Treatment of hepatitis C virus infection with direct-acting antivirals plus ribavirin eliminates viral RNA from peripheral blood mononuclear cells and reduces virologic relapse in diverse hepatic parenchymal changes

Abstract

Elimination of hepatitis C virus (HCV) may fail, leading to a non-response outcome because of inappropriate testing for viral RNA in peripheral blood mononuclear cells (PBMCs). Sequelae of HCV genotype 4 therapy with sofosbuvir and daclatasvir ± ribavirin were assessed in our study at the 12th week after end of treatment (EOT) by screening for viral genomic RNA in serum and PBMCs with correlation to hepatic parenchymal changes. We recruited 102 out of 2165 patients who had received sofosbuvir/daclatasvir, either alone (n = 1573) or together with ribavirin (n = 592). Subjects were classified into three groups based on testing by single-step reverse transcription PCR: group I, HCV negative in both serum and PBMCs (n = 25); group II, HCV positive in PBMCs only (n = 52); and group III, HCV positive in both serum and PBMCs (n = 25). Groups I and II (n = 77) were selected out of 2102 (every 27th subject), while group III (n = 25) were selected from every second or third serologic relapse (n = 63). The pre-sampling population (n = 2165) showed sustained virologic response (SVR) in 33.21%; serologic relapse in 2.91%; HCV RNA only in PBMCs (66.79%) compared to serologic relapses and potential cure (P < 0.0001); higher serologic (38 out of 63, P = 0.03210) and cellular (36 out of 52, P = 0.0002) relapses in dual therapy than in triple therapy. The post-sampling population (n = 102) showed more HCV relapses in dual (50 out of 60) than in triple (27 out of 42) therapy (P = 0.0351); increased HCV antisense RNA strand in relapses compared to positive-sense strands alone (P < 0.001); and significant SVR events in undetectable (15 out of 31) compared to early (10 out of 55, P = 0.0058) and cirrhotic liver tissue changes (0 out of 16, P = 0.0006). In summary, HCV treatment with sofosbuvir/daclatasvir is followed by higher rates of serologic and intracellular viral RNA relapse than treatment with sofosbuvir/daclatasvir plus ribavirin. Cellular and serum viral RNA relapses are accompanied by HCV-induced hepatic pathology. An increased SVR with no detectable liver tissue changes was observed after triple therapy due to elimination of HCV RNA from PBMCs.

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Fig. 1

Abbreviations

PBMCs:

Peripheral blood mononuclear cells

SRT:

Single-step reverse transcription

DAAs:

Direct-acting antiviral agents

SVR:

Sustained virologic response

OCI:

Occult HCV infection

EOT:

End of treatment

TACE:

Treatment-associated challenge evaluation

PPV:

Positive predictive value

NPV:

Negative predictive value

References

  1. 1.

    Ruane PJ, Ain D, Stryker R, Meshrekey R et al (2015) Sofosbuvir plus ribavirin for the treatment of chronic genotype 4 hepatitis C virus infection in patients of Egyptian ancestry. J Hepatol 62(5):1040–1046

    CAS  PubMed  Google Scholar 

  2. 2.

    Doss W, Shiha G, Hassany M, Soliman R et al (2015) Sofosbuvir plus ribavirin for treating Egyptian patients with hepatitis C genotype 4. J Hepatol 63(3):581–585

    CAS  PubMed  Google Scholar 

  3. 3.

    Eletreby R, Elakel W, Said M, El Kassas M et al (2017) Real life Egyptian experience of efficacy and safety of Simeprevir/Sofosbuvir therapy in 6211 chronic HCV genotype IV infected patients. Liver Int 37(4):534–541

    CAS  PubMed  Google Scholar 

  4. 4.

    Eletreby R, Elakel W, El Raziky M, Esmat G (2017) Response to Real life Egyptian experience of efficacy/safety of Simeprevir\Sofosbuvir in HCV genotype IV. Liver Int 37:766–766

    PubMed  Google Scholar 

  5. 5.

    Hézode C, Hirschfield GM, Ghesquiere W, Sievert W et al (2015) Daclatasvir plus peginterferon alfa and ribavirin for treatment-naive chronic hepatitis C genotype 1 or 4 infection: a randomised study. Gut 64(6):948–956

    PubMed  Google Scholar 

  6. 6.

    Moreno C, Hezode C, Marcellin P, Bourgeois S et al (2015) Efficacy and safety of simeprevir with PegIFN/ribavirin in naive or experienced patients infected with chronic HCV genotype 4. J Hepatol 62(5):1047–1055

    CAS  PubMed  Google Scholar 

  7. 7.

    Forns X, Lee SS, Valdes J, Lens S, Ghalib R, Aguilar H et al (2017) Glecaprevir plus pibrentasvir for chronic hepatitis C virus genotype 1, 2, 4, 5, or 6 infection in adults with compensated cirrhosis (EXPEDITION-1): a single-arm, open-label, multicentre phase 3 trial. Lancet Infect Dis 17(10):1062–1068

    CAS  PubMed  Google Scholar 

  8. 8.

    Asselah T, Kowdley KV, Zadeikis N et al (2018) Efficacy of glecaprevir/pibrentasvir for 8 or 12 weeks in patients with HCV genotype 2,4,5, or 6 infection without cirrhosis. Clin Gastroenterol Hepatol 16(3):417–426

    CAS  PubMed  Google Scholar 

  9. 9.

    Feld JJ, Jacobson IM, Hézode C, Asselah T et al (2015) Sofosbuvir and velpatasvir for HCV genotype 1, 2, 4, 5, and 6 infection. N Engl J Med 373(27):2599–2607

    CAS  PubMed  Google Scholar 

  10. 10.

    Kwo PY, Poordad F, Asatryan A, Wang S, Wyles DL et al (2017) Glecaprevir and pibrentasvir yield high response rates in patients with HCV genotype 1–6 without cirrhosis. J Hepatol 67(2):263–271

    CAS  PubMed  Google Scholar 

  11. 11.

    Asselah T, Reesink H, Gerstoft J, de Ledinghen V et al (2018) Efficacy of elbasvir and grazoprevir in participants with hepatitis C virus genotype 4 infection: a pooled analysis. Liver Int 38(9):1583–1591

    CAS  PubMed  Google Scholar 

  12. 12.

    El Kassas M, Elbaz T, Abd El Latif Y, Esmat G (2016) Elbasvir and grazoprevir for chronic hepatitis C genotypes 1 and 4. Expert Rev Clin Pharmacol 9(11):1413–1421

    PubMed  Google Scholar 

  13. 13.

    Kohli A, Kapoor R, Sims Z, Nelson A et al (2015) Ledipasvir and sofosbuvir for hepatitis C genotype 4: a proof-of-concept, single-centre, open-label phase 2a cohort study. Lancet Infect Dis 15(9):1049–1054

    CAS  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Abergel A, Metivier S, Samuel D, Jiang D et al (2016) Ledipasvir plus sofosbuvir for 12 weeks in patients with hepatitis C genotype 4 infection. Hepatology 64(4):1049–1056

    CAS  PubMed  Google Scholar 

  15. 15.

    Waked I, Shiha G, Qaqish RB, Esmat G et al (2016) Ombitasvir, paritaprevir, and ritonavir plus ribavirin for chronic hepatitis C virus genotype 4 infection in Egyptian patients with or without compensated cirrhosis (AGATE-II): a multicentre, phase 3, partly randomised open-label trial. Lancet Gastroenterol Hepatol 1(1):36–44

    PubMed  Google Scholar 

  16. 16.

    Hézode C, Asselah T, Reddy KR, Hassanein T et al (2015) Ombitasvir plus paritaprevir plus ritonavir with or without ribavirin in treatment-naive and treatment-experienced patients with genotype 4 chronic hepatitis C virus infection (PEARL-I): a randomised, open-label trial. Lancet 385(9986):2502–2509

    PubMed  Google Scholar 

  17. 17.

    Feld JJ, Jacobson IM, Sulkowski MS, Poordad F, Tatsch F, Pawlotsky JM (2017) Ribavirin revisited in the era of direct-acting antiviral therapy for hepatitis C virus infection. Liver Int 37(1):5–18

    CAS  PubMed  Google Scholar 

  18. 18.

    Curry MP, Forns X, Chung RT, Terrault NA et al (2015) Sofosbuvir and ribavirin prevent recurrence of HCV infection after liver transplantation: an open-label study. Gastroenterology 148(1):100–107

    CAS  PubMed  Google Scholar 

  19. 19.

    Charlton M, Everson GT, Flamm SL, Kumar P et al (2015) Ledipasvir and sofosbuvir plus ribavirin for treatment of HCV infection in patients with advanced liver disease. Gastroenterology 149(3):649–659

    CAS  PubMed  Google Scholar 

  20. 20.

    Soliman G, Negm MS, Elzalabany M, Malik AA et al (2018) Is treatment of hepatitis C with controlled generic direct acting antiviral drugs effective? An Egyptian experience. J Hepatol 68:S276

    Google Scholar 

  21. 21.

    Hathorn E, Elsharkawy AM (2016) Management of hepatitis C genotype 4 in the directly acting antivirals era. BMJ Open Gastroenterol 3(1):e000112

    PubMed  PubMed Central  Google Scholar 

  22. 22.

    Salama H, Zekri A, Medhat E et al (2016) Sofosbuvir plus daclatasvir with fixed versus weight adjusted dose of ribavirin for treatment of HCV genotype 4 among Egyptian patients. EC Gastroenterol Dig Syst 1:143–153

    Google Scholar 

  23. 23.

    Hanno AF, Mohiedeen KM, Alshayeb AF, Deghedy A (2014) HCV RNA in peripheral blood mononuclear cells (PBMCs) as a predictor of the response to antiviral therapy in chronic hepatitis C. Alex J Med 50(4):317–322

    Google Scholar 

  24. 24.

    Castillo I, Bartolomé J, Quiroga JA, Barril G, Carreño V (2010) Diagnosis of occult hepatitis C without the need for a liver biopsy. J Med Virol 82:1554–1559

    CAS  PubMed  Google Scholar 

  25. 25.

    Castillo I, Pardo M, Bartolomé J et al (2004) Occult hepatitis C virus infection in patients in whom the etiology of persistently abnormal results of liver-function tests is unknown. J Infect Dis 189(1):7–14

    PubMed  Google Scholar 

  26. 26.

    Abd Alla MDA, El Awady MK (2017) Hepatitis C virus RNA strands detection in peripheral blood mononuclear cells legitimizes virus eradication in negative serum PCR naïve and post-treatment patients. J Clin Transl Hepatol 5:1–8

    PubMed  PubMed Central  Google Scholar 

  27. 27.

    Abd Alla MDA, Elibiary SA, Wu GY, El-Awady MK (2017) Occult HCV infection (OCI) diagnosis in cirrhotic and non-cirrhotic naïve patients by intra-PBMC nested viral rNA PCR. J Clin Transl Hepatol 5:319–326

    PubMed  PubMed Central  Google Scholar 

  28. 28.

    Abd Alla MDA, El Awady MK, Dawood RM, Elhawary MA et al (2018) Hepatitis C virus serologic relapse after treatment with direct-acting antivirals is dependent on viral RNA levels in peripheral blood mononuclear cells and the grade of liver cirrhosis. Adv Virol 163(10):2765–2774

    CAS  Google Scholar 

  29. 29.

    Pawlosky JM (2016) Hepatitis C virus resistance to direct-acting antiviral drugs in interferon free regimens. Gastroenterology 151:70–86

    Google Scholar 

  30. 30.

    Corchado S, López CLF, Rivero JA et al (2014) Liver fibrosis, host genetic and hepatitis C virus related parameters as predictive factors of response to therapy against hepatitis C virus in HIV/HCV coinfected patients. PLoS One 9(7):e101760. https://doi.org/10.1371/journal.pone.0101760

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Pawlosky JM (2011) Treatment failure and resistance with direct-acting antiviral drugs against hepatitis C virus. Hepatology 53:1742–1751

    Google Scholar 

  32. 32.

    Calleja JL, CrespoJ RD et al (2017) Effectiveness, safety and clinical outcomes of direct-acting antiviral therapy in Hepatitis C Virus genotype 1 infection: results from a Spanish real-world cohort. J of hepatology 66(6):1138–1148

    CAS  Google Scholar 

  33. 33.

    Afdhal NH, BaconBR PK, Lawitz EJ et al (2015) Accuracy of fibroscan, compared with histology, in analysis of liver fibrosis in patients with hepatitis B or C: a United States multicenter study. Clin Gastroenterol Hepatol 13(4):772–779

    PubMed  Google Scholar 

  34. 34.

    Calès P, Oberti F, Michalak S, Hubert-Fouchard I et al (2005) A novel panel of blood markers to assess the degree of liver fibrosis. Hepatology 42(6):1373–1381

    PubMed  Google Scholar 

  35. 35.

    Reedy DW, Loo AT, Levine RA (1998) AST/ALT ratio ≥ 1 is not diagnostic of cirrhosis in patients with chronic hepatitis C. Dig Dis Sci 43:2156–2159

    CAS  PubMed  Google Scholar 

  36. 36.

    Wahab EA, Fathy T, Saber S, Ahmad HS (2017) Hepatic elastography and fib-4 score versus liver biopsy for assessment of liver fibrosis in chronic Hcv patients. Zagazig Univ Med J 21:1–11

    Google Scholar 

  37. 37.

    Chomczyński P, Sacchi N (1987) Single-step method of RNA isolation by acid guanidinum thiocyanate-phenol-chlotoform extraction. Anal Biochem 162:156–159

    PubMed  Google Scholar 

  38. 38.

    El-Awady MK, Abdel Rahman MM, Ismail SM, Amr KS, Omran M et al (2003) Prediction of relapse after interferon therapy in hepatitis C virus-infected patients by the use of triple assay. J Gastroenterol Hepatol 18:68–7339

    CAS  PubMed  Google Scholar 

  39. 39.

    Elzahaby AA, Soliman GM, Korany MA et al (2017) Association between post treatment existence Of HCV/RNA positive strand and/or negative strand in the PBMCs and HCV relapse. J Egypt Soc Parasitol 47:323–330

    Google Scholar 

  40. 40.

    Pawełczyk A, Kubisa N, Jabłońska J et al (2013) Detection of hepatitis C virus (HCV) negative strand RNA and NS3 protein in peripheral blood mononuclear cells (PBMC): CD3+, CD14+ and CD19+. Virol J 10(1):346. https://doi.org/10.1186/1743-422X-10-346

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    El-Awady MK, Ismail SM, El-Sagheer M et al (1999) Assay for hepatitis C virus in peripheral blood mononuclear cells enhances sensitivity of diagnosis and monitoring of HCV-associated hepatitis. Clin Chim Acta 283(1–2):1–14

    CAS  PubMed  Google Scholar 

  42. 42.

    Abd Alla MDA, Elibiary SA, Elshaboury RH et al (2018) HCV therapy follow-up fractionation (CTF2) by intra-PBMC nested RNA PCR recognizes early virologic response and relapse. J Clin Trans Hepatol 6(2):1–8

    Google Scholar 

  43. 43.

    Abd Alla MDA, Gomaa AA, Farrag GAA et al (2018) Retrospective study of hepatitis c virus relapse after treatment with sofosbuvir and daclatasvir with or without ribavirin. Al-Azhar Assiut Med J 16(2):197–204

    Google Scholar 

  44. 44.

    Huang CF, Yeh ML, Huang CI et al (2020) Ribavirin facilitates early viral kinetics in chronic hepatitis C patients receiving daclatasvir/asunaprevir. J Gastroenterol Hepatol 35(1):151–156

    CAS  PubMed  Google Scholar 

  45. 45.

    Elsharkawy A, Hashem M, Fouad R, Negm M et al (2017) Safety and efficacy of the generic products of sofosbuvir and daclatasvir in treatment of HCV genotype 4 Egyptian patients. Merit Res J Med Med Sci 5:209–213

    Google Scholar 

  46. 46.

    Zeng QL, Li CX, Zhang DW et al (2016) safety and efficacy of sofosbuvir plus daclatasvir with ribavirin for 12 weeks in Chinese treatment-experienced cirrhotic genotype 1b patients with HCV. Aliment Pharm Ther 43:842–843

    Google Scholar 

  47. 47.

    Nelson DR, Cooper JN, Lalezari JP, Lawitz E et al (2015) All-oral 12-week treatment with daclatasvir plus sofosbuvir in patients with hepatitis C virus genotype 3 infection: ALLY-3 phase III study. Hepatology 61(4):1127–1135

    CAS  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Ioannou GN, Beste LA, Chang MF et al (2016) Effectiveness of sofosbuvir, ledipasvir/sofosbuvir, or paritaprevir/ritonavir/ombitasvir and dasabuvir regimens for treatment of patients with hepatitis C in the Veterans Affairs National Health Care System. Gastroenterology 151(3):457–471

    CAS  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Sterling RK, Kuo A, Rustgi VK et al (2015) Virological outcomes and treatment algorithms utilisation in observational study of patients with chronic hepatitis C treated with boceprevir or telaprevir. Aliment Pharm Ther 41(7):671–685

    CAS  Google Scholar 

  50. 50.

    Boglione L, Pinna SM, Cardellino CS et al (2017) Treatment with daclatasvir and sofosbuvir for 24 weeks without ribavirin in cirrhotic patients who failed first-generation protease inhibitors. Infection 45(1):103–106

    CAS  PubMed  Google Scholar 

  51. 51.

    Merat S, Sharifi AH, Haj-Sheykholeslami A et al (2017) The efficacy of 12 weeks of sofosbuvir, daclatasvir, and ribavirin in treating hepatitis C patients with cirrhosis, genotypes 1 and 3. Hepat Mon 17(1):e44564. https://doi.org/10.5812/hepatmon.44564

    CAS  Article  Google Scholar 

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Acknowledgements

Financial support for this study was provided by the Faculty of Medicine at Al-Azhar University and National Research Center (Cairo, Egypt).

Funding

Funding for this study came from Department of Hepatology, Gastroenterology, and Infectious Diseases; Faculty of Medicine at Al-Azhar University; Cairo, Egypt. The institutes have no conflict of interest.

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The second and last two authors executed the virologic investigation and helped in writing the manuscript. The corresponding author took care of study design, case management, data analysis, and writing the manuscript; other co-authors helped in recruiting and management of patients and revised the manuscript.

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Correspondence to Mohamed Darwish Ahmed Abd Alla.

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All procedures performed in the current study that involved human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the current study. This article does not contain any studies with animals performed by any of the authors.

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Abd Alla, M.D.A., Dawood, R.M., Rashed, H.A.EH. et al. Treatment of hepatitis C virus infection with direct-acting antivirals plus ribavirin eliminates viral RNA from peripheral blood mononuclear cells and reduces virologic relapse in diverse hepatic parenchymal changes. Arch Virol 166, 1071–1081 (2021). https://doi.org/10.1007/s00705-021-04969-4

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