Abstract
Chronic hepatitis B virus (HBV) infection is a major global health burden and cure is rarely achieved by current antiviral therapies. Therefore, there is an urgent need for new therapeutic options. Immune modulation with the goal to restore dysfunctional HBV-specific immunity is an interesting target for new therapeutic strategies. Based on the current evidence on immunology in resolving and persistent HBV infection, we will review the growing field of immunotherapeutic approaches for treatment of chronic HBV infection. We will also discuss the challenge of a heterogeneous patient population and personalized treatment as a possible key factor of success.
Graphical abstract
Similar content being viewed by others
References
Agarwal K, Ahn SH, Elkhashab M, Lau AH, Gaggar A, Bulusu A, et al. Safety and efficacy of vesatolimod (GS-9620) in patients with chronic hepatitis B who are not currently on antiviral treatment. J Viral Hepat 2018;25:1331–1340
Alberti A, Diana S, Sculard GH, Eddleston AL, Williams R. Detection of a new antibody system reacting with Dane particles in hepatitis B virus infection. Br Med J 1978;2:1056–1058
Asabe S, Wieland SF, Chattopadhyay PK, Roederer M, Engle RE, Purcell RH, et al. The size of the viral inoculum contributes to the outcome of hepatitis B virus infection. J Virol 2009;83:9652–9662
Balkow S, Kersten A, Tran TTT, Stehle T, Grosse P, Museteanu C, et al. Concerted action of the FasL/Fas and perforin/granzyme A and B pathways is mandatory for the development of early viral hepatitis but not for recovery from viral infection. J Virol 2001;75:8781–6791
Bengsch B, Martin B, Thimme R. Restoration of HBV-specific CD8+ T cell function by PD-1 blockade in inactive carrier patients is linked to T cell differentiation. J Hepatol 2014;61:1212–1219.
Bertoletti A, Ferrari C. Adaptive immunity in HBV infection. J Hepatol 2016;64:S71–S83
Bertoletti A, Tan AT, Koh S. T-cell therapy for chronic viral hepatitis. Cytotherapy 2017;19:1317–1324
Meyer Zum Büschenfelde KH, Löhr HF. Regulation of the neutralizing anti-hepatitis B surface (HBs) antibody response in vitro in HBs vaccine recipients and patients with acute or chronic hepatitis B virus (HBV) infection. Clin Exp Immunol 1996;105:52–58
Boettler T, Panther E, Bengsch B, Nazarova N, Spangenberg HC, Blum HE, et al. Expression of the interleukin-7 receptor alpha chain (CD127) on virus-specific CD8+ T cells identifies functionally and phenotypically defined memory T cells during acute resolving hepatitis B virus infection. J Virol 2006;80:3532–3540
Boni C, Fisicaro P, Valdatta C, Amadei B, Di Vincenzo P, Giuberti T, et al. Characterization of hepatitis B virus (HBV)-specific T-cell dysfunction in chronic HBV infection. J Virol 2007;81:4215–4225
Boni C, Laccabue D, Lampertico P, Giuberti T, Viganò M, Schivazappa S, et al. Restored function of HBV-specific T cells after long-term effective therapy with nucleos(t)ide analogues. Gastroenterology 2012;143:963.e9–973.e9
Boni C, Vecchi A, Rossi M, Laccabue D, Giuberti T, Alfieri A, et al. TLR7 agonist increases responses of hepatitis B virus-specific T cells and natural killer cells in patients with chronic hepatitis B treated with nucleos(t)ide analogues. Gastroenterology 2018;154:1764.e7–1777.e7
Cheng X, Xia Y, Serti E, Block PD, Chung M, Chayama K, et al. Hepatitis B virus evades innate immunity of hepatocytes but activates cytokine production by macrophages. Hepatol Baltim Md 2017;66:1779–1793.
Chu C-M, Liaw Y-F. Hepatitis B surface antigen seroclearance during chronic HBV infection. Antivir Ther 2010;15:133–143
Cornberg M, Höner Zu Siederdissen C. HBsAg seroclearance with NUCs: rare but important. Gut 2014;63:1208–1209.
Das A, Ellis G, Pallant C, Lopes AR, Khanna P, Peppa D, et al. IL-10–producing regulatory B cells in the pathogenesis of chronic hepatitis B virus infection. J Immunol 2012;189:3925–3935
Dembek C, Protzer U, Roggendorf M. Overcoming immune tolerance in chronic hepatitis B by therapeutic vaccination. Curr Opin Virol 2018;30:58–67
Desmond CP, Gaudieri S, James IR, Pfafferott K, Chopra A, Lau GK, et al. Viral adaptation to host immune responses occurs in chronic hepatitis B virus (HBV) infection, and adaptation is greatest in HBV e antigen-negative disease. J Virol 2012;86:1181–1192.
Diepolder HM, Jung MC, Keller E, Schraut W, Gerlach JT, Grüner N, et al. A vigorous virus-specific CD4+ T cell response may contribute to the association of HLA-DR13 with viral clearance in hepatitis B. Clin Exp Immunol 1998;113:244–251
Dunn C, Peppa D, Khanna P, Nebbia G, Jones M, Brendish N, et al. Temporal analysis of early immune responses in patients with acute hepatitis B virus infection. Gastroenterology 2009;137:1289–1300
El-Khoueiry AB, Sangro B, Yau T, Crocenzi TS, Kudo M, Hsu C, et al. Nivolumab in patients with advanced hepatocellular carcinoma (CheckMate 040): an open-label, non-comparative, phase 1/2 dose escalation and expansion trial. Lancet 2017;389:2492–2502
European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu, and European Association for the Study of the Liver. EASL 2017 clinical practice guidelines on the management of hepatitis B virus infection. J Hepatol 2017;67:370–98
Evens AM, Jovanovic BD, Su Y-C, Raisch DW, Ganger D, Belknap SM, et al. Rituximab-associated hepatitis B virus (HBV) reactivation in lymphoproliferative diseases: meta-analysis and examination of FDA safety reports. Ann Oncol 2011;22:1170–1180
Fisicaro P, Valdatta C, Boni C, Massari M, Mori C, Zerbini A, et al. Early kinetics of innate and adaptive immune responses during hepatitis B virus infection. Gut 2009;58:974–982
Fisicaro P, Valdatta C, Massari M, Loggi E, Biasini E, Sacchelli L, et al. Antiviral intrahepatic T-cell responses can be restored by blocking programmed death-1 pathway in chronic hepatitis B. Gastroenterology 2010;138(2):682–693.e4
Fisicaro P, Barili V, Montanini B, Acerbi G, Ferracin M, Guerrieri F, et al. Targeting mitochondrial dysfunction can restore antiviral activity of exhausted HBV-specific CD8 T cells in chronic hepatitis B. Nat Med 2017;23:327–336
Guidotti LG, Chisari FV. Immunobiology and pathogenesis of viral hepatitis. Annu Rev Pathol 2006;1:23–61
Guidotti LG, Rochford R, Chung J, Shapiro M, Purcell R, Chisari FV. Viral clearance without destruction of infected cells during acute HBV infection. Science 1999;284:825–829
Hadziyannis SJ. Natural history of chronic hepatitis B in Euro-Mediterranean and African countries. J Hepatol 2011;55:183–191
Hoh A, Heeg M, Ni Y, Schuch A, Binder B, Hennecke N, et al. Hepatitis B virus-infected HepG2hNTCP cells serve as a novel immunological tool to analyze the antiviral efficacy of CD8+ T cells in vitro. J Virol 2015;89:7433–7438
Hösel M, Quasdorff M, Wiegmann K, Webb D, Zedler U, Broxtermann M, et al. Not interferon, but interleukin-6 controls early gene expression in hepatitis B virus infection. Hepatol Baltim Md 2009;50:1773–1782
Iannacone M, Sitia G, Ruggeri ZM, Guidotti LG. HBV pathogenesis in animal models: recent advances on the role of platelets. J Hepatol 2007;46:719–726
Im SJ, Hashimoto M, Gerner MY, Lee J, Kissick HT, Burger MC, et al. Defining CD8+ T cells that provide the proliferative burst after PD-1 therapy. Nature 2016;537:417–421
Kah J, Koh S, Volz T, Ceccarello E, Allweiss L, Lütgehetmann M, et al. Lymphocytes transiently expressing virus-specific T cell receptors reduce hepatitis B virus infection. J Clin Investig 2017;127:3177–3188
Kefalakes H, Budeus B, Walker A, Jochum C, Hilgard G, Heinold A, et al. Adaptation of the hepatitis B virus core protein to CD8(+) T-cell selection pressure. Hepatol Baltim Md 2015;62:47–56
Kennedy PTF, Sandalova E, Jo J, Gill U, Ushiro-Lumb I, Tan AT, et al. Preserved T-cell function in children and young adults with immune-tolerant chronic hepatitis B. Gastroenterology 2012;143:637–645
Koh S, Kah J, Tham CYL, Yang N, Ceccarello E, Chia A, et al. Nonlytic lymphocytes engineered to express virus-specific T-cell receptors limit HBV infection by activating APOBEC3. Gastroenterology 2018;155:180–193.e6
Lanford RE, Guerra B, Chavez D, Giavedoni L, Hodara VL, Brasky KM, et al. GS-9620, an oral agonist of Toll-like receptor-7, induces prolonged suppression of hepatitis B virus in chronically infected chimpanzees. Gastroenterology 2013;144(1508–1517):1517.e1–1517.e10
Lee YB, Lee J-H, Kim YJ, Yoon J-H, Lee H-S. The effect of therapeutic vaccination for the treatment of chronic hepatitis B virus infection. J Med Virol 2015;87:575–582
Li L, Barry V, Daffis S, Niu C, Huntzicker E, French DM, et al. Anti-HBV response to toll-like receptor 7 agonist GS-9620 is associated with intrahepatic aggregates of T cells and B cells. J Hepatol 2018;68:912–921
Lim K-H, Park E-S, Kim DH, Cho KC, Kim KP, Park YK, et al. Suppression of interferon-mediated anti-HBV response by single CpG methylation in the 5’-UTR of TRIM22. Gut 2018;67:166–178
Liu J, Zhang E, Ma Z, Wu W, Kosinska A, Zhang X, et al. Enhancing virus-specific immunity in vivo by combining therapeutic vaccination and PD-L1 blockade in chronic hepadnaviral infection. PLoS Pathog 2014;10:e1003856
Liu Y, Cheng L-S, Wu S, Wang S-Q, Li L, She W-M, et al. IL-10-producing regulatory B-cells suppressed effector T-cells but enhanced regulatory T-cells in chronic HBV infection. Clin Sci Lond Engl 2016;1979(130):907–919
Lok AS, Zoulim F, Dusheiko G, Ghany MG. Hepatitis B cure: from discovery to regulatory approval. J Hepatol 2017;67:847–861
Madaliński K, Bragiel I. HBsAg immune complexes in the course of infection with hepatitis B virus. Clin Exp Immunol 1979;36:371–378
Maini MK, Gehring AJ. The role of innate immunity in the immunopathology and treatment of HBV infection. J Hepatol 2016;64:S60–S70
Maini MK, Pallett LJ. Defective T-cell immunity in hepatitis B virus infection: why therapeutic vaccination needs a helping hand. Lancet Gastroenterol Hepatol 2018;3:192–202
Maini MK, Boni C, Ogg GS, King AS, Reignat S, Lee CK, et al. Direct ex vivo analysis of hepatitis B virus-specific CD8(+) T cells associated with the control of infection. Gastroenterology 1999;117:1386–1396
Marcellin P, Gane E, Buti M, Afdhal N, Sievert W, Jacobson IM, et al. Regression of cirrhosis during treatment with tenofovir disoproxil fumarate for chronic hepatitis B: a 5-year open-label follow-up study. Lancet 2013;381:468–475
Menne S, Tumas DB, Liu KH, Thampi L, AlDeghaither D, Baldwin BH, et al. Sustained efficacy and seroconversion with the Toll-like receptor 7 agonist GS-9620 in the Woodchuck model of chronic hepatitis B. J Hepatol 2015;62:1237–1245
Mohamadkhani A, Naderi E, Sotoudeh M, Katoonizadeh A, Montazeri G, Poustchi H. Clinical feature of intrahepatic B-lymphocytes in chronic hepatitis B. Int J Inflamm 2014;2014:896864
Mutz P, Metz P, Lempp FA, Bender S, Qu B, Schöneweis K, et al. HBV bypasses the innate immune response and does not protect HCV from antiviral activity of interferon. Gastroenterology 2018;154:1791.e22–1804.e22
Nassal M. HBV cccDNA: viral persistence reservoir and key obstacle for a cure of chronic hepatitis B. Gut 2015;64:1972–1984
Oliviero B, Varchetta S, Paudice E, Michelone G, Zaramella M, Mavilio D, et al. Natural killer cell functional dichotomy in chronic hepatitis B and chronic hepatitis C virus infections. Gastroenterology 2009;137(1151–1160):1160.e1–1160.e7
Oliviero B, Cerino A, Varchetta S, Paudice E, Pai S, Ludovisi S, et al. Enhanced B-cell differentiation and reduced proliferative capacity in chronic hepatitis C and chronic hepatitis B virus infections. J Hepatol 2011;55:53–60
Paley MA, Kroy DC, Odorizzi PM, Johnnidis JB, Dolfi DV, Barnett BE, et al. Progenitor and terminal subsets of CD8+ T cells cooperate to contain chronic viral infection. Science 2012;338:1220–1225
Pauken KE, Sammons MA, Odorizzi PM, Manne S, Godec J, Khan O, Drake AM, Chen Z, Sen DR, Kurachi M, et al. Epigenetic stability of exhausted T cells limits durability of reinvigoration by PD-1 blockade. Science 2016;354:1160–1165
Paul S, Dickstein A, Saxena A, Terrin N, Viveiros K, Balk EM, et al. Role of surface antibody in hepatitis B reactivation in patients with resolved infection and hematologic malignancy: a meta-analysis. Hepatol Baltim Md 2017;66:379–388
Ravi S, Spencer K, Ruisi M, Ibrahim N, Luke JJ, Thompson JA, et al. Ipilimumab administration for advanced melanoma in patients with pre-existing Hepatitis B or C infection: a multicenter, retrospective case series. J Immunother Cancer 2014;2:33
Raziorrouh B, Schraut W, Gerlach T, Nowack D, Grüner NH, Ulsenheimer A, et al. The immunoregulatory role of CD244 in chronic hepatitis B infection and its inhibitory potential on virus-specific CD8+ T-cell function. Hepatol Baltim Md 2010;52:1934–1947
Raziorrouh B, Heeg M, Kurktschiev P, Schraut W, Zachoval R, Wendtner C, et al. Inhibitory phenotype of HBV-specific CD4+ T-cells is characterized by high PD-1 expression but absent coregulation of multiple inhibitory molecules. PLoS One 2014;9:e105703
Rehermann B, Pasquinelli C, Mosier SM, Chisari FV. Hepatitis B virus (HBV) sequence variation of cytotoxic T lymphocyte epitopes is not common in patients with chronic HBV infection. J Clin Investig 1995;96:1527–1534
Rehermann B, Nascimbeni M. Immunology of hepatitis B virus and hepatitis C virus infection. Nat Rev Immunol 2005;5(3):215–229
Rivino L, Bert NL, Gill US, Kunasegaran K, Cheng Y, Tan DZM, et al. Hepatitis B virus-specific T cells associate with viral control upon nucleos(t)ide-analogue therapy discontinuation. J Clin Investig 2018;128:668–681
Sarin SK, Kumar M, Lau GK, Abbas Z, Chan HLY, Chen CJ, Chen DS, Chen HL, et al. Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update. Hepatol Int 2016;10:1–98
Sato S, Li K, Kameyama T, Hayashi T, Ishida Y, Murakami S, et al. The RNA sensor RIG-I dually functions as an innate sensor and direct antiviral factor for hepatitis B virus. Immunity 2015;42:123–132
Schurich A, Khanna P, Lopes AR, Han KJ, Peppa D, Micco L, et al. Role of the coinhibitory receptor cytotoxic T lymphocyte antigen-4 on apoptosis-Prone CD8 T cells in persistent hepatitis B virus infection. Hepatol Baltim Md 2011;53:1494–1503
Schurich A, Pallett LJ, Jajbhay D, Wijngaarden J, Otano I, Gill US, et al. Distinct metabolic requirements of exhausted and functional virus-specific CD8 T cells in the same host. Cell Rep 2016;16:1243–1252
Schweitzer A, Horn J, Mikolajczyk RT, Krause G, Ott JJ. Estimations of worldwide prevalence of chronic hepatitis B virus infection: a systematic review of data published between 1965 and 2013. Lancet Lond Engl 2015;386:1546–1555
Seto W-K, Chan TSY, Hwang Y-Y, Wong DK-H, Fung J, Liu KS-H, 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
Seto W-K, Cheung K-S, Wong DK-H, Huang F-Y, Fung J, Liu KS-H, Let al. Hepatitis B surface antigen seroclearance during nucleoside analogue therapy: surface antigen kinetics, outcomes, and durability. J Gastroenterol 2016;51:487–495
Shin E-C, Sung PS, Park S-H. Immune responses and immunopathology in acute and chronic viral hepatitis. Nat Rev Immunol 2016;16:509–523
Singh AK, Rooge SB, Varshney A, Vasudevan M, Bhardwaj A, Venugopal SK, et al. Global microRNA expression profiling in the liver biopsies of hepatitis B virus-infected patients suggests specific microRNA signatures for viral persistence and hepatocellular injury. Hepatol Baltim Md 2018;67:1695–709
Thimme R, Dandri M. Dissecting the divergent effects of interferon-alpha on immune cells: time to rethink combination therapy in chronic hepatitis B? J Hepatol 2013;58:205–209
Thimme R, Wieland S, Steiger C, Ghrayeb J, Reimann KA, Purcell RH, et al. CD8(+) T cells mediate viral clearance and disease pathogenesis during acute hepatitis B virus infection. J Virol 2003;77:68–76
Thomsen MK, Nandakumar R, Stadler D, Malo A, Valls RM, Wang F, et al. Lack of immunological DNA sensing in hepatocytes facilitates hepatitis B virus infection. Hepatol Baltim Md 2016;64:746–759
van den Ende C, Marano C, van Ahee A, Bunge EM, De Moerlooze L. The immunogenicity of GSK’s recombinant hepatitis B vaccine in children: a systematic review of 30 years of experience. Expert Rev Vaccines 2017;16:789–809
Vanwolleghem T, Hou J, van Oord G, Andeweg AC, Osterhaus ADME, Pas SD, et al. Re-evaluation of hepatitis B virus clinical phases by systems biology identifies unappreciated roles for the innate immune response and B cells. Hepatol Baltim Md 2015;62:87–100
Verrier ER, Yim S-A, Heydmann L, El Saghire H, Bach C, Turon-Lagot V, et al. Hepatitis B virus evasion from cyclic guanosine monophosphate-adenosine monophosphate synthase sensing in human hepatocytes. Md: Hepatol Baltim; 2018
Wang R, Xie R, Song Z. Circulating regulatory Tfh cells are enriched in patients with chronic hepatitis B infection and induce the differentiation of regulatory B cells. Exp Cell Res 2018;365:171–176
Wang X, Dong Q, Li Q, Li Y, Zhao D, Sun J, et al. Dysregulated response of follicular helper T cells to hepatitis B surface antigen promotes HBV persistence in mice and associates with outcomes of patients. Gastroenterology 2018;154:2222–2236
Wherry EJ. T cell exhaustion. Nat Immunol 2011;12:492–499
WHO, W.H. Global hepatitis report 2017. Geneva: World Health Organization; 2017
Wieland D, Hofmann M, Thimme R. Overcoming CD8+ T-cell exhaustion in viral hepatitis: lessons from the mouse model and clinical perspectives. Dig Dis Basel Switz 2017;35:334–338
Wieland S, Thimme R, Purcell RH, Chisari FV. Genomic analysis of the host response to hepatitis B virus infection. Proc Natl Acad Sci USA 2004;101:6669–6674
Xia Y, Stadler D, Lucifora J, Reisinger F, Webb D, Hösel M, et al. Interferon-γ and tumor necrosis factor-α produced by t cells reduce the HBV persistence form, cccDNA, without cytolysis. Gastroenterology 2016;150:194–205
Xu D-Z, Wang X-Y, Shen X-L, Gong G-Z, Ren H, Guo L-M, et al. Results of a phase III clinical trial with an HBsAg–HBIG immunogenic complex therapeutic vaccine for chronic hepatitis B patients: experiences and findings. J Hepatol 2013;59:450–456
Xu X, Shang Q, Chen X, Nie W, Zou Z, Huang A, et al. Reversal of B-cell hyperactivation and functional impairment is associated with HBsAg seroconversion in chronic hepatitis B patients. Cell Mol Immunol 2015;12:309–316.
Yip TC, Wong GL, Wong VW, Tse YK, Lui GC, Lam KL, Chan HL. Durability of hepatitis B surface antigen seroclearance in untreated and nucleos(t)ide analogue-treated patients. J Hepatol 2017. https://doi.org/10.1016/j.jhep.2017.09.018
Yu W-H, Cosgrove C, Berger CT, Cheney PC, Krykbaeva M, Kim AY, et al. ADCC-mediated CD56DIM NK cell responses are associated with early HBsAg clearance in acute HBV infection. Pathog Immun 2018;3:2–18
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Compliance with ethical requirements
This article does not contain any studies with human or animal subjects.
Conflict of interest
Julia Lang, Christoph Neumann-Haefelin and Robert Thimme declare that they have no competing interests.
Rights and permissions
About this article
Cite this article
Lang, J., Neumann-Haefelin, C. & Thimme, R. Immunological cure of HBV infection. Hepatol Int 13, 113–124 (2019). https://doi.org/10.1007/s12072-018-9912-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12072-018-9912-8