Next Article in Journal
A Recombinant Turkey Herpesvirus Expressing F and HN Genes of Avian Avulavirus-1 (AAvV-1) Genotype VI Confers Cross-Protection against Challenge with Virulent AAvV-1 Genotypes IV and VII in Chickens
Next Article in Special Issue
Hepatitis B Virus (HBV) Reactivation Following Pharmacological Eradication of Hepatitis C Virus (HCV)
Previous Article in Journal
Identification of Key Residues Required for RNA Silencing Suppressor Activity of p23 Protein from a Mild Strain of Citrus Tristeza Virus
Previous Article in Special Issue
Immune-Escape Hepatitis B Virus Mutations Associated with Viral Reactivation upon Immunosuppression
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Viruses
Volume 11
Issue 9
10.3390/v11090783
viruses-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

New Markers in Monitoring the Reactivation of Hepatitis B Virus Infection in Immunocompromised Hosts

by
Valentina Svicher
1,
Romina Salpini
1,
Vincenzo Malagnino
2,
Lorenzo Piermatteo
1,
Mohammad Alkhatib
1,
Carlotta Cerva
2 and
Loredana Sarmati
2,*
1
Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, 00133 Rome, Italy
2
Clinic of Infectious Diseases, Department of System Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
*
Author to whom correspondence should be addressed.
Viruses 2019, 11(9), 783; https://doi.org/10.3390/v11090783
Submission received: 27 July 2019 / Revised: 21 August 2019 / Accepted: 23 August 2019 / Published: 25 August 2019
(This article belongs to the Special Issue Hepatitis B Virus Reactivation)
Review Reports Versions Notes

Abstract

:
Hepatitis B virus (HBV) persistence is at the basis of HBV reactivation as a consequence of chemotherapy and immunosuppressive treatments. The identification of early viral replication indicators and markers of effective HBV immunological control would be useful in monitoring patients who are at risk of potential viral reactivation during the course of immunosuppressive treatment. Currently, international guidelines have shared some criteria to identify patients with a low, medium or high risk of HBV reactivation; however, permanently placing a patient in a definitive category is not always easy. More often, patients move from one category to another during the course of their immunosuppressive treatment; therefore, in many cases, there are no precise indicators or tools for monitoring possible reactivation and establishing the duration and suspension of antiviral prophylaxis. Historically, the sequence of HBV antigens and antibodies and HBV DNA levels has been used to evaluate the different stages of the acute and chronic phases of an HBV infection. In the last few years, new biomarkers, such as anti-HBs and anti-HBc titres, HBV core-related antigen (HBcrAg), ultra-sensitive HBsAg evaluation and HBV RNA, have been used in patients with an HBV infection to evaluate their diagnostic and prognostic potential. The aim of this review is to evaluate the published results on the use of new infection markers in the diagnosis and monitoring of HBV reactivation over the course of immunosuppressive treatments. Moreover, the importance of viral genotypic studies was emphasized, given the diagnostic and therapeutic implications of the mutational profiles of HBsAg during the HBV reactivation phase.

1. Introduction

Patients with a hepatitis B virus (HBV) infection remain at risk of serious consequences, such as chronic hepatitis (CHB) or hepatocellular carcinoma (HCC), conditions that are more frequent in some regions of the world due to the high risk of infection acquisition in childhood and to the presence of some particularly aggressive viral genotypes [1]. Currently, anti-HBV treatments inhibit HBV replication, increasing the survival rates and quality of living in CHB patients; however, they cannot completely eliminate HBV from hepatic cells. Therefore, to date, there is no definitive cure for HBV infection.
HBV persistence is a common condition not only in patients with CHB but also in patients who have completely recovered from natural infection, and it is at the basis of HBV reactivation in cancer patients and in other immunocompromised subjects as a consequence of chemotherapy and immunosuppressive treatments.
HBV reactivation (HBV-R) in immunocompromised hosts can be associated with extremely serious clinical consequences. A retrospective Japanese study reported 20% fulminant hepatic failure with a subsequent 100% mortality rate in HBV-R in haematological patients, which resulted in a higher risk of mortality associated with fulminant HBV hepatitis than otherwise healthy people with acute HBV infection [2].
Recently, the American Gastroenterological Association [3] classified immunosuppressive treatment as low (<1% of cases), moderate (1–10% of cases), or high risk (>10% of cases) of HBV-R based on the knowledge from a systematic review. Based on the risk attributable to the drugs, the condition of the patient and the duration of treatment, indications of screening, prevention and prophylaxis have been established for the different categories of patients at risk of HBV-R. However, it is not always easy to identify the real risk in patients who switch from one immunosuppressive therapy to another, patients who are treated for a long time, or haematological and transplant patients with a high grade of immunosuppression. In this kind of subject, the grade of HBV-R risk and the length of immunosuppression are not always clearly quantifiable; therefore, many unclear areas remain regarding the duration of monitoring for HBV-R, prophylaxis or pre-emptive therapy. In these categories of patients, the identification of early viral replication markers or the best indicators of HBV immunological control would be useful in monitoring patients at risk of potential viral reactivation or to identify the right time for the suspension of antiviral prophylaxis.
A series of viral markers, such as HBsAg, HBeAg, anti-HBc, anti-HBe and anti-HBs, has been historically used to evaluate the natural course and to establish the phases of HBV infection. Moreover, the detection of HBV-DNA levels has become a fundamental practice for establishing the extent of viral replication and guiding the start of therapy. In particular, HBV-DNA level monitoring is recommended in immune-compromised CHB patients receiving antivirals to monitor for reactivation before the end of antiviral treatment and periodically thereafter. In patients with resolved HBV infection (anti-HBc positive anti HBsAg negative), there is no shared opinion supporting HBV-DNA monitoring for reactivation; however, watchful monitoring may also be a reasonable choice (i.e.; in the course of rituximab treatment) [4,5].
Recently, new biomarkers, such as titres of anti-HBs and anti-HBc, HBV core-related antigen (HBcrAg), ultra-sensitive HBsAg evaluation, and HBV-RNA, have been used in patients with HBV infection to evaluate their diagnostic and prognostic potential [6,7].
The aim of this review is to evaluate the existing literature on the use of new HBV markers in the assessment of the immunocompromised patient at risk for HBV-R to understand the clinical areas in which they could be wisely used and discuss the issues that need additional research results. In the final paragraph, a brief discussion of the characteristics of the viral strains isolated during HBV-R in patients with immunodeficiency is reported. The relevance of this topic is related to the changes in the HBV genome frequently reported in these cases and often associated with manifestations of viral immune escape and drug resistance, which can complicate the diagnosis and treatment processes.

2. Literature Search

The literature review was based on a search strategy for English-language literature in PubMed and the Cochrane Library. The research was performed by the authors, who independently reviewed all articles for study inclusion. The search terms used either alone or in combination were ‘hepatitis B virus,’ ‘HBV,’ ‘new hepatitis B viral biomarkers’, ‘immunocompromised host’, ‘HBsAg’, ‘HBsAg titer’, ‘ultra-sensitivity HBsAg titer’, ‘HBV core related antigen’, ‘HBcrAg’, ‘HBV-DNA’, ‘anti-HBcAb’, ‘HBV-RNA’, and ‘hepatitis B virus reactivation’. Studies evaluating non-immunocompromised patients were excluded.
A total of 10 studies containing the use of new HBV viral biomarkers in the evaluation of HBV infection reactivation in immunocompromised hosts were included for review. In all the selected studies, the reactivation of HBV infection (defined as an abrupt appearance/rise in HBV-DNA levels and a reverse seroconversion to an HBsAg-positive status (reappearance of HBsAg)) concerned immunosuppressed people.
Of the 10 studies evaluated, six were on anti-HBsAg titre, two studies were on anti-HBcAb titre, one on HBcrAg and one on ultra-sensitive HBsAg (Table 1). For the relevance and novelty of the results, an abstract presented at the “52nd Annual Meeting of the Italian Association for the Study of the Liver” on the theme of the review was also considered.

3. Role of New markers in Monitoring Patients at Risk of HBV Reactivation

A series of viral biomarkers of HBV have been recently correlated with the clinical evolution and response to therapy in HBV-infected patients. For some of these, recent research data suggest a possible practical use, while others are still being studied for possible future applications.
Below is the list of the new markers of HBV infection with their most significant meanings resulting from the published studies.
Anti-HBs titres: A reduction or a disappearance of anti-HBs titres has been correlated with a major risk of HBV relapse.
Anti-HBc titres: High titres of HBcAb have been correlated with HBeAg clearance [18], the efficacy of antiviral therapy, and the absence of HBV relapse to treatment suspension [19].
HBcrAg: HBcrAg is considered to be a marker of intrahepatic HBV cccDNA. A decrease in HBcrAg has been related to the loss of HBeAg and HBsAg and the safe discontinuation of HBV treatment [20].
HBV-RNA: Serum pre-genomic RNA transcribed from cccDNA has a strong correlation with intrahepatic cccDNA and is considered to be an indirect marker of reservoir size [21].
Ultra-sensitive HBsAg: HBsAg quantification (qHBsAg) levels are correlated with intra-hepatic covalently closed circular (ccc) DNA [22].
Below, the results of studies that have speculated applications for the above markers in immunocompromised patients are reported (Table 1).

3.1. Anti-HBs Titre

Although the quantification of anti-HBs has been available for several years, the clinical relevance of anti-HBs titres in the context of immunosuppression has only recently been investigated. In particular, the role of anti-HBs titres in predicting HBV-R was first analysed in a study of 260 patients with resolved HBV infection receiving rituximab-containing chemotherapy [9]. In this study, HBV-R occurred in 30.2% of patients after a median of 23 weeks of rituximab treatment [9]. An undetectable anti-HBs titre (<10 mIU/mL) at baseline was the only significant risk factor correlated with the increased risk of HBV-R (hazard ratio (HR): 3.51 (95% confidence interval (CI): 1.37–8.98); p = 0.009). Indeed, patients negative for anti-HBs at baseline had a significantly higher 2-year cumulative rate of HBV-R compared to patients positive for anti-HBs (68.3% vs 34.4%; p = 0.012). In a subsequent study, Cho Y. and collaborators [10] showed that in a group of 108 patients with B-cell lymphoma, those with an anti-HBsAg titre <100 IU/mL had a risk of reactivating HBV equal to 8.3% and 17.3% after 6 and 24 months of rituximab treatment, respectively.
In line with these results, another study focused on 336 patients with resolved HBV infection undergoing kidney transplantation, and the patients were stratified according to the use of rituximab for desensitization [12]. The authors found that standard-dose rituximab was significantly associated with a steeper decline in anti-HBs titres compared to reduced-dose rituximab. Furthermore, standard-dose rituximab (HR (95% CI): 10.6 (2.52–44.60), p = 0.001) and anti-HBs  < 100 IU/L at transplantation (HR (95% CI): 9.06 (1.11–74.30); p =  0.04) were independent risk factors for HBV-R. In the context of solid tumours, a recent study showed that an undetectable anti-HBs titre and a dexamethasone dose >1.0 mg/day were high risk factors of HBV-R (OR (95% CI): 5.94 (1.15–30.6), p = 0.03, and 8.69 (1.27–58.8), p = 0.02, respectively) [13].
Similar results were obtained from two large prospective studies from Japan [11] and China [14] on the risk of the reactivation of hepatitis B in a large number of patients treated with immunosuppressive drugs for a rheumatic disease. In the Japanese study, which enrolled 1042 patients over 2 years, low (<100 mIU/mL) or no (<10 mIU/mL) anti-HBsAg titres were one of the risk factors (together with age >69 years) for HBV-R. In the Chinese study, 380 patients were prospectively evaluated from 2013 to 2017 during antirheumatic therapy with biological agents. The study showed an incidence rate of HBV-R of 4.7/100 persons a year, 2.5/100 persons a year and 0/100 persons a year for the groups of patients with a negative anti-HBsAg titre (<10 UI mL), a low anti-HBsAg titre (10–100 IU/mL), and a high anti-HBsAg titre (>100 IU/mL), respectively.
These results were confirmed also by a recent study showing that an anti-HBs titer < 100 mIU/mL at baseline is the only virological marker correlated with a higher risk of developing HBV-R (55.6% of pts with anti-HBs < 100 mIU/mL vs 0% with anti-HBs > 100 mIU/mL experienced HBV-R, p = 0.046) [23].
Overall, these findings support the idea that the progressive weakening of humoural responses can play an important role in driving HBV-R. A low/undetectable anti-HBs titre can thus be useful in identifying patients at higher HBV-R risk who could benefit from vaccination to elevate the antibody titres.

3.2. Anti-HBc Titres

Beyond anti-HBs, anti-HBc titres can play a role in identifying patients at a higher HBV-R risk who can be candidates for antiviral prophylaxis. In this regard, a recent study has analysed liver biopsies from 100 transplant donors positive for anti-HBc with standard serologic testing [24]. cccDNA was detected in 52% of samples [24]. The authors found that the median anti-HBc titres were significantly higher in cccDNA-positive than negative liver tissues (17.0 (7.0–39.2) vs. 5.7 (3.6–9.7) cut-off index (COI), p = 0.007) [24]. Interestingly, by multivariate analysis, an anti-HBc IgG titre >4.4 COI was correlated with cccDNA detection (OR: 8.516, p = 0.009). Thus, such a threshold can be indicative of cccDNA persistence in the liver of patients with a resolved HBV infection. It is conceivable that such cccDNA can drive the production of viral antigens (albeit at minimal levels) capable of stimulating anti-HBc production.
In only two studies was the anti-HBc titre correlated with reactivation in the immunocompromised host, and it is always associated with the presence or absence of antibodies to HBsAg. Yang and colleagues [16] focused on 197 patients with lymphoma and resolved HBV infection. In this study, HBV-R occurred in 12.2% of patients with an incidence of 11.6/100 person-years. Interestingly, the authors found that patients with an anti-HBc titre ≥ 6.41mIU/mL and an anti-HBs titre < 56.48 mIU/mL were characterized by the highest risk of HBV-R (HR (95% CI): 17.29 (3.92–76.30), p < 0.001) and by an inferior overall survival (HR (95% CI): 2.41 (1.15–5.05), p = 0.02) [16]. According to these results, the authors suggest that baseline anti-HBc/anti-HBs levels can help identify patients at high risk of HBV-R who should receive antiviral prophylaxis. In this regard, a Japanese study conducted on 77 patients with lymphoma and signs of resolved hepatitis shows that the combination of anti-HBc and anti-HBs levels may be useful for predicting the development and timing of chemotherapy-induced hepatitis [15]. Unexpectedly, the authors demonstrated that anti-HBsAg-negative patients with high anti-HBc titres (>10 signal to cut off ratio (S/CO)) prior to chemotherapy experienced a significantly higher rate of HBV reactivation than patients with both low anti-HBc (<10 S/CO) and high anti-HBs levels (>28 mIU/mL) who did not completely reactivate.

3.3. HBcrAg

A unique recent study focused on the role of HBcrAg in predicting HBV-R [17]. By analysing 124 oncohaematological patients with serologically resolved HBV infection, Seto and colleagues showed that HBcrAg positivity at baseline was significantly associated with HBV-R (HR (95% CI): 2.94 (1.43–6.07), p = 0.004). In particular, HBcrAg-positive patients were characterized by a significantly higher HBV-R rate than HBcrAg-negative patients (71.8 vs. 31%, p = 0.002). Furthermore, in a subgroup of patients receiving rituximab, positivity to HBcrAg and negativity to anti-HBs were independent factors associated with a higher HBV-R risk (HR (95% CI): 3.65 (1.35–9.86), p = 0.011 and 2.84 (1.10–7.37), p = 0.032, respectively).
Overall, these results support the role of HBcrAg in identifying patients with transcriptionally active cccDNA who can be more prone to HBV-R, thus benefitting from antiviral prophylaxis.

3.4. Serum HBV-RNA

As mentioned in the previous paragraph, another intriguing biomarker is represented by serum HBV-RNA. This biomarker measures the number of virions containing pre-genomic RNA that are released from infected hepatocytes. Interestingly, recent studies have shown that RNA-containing virions can be the prominent type of virion during nucleoside analogue (NUC) treatment since pre-genomic RNA is not converted into DNA by HBV reverse transcriptase [25,26]. The only demonstration of a correlation between HBV-RNA elevation and immunosuppressive drugs is an in vitro study in which the exposure of HepG2 cells to epirubicin determined elevated levels of HBV-DNA and pre-genomic HBV-RNA [27].
Until now, the role of serum HBV-RNA in the setting of human immunosuppression-driven HBV-R has not been investigated, even if it is possible to argue that this biomarker could help in identifying a transcriptionally active cccDNA during the administration of antiviral prophylaxis, thus helping in optimizing the duration of antiviral prophylaxis.

3.5. Ultra-Sensitive HBsAg

The lower limit of detection (LLOD) of the currently available assays for HBsAg detection is 5 mIU/mL. Thus far, more sensitive assays for HBsAg detection and quantification (LLOD: 0.5 mIU/mL) have been developed. These assays could be useful in patients with a resolved HBV infection to identify minimal cccDNA transcriptional activity and, in turn, minimal HBV replication. Shinkai and co-authors [8] compared three ultra-sensitive HBsAg assays to study serum samples from 120 patients with haematological malignancy receiving systemic chemotherapy; in particular, in 13 subjects with demonstrated HBV-R by HBV-DNA elevation. The authors show how a semi-automated immune complex transfer chemiluminescence enzyme technique (ICT-CLEIA) was able to detect the presence of HBsAg on 12 of 13 patients (in two cases, even before HBV-DNA elevation) with a sensitivity comparable to the evaluation of HBV-DNA. Despite these interesting results, there are limited applications of these assays in the field of immunocompromised patients. A recent observation suggests that the on-monitoring analysis of ultra-sensitive HBsAg might be another risk factor for HBV-R [23]. Nevertheless, further investigation is needed to unravel this topic which could help in identifying patients prone to being HBV-R candidates for antiviral prophylaxis.

4. Future Perspectives on the Use of Biomarkers for Predicting HBV-R

Overall, the findings support the use of innovative biomarkers in identifying patients who are more prone to developing HBV-R and who are candidates to receive antiviral prophylaxis. Nevertheless, further issues should be addressed. In particular, the role of innovative biomarkers has been mainly investigated in oncohaematological patients with a resolved HBV infection at a higher risk of HBV-R. Further studies are needed to unravel the role of biomarkers in patients with an intermediate or a low risk of HBV-R. This is critical for the tailored management of preventive strategies for patients at risk of HBV-R.
The current guidelines recommend antiviral prophylaxis administered for 12–18 months after stopping the administration of immunosuppressive drugs in patients at a high risk of HBV-R with HBeAg-negative CHB or with resolved HBV infection [28]. Nevertheless, the duration of antiviral prophylaxis is still under debate, since several cases of HBV-R have been described after prophylaxis suspension, particularly in the setting of profound immune suppression [29,30,31,32,33,34]. The role of biomarkers in identifying patients with or without a transcriptionally active cccDNA deserves further investigation to identify patients who should continue or interrupt antiviral prophylaxis.
Finally, another setting in which the role of innovative biomarkers should be investigated is represented by HIV co-infection. Interestingly, a recent study has highlighted the issue of HBV reactivation in anti-HBc positive HBsAg-negative patients switching to an antiretroviral regimen not including drugs with anti-HBV activity [35]. Studies addressing the role of biomarkers in detecting minimal HBV replication can help to identify patients who should continue or should safely suspend tenofovir.

5. Detection of Mutational Profiles in HBsAg by Genotypic Testing

The biomarkers described so far can be useful when starting an immunosuppressive treatment to identify patients with a higher risk of HBV-R, whereas, in patients experiencing HBV-R, the characterization of mutational profiles in HBsAg can be useful. Indeed, several studies have highlighted a high degree of genetic variability of HBsAg in patients experiencing immune-suppression-driven HBV-R [31,32,36,37,38,39,40]. In particular, a previous study identified specific genetic signatures of HBsAg that were significantly correlated with the status of HBV-R [32]. Notably, the majority of these mutations reside in the major hydrophilic HBsAg region (MHR), the main B cell HBsAg epitope target of neutralizing antibodies, and are known to hamper HBsAg recognition from antibodies. Among them, D144E has been implicated in immune escape and/or diminished affinity for monoclonal antibodies [41]. This mutation has also been described in a case of the corticosteroid-induced reactivation of latent hepatitis B virus infection in an HIV-positive patient [37]. Similarly, an enrichment of mutations at HBsAg position 145 (G145A/R) was detected in patients with HBV-R. Mutations at this position are known not only to reduce the HBsAg affinity for neutralizing antibodies but also to abrogate the production of neutralizing antibodies in a murine model [42]. Overall, the clustering of mutations associated with HBV-R in HBsAg immune-active regions suggests that these mutations may contribute to the re-uptake of viral replication during the progressive weakening of the immune system.
Recent studies have shown that the presence of immune-escape mutations at the start of anti-HBV treatment can hamper the subsequent achievement of HBsAg loss [43,44]. Thus, such mutations can hinder the return to an HBsAg-negative status during NUC treatment in HBV-reactivated patients with a previously resolved HBV infection.
Furthermore, recent studies have shown that a substantial proportion (approximately 20% in European studies) of patients who were HBsAg-negative and anti-HBc-positive at screening remained HBsAg-negative despite the reactivation of viral replication and high levels of serum HBV DNA [32,36,45]. Again, this can be ascribed to the genetic characteristics of HBsAg observed in patients with HBV-R. In particular, a previous study has highlighted an enrichment of N-linked glycosylation sites in HBsAg in patients remaining HBsAg negative despite viral reactivation [32]. N-linked glycosylation sites play a critical role in the viral evasion from humoural responses since the glycan shield can mask the B-cell epitope target of neutralizing antibodies [46,47]. In this regard, a recent study has shown that the N-linked glycosylation sites detected in HBV-reactivated patients profoundly affect HBsAg recognition by antibodies in vitro [32]. These findings reinforce the role of immune-escape mutations in immune-suppression-driven HBV-R. At the same time, this highlights the importance of considering serum HBV-DNA or innovative HBsAg assays targeting HBsAg epitopes outside the major hydrophilic region (MHR) in the diagnosis of HBV-R.
Finally, due to the peculiar organization of the HBV genome, the gene encoding HBsAg overlaps with the gene encoding reverse transcriptase (RT). This implies that some immune-escape HBsAg mutations can introduce mutations in HBV RT, which can have implications for the efficacy of lamivudine prophylaxis. Indeed, previous studies have demonstrated that these RT mutations can restore the viral replication capacity impaired by the classical lamivudine resistance mutations M204I/V [48,49]. This suggests that the high degree of HBsAg variability observed in patients with HBV-R may provide a genetic backbone that may contribute to the emergence of drug-resistance mutations. This concept also has implications in the setting of antiviral prophylaxis, supporting the use of more potent anti-HBV drugs to prevent HBV-R, particularly in patients with chronic HBeAg-negative infection.

6. Conclusions

In conclusion, a series of new biomarkers have been correlated with the different phases of HBV infection; however, as mentioned above, their applications in the diagnosis and monitoring of HBV-R during immunosuppressive treatments are insufficient to establish their correct positioning in the diagnosis of HBV-R.
To date, it seems likely that anti-HBs and anti-HBc titre assays could be the most readily applicable assays. Their use in clinical practice could reasonably provide useful information about the level of specific protective responses during immunosuppressive treatments and stimulate possible considerations regarding the use of the HBV vaccine with the purpose of enhancing the immune response. The ultra-sensitive HBsAg levels assay could replace HBV-DNA detection; however, we are still far from the routine use of tests for the assessment of the HBV reservoir (HBcrAg, HBV-RNA).
Finally, it seems useful to reinforce the importance of resistance mutation studies on HBV isolates from patients experiencing a reactivation of the infection, given the relevant implications that they have in the diagnostic and therapeutic fields.

Author Contributions

All authors contributed equally to this paper with the conception and design of the study, literature review and analysis, drafting, critical revision and editing, and approval of the final version.

Funding

Valentina Svicher received travel grants and research funding from Diasorin, Fujirebio, Bristol Meyer Squibb, and Gilead. Sarmati Loredana received travel grants from Gilead, Merck, Bristol, and Pfizer, payment for lectures from Merck, Gilead, Bristol, and Abbvie, and research funding from Gilead.

Conflicts of Interest

There were no potential conflicts of interest in the drafting of the paper. All the other authors declare no conflict of interest.

References

  1. Perz, J.F.; Armstrong, G.L.; Farrington, L.A.; Hutin, Y.J.; Bell, B.P. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J. Hepatol. 2006, 45, 529–538. [Google Scholar] [CrossRef] [PubMed]
  2. Umemura, T.; Tanaka, E.; Kiyosawa, K.; Kumada, H. Japan de novo Hepatitis B Research Group. Mortality secondary to fulminant hepatic failure in patients with prior resolution of hepatitis B virus infection in Japan. Clin. Infect. Dis. 2008, 47, e52–e56. [Google Scholar] [CrossRef] [PubMed]
  3. Perrillo, R.P.; Gish, R.; Falck-Ytter, Y.T. American Gastroenterological Association Institute technical review on prevention and treatment of hepatitis B virus reactivation during immunosuppressive drug therapy. Gastroenterology 2015, 148, 221–244. [Google Scholar] [CrossRef] [PubMed]
  4. Loomba, R.; Liang, T.J. Hepatitis B Reactivation Associated with Immune Suppressive and Biological Modifier Therapies: Current Concepts, Management Strategies, and Future Directions. Gastroenterology 2017, 152, 1297–1309. [Google Scholar] [CrossRef] [PubMed]
  5. Sarmati, L.; Andreoni, M.; Antonelli, G.; Arcese, W.; Bruno, R.; Coppola, N.; Gaeta, G.B.; Galli, M.; Girmenia, C.; Mikulska, M.; et al. Recommendations for screening, monitoring, prevention, prophylaxis and therapy of hepatitis B virus reactivation in patients with haematologic malignancies and patients who underwent haematologic stem cell transplantation-a position paper. Clin. Microbiol. Infect. 2017, 23, 935–940. [Google Scholar] [CrossRef] [PubMed]
  6. Höner Zu Siederdissen, C.; Maasoumy, B.; Cornberg, M. New viral biomarkers for Hepatitis B: Are we able to change practice? J. Viral. Hepat. 2018, 25, 1226–1235. [Google Scholar] [CrossRef] [PubMed]
  7. Höner Zu Siederdissen, C.; Maasoumy, B.; Cornberg, M. What is new on HBsAg and other diagnostic markers in HBV infection? Best Pract. Res. Clin. Gastroenterol. 2017, 31, 281–289. [Google Scholar] [CrossRef]
  8. Shinkai, N.; Kusumoto, S.; Murakami, S.; Ogawa, S.; Ri, M.; Matsui, T.; Tamori, A.; Toyoda, H.; Ishida, T.; Iida, S.; et al. Novel monitoring of hepatitis B reactivation based on ultra-high sensitive hepatitis B surface antigen assay. Liver Int. 2017, 37, 1138–1147. [Google Scholar] [CrossRef]
  9. Seto, W.K.; Chan, T.S.; Hwang, Y.Y.; Wong, D.K.; Fung, J.; Liu, K.S.; Gill, H.; Lam, Y.F.; Lie, A.K.; Lai, C.L.; et al. Hepatitis B reactivation in patients with previous hepatitis B virus exposure undergoing rituximab-containing chemotherapy for lymphoma: a prospective study. J. Clin. Oncol. 2014, 32, 3736–3743. [Google Scholar] [CrossRef]
  10. Cho, Y.; Yu, S.J.; Cho, E.J.; Lee, J.H.; Kim, T.M.; Heo, D.S.; Kim, Y.J.; Yoon, J.H. High titers of anti-HBs prevent rituximab-related viral reactivation in resolved hepatitis B patient with non-Hodgkin’s lymphoma. J. Med. Virol. 2016, 88, 1010–1017. [Google Scholar] [CrossRef]
  11. Fukuda, W.; Hanyu, T.; Katayama, M.; Mizuki, S.; Okada, A.; Miyata, M.; Handa, Y.; Hayashi, M.; Koyama, Y.; Arii, K.; et al. Incidence of hepatitis B virus reactivation in patients with resolved infection on immunosuppressive therapy for rheumatic disease: A multicentre, prospective, observational study in Japan. Ann. Rheum. Dis. 2017, 7, 1051–1056. [Google Scholar] [CrossRef] [PubMed]
  12. Lee, J.; Park, J.Y.; Kim, D.G.; Lee, J.Y.; Kim, B.S.; Kim, M.S.; Kim, S.; Kim, Y.S.; Huh, K.H. Effects of rituximab dose on hepatitis B reactivation in patients with resolved infection undergoing immunologic incompatible kidney transplantation. Sci. Rep. 2018, 8, 15629. [Google Scholar] [CrossRef] [PubMed]
  13. Kotake, T.; Satake, H.; Okita, Y.; Hatachi, Y.; Hamada, M.; Omiya, M.; Yasui, H.; Hashida, T.; Kaihara, S.; Inokuma, T.; et al. Prevalence and risk factors of hepatitis B virus reactivation in patients with solid tumors with resolved HBV infection. Asia Pac. J. Clin. Oncol. 2019, 15, 63–68. [Google Scholar] [CrossRef] [PubMed]
  14. Tien, Y.C.; Yen, H.H.; Li, C.F.; Liu, M.P.; Hsue, Y.T.; Hung, M.H.; Chiu, Y.M. Changes in hepatitis B virus surface antibody titer and risk of hepatitis B reactivation in HBsAg-negative/HBcAb-positive patients undergoing biologic therapy for rheumatic diseases: A prospective cohort study. Arthritis Res. Ther. 2018, 20, 246. [Google Scholar] [CrossRef] [PubMed]
  15. Matsubara, T.; Nishida, T.; Shimoda, A.; Shimakoshi, H.; Amano, T.; Sugimoto, A.; Takahashi, K.; Mukai, K.; Yamamoto, M.; Hayashi, S.; et al. The combination of anti-HBc and anti-HBs levels is a useful predictor of the development of chemotherapy-induced reactivation in lymphoma patients with resolved HBV infection. Oncol. Lett. 2017, 14, 6543–6552. [Google Scholar] [CrossRef] [PubMed]
  16. Yang, H.C.; Tsou, H.H.; Pei, S.N.; Chang, C.S.; Chen, J.H.; Yao, M.; Lin, S.J.; Lin, J.; Yuan, Q.; Xia, N.; et al. Taiwan Cooperative Oncology Group. Quantification of HBV core antibodies may help predict HBV reactivation in patients with lymphoma and resolved HBV infection. J. Hepatol. 2018, 69, 286–292. [Google Scholar] [CrossRef] [PubMed]
  17. Seto, W.K.; Wong, D.K.; Chan, T.S.; Hwang, Y.Y.; Fung, J.; Liu, K.S.; Gill, H.; Lam, Y.F.; Cheung, K.S.; Lie, A.K.; et al. Association of Hepatitis B Core-Related Antigen With Hepatitis B Virus Reactivation in Occult Viral Carriers Undergoing High-Risk Immunosuppressive Therapy. Am. J. Gastroenterol. 2016, 111, 1788–1795. [Google Scholar] [CrossRef]
  18. Yuan, Q.; Song, L.W.; Liu, C.J.; Li, Z.; Liu, P.G.; Huang, C.H.; Yan, Y.; Ge, S.X.; Wang, Y.B.; Peng, C.Y.; et al. Quantitative hepatitis B core antibody level may help predict treatment response in chronic hepatitis B patients. Gut 2013, 62, 182–184. [Google Scholar] [CrossRef]
  19. Chi, H.; Li, Z.; Hansen, B.E.; Yu, T.; Zhang, X.; Sun, J.; Hou, J.; Janssen, H.L.A.; Peng, J. Serum Level of Antibodies Against Hepatitis B Core Protein Is Associated With Clinical Relapse After discontinuation of Nucleos(t)ide Analogue Therapy. Clin. Gastroenterol. Hepatol. 2019, 17, 182–191. [Google Scholar] [CrossRef]
  20. Wong, D.K.; Seto, W.K.; Cheung, K.S.; Chong, C.K.; Huang, F.Y.; Fung, J.; Lai, C.L.; Yuen, M.F. Hepatitis B virus core-related antigen as a surrogate marker for covalently closed circular DNA. Liver Int. 2017, 37, 995–1001. [Google Scholar] [CrossRef]
  21. Wang, J.; Shen, T.; Huang, X.; Kumar, G.R.; Chen, X.; Zeng, Z.; Zhang, R.; Chen, R.; Li, T.; Zhang, T.; et al. Serum hepatitis B virus RNA is encapsidated pregenome RNA that may be associated with persistence of viral infection and rebound. J. Hepatol. 2016, 65, 700–710. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  22. Chan, H.L.; Wong, V.W.; Tse, A.M.; Tse, C.H.; Chim, A.M.; Chan, H.Y.; Wong, G.L.; Sung, J.J. Serum hepatitis B surface antigen quantitation can reflect hepatitis B virus in the liver and predict treatment response. Clin. Gastroenterol. Hepatol. 2007, 5, 1462–1468. [Google Scholar] [CrossRef] [PubMed]
  23. Salpini, R.; Cerva, C.; Battisti, A.; Piermatteo, L.; Sacco, A.; Malagnino, V.; Arcese, W.; Cantonetti, M.; Ceccherini-Silberstein, F.; Perno, C.F.; et al. A close monitoring of virological and immunological hepatitis B markers can improve the diagnosis of HBV reactivation in HBsAg-negative/anti-HBc-positive patients with oncohematological diseases. Digestive Liver Dis. 2019, 51 Suppl. 1, e67. [Google Scholar]
  24. Caviglia, G.P.; Abate, M.L.; Tandoi, F.; Ciancio, A.; Amoroso, A.; Salizzoni, M.; Saracco, G.M.; Rizzetto, M.; Romagnoli, R.; Smedile, A. Quantitation of HBV cccDNA in anti-HBc-positive liver donors by droplet digital PCR: A new tool to detect occult infection. J. Hepatol. 2018, 69, 301–307. [Google Scholar] [CrossRef] [PubMed]
  25. Giersch, K.; Allweiss, L.; Volz, T.; Dandri, M.; Lütgehetmann, M. Serum HBV pgRNA as a clinical marker for cccDNA activity. J. Hepatol. 2017, 66, 460–462. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  26. Wang, J.; Sheng, Q.; Ding, Y.; Chen, R.; Sun, X.; Chen, X.; Dou, X.; Lu, F. HBV RNA virion-like particles produced under nucleos(t)ide analogues treatment are mainly replication-deficient. J. Hepatol. 2017. [Google Scholar]
  27. Xu, L.; Tu, Z.; Xu, G.; Wang, Y.; Pan, W.; Zhan, X.; Luo, Q.; Huang, Y.; Chen, J.; Huang, A. Epirubicin directly promotes hepatitis B virus (HBV) replication in stable HBV-expressing cell lines: a novel mechanism of HBV reactivation following anticancer chemotherapy. Mol. Med. Rep. 2014, 9, 1345–1350. [Google Scholar] [CrossRef] [PubMed]
  28. European Association for the Study of the Liver. Electronic address: [email protected]; European Association for the Study of the Liver. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. J. Hepatol. 2017, 67, 370–398. [Google Scholar] [CrossRef]
  29. Hammond, S.P.; Borchelt, A.M.; Ukomadu, C.; Ho, V.T.; Baden, L.R.; Marty, F.M. Hepatitis B virus reactivation following allogeneic hematopoietic stem cell transplantation. Biol. Blood Marrow Transplant. 2009, 15, 1049–1059. [Google Scholar] [CrossRef]
  30. Hwang, J.P.; Lok, A.S. Management of patients with hepatitis B who require immunosuppressive therapy. Nat. Rev. Gastroenterol. Hepatol. 2014, 11, 209–219. [Google Scholar] [CrossRef]
  31. Ceccarelli, L.; Salpini, R.; Sarmati, L.; Svicher, V.; Bertoli, A.; Sordillo, P.; Ricciardi, A.; Perno, C.F.; Andreoni, M.; Sarrecchia, C. Late hepatitis B virus reactivation after lamivudine prophylaxis interruption in an anti-HBs-positive and anti-HBc-negative patient treated with rituximab-containing therapy. J. Infect. 2012, 65, 180–183. [Google Scholar] [CrossRef] [PubMed]
  32. Salpini, R.; Colagrossi, L.; Bellocchi, M.C.; Surdo, M.; Becker, C.; Alteri, C.; Aragri, M.; Ricciardi, A.; Armenia, D.; Pollicita, M.; et al. Hepatitis B surface antigen genetic elements critical for immune escape correlate with hepatitis B virus reactivation upon immunosuppression. Hepatology 2015, 61, 823–833. [Google Scholar] [CrossRef] [PubMed]
  33. Cerva, C.; Maffongelli, G.; Svicher, V.; Salpini, R.; Colagrossi, L.; Battisti, A.; Mariotti, B.; Cerretti, R.; Cudillo, L.; Sarmati, L. Hepatitis B reactivation characterized by HBsAg negativity and anti-HbsAg antibodies persistence in haematopoietic stem cell transplanted patient after lamivudine withdrawal. BMC Infect. Dis. 2017, 15, 566. [Google Scholar] [CrossRef] [PubMed]
  34. Marrone, A.; Capoluongo, N.; D’Amore, C.; Pisaturo, M.; Esposito, M.; Guastafierro, S.; Siniscalchi, I.; Macera, M.; Boemio, A.; Onorato, L.; et al. Eighteen-month lamivudine prophylaxis on preventing occult hepatitis B virus infection reactivation in patients with haematological malignancies receiving immunosuppression therapy. J. Viral. Hepat. 2018, 25, 198–204. [Google Scholar] [CrossRef] [PubMed]
  35. Bloquel, B.; Jeulin, H.; Burty, C.; Letranchant, L.; Rabaud, C.; Venard, V. Occult hepatitis B infection in patients infected with HIV: report of two cases of hepatitis B reactivation and prevalence in a hospital cohort. J. Med. Virol. 2010, 82, 206–212. [Google Scholar] [CrossRef] [PubMed]
  36. Borentain, P.; Colson, P.; Coso, D.; Bories, E.; Charbonnier, A.; Stoppa, A.M.; Auran, T.; Loundou, A.; Motte, A.; Ressiot, E.; et al. Clinical and virological factors associated with hepatitis B virus reactivation in HBsAg-negative and anti-HBc antibodies-positive patients undergoing chemotherapy and/or autologous stem cell transplantation for cancer. J. Viral. Hepat. 2010, 17, 807–815. [Google Scholar] [CrossRef] [PubMed]
  37. Martel, N.; Cotte, L.; Trabaud, M.A.; Trepo, C.; Zoulim, F.; Gomes, S.A.; Kay, A. Probable corticosteroid-induced reactivation of latent hepatitis B virus infection in an HIV-positive patient involving immune escape. J. Infect. Dis. 2012, 205, 1757–1766. [Google Scholar] [CrossRef]
  38. Milazzo, L.; Ebranati, E.; Cattaneo, D.; Gabanelli, E.; Lai, A.; Zehender, G.; Gervasoni, C. Recurrence of another hepatitis B virus escape mutant comes back in a patient infected with HIV and low CD4+ count. J. Med. Virol. 2014, 86, 97–101. [Google Scholar] [CrossRef]
  39. Colson, P.; Borentain, P.; Coso, D.; Motte, A.; Aurran-Schleinitz, T.; Charbonnier, A.; Stoppa, A.M.; Chabannon, C.; Serrero, M.; Bertrand, J.; et al. Hepatitis B virus reactivation in HBsAg-negative patients is associated with emergence of viral strains with mutated HBsAg and reverse transcriptase. Virology 2015, 484, 354–363. [Google Scholar] [CrossRef] [Green Version]
  40. Coppola, N.; Loquercio, G.; Tonziello, G.; Azzaro, R.; Pisaturo, M.; Di Costanzo, G.; Tonziello, G.; Starace, M.; Pasquale, G.; Cacciapuoti, C.; et al. HBV transmission from an occult carrier with five mutations in the major hydrophilic region of HBsAg to an immunosuppressed plasma recipient. J. Clin. Virol. 2013, 58, 315–317. [Google Scholar] [CrossRef]
  41. Protzer-Knolle, U.; Naumann, U.; Bartenschlager, R.; Berg, T.; Hopf, U.; Meyer zum Büschenfelde, K.H.; Neuhaus, P.; Gerken, G. Hepatitis B virus with antigenically altered hepatitis B surface antigen is selected by high-dose hepatitis B immune globulin after liver transplantation. Hepatology 1998, 27, 254–256. [Google Scholar] [CrossRef] [PubMed]
  42. Wu, C.; Deng, W.; Deng, L.; Cao, L.; Qin, B.; Li, S.; Wang, Y.; Pei, R.; Yang, D.; Lu, M.; et al. Amino acid substitutions at positions 122 and 145 of hepatitis B virus surface antigen (HBsAg) determine the antigenicity and immunogenicity of HBsAg and influence in vivo HBsAg clearance. J. Virol. 2012, 8, 4658–4669. [Google Scholar] [CrossRef] [PubMed]
  43. Charuworn, P.; Hengen, P.N.; Aguilar Schall, R.; Dinh, P.; Ge, D.; Corsa, A.; Reesink, H.W.; Zoulim, F.; Kitrinos, K.M. Baseline interpatient hepatitis B viral diversity differentiates HBsAg outcomes in patients treated with tenofovir disoproxil fumarate. J. Hepatol. 2015, 62, 1033–1039. [Google Scholar] [CrossRef] [PubMed]
  44. Velay, A.; Jeulin, H.; Eschlimann, M.; Malvé, B.; Goehringer, F.; Bensenane, M.; Frippiat, J.P.; Abraham, P.; Ismail, A.M.; Murray, J.M.; et al. Characterization of hepatitis B virus surface antigen variability and impact on HBs antigen clearance under nucleos(t)ide analogue therapy. J. Viral. Hepat. 2016, 23, 387–398. [Google Scholar] [CrossRef] [PubMed]
  45. Seto, W.K.; Chan, T.S.; Hwang, Y.Y.; Wong, D.K.; Fung, J.; Liu, K.S.; Gill, H.; Lam, Y.F.; Lau, E.H.Y.; Cheung, K.S.; et al. Hepatitis B reactivation in occult viral carriers undergoing hematopoietic stem cell transplantation: A prospective study. Hepatology 2017, 65, 1451–1461. [Google Scholar] [CrossRef] [PubMed]
  46. Yu, D.M.; Li, X.H.; Mom, V.; Lu, Z.H.; Liao, X.W.; Han, Y.; Pichoud, C.; Gong, Q.M.; Zhang, D.H.; Zhang, Y.; et al. N-glycosylation mutations within hepatitis B virus surface major hydrophilic region contribute mostly to immune escape. J. Hepatol. 2014, 60, 515–522. [Google Scholar] [CrossRef]
  47. Julithe, R.; Abou-Jaoudé, G.; Sureau, C. Modification of the hepatitis B virus envelope protein glycosylation pattern interferes with secretion of viral particles, infectivity, and susceptibility to neutralizing antibodies. J. Virol. 2014, 88, 9049–9059. [Google Scholar] [CrossRef] [PubMed]
  48. Bock, C.T.; Tillmann, H.L.; Torresi, J.; Klempnauer, J.; Locarnini, S.; Manns, M.P.; Trautwein, C. Selection of hepatitis B virus polymerase mutants with enhanced replication by lamivudine treatment after liver transplantation. Gastroenterology 2002, 122, 264–273. [Google Scholar] [CrossRef]
  49. Amini-Bavil-Olyaee, S.; Vucur, M.; Luedde, T.; Trautwein, C.; Tacke, F. Differential impact of immune escape mutations G145R and P120T on the replication of lamivudine-resistant hepatitis B virus e antigen-positive and -negative strains. J. Virol. 2010, 84, 1026–1033. [Google Scholar] [CrossRef]
Table
Table 1. Summary of studies led in patients with resolved hepatitis B virus (HBV) infection addressing the role of HBV biomarkers in predicting HBV reactivation.
Table 1. Summary of studies led in patients with resolved hepatitis B virus (HBV) infection addressing the role of HBV biomarkers in predicting HBV reactivation.
Advantages of New HBV Markers Tests ReferenceNo. of PatientsClinical Setting% of HBV-R *Association of Biomarker with Risk of HBV-R
HBsAg Titer
HBsAg detection at lower limit (0.5 mIU/mL) predictive of HBV-RSkinkai et al. Liver Int. 2017 [8]120 (13 with HBV-RNA detectable)Oncohematological HBV-resolved patients100%Architect HBsAg-QT (detection limit:50 mIU/mL), HBsAg-HQ (5 mIU/mL) and ICT-CLEIA (0.5 mIU/mL) were used to test stored samples. ICT-CLEIA was detected in all 12 patients (100%) with a sensitivity comparable to HBV-DNA
Anti-HBs Titer
Low anti-HBsAg levels (<100 UI/mL) and major risk of HBV-RSeto et al. 2014 [9]260Oncohematological patients receiving rituximab30.2%Anti-HBs negativity at baseline:
HR (95%CI):3.51(1.37–8.98), p = 0.009
Cho Y et al. 2016 [10]108B-cell lymphoma receiving rituximab not antiviral prophylaxis11.6%Anti-HBs < 100 IU/mL
HBV-R rates at 6, 12, 36, and 48 months after chemotherapy as high as 8.3, 17.3, 21.1, and 25.7%
Fukuda et al. 2016 [11]1042Rheumatic diseases3.3%Anti-HBs < 100 IU/mL
OR (95% CI): 2.8 (1.3 to 6.8)
Lee et al. 2018 [12]366Kidney-transplanted patients using rituximab for desensitization2.5%Anti-HBs < 100 IU/L at transplantation:
HR (95% CI): 9.06 (1.11–74.3), p = 0.04
standard-dose rituximab at transplantation:
HR (95% CI): 10.60 (2.52–44.60), p = 0.001
Kotake et al. 2018 [13]243Patients with solid tumors2.1%Anti-HBs negativity at baseline:
OR (95% CI):5.94 (1.15–30.6), p = 0.03
dexamethasone > 1.0 mg/day at baseline:
OR (95% CI): 8.69 (1.27–58.8), p = 0.02
Tien et al. 2018 [14]380Rheumatic diseases treated with biologic therapy4.4%Anti-HBs > 100 IU/mL at baseline
Rate of HBV-R person year 0/100
Anti-HBs 10–100 IU/mL at baseline
Rate of HBV-R person year 2.5/100 Anti-HBs < 10 IU/mL at baseline
Rate of HBV-R person year 4.7/100
Anti HBc Titer
Combination of anti-HBc/anti-HBs low levels identify high risk of HBV-RMatsubara et al. 2017 [15]77Lymphoma patients12.9%Anti-HBcAb < 10 (S/CO) at baseline
OR(95% CI) 0.11 (0.013–0.665), p = 0.016
Anti-HBcAb < 28 (mUI/mL) at baseline
OR(95% CI) 10.5 (1.749–105.993), p = 0.009
Yang et al. 2018 [16]197Oncohematological patients12.2%AntiHBs < 56.48 mIU/mL + anti-HBc ≥ 6.41IU/mL at baseline: HR (95% CI):17.29 (3.9–76.3), p < 0.001
HBcrAg Presence
HBcrAg positivity associated with HBV-RSeto et al. 2016 [17]124Oncohematological patients25%HBcrAg positivity at baseline:
HR (95% CI): 2.94 (1.43–6.07), p = 0.004
62Oncohematological patients receiving rituximab29%HBcrAg positivity at baseline:
HR(95% CI):3.65(1.35–9.86), p = 0.011
anti-HBs negativity at baseline:
HR (95% CI): 2.84 (1.10–7.37), p = 0.032
* HBV-R = HBV reactivation; ICT-CLEIA: immune complex transfer chemiluminescence enzyme technique.

Share and Cite

MDPI and ACS Style

Svicher, V.; Salpini, R.; Malagnino, V.; Piermatteo, L.; Alkhatib, M.; Cerva, C.; Sarmati, L. New Markers in Monitoring the Reactivation of Hepatitis B Virus Infection in Immunocompromised Hosts. Viruses 2019, 11, 783. https://doi.org/10.3390/v11090783

AMA Style

Svicher V, Salpini R, Malagnino V, Piermatteo L, Alkhatib M, Cerva C, Sarmati L. New Markers in Monitoring the Reactivation of Hepatitis B Virus Infection in Immunocompromised Hosts. Viruses. 2019; 11(9):783. https://doi.org/10.3390/v11090783

Chicago/Turabian Style

Svicher, Valentina, Romina Salpini, Vincenzo Malagnino, Lorenzo Piermatteo, Mohammad Alkhatib, Carlotta Cerva, and Loredana Sarmati. 2019. "New Markers in Monitoring the Reactivation of Hepatitis B Virus Infection in Immunocompromised Hosts" Viruses 11, no. 9: 783. https://doi.org/10.3390/v11090783

APA Style

Svicher, V., Salpini, R., Malagnino, V., Piermatteo, L., Alkhatib, M., Cerva, C., & Sarmati, L. (2019). New Markers in Monitoring the Reactivation of Hepatitis B Virus Infection in Immunocompromised Hosts. Viruses, 11(9), 783. https://doi.org/10.3390/v11090783

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop