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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
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
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
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)
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