BACKGROUND AND AIMS:Hepatitis E virus (HEV) infection is very frequent in Europe with more than 2 million annual infections. Patients with liver cirrhosis may face an increased risk of suffering from acute-on-chronic liver failure (ACLF) due to HEV infection. We explored the consequences and prevalence of HEV infection in individuals with liver cirrhosis. METHODS:We retrospectively analysed the clinical outcome of all consecutive patients who were hospitalized at our center due to acute HEV infection and analysed their outcome between 2014 and 2024. Next, we tested 249 sera from 184 cirrhotic patients during individual episodes of acute hepatic decompensation for anti-HEV IgM and HEV-RNA to analyse the relevance of acute HEV infection as a triggering event. Finally, we established a single center cohort of patients with advanced liver cirrhosis, and assessed the anti-HEV IgG seroprevalence (n = 332). RESULTS:Over the past decade, 32 patients with liver cirrhosis who were hospitalized due to acute HEV infection were identified. Among these patients, 16 (50%) developed ACLF, resulting in five fatalities (31.3%) and three individuals (18.8%) requiring liver transplantation for survival. Of 249 sera obtained during acute hepatic decompensation, 11 (4.4%) were either HEV-RNA positive (n = 2) and/or anti-HEV IgM positive (n = 10), linking HEV infection to these acute decompensations. Screening of patients with liver cirrhosis for anti-HEV IgG showed that 67.2% of patients (223/332) were anti-HEV negative and thus at potential risk for future HEV infection. CONCLUSIONS:Patients with advanced liver cirrhosis are at risk of acute HEV infection, which is a relevant cause of hepatic decompensation and ACLF with high mortality in these patients. TRIAL REGISTRATION:DRKS00010664; NCT04801290.

Acute infection with hepatitis C virus (HCV) is a rare event that can be treated successfully with direct-acting antivirals (DAAs). As natural killer (NK) cells play an important role during the natural course of acute HCV, we assessed the NK cell compartment via flow cytometry and single-cell sequencing in longitudinally sampled patients with acute HCV and compared this to healthy controls and patients with chronic HCV. At the transcriptomic level, we identified a subset of highly activated NK cells with a robust type I interferon imprint. While the population of activated NK cells vanished after DAA-mediated cure, a long-term phenotypic imprint of infection was observed in comparison to healthy controls. Collectively, these data suggest an interferon-driven rise of an activated NK cell population during acute hepatitis C that is largely restored upon viral clearance. This study provides insights into the immunological basis for successful antiviral response to hepatitis C.

BACKGROUND AND AIMS:Bulevirtide (BLV) is a novel and the only approved treatment option for patients with chronic hepatitis D (CHD). BLV alleviates liver inflammation early during treatment when only minor HDV RNA changes are observed. We hypothesized that BLV treatment may influence immune cells in patients with CHD and performed a high-resolution analysis of natural killer (NK) cells before and during BLV therapy. APPROACH AND RESULTS:BLV-treated patients with CHD (n=20) from a single-center cohort were longitudinally analyzed for clinical, molecular, and virological parameters. Peripheral blood mononuclear cells were studied at baseline, and therapy weeks 3 and 48 by spectral flow cytometry. Healthy donors, patients with chronic hepatitis C after direct-acting antiviral treatment, and patients with chronic hepatitis B were used as controls. Overall, NK cell frequencies remained stable during BLV treatment. However, biochemical responders showed distinct NK cell immunophenotypic features before and during therapy. TIGIT expression increased on CD56 dim and CD56 bright NK cells during the course of BLV treatment and inversely correlated with ALT levels in CHD but not patients with CHC or CHB. High frequencies of TIGIT - CD57 + CD56 dim NK cells at baseline and low levels during therapy were indicative of a biochemical response. CONCLUSIONS:We here suggest that lacking the expression of the immune checkpoint inhibitor TIGIT on NK cell subtypes may be a hallmark of liver inflammation in HDV infection. BLV therapy is associated with a reappearance of TIGIT on these cells, which may be one mechanism of why liver enzymes rapidly improve during therapy.

BACKGROUND:Metabolic dysfunction-associated steatotic liver disease (MASLD) is a major cause of chronic liver disease. Metabolic dysfunction-associated steatohepatitis (MASH), a progressive form of MASLD, can lead to fibrosis and cirrhosis. The incidence and burden of MASH in Germany are expected to double by 2030, while diagnostic and management challenges persist. Expert consensus on diagnostic strategies and treatment modalities in MASLD and MASH is required. OBJECTIVES:The panel aimed to gather insights and consensus on the diagnostic pathway and current treatment modalities for MASH in Germany. METHODS:A three-round web-based survey, integrating Delphi panel methodology with a standard survey, was conducted from February to May 2024 to reach consensus on predefined questions. The survey involved 12 gastroenterology, diabetology and/or hepatology specialists in Germany. RESULTS:The Delphi panel revealed that ~75% of MASH patients in Germany remain undiagnosed. Non-invasive measures, such as fibrosis scores (values from clinical and imaging tests to assess fibrosis), liver enzyme tests and liver stiffness measurement, were primary methods for diagnosing and monitoring MASH patients. Lifestyle modifications were the primary management strategy, given the absence of approved pharmacological treatments for MASH. The panel also highlighted significant challenges in managing MASH, including the lack of approved medications and the difficulty in sustaining lifestyle changes. CONCLUSIONS:The survey underscores the substantial underdiagnosis of MASH and the reliance on non-invasive diagnostic methods in Germany. The lack of approved treatments necessitates a focus on lifestyle modifications and comorbidity management. The Delphi panel's insights call for enhanced screening, early detection and standardised algorithms to improve patient outcomes.

ABSTRACTBackground and AimsChronic hepatitis D virus (HDV) infection can cause severe liver disease. With new treatment options available, it is important to identify patients at risk for liver‐related complications. We aimed to investigate kinetics and predictive values of novel virological and immunological markers in the natural course of chronic HDV infection.MethodsHBcrAg, HBV RNA and quantitative anti‐HBc were analysed in samples from HDV‐infected patients at three consecutive time points. Results were linked to clinical outcome by univariable and multivariable analyses. Primary endpoint was the composite endpoint of any liver‐related event.ResultsSamples from 190 individual patients were analysed with a median clinical follow‐up time of 2.69 (IQR 1.13–6.51) years. The majority of patients had cirrhosis (98/190, 52%), and the primary endpoint occurred in 33% (62/190). In univariable analysis, age, cirrhosis, lower quantitative anti‐HBc, higher ratio of HBcrAg/anti‐HBc and detectable HDV RNA were associated with the primary endpoint. In multivariable analysis, only the presence of liver cirrhosis (HR 7.74, p < 0.001) and age (1.06, p < 0.001) remained independently associated with the primary endpoint. Kinetics of virological parameters during follow‐up were similar between the groups. Quantitative anti‐HBc was significantly lower in patients with liver cirrhosis (687 (IQR 188–3388) IU/ml vs. 309 (IQR 82–924) IU/ml, p < 0.0004), and lower levels were independently associated with the development of the primary endpoint (HR 1.0, p = 0.014).ConclusionIn chronic HDV infection, neither baseline values nor kinetics of HBV RNA, HBcrAg and anti‐HBc were independently associated with clinical outcome, while stage of liver disease and age were predictors of liver‐related events.

BACKGROUND:Bulevirtide (BLV) is the only approved therapy for chronic hepatitis D (CHD) and compensated liver disease. Daily subcutaneous injection and the need for refrigeration may pose challenges, especially in patients with limited language proficiency. AIMS:Assessment of patient-reported BLV handling and satisfaction and association with virologic response. METHODS:Patients receiving BLV were assessed using a structured questionnaire on injection preparation, administration, refrigeration, adverse effects, and language proficiency. Virologic response was defined as complete (≥ 2 log10 reduction from baseline or HDV RNA undetectable), intermediate (≥ 1 log10 but < 2 log10 reduction), non-response (< 1 log10 reduction or increase), or breakthrough (> 1 log10 increase after ≥ 2 log10 reduction). RESULTS:A total of 115 patients from 30 countries were recruited at 12 German centres. German language skills were rated as good, sufficient, poor or absent in 58%, 25% and 17% of cases. Reported difficulties included injection preparation (17%), administration (25%) and refrigeration (27%). Patients without virologic response or with viral breakthrough reported difficulties with injection administration in 56% compared to 17% with intermediate or complete response (p = 0.0002), while no differences were observed regarding preparation or refrigeration. Injection site reactions occurred in 57% of patients. Overall, 82% were satisfied with the practical handling and 94% with the tolerability of BLV. Good language proficiency was associated with greater satisfaction with the practical handling (p = 0.0067), which in turn correlated with virologic response (p = 0.0001). CONCLUSIONS:BLV administration is generally well manageable. Limited language proficiency and injection difficulties may negatively affect patient satisfaction and potentially influence treatment outcomes. TRIAL REGISTRATION:German Clinical Trials Registry (DRKS 00033153).

Background & Aims:Portal hypertension (PH) drives decompensation in patients with advanced chronic liver disease. Effects of antiviral treatment with bulevirtide (BLV) and achievement of suggested treatment endpoints on PH in patients with chronic hepatitis D (CHD) are unknown. Methods:BLV-treated CHD patients with PH were prospectively enrolled in this observational, multicenter study. Hepatic venous pressure gradient (HVPG) was measured before (BL) and after ≥12 months of BLV treatment (M12). HVPG response (≥10% decline) rates were compared between virological (VR), biochemical (BR), and combined (CR) responders vs. non-responders as defined in the BLV phase III studies. Associated changes in biomarkers of bacterial translocation, (dys)angiogenesis/endothelial dysfunction, and systemic inflammation (SI) were investigated. Results:Of 34 patients receiving BL HVPG measurement, 20 patients with paired HVPG measurement and a BL clinically significant portal hypertension (CSPH) (≥10 mmHg HVPG) prevalence of 85% were included. At M12, HVPG significantly decreased in patients with CR (n = 12; 15.5 [IQR 10.5-21.8] to 12 [IQR 7.3-15.8] mmHg; p <0.001), VR (n = 14; 14.5 [IQR 10-21.3] to 12 [IQR 7.8-16.5] mmHg, p = 0.003), and BR (n = 16; 12.5 [IQR 10-20.5] to 10.5 [IQR 8-15] mmHg, p = 0.002); but not in non-responders. All patients with CSPH with CR (n = 10/10) and most of VR (83%, n = 10/12) and BR (85%, n = 11/13) achieved HVPG response, but no BLV non-responder. CSPH resolved in three of 17 (17.6%) patients. Markers of bacterial translocation (sCD163; p = 0.001), (dys)angiogenesis/endothelial dysfunction (Ang2; p = 0.001) and SI (IFNγ, IL-1RA, sCD25/IL-2Rα, CCL3/MIP-1alpha, HGF; all p <0.05) decreased in responders but not in non-responders. Conclusions:Significant HVPG decreases accompanied by improvement of bacterial translocation, (dys)angiogenesis/endothelial dysfunction and SI are observed in patients with CHD achieving BLV response. These findings provide evidence for the validity and clinical relevance of the currently recommended on-treatment response criteria. Clinical trials registration:This study is registered at ClinicalTrials.gov (NCT04863703). Impact and implications:Portal hypertension is the main mechanism driving clinical deterioration in patients with compensated advanced chronic liver disease, for which patients with chronic hepatitis D (CHD) are at particularly high risk. This study demonstrates that in patients with CHD with portal hypertension, achieving response to antiviral treatment with bulevirtide decreases the hepatic venous pressure gradient (HVPG). Importantly, a clinical meaningful reduction in HVPG was observed only in treatment responders as defined by endpoints used in clinical trials, in particular, in all patients achieving combined response. Biomarkers of important pathophysiological mechanisms were also improved. The finding of a clinical meaningful HVPG decline in patients with CHD responding to antiviral treatment strengthens the clinical significance of the suggested on-treatment response criteria, supporting a disease-modifying effect of BLV response, likely translating into decreased morbidity and mortality in patients with CHD.

Hepatitis B (HBV) and C (HCV) virus coinfection is linked to a higher risk of cirrhosis and hepatocellular carcinoma (HCC) compared to monoinfection. Despite this, data are limited, and further investigation is needed to understand the underlying mechanisms. While patients are classified based on dominance patterns, the impact on the immune system remains largely unknown. It is recognised that HBV reactivation may occur following HCV clearance. This study aims to explore the potential immune interactivity between HCV and HBV by analysing patterns of soluble immune mediators (SIM). A total of 58 soluble immune mediators were measured in serum or plasma samples of 49 patients chronically infected with hepatitis B and hepatitis C virus in a cross-sectional study design. Patients were classified based on dominance patterns: HBV dominance (n = 8), HCV dominance (n = 22), HBV and HCV codominance (n = 11) and no dominance (n = 8). SIM expression was distinct based on different dominance patterns. HBV activity induced higher SIM expression and altered the soluble inflammatory milieu (22 SIM altered, p < 0.05). Altered pathways included JAK-STAT pathway (p = 1.36 × 10-20), IL-17 signalling (p = 2.47 × 10-13) and Th17 cell differentiation (p = 1.69 × 10-9). CCL27/CTACK (r = -0.69, p = 7.02 × 10-6) and SDF-1alpha (r = -0.55, p = 0.002) correlated inversely with HCV-RNA. Serologically classifying dominance patterns in HBV and HCV coinfection may manifest in a distinct soluble inflammatory milieu. Elevated HBV activity correlates with an increased expression of soluble immune mediators, particularly influencing the alteration of key signalling pathways such as JAK-STAT and the Th17/IL-17 axis. These changes have a potential role in the development of liver fibrosis.

Background/Aims Hepatitis C virus (HCV) infection remains a global health challenge, leading to chronic liver disease, cirrhosis, and hepatocellular carcinoma (HCC). Despite the high efficacy of direct-acting antiviral therapy in achieving sustained virologic response (SVR), concerns persist regarding long-term immune alterations and residual risks, particularly in cirrhotic patients. Methods This study investigates 75 soluble immune mediator (SIM) profiles in 102 chronic HCV patients, stratified by cirrhosis status, at therapy initiation, end of treatment, and long-term follow-up (median 96 weeks). Findings were compared with 51 matched healthy controls and validated in an independent cohort of 47 cirrhotic patients, 17 of whom developed HCC. Results We observed significant SIM alterations at baseline, with cirrhotic patients displaying a more profoundly dysregulated inflammatory milieu. Despite an overall decline in inflammatory markers following SVR, persistent alterations were evident, particularly in cirrhotic patients. Notably, those with liver stiffness exceeding 14 kPa exhibited sustained inflammatory dysregulation, correlating with liver elastography values. Key SIM such as interleukin (IL)-6, IL-8, urokinase plasminogen activator, and hepatocellular growth factor remained elevated and were associated with HCC development. Network analysis highlighted their roles in liver fibrosis, regeneration, and carcinogenesis. Conclusions These findings underscore the importance of early antiviral intervention to prevent cirrhosis-related sequelae. Future studies should explore the mechanistic pathways linking chronic inflammation, fibrosis, and oncogenesis to identify predictive biomarkers and novel therapeutic targets. Addressing persistent immune alterations post-HCV clearance may improve long-term outcomes, particularly in patients with advanced liver disease.

Hepatitis D virus (HDV) infection is the most severe form of viral hepatitis and has been shown to be associated with reduced quality of life. With the approval of the entry inhibitor bulevirtide, the first specific agent for HDV infection became available. Here, we report data on quality of life (QOL) before and during antiviral therapy with bulevirtide in a single center real-world cohort.We investigated QOL assessed by the Short Form 36 Health Survey (SF-36) in 25 patients undergoing antiviral treatment with bulevirtide. Surveys were completed before the beginning of antiviral therapy and up to week 152 of treatment as a long-term follow up.The study cohort included 7 women (28%) and 18 men (72%) with a median age of 46 years. Liver cirrhosis (defined as liver stiffness measurement ≥ 15.2 kPa) was present in 16 patients (64%) at the start of antiviral treatment. During the course of antiviral treatment with bulevirtide, scores for vitality, mental health and bodily pain significantly improved. The physical component score showed a minimal clinically important increase of ≥ 2.5 points in 10 patients (42%) at week 24 and in 6 patients (30% of patients with full data available) at week 48. The mental component score showed a minimal clinically important increase (≥ 2.5 points compared to baseline) in 10 patients (42%) at week 24 and in 12 patients (60%) at week 48. In the patient cohort with an improvement of physical or mental component scores at week 48, a further improvement beyond week 48 was evident in single cases but not in all patients. Importantly, changes of physical or mental component scores were not associated with virological or biochemical responses.Vitality, mental health and bodily pain improved during BLV treatment. As a sign of the good tolerability of BLV, no significant deteriorations in QOL scores were observed. Findings need to be confirmed and further evaluated in larger cohorts and longer follow-up is needed.

Background & Aims: Non-invasive tests (NITs) for clinically significant portal hypertension (CSPH) require validation in patients with hepatitis D virus (HDV)-related compensated advanced chronic liver disease (cACLD). Therefore, we aimed to validate existing NIT algorithms for CSPH in this context. Methods: Patients with HDV-cACLD (LSM >-10 kPa or histological METAVIR F3/F4 fibrosis) who underwent paired HVPG and NIT assessment at Medical University of Vienna or Hannover Medical School between 2013 and 2023 were retrospectively included. Liver stiffness measurement (LSM), von Willebrand factor to platelet count ratio (VITRO), and spleen stiffness measurement (SSM) were assessed. Individual CSPH risk was calculated according to previously published models (ANTICIPATE, 3P/5P). The diagnostic performance of Baveno VII criteria and refined algorithms (Baveno VII-VITRO, Baveno VII-SSM) was evaluated. The prognostic utility of NITs was investigated in the main cohort and an independent, multicenter, validation cohort. Results: Fifty-one patients (HVPG >-10 mmHg/CSPH prevalence: 62.7%, varices: 42.2%) were included. Patients with CSPH had significantly higher LSM (25.8 [17.2-31.0] vs. 14.0 [10.5-19.8] kPa; p <0.001), VITRO (n = 31, 3.5 [2.7-4.5] vs. 1.3 [0.6-2.0] %/[G/L]; p <0.001), and SSM (n = 20, 53.8 [41.7-75.5] vs. 24.0 [17.0-33.9] kPa; p <0.001). Composite CSPH risk models yielded excellent AUROCs (ANTICIPATE: 0.885, 3P: 0.903, 5P: 0.912). Baveno VII criteria ruled out CSPH with 100% sensitivity and ruled in CSPH with 84.2% specificity. The Baveno VII 'grey zone' (41.1%) was significantly reduced by Baveno VII-VITRO or Baveno VII-SSM algorithms, which maintained diagnostic accuracy. Hepatic decompensation within 2 years only occurred in patients who had CSPH or met Baveno VII rule-in criteria. The prognostic value of NITs was confirmed in the validation cohort comprising 92 patients. Conclusions: Standalone and composite NIT/diagnostic algorithms are useful for CSPH diagnosis in patients with HDV-cACLD. Thus, NITs may be applied to identify and prioritize patients with CSPH for novel antiviral treatments against chronic hepatitis D. (c) 2024 The Authors. Published by Elsevier B.V. on behalf of European Association for the Study of the Liver. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).