Hepatitis D:A Case Presentation

Daphne Meyer

GI Research & Hepatitis Support

Canadian Association of Hepatology Nurses March 1, 2013

Requires HBsAg to complete it’s life cycle, enter hepatocytes & propogate infection

most severe form of viral hepatitis in humans

8 genotypes, geography, distinct clinical course

Co-Infection or super infection

risk of cirrhosis + HCC

Aggressive

Small defective RNA virus

Est. 15-20 million infected (~ 5% of B’s)

How do we measure for Hepatitis D?????

Antibody

RNA

HBV DNA ALT **Immigrant

CLINICAL CLUE:

53 yr-old married caucasian woman Homemaker

Patient Profile

From Afghanistan, Moved to Canada in 2006

Diagnosis Hep B GP

What brought her to doctor?

Diagnosed Hep D at Liver Centre

Med Hx: Stable depression, hyperlipidemia, headaches, osteopenia, esophagitis, hysterectomy/oopherectomy),

Obese (BMI: 30.7) Meds: Zoloft, simvastatin, omeprazole,

risedronate

Ø previous hepatitis tx

History, Etc.

Abdominal U/S:

Fibrotest:

Fibroscan:

Biopsy:

CT Abdomen:

Suggested Cirrhosis, echogenic nodule

6.1 KPa mild disease

A2, F2, no steatosis

No HCC, tiny focal lesions

0.29 mild fibrosis

DIAGNOSTIC PROCEDURES

Treatment ???

Pre-Tx Lab ValuesHBsAg 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 ConsiderationsHx depression during transition to CanadaHx insomnia, fatigue, anxiety (PTSD - conflict in Afghanistan)Pre tx: stable on anti-depressant

Referred to psychiatrist Depression in

remissionPTSD 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

Mental Status

Other Pre-Tx Considerations

Pegassist - Ontario doesn’t cover

Married 30 yearsHusband attends appointments25 year old son at homeSpeaks and understands PersianAttending English classesHusband interpretsPatient wanted treatment

Family Support

Drug Coverage

Language Barrier

Willingness

Good Candidate

Peg-IFN x 48 wks 20-30% sustained reduction in HDV RNA

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

Tx Guidelines

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 1.04 52 110 2.2 151 0.9

20 25Nov09 59 50 1.03 101 2.6 139 1.3

24 16Dec09 48 48 91 0.95 51 103 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 10 1.11 56 109 2.1 134 0.8

40 14Apr10 56 58 1.05 107 3.5 129 2.0

44 12May10 65 58 91 1.01 52 103 1.9 118 0.7

48 9Jun10 62 53 1.02 54 104 2.0 135 0.9

Treatment Labs

Hepatitis Labs During TxWeek Date Hbe

AbHbe Ag HBs Ab HBs Ag Hep D

RNA

36 19Mar10

Positive Negative

48 09Jun10 Positive Negative

Negative

Date HBV DNA

02Oct09 < 12 (1.2x101 IU/ml)

16Dec09 < 12 (1.2x101

IU/ml)

19Mar10 < 12 (1.2x101

IU/ml)

09Jun10 < 13 (1.3x101 IU/ml)

Generally Tolerated Well

Mood Disturbance

Treatment Side Effects

POST TREATMENT

Post-Tx LabsDate ALT

AST

ALP INR Creat HB WBC PLT NEUT

3 mthPost

08Sep10 36 31 81 0.98 60 131 3.6 185 1.8

6 mth post

08Dec10 275 16

3 1.12 60 123 5.1 237 2.89

7 mth post

13Jan10 198 130

1 yr post

09Aug11 164 95 87 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 84 1.05 54 134 5.0 188 2.54

Flared after stopping tx

Hepatitis Testing Post-TxDate Hbe

AbHbe 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 3.5 KPaFeb 2012 3.1 KPa

Abdominal Ultrasounds

Jan 20/11: Stable, Fatty, No HCCFeb 23/12: Stable, NO HCCAug 30/12: Stable, slightly nodular, NO HCC

Patient Feels Well Lost 3kg wt. in past year

Continue to Assess q 6 mths

? Treat Hep B

Current Status

HBV DNA , ALT , immigrant ?? HEP D

Treat with Peg-IFN x 48 weeks

Drug Coverage

Success rate is low

Treatment generally tolerated well

Key Points

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

References

THANK YOU!