Efficacy of Peginterferon Alpha-2B in Chronic Hepatitis Delta: Relevance of Quantitative RT-PCR for Follow-Up

Efﬁcacy of Peginterferon alpha-2b in Chronic Hepatitis delta: Relevance of Quantitative RT-PCR for Follow-Up

Corinne Castelnau,1 Fred´ eric´ Le Gal,2 Marie-Pierre Ripault,1 Emmanuel Gordien,2 Michelle Martinot-Peignoux,1 Nathalie Boyer,1 Bach-Nga Pham,3 Sarah Maylin,3 Pierre Bedossa,4 Paul Deny,´ 2 Patrick Marcellin,1 and Elyanne Gault2

Hepatitis delta virus (HDV) can cause severe acute and chronic liver disease in patients infected by hepatitis B virus. Interferon alpha at high doses, although poorly efficient, is the only treatment reported to provide some benefit in chronic hepatitis delta. Pegylated interferon alpha (PEG-IFN) has not yet been evaluated. Treatment is usually monitored by the qualitative detection of HDV-RNA in serum. In this study, safety and efficacy of PEG-IFN were assessed in chronic hepatitis delta, and serum HDV-RNA kinetics were determined using quantitative RT- PCR. Fourteen patients with chronic hepatitis delta received subcutaneous PEG-IFN alpha-2b during 12 months (1.5 ␮g/kg per week). Serum HDV-RNA was quantified at initiation and during the course of therapy, and during the posttreatment follow-up period, which ranged from 6 to 42 months (median 16 months). PEG-IFN alpha-2b was well tolerated, inducing no serious adverse effect. Sustained biochemical response was obtained in 8 patients (57%). At the end of treatment, 8 patients (57%) had achieved virological response (undetectable HDV-RNA). Sus- tained virological response throughout the posttreatment follow-up period was observed in 6 patients (43%). HDV-RNA kinetics were predictive of the response: after 3 months of PEG-IFN, HDV-RNA levels were significantly lower in the responders than in the nonresponders group After 6 months of therapy, a negative HDV-RNA was predictive of sustained response .(018. ؍ P) In conclusion, this preliminary study indicates that PEG-IFN alpha-2b is safe and .(021. ؍ P) efficient for treatment of chronic hepatitis delta. The follow-up of HDV-RNA levels during therapy, which allows the differentiation of various profiles of virological responses, improves treatment monitoring. (HEPATOLOGY 2006;44:728-735.)

disease, with a chronicity rate reaching 70% to 90% in See Editorial on Page 536 cases of super-infection,1-3 and a common progression to cirrhosis (60%-70%) accounting for frequent evolution epatitis delta virus (HDV) is a satellite RNA 4,5 virus, which depends on the hepatitis B virus to end-stage liver disease and hepatocellular carcinoma. (HBV) for virion assembly and propagation.1 To date, treatment of chronic hepatitis delta relies on H interferon alpha (IFN), but the efficacy is limited.6 Anti- HDV infection can cause severe acute and chronic liver viral drugs such as ribavirin, acyclovir, or famcyclovir are inefficient,7,8 and anti-HBV drugs such as lamivudine, Abbreviations: HDV, hepatitis delta virus; HBV, hepatitis B virus; IFN, inter- which efficiently reduce HBV viremia but not HBsAg feron alpha; PEG-IFN, pegylated interferon alpha; ALT, alanine aminotransferase; levels have no effect on hepatitis delta,9 even when asso- HbsAg, hepatitis B virus surface antigen. 10 From the 1Service d’He´patologie, Hoˆpital Beaujon, AP-HP; INSERM U773 ciated to IFN. Clevudine, which induces a reduction in CRB3, Clichy, France; 2Service de Bacte´riologie-Virologie-Hygie`ne, Laboratoire the covalently closed circular DNA replication template associe´ au Centre National de Re´fe´rence des He´patites B et C, Hoˆpital Avicenne, levels could be useful in the treatment of chronic hepatitis AP-HP; Universite´ Paris 13, EA3604, Bobigny, France; 3De´partement d’Immunologie Microbiologie des Pathologies Infectieuses, Hoˆpital Beaujon, AP- delta but has only been evaluated in the woodchuck HP; INSERM U773 CRB3, Clichy, France; and 4Service d’Anatomie model for this indication.11 The pegylated form of IFN pathologique, Hoˆpital Beaujon, AP-HP, Clichy; CNRS UMR 8149, Faculte´de (PEG-IFN), which has been proved to be more efficient Pharmacie Paris V, France. Received May 3, 2006; accepted June 22, 2006. than standard IFN in chronic hepatitis B and C, might Supported by grants from the Assistance Publique Hoˆpitaux de Paris: Progre`s improve the outcome of chronic hepatitis delta, but such Me´dical et Innovation The´rapeutique, and by the French Ministe`re de la Sante´. treatment has not yet been evaluated.12,13 Address reprint requests to: Dr. Elyanne Gault, Laboratoire de Bacte´riologie- Virologie-Hygie`ne, Hoˆpital Avicenne, 125 ave de Stalingrad, 93009 Bobigny Ce- The diagnosis of HDV infection usually relies on the dex, France. E-mail: [email protected]; fax number: (33) 1 4895 5911. detection of specific anti-HDV antibodies, with the pres- Copyright © 2006 by the American Association for the Study of Liver Diseases. ence of anti-HDV IgM reflecting ongoing viral replica- Published online in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/hep.21325 tion. However, serological approach for the detection of Potential conflict of interest: Nothing to report. virus replication lacks sensitivity and HDV-RNA detec-

728 HEPATOLOGY, Vol. 44, No. 3, 2006 CASTELNAU ET AL. 729 tion in serum appears to be the most suitable means to the end of therapy and throughout the posttreatment fol- assess active HDV infection.10,14,15 As for other chronic low-up period. Patients were considered nonresponders viral infections, quantification of HDV-RNA levels in when HDV-RNA was still detected in serum at the end of serum might improve the monitoring of treatment effi- therapy. Biochemical response was assessed at the end of cacy, but the relevance of viral load determination in the therapy by normal ALT levels. management of hepatitis delta remains to be established. Liver biopsies were performed before initiation of ther- However, HDV-RNA quantification might help with the apy in all patients, and at the end of therapy for some of understanding of the physiopathology of HDV infection, them. Each biopsy was anonymously re-analyzed by a contribute to the evaluation of the severity of the liver single pathologist. disease and improve treatment monitoring.16,17 Virological Assays. Virological assays were performed The aims of our study were (1) to evaluate the efficacy at inclusion, during the course of therapy and during the and safety of PEG-IFN alpha-2b therapy in patients with posttreatment follow-up period. HBsAg and HBeAg, as well chronic hepatitis delta and (2) to assess the usefulness of as anti-HBs and anti-HBe antibodies were detected using the HDV-RNA quantification to follow the response to treat- AxSYM system (ABBOTT, Rungis, France). HBV-DNA ment. For this purpose, fourteen patients with chronic was quantified by quantitative PCR, with COBAS TaqMan hepatitis delta received PEG-IFN alpha-2b during 12 HBV (Roche Diagnostics Systems, Meylan, France), sensi- months. Treatment efficacy and HDV-RNA kinetics tivity threshold, 50 copies/mL. were evaluated during the course of the treatment and the Anti-HCV antibodies were detected using the AxSYM posttreatment follow-up. HCV system V3.0 (ABBOTT). Serum HCV-RNA was detected by the use of the VERSANT HCV-RNA Qual- Patients and Methods itative Assay (TMA) (Bayer HealthCare, Puteaux, France), sensitivity threshold, 50 copies/mL. Patients. Patients with chronic hepatitis delta, aged Total antibodies to HDV were detected with ETI-AB- 28 to 52 years, were included in the study between De- DELTA-2 (DiaSorin S. A, Antony, France), and specific cember 2000 and December 2003. Chronic hepatitis anti-HDV IgM were detected with ETI-DELTA- delta was defined by the following criteria over a period of IGMK-2 (DiaSorin). In this ELISA-format test, the pres- 6 months: histological evidence of chronic hepatitis, se- ence or absence of IgM is determined by comparing the rum alanine aminotransferase (ALT) levels Ͼ1.3 fold the absorbance value of the unknown sample to that of the upper limit of normal (normal range 5 to 40 IU/L), de- cutoff value. Samples with absorbance values repeatedly Ϯ tectable hepatitis B virus surface antigen (HBsAg), HDV within 10% of the cutoff value were considered “inde- total antibody and HDV-RNA in serum. terminate” for anti-HDV IgM detection. Patients with another cause of chronic liver disease Qualitative detection of HDV-RNA in serum was per- were excluded, as well as patients with HIV infection, formed as previously described by the use of a sensitive Ϸ 19 serious medical illness, hepatocellular carcinoma, decom- RT-PCR assay (sensitivity threshold 100 copies/mL). pensated liver disease, platelet count Ͻ50 000/mm3 and HDV-RNA quantification was performed simulta- pregnant or breastfeeding women. neously for each patient, from serum aliquots kept frozen Ϫ Treatment Schedule. All patients received 1.5 ␮g/kg at 80°C, using a recently described real-time quantita- Ϸ 17 subcutaneous PEG-IFN alpha-2b (Viraferon Peg, Scher- tive PCR assay (sensitivity threshold 100 copies/mL). ing Plough) weekly for 12 months. HDV genotype was determined by phylogenetic analysis Assessment of Treatment Efficacy. Treatment was of the amplified R0 region of the genome (nucleotides monitored with biochemical, histological and virological 885 to 1285) as previously described.20 markers, namely serum ALT levels, METAVIR scoring of Statistical Analysis. The nonparametric Mann Whit- the necroinflammatory activity and fibrosis of the liver,18 ney U test and Willcoxon Rank test (StatView 4.02), and the anti-HDV IgM and HDV-RNA. Biochemical and viro- exact Fisher t-test were used for statistical comparisons. Dif- logical responses were evaluated every 3 months during ferences were considered significant at P values less than .05. the course of the treatment (M3, M6, M9 and M12), at the end of therapy, and every 3 months during the post- Results treatment follow-up period. The primary efficacy param- eter of the study was virological response, which was Characteristics of the Patients at Baseline (Table assessed at the end of therapy by undetectable HDV-RNA 1). Fourteen patients chronically infected with HBV in the serum. Sustained virological response was defined and HDV were enrolled in this study. Patients consisted by undetectable HDV-RNA in the serum 6 months after of 12 men and 2 women, aging from 28 to 52 (median age 730 CASTELNAU ET AL. HEPATOLOGY, September 2006

Table 1. Baseline Characteristics of 14 Patients With ies, but negative for the detection of HCV-RNA during at Chronic Hepatitis delta least the past 3 to 9 years. n (%) Median (Range) Safety. Safety profile was similar to that usually ob- Male sex 12 (86) — served with PEG-IFN alpha-2b in patients with chronic Age, years — 42 (28-52) hepatitis C. Mild adverse effects such as flu-like symp- African origin 6 (43) — toms and asthenia were observed in most patients during French origin 8 (57) — Unknown source of infection 6 (43) — the first weeks of treatment but attenuated with time. Intravenous drug use 7 (50) — Dose reduction from 1.5 to 1␮g/kg was required in five Previous treatment with patients because of leucopoenia, but no other severe side standard IFN 12 (86) — ALT level, x ϫ the normal value — 1.95 (1.3-7.5) effect was noted, and no treatment withdrawal was Necroinflammatory activitya — 2 (1-3) needed. Fibrosis stagea — 3 (1-4) Treatment Efficacy. The median posttreatment fol- HDV genotype 1/5b 12/2 (86/14) — Positive anti-HDV IgM 11 (78) — low-up duration was 16 months, ranging from 6 to 42 Positive HBV-DNA 4 (28) months (Table 1). Eight patients (57%) were virological HBV-DNA level, copies/mL — Ͻ50 (Ͻ50-1.9x106) responders at the end of therapy (undetectable HDV- Positive HBeAg 0 — RNA), but 2 of them relapsed during posttreatment fol- Positive anti-HBe 14 (100) — Positive anti-HCV 8 (57) — low-up. Thus, 6 patients (43%) were sustained virological Follow-up duration,months — 16 (6-42) responders and 6 were nonresponders (43%). HDV-RNA level, copies/mL — 9x105 (4.8ϫ104 - 1.1ϫ107) Five patients (36%) were biochemical responders at aMETAVIR score. the end of therapy, but 1 of them relapsed during post- bgenotype 1 or 5, as defined by the analysis of the R0 region of the genome. treatment follow-up. However, 4 patients, who were considered biochemical nonresponders at the end of therapy 42). Six patients were of African origin and were consid- achieved ALT level normalization during posttreatment ered to have been infected during childhood, as no other follow-up. Thus, 8 patients (57%) presented a biochem- risk factor was identified. The eight remaining patients ical sustained response. Among them, 6 were sustained were of French origin, and for 7 of them, past intravenous virological responders and 2 were nonresponders. drug use was assumed to be the cause of the infection. In the virological responders group, 6 patients of 8 had Twelve patients (85%) had previously been treated with previously been unsuccessfully treated 12 months with standard IFN (9 MU, 3 times a week) during 6 to 22 standard IFN, indicating that PEG-IFN may be effective months (median treatment duration: 12 months). In all in patients with chronic hepatitis delta, even as a second cases, this former treatment had been interrupted at least line treatment. In the nonresponders group, 4 patients 1 year before enrollment in the present study. out of 6 required a dose reduction from 1.5 ␮g/kg to 1 All patients had abnormal ALT levels, comprised be- ␮g/kg because of leucopoenia, while in the responders tween 1.3 to 7.5 times (median 1.95) the upper limit of group, 7 patients out of 8 received the full dose of 1.5 normal. Liver histology, assessed with METAVIR (18) ␮g/kg. scoring system, indicated that most patients had moderate Eight patients (3 nonresponders, 3 sustained respond- necroinflammatory activity (median METAVIR score: 2, ers and 2 responders-relapsers) underwent a second liver ranging from 1 to 3) associated to severe fibrosis (median biopsy at the end of the treatment. METAVIR scoring score: 3, ranging from 1 to 4). Cirrhosis was evident in 4 indicated no significant short-term histological improve- patients. ment, neither for necroinflammatory activity, nor for fi- HDV genotype determination indicated that 12 pa- brosis. tients (86%) were infected by HDV-1, and 2 by HDV-5. Tests to detect specific anti-HDV IgM were performed Specific anti-HDV IgM were positive in 11 patients, neg- at initiation of therapy, during the course of the treatment ative in 1 and indeterminate in 2. HBV replication level and during follow-up. As illustrated in Table 2, the results was evaluated with a sensitive quantitative PCR assay. of IgM detection did not strictly correlate those of HDV- HBV-DNA was below the sensitivity threshold (50 cop- RNA, with, for example, negative or indeterminate IgM ies/mL) in 10 (71%) patients, was comprised between at initiation of therapy (3 patients), or positive IgM at the 3.3ϫ102 and 5.2ϫ104 copies/mL in 3 patients, and was end of follow-up in 2 sustained responders. 1.9x106 copies/mL in one. In all patients, HBeAg was HBsAg remained positive throughout treatment and negative, while anti-HBe was positive. follow-up periods in all patients except one from the sus- Past and resolved HCV infection was evidenced in tained responders group, who lost HBsAg and developed eight patients, who were positive for anti-HCV antibod- anti-HBs antibodies at month 9 of therapy. Serum HBV- HEPATOLOGY, Vol. 44, No. 3, 2006 CASTELNAU ET AL. 731

Table 2. Comparative Detection of Specific Anti-HDV IgM Rank test). Median viral load loss was of 2.28 log10 after 3 and HDV-RNA in Serum months of treatment, and 3.95 log10 after 6 months Number IgM / HDV-RNA detection at: (HDV-RNA being undetectable in 6 of 8 responders at of patients T0a EOT FU M6 of treatment). In the nonresponders group, although (14 ؍ Patients (n median HDV-RNA levels decreased during therapy (0.67 3 ϩb / ϩ ϩ / Ϫϩ/ Ϫ 1 ϩ / ϩϪ/ ϪϪ/ Ϫ log10 during the first 3 months, 1.84 log10 throughout the 1 Ϫ / ϩϪ/ ϪϪ/ Ϫ treatment) the reduction was not significant, and viral Sustained responders (n ϭ 6) 1 ϩ / ϩϪ/ Ϫϩ/ Ϫ loads re-increased after the end of the treatment. None of ϩ ϩϪϪϩϩ 1 / / / the nonresponders had undetectable HDV-RNA at M6 Responder-relapsers (n ϭ 2) 1I/ϩ I/Ϫ I/ϩ 5 ϩ / ϩϩ/ ϩϩ/ ϩ of treatment. Nonresponders (n ϭ 6) 1I/ϩϩ/ ϩϩ/ ϩ Median ALT levels roughly followed those of the viral a T0: initiation of therapy, EOT: end of treatment, FU: end of follow-up loads in the responders group, but not in the group of b ϩ: Positive, Ϫ: Negative, I: indeterminate nonresponders (Fig. 2B). Moreover, the decrease in ALT levels was never significant, even in the responders group. These results indicate that although ALT levels follow DNA was undetectable at the end of the treatment and HDV viral loads during PEG-IFN therapy, they are not during the posttreatment follow-up period in all patients sufficiently accurate to monitor treatment efficiency. In- (responders and nonresponders) but one, who developed dividual HDV-RNA and ALT levels are represented on a symptomatic acute hepatitis (ALT level 22 folds over the Fig. 3, except for 2 patients for whom the number of normal value) 10 months after initiation of PEG-IFN. available frozen samples was insufficient to allow a kinetic This episode occurred as HDV-RNA was becoming un- follow-up. Figure 3 represents the four profiles of HDV- detectable and was accompanied by an increase of HBV- RNA and ALT levels observed during PEG-IFN therapy. DNA load, which exceeded 109 copies/mL (Fig. 1). In Fig. 3A-B represent the typical profiles observed for the this particular case, HBV-DNA load was 1.9ϫ106 cop- sustained responders and the nonresponders, respectively. ies/mL at baseline and had initially been reduced by PEG- Fig. 3C represents the profile observed for the responders- IFN therapy. PEG-IFN therapy was interrupted and was relapsers. For 2 nonresponders, a distinct profile was ob- replaced by lamivudine. During the following months, served (Fig. 3D): HDV-RNA significantly decreased HBV-DNA level decreased under lamivudine while HDV-RNA re-increased. The patient was thus considered responder-relapser to PEG-IFN for HDV infection. Taken together, these results tend to indicate that although HBV replication was low at baseline in most patients (possibly because of an inhibitory effect of HDV on HBV) the clearance of HDV-RNA under PEG-IFN therapy did not lead to the reactivation of HBV, except in one particular case, where HBV-DNA was unusually high at baseline. Serum HCV-RNA remained undetectable in the 8 patients with anti-HCV antibodies, throughout the treatment and follow-up periods. The role of HDV on HCV replication is not well known, but previous studies have indicated a possible inhibition of HCV by HDV.21 The absence of HCV re-activation in the sustained responders group is probably indicative of a favorable outcome of a past HCV infection in these patients. Serum HDV-RNA Levels During Therapy. At Fig. 1. Evolution of HDV-RNA, HBV-DNA and ALT levels in a case of ϫ 4 acute HBV reactivation during the treatment. Viral load kinetics are baseline, HDV-RNA levels ranged from 4.8 10 to represented on the upper part of the panel, ALT levels on the middle part, 1.1ϫ107 copies/mL (Table 1). Median HDV-RNA levels and treatment schedule on the lower part. Viral loads are represented by are shown in Fig. 2A. In the responders group (including circles (black circles for HDV, white circles for HBV) and ALT levels are sustained responders and relapsers), HDV-RNA levels represented by white triangles. Treatment schedule is represented by a box along a scale of time starting at initiation of therapy (T0: initiation of significantly decreased during the first 3 and 6 months of PEG-IFN, which was replaced after 10 months by lamivudine) until the treatment (P ϭ .028, using the nonparametric Wilcoxon end of follow-up (in months). 732 CASTELNAU ET AL. HEPATOLOGY, September 2006

statistical analysis. However, our results indicate that HDV-RNA kinetics might provide predictive information concerning the response to PEG-IFN. Indeed, after 3 months of PEG-IFN, HDV-RNA levels were significantly lower in the responders than in the group of nonresponders (P ϭ .018 by the use of the nonparametric Mann-Whitney U test). This trend was confirmed after 6 months of PEG-IFN (P ϭ .006), with 75% of the responders being undetectable for HDV-RNA, versus none in the nonresponders group. Moreover, negative HDV- RNA at M6 was predictive of sustained response (P ϭ .021). At baseline, neither HDV-RNA levels, nor ALT levels, IgM detection or histological grade were predictive of treatment response. Discussion In this study, 14 patients with chronic hepatitis delta received 12 months of PEG-IFN alpha-2b, and a sustained virological response was achieved in 6 patients (43%). In 2 recent studies evaluating the virological response to standard IFN therapy by the means of qualitative RT-PCR assays with sensitivity thresholds similar to the one we describe,22,23 a sustained virological response was obtained after two years of IFN monotherapy (9 MU three times weekly) in 20% of the patients. Thus, our Fig. 2. Median HDV-RNA and ALT levels in virological responders results seem to indicate that PEG-IFN is probably at least versus nonresponders to PEG-IFN. Median HDV-RNA levels are repre- as effective as standard IFN for treatment of chronic hep- sented on the upper panel, median ALT levels on the lower panel. Medians obtained from the responders group are represented in black, atitis delta, with sustained responses obtained after one those from the nonresponders group in white. The virological responders year of treatment. Moreover, we observed that the toler- group includes sustained responders and responder-relapsers. Medians ance profile was not different from that described during were calculated from the values obtained at initiation of therapy (T0), the treatment of chronic hepatitis C although 5 (36%) after 3 and 6 months of treatment (M3 and M6, respectively), at the end of therapy (M12) and at the end of follow-up (FU). Upper and lower bars patients required a dose reduction because of leucopoe- indicate upper and lower quartiles, respectively. nia. Interestingly, 4 of these patients were nonresponders, suggesting that virological response might be related to the dose (P ϭ .036). As previously suggested by a single during the course of the treatment (3 log10 copies/mL) case of an HIV positive patient with chronic hepatitis Ͼ 24 but remained 2 log10 copies/mL at the end of therapy, delta, we believe that the use of PEG-IFN could be and increased again after its ending. For all profiles, ALT extended to the treatment of hepatitis delta, and that its levels, expressed as a multiple number of the normal up- efficacy should be compared to that of standard IFN by per limit value, roughly followed HDV viral kinetics. the means of large scale comparative studies. However, in some cases, moderate ALT flares were ob- We monitored the efficacy of PEG-IFN by the means served (Fig. 3A,D). In these examples, peaks of ALT of biochemical, serological and molecular analyses. could be explained neither by HDV nor by HBV replica- HDV-RNA was detected by the means of a very sensitive tion rebounds. qualitative RT-PCR,19 quantification being secondarily Predictive Factors of Response. The limited num- performed from frozen aliquots of the sera. We found that ber of patients included in this study did not allow us to the most reliable biological marker for treatment moni- determine accurate predictive factors of response to PEG- toring was HDV-RNA quantification in serum. Indeed, IFN treatment. In particular, epidemiological data such as we detected flares of cytolysis that were independent of the geographic origin (France or Africa), the HDV geno- HDV replication (as illustrated in Fig. 3A,C-D), but type (HDV-1 or HDV-5), the mode of contamination might have been generated by the treatment itself, as pre- (unknown or use of intravenous drugs), or the age at the viously described in chronic hepatitis B.25-27 Moreover, initiation of treatment could not be taken into account for like others,6 we observed that anti-HDV IgM could re- HEPATOLOGY, Vol. 44, No. 3, 2006 CASTELNAU ET AL. 733

Fig. 3. HDV-RNA and ALT levels during PEG-IFN therapy. Four profiles of response to PEG-IFN were observed. Viral load kinetics are represented on the upper part of each panel and ALT levels on the lower part. In each panel, the same symbol is used for a given patient (in black for viral loads, in white for ALT levels) and each curve corresponds to a single patient. The scale of time starts at initiation of therapy (T0) until the end of follow-up (in months). End of treatment is M12. (A) 5 patients with sustained response: virological response was observed between 3 and 12 months of treatment. (B) 3 patients showing no response to PEG-IFN. (C) Virological response at M12 and relapse during follow-up. (D) Incomplete virological response at M12 but significant viral load decrease during the course of the treatment; relapse after the end of the treatment. main undetected despite HDV replication, or, on the that PEG-IFN might need to be continued for more than contrary, could be detected while no HDV-RNA was 12 months, if possible. Four patients of the nonre- Ͻ detected in the serum (Table 2). Therefore, as previously sponders group kept a viral load decrease 2 log10 cop- suggested,28-30 and despite the usefulness of tests to detect ies/mL throughout the 12 months therapy. In such cases anti-HDV IgM, we recommend the use of a consensus of insignificant viral load decrease after a period of time and sensitive RT-PCR approach for treatment monitor- which remains to be defined (probably ranging between 9 ing of chronic hepatitis delta. and 12 months of treatment), we suggest that a change in Besides qualitative detection, quantification of HDV- the treatment schedule might be considered, depending RNA provides useful information regarding the individ- on the tolerance and on the effect of the treatment upon ual viral load kinetics during treatment, and might be liver fibrosis. In 2 patients of the non responders group taken into account for the adjustment of treatment dura- (Fig. 3D), the kinetic profiles looked more like those of tion. Indeed in most studies, interferon is administered the group of responder-relapsers (Fig. 3C) than like those during 12 months15,31-34 although some authors adopt of the nonresponders (Fig. 3B), suggesting the existence longer regimens or adapt treatment length to individual of slow responders among patients considered nonre- factors.22,23,35 In our study, most patients of the responder sponders after only 12 months of treatment.17 When slow group had achieved HDV-RNA clearance during the first responders can be identified on the basis of HDV-RNA 6 months of treatment. However, the fact that 2 of them kinetics, long-term treatment may need to be considered. relapsed after the end of the treatment seems to indicate Further studies implying a greater number of patients are 734 CASTELNAU ET AL. HEPATOLOGY, September 2006 needed to specify these preliminary suggestions. Consid- in compensated cirrhosis type B. The European Concerted Action on Viral ering the small number of patients followed in most spe- Hepatitis (Eurohep). Gut 2000;46:420-426. 5. Saracco G, Rosina F, Brunetto MR, Amoroso P, Caredda F, Farci P, et al. cialized care centers, large-scale multicenter studies are Rapidly progressive HBsAg-positive hepatitis in Italy. The role of hepatitis required to define guidelines for optimal management of delta virus infection. J Hepatol 1987;5:274-281. patients with chronic hepatitis delta. 6. Niro G, Rosina F, Rizzetto M. Treatment of hepatitis D. J Viral Hepat 2005;12:2-9. In this study, the course of HBV infection was also 7. Berk L, de Man RA, Housset C, Berthelot P, Schalm SW. Alpha lympho- considered because of the specific relationship between blastoid interferon and acyclovir for chronic hepatitis delta. Prog Clin Biol HBV and HDV during chronic hepatitis delta. Indeed, Res 1991;364:411-420. although HDV depends on HBV to produce infectious 8. Garripoli A, Di Marco V, Cozzolongo R, Costa C, Smedile A, Fabiano A, et al. Ribavirin treatment for chronic hepatitis D: a pilot study. Liver viral particles, it also inhibits HBV replication in vitro as 1994;14:154-157. well as in vivo.36-39 Moreover, PEG-IFN, which was used 9. Lau DT, Doo E, Park Y, Kleiner DE, Schmid P, Kuhns MC, et al. Lami- to treat hepatitis delta is also efficient to treat HBV infec- vudine for chronic delta hepatitis. HEPATOLOGY 1999;30:546-549. 10. Wolters LM, van Nunen AB, Honkoop P, Vossen AC, Niesters HG, 12,40 tion. PEG-IFN therapy led to HBsAg seroconversion Zondervan PE, et al. Lamivudine-high dose interferon combination ther- in only one of the sustained responders, and there was no apy for chronic hepatitis B patients co-infected with the hepatitis D virus. example of HBV reactivation during the posttreatment J Viral Hepat 2000;7:428-434. 11. Casey J, Cote PJ, Toshkov IA, Chu CK, Gerin JL, Hornbuckle WE, et al. follow-up period in the group of sustained responders. Clevudine inhibits hepatitis delta virus viremia: a pilot study of chronically However, in one case, an acute HBV reactivation oc- infected woodchucks. Antimicrob Agents Chemother 2005;49:4396- curred after 10 months of treatment, while HDV-RNA 4399. was no longer detected (Fig. 1). The replacement of PEG- 12. Cooksley WG, Piratvisuth T, Lee S, Mahachai V, Chao YC, Tanwandee T, et al. Peginterferon alpha-2a (40 kDa): an advance in the treatment of IFN by lamivudine led to the disappearance of HBV- hepatitis B e antigen-positive chronic hepatitis B. J Viral Hepat 2003;10: DNA in serum, while HDV started to replicate again. 298-305. Although unclear, the mechanism of this dual balance of 13. Manns MP, McHutchison JG, Gordon SC, Rustgi VK, Shiffman M, Reindollar R, et al. 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