBe
Non-replicative Phase
(Inactive HBsAg Carrier)
Anti-HBe
Lok & McMahon. Hepatology 2007; 45: 507-39
HBV DNA
Levels (IU/mL)
High (>
105)
High (> 105)
Low (< 104)
ALT Levels
Liver
Histology
Normal
Normal or
minimal
inflammation
Elevated
Chronic
inflammation
Normal
Normal or
minimal
inflammation
HBeAg-negative CHB characteristics
•
•
•
•
•
•
•
•
•
Growing prevalence
Liver disease typically advanced
Male
Age range 36–45 years
Sustained spontaneous remission is rare
Persistent or intermittent HBV replication
Fluctuations in ALT and viraemia levels
Severe liver necroinflammation
Progressive fibrosis
– ~40% of patients in some studies have cirrhosis
Hadziyannis SJ et al. N Engl J Med 2003; 348:800–807
Fattovich G Semin Liver Dis 2003; 23:47–58
¿Hay cambios en la epidemiología de la
infección por VHB en Europa?
Nuevos pacientes
Pacientes “viejos”
Inmigrantes
↑Casos HBeAg-positivo
Edad < 35 años
Diferentes genotipos
Coinfecciones (VHC,VIH)
Mayoría naïves tto.
Nativos
90% HBeAg-negativo
Edad > 45 años
Mayoría genotipo D
Pocas coinfecciones
(VHC o VHD)
Enfermedad avanzada
Mayoría tratados
Edad
10
20
30
40
50
60
70
80
Role of HBV DNA Testing
• Diagnosis of HBV infection
• Disease prognosis (risk for development of cirrhosis and
hepatocellular carcinoma)
• Pre-treatment evaluation
• Decision to treat
• Treatment indication (IFN vs analogues)
• Monitoring of virologic responses to therapy
• Assessment of treatment failure and resistance selection
Significance of
HBV DNA/viral replication
Presence of HBV
DNA/viral replication
precedes
Elevated ALT
Worsening
histology
HCC
High Baseline HBV DNA Associated with
Increased Risk of Cirrhosis and HCC
Cumulative incidence of HCC at
year 13 follow-up[1] (N = 3,653)
Cumulative incidence of cirrhosis at
year 13 follow-up[2] (N = 3,582)
Baseline HBV DNA (copies/mL)
Chen et al. JAMA. 2006;295:65-73.
Iloeje et al. Gastroenterology. 2006;130:678-686.
¿Qué ensayos debemos usar
para cuantificar el DNA VHB?
Technical Achievements of
Real-time PCR
• No carryover contamination
• Improved analytical sensitivity
• Extended range of linear quantification
• Precision and reproducibility
• High throughput through automation
Dynamic Ranges of Quantification
of HBV DNA Assays
10
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
102
103
104
105
106
107
108
109
Hepatitis C
Diagnóstico serológico de la hepatitis C
• Anticuerpos anti-VHC
• ARN-VHC (marcador directo de replicación)
• Genotipo (característica molecular propia del
virus circulante)
• Antígeno del core del VHC (marcador de
replicación activa; correlación con niveles
circulantes de ARN-VHC)
Anti-HCV Antibody Testing for HCV
ELISA screening tests
• Detect circulating HCV antibodies
• Sensitivity: 97% to 100%
• Positive predictive value
– 95% with risk factors and elevated ALT
– 50% without risk factors and normal ALT
False Positives More Likely in:
False Negatives More Likely in:
Patients with low risk of HCV infection
Severely immunosuppressed patients
Transplantation recipients
Patients with chronic renal failure on dialysis
HIV-positive patients
NIH Consensus Statement. Available at: http://consensus.nih.gov/2002/2002HepatitisC2002116html.htm.
Accessed May 7, 2009. Carithers RL Jr, et al. Semin Liver Dis. 2000;20:159-171.
Pawlotsky JM. Hepatology. 2002;36(suppl 1):S65-S73.
Utilidad de los tests de ARN VHC
• Diagnóstico de infección activa por VHC
• Diagnóstico precoz de la infección aguda
• Diagnóstico de la infección perinatal
• Evaluación pre-tratamiento
• Monitorización de la respuesta al tratamiento
AASLD HCV RNA Testing Recommendations
“HCV RNA testing should be performed in:
a) Patients with a positive anti-HCV test.
b) Patients for whom antiviral treatment is being considered, using
a sensitive quantitative assay.
c) Patients with unexplained liver disease whose anti-HCV test is
negative and who are immunocompromised or suspected of
having acute HCV infection.”
Ghany MG, et al. Hepatology. 2009;49:1335-1374.
Quantitative Assays for Serum/Plasma HCV RNA
Method
IU/mL
Conv Factor
(copies/mL)
Dynamic Range
(IU/mL)
FDA
Approved
Amplicor HCV Monitor
Manual RT-PCR
0.9
600-500,000
Y
Cobas Amplicor HCV Monitor
V2.0
Semiautomated
RT-PCR
2.7
Versant HCV RNA 3.0 Assay
Semiautomated bDNA
signal amplification
5.2
615-7,700,000
Y
LCx HCV-RNA Quantitative
Assay
Semiautomated
RT-PCR
3.8
25-2,630,000
N
SuperQuant
Semiautomated
RT-PCR
3.4
30-1,470,000
N
Semiautomated real
time PCR
NA
43-69,000,000
Y
Semiautomated
RT-PCR
NA
12-100,000,000
N
Assay
Cobas Taqman HCV Test
RealTime
600-500,000
Diagnosis, management, and treatment of hepatitis C: an update, Ghany MG, et al. Hepatology.
2009;49:1335-1374. Copyright © 2009. Reproduced with permission of John Wiley & Sons, Inc.
Y
Interpretation of HCV Laboratory Tests
 If anti-HCV positive and HCV RNA positive
– Acute or chronic HCV infection depending on clinical context
 If anti-HCV positive and HCV RNA negative
– Resolution of HCV; acute HCV infection during period of low-level
viremia
 If anti-HCV negative and HCV RNA positive
– Early acute HCV infection; chronic HCV infection in setting of
immunosuppression; false-positive HCV RNA test
 If anti-HCV negative and HCV RNA negative
– Absence of HCV infection
Ghany MG, et al. Hepatology. 2009;49:1335-1374.
EVALUACIÓN DE LA FIBROSIS HEPÁTICA
EN LA HEPATITIS CRÓNICA VÍRICA
• Pronóstico (¿hay cirrosis?)
• Decisiones terapéuticas
(¿existe fibrosis?)
Confirmar el
diagnóstico clínico
Riesgos asociados:
hemorragia <1%
muerte 0,01 – 1%3
Evaluar la gravedad de
la fibrosis y la
necroinflamación1,2
Papel de la biopsia
hepática en la
infección por VHC
Evaluar posibles procesos
patológicos concomitantes
(como enfermedad hepática
alcohólica, EHNA)1,2
Puede ayudar en
la toma de
decisiones
Evaluar la
intervención
terapéutica1
1. NIH Consensus Statement Online. Management of hepatitis C. 2. British Liver Trust
Information Service. A guide to liver function tests. 3. Canadian Liver Foundation.
HEPATITIS CRÓNICA VÍRICA
Biopsia Hepática – Diagnóstico Histológico
Knodell et al
Hepatology, 1981
IAH (0-22)
Inflamación portal
Necrosis periportal
Necrosis lobulillar
Fibrosis
0-4
0-10
0-4
0-4
HEPATITIS CRÓNICA VÍRICA
Biopsia Hepática – Diagnóstico Histológico
P. Scheuer
J Hepatol 1991
GRADO
Clasif. METAVIR
Hepatology 1996
ESTADIO
GRADO
P0
L0
F0
-
-
F0
A0
P1
L1
F1
- portal -
F1
A1
P2
L2
F2
- periportal -
F2
A2
P3
L3
F3
- septal -
F3
A3
P4
L4
F4
- cirrosis -
F4
HC (P3,L2,F2)
no
ESTADIO
HC (A1,F2)
HEPATITIS CRÓNICA – F1
HEPATITIS CRÓNICA – F2
HEPATITIS CRÓNICA – F4
Inconvenientes de la biopsia hepática
• Complicaciones (0,6% graves y
mortalidad 1/10.000)
• Mal aceptada por el paciente
• Variabilidad inter e intraobservador
• Error de muestra
• Difícilmente repetible
• Coste
Biopsia hepática:
¿gold standard?
1/50.000 de tejido hepático
Regev et al. Am J Gastroenterol 2002; 97: 2614-8
Precisión diagnóstica de la biopsia
hepática
•
Subestimación
cirrosis: 10%-25%
•
Discordancias = 33%
(lóbulo dcho vs izdo)
Colloredo et al. J Hepatol 2003; 39: 239-44.
Regev et al. Am J Gastroenterol 2002; 97:2614-8
MÉTODOS NO CRUENTOS DE
EVALUACIÓN DE LA FIBROSIS
1. MARCADORES SÉRICOS E ÍNDICES BIOQUÍMICOS
– DIRECTOS
– INDIRECTOS
2. PRUEBAS DE IMAGEN
 ULTRASONOGRAFÍA
 TAC
 RMN
 SPECT / PET
 ELASTOGRAFÍA (FIBROSCAN®)
3. OTROS
– GENÉTICOS
– MOLECULARES (microarray, proteómicos, glicómicos)
Marcadores séricos de fibrosis
Test
Elementos
Cutoff
Sensibilidad
Especificidad
APRI
AST
PLT
< 0.5
> 1.5
91
41
47
95
FORNS
Edad, colest,
GGT, PLT
< 4.2
> 6.9
94
30
51
95
FIBROTEST
APOA1,GGT
A2MG,Bt,
glob, 2glob
0.3
87
59
FIB-4
Age, AST
ALT, PLT
< 1.45
> 3.25
70
22
74
97
Transient elastography: FibroScan
The probe induces an elastic wave
through the liver
The velocity of the wave is evaluated in a
region located from 2.5 to 6.5 cm below the
skin surface
The velocity of the wave is related to liver stiffness and to fibrosis
Explored volume
2.5 cm
1 cm 
4 cm
LB : 1/50,000 of the liver
FibroScan : 1/500 of the liver
The harder the tissue, the faster the wave propagates
FIBROSCAN
•Inocuo/Sencillo
•Duración menor de 5 minutos
•Grado de fibrosis desde F0 a F4
FibroScan: rigidez hepática y fibrosis
75
F4
12-14
F3
9-10
F2
7-8
kPa
2,5-75 kPa
Limitaciones del FibroScan
•
Obesidad mórbida
•
Espacios intercostales estrechos
•
Ascitis
FibroScan in HCV patients
Chronic HCV infection
N = 251
Ziol et al. Hepatology 2005; 41: 48-54
F≥2
0.84
F≥3
0.90
F=4
0.94
FibroScan in HBV patients
1
Sensitivity
0,8
AUROC
F≥2 : 0.82
0,6
F≥3 : 0.92
0,4
F=4 : 0.90
F01 versus F234
F012 versus F34
0,2
F0123 versus F4
N=170
0
0
0,2
Marcellin P et al. AASLD 2005
0,4
0,6
1 - Specificity
0,8
1
HEPATITIS CRÓNICA VÍRICA
Evaluación “incruenta” de la fibrosis
Fibrotest®
APRI
Fibroscan®
Discrepancia
Biopsia hepática
Castéra et al. Gastroenterology 2005; 125: 343-59