Observational Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 14, 2019; 25(38): 5883-5896
Published online Oct 14, 2019. doi: 10.3748/wjg.v25.i38.5883
Prevalence of hepatocarcinoma-related hepatitis B virus mutants in patients in grey zone of treatment
Ana Isabel Gil-García, Antonio Madejón, Irene Francisco-Recuero, Ana López-López, Emiliana Villafranca, Miriam Romero, Araceli García, Antonio Olveira, Rocío Mena, Juan Ramón Larrubia, Javier García-Samaniego
Ana Isabel Gil-García, Antonio Madejón, Irene Francisco-Recuero, Emiliana Villafranca, Miriam Romero, Araceli García, Antonio Olveira, Javier García-Samaniego, Hepatology Unit, Hospital Universitario La Paz, Madrid 28046, Spain
Ana Isabel Gil-García, Antonio Madejón, Irene Francisco-Recuero, Miriam Romero, Antonio Olveira, Javier García-Samaniego, Centro de Investigación Biomédica en Red, Instituto de Salud Carlos III, Madrid 28029, Spain
Irene Francisco-Recuero, Javier García-Samaniego, Instituto de Investigación del Hospital Universitario la Paz, Madrid 28046, Spain
Ana López-López, Biochemistry Department, Faculty of Medicine, Universidad Autónoma de Madrid, Madrid 28029, Spain
Rocío Mena, Instituto de Genética Médica y Molecular, Hospital Universitario La Paz, Madrid 28046, Spain
Juan Ramón Larrubia, Translational Hepatology Unit, Hospital General Universitario de Guadalajara, Guadalajara 19002, Castilla-La Mancha, Spain
Author contributions: Gil-García AI, Madejón A and García-Samaniego J studied concept, designed and drafted the manuscript; Gil-García AI and Madejón A interpreted the data and revised the manuscript; Ana I Gil-García AI and Madejón A analysed data; Francisco-Recuero I, López-López A, Villafranca E, Romero M and García A got and interpreted data; Mena R sequenced analysis of samples; Olveira A and Larrubia JR reviewed the manuscript; García-Samaniego J revised the manuscript key intellectual contribution, funded provision and studied supervision. All the authors reviewed and approved the final version of the manuscript.
Supported by Análisis genético y epigenético del VHB en pacientes portadores asintomáticos. Implicaciones en la decisión terapéutica funded in the 1st Edition of the Gilead Fellowship Program, No. GLD13/00046 and Modificaciones de los niveles de expresión génica mediada por mutantes naturales de la región PreS del virus de la hepatitis B, y asociación con genes implicados en el desarrollo de hepatocarcinoma Efecto del tratamiento antiviral.
Institutional review board statement: The study was approved by the Ethical Committee of the Hospital Carlos III in Madrid, conforms to the ethical guidelines of the 1975 Declaration of Helsinki.
Informed consent statement: All the participants received and signed written consent for its participation.
Conflict-of-interest statement: All the authors have nothing to disclose.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Javier García-Samaniego, MD, PhD, Chief Doctor, Hepatology Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain. Centro de Investigación Biomédica en Red. Instituto de Investigación del Hospital Universitario la Paz, Paseo de la Castellana 261, Madrid 28046, Spain. javiersamaniego@telefonica.net
Telephone: +34-91-7277204
Received: June 3, 2019
Peer-review started: June 3, 2019
First decision: July 21, 2019
Revised: August 8, 2019
Accepted: September 13, 2019
Article in press: September 13, 2019
Published online: October 14, 2019

Antiviral treatment of patients with chronic hepatitis B (CHB) in the grey zone of treatment comands risk management in order to optimize the health outcome. In this sense, the identification of HBV mutants related with an increased risk of hepatocellular carcinoma (HCC) could be useful to identify subpopulations with potential indication of antiviral treatment.


To analyze the prevalence/persistence of hepatitis B virus (HBV) preS and basal core promoter (BCP)/precore/core variants associated to HCC development in CHB patients in the grey zone.


Work was designed as a longitudinal retrospective study, including 106 plasma samples from 31 patients with CHB in the grey zone of treatment: Hepatitis B e antigen negative, HBV-DNA levels between 12-20000 IU/mL, normal or discordant transaminase levels during follow up and mild/moderate necro-inflammatory activity in liver biopsy or Fibroscan (up to 9.5 kPa). Serum HBV-DNA was tested using the Abbott Real Time HBV Assay and the BCP/precore/core and the hepatitis B surface antigen (HBsAg) coding regions were analyzed in positive samples by PCR/bulk-sequencing to identify the HCC-related HBV mutants.


High-risk HCC related mutants were detected in 24 (77%) patients: 19 (61%) in the BCP/precore/core, and 7 (23%) in the HBsAg coding region (2 preS1 and 5 preS2 deletions). The prevalence of preS deletions was genotype-dependent: 3/5 (60%) patients with preS2 deletions and 1/2 with preS1 deletions were infected with the HBV-E genotype. Since HBV-E was the most prevalent in sub-Saharan patients, a correlation between preS deletions and ethnicity was also found: 6/8 (75%) sub-Saharan vs 1/19 (5%) Caucasian patients had preS deletions (P = 0.00016). Remarkably, this correlation was maintained in those patients infected with HBV-A, a minor genotype in sub-Saharan patients: 2/2 patients infected with HBV-A from West Africa vs 0/6 of Caucasian origin had preS deletions. The HCC related variants were the major strains and persisted over time (up to 48 mo). Patients with preS deletions had a significant higher prevalence of F2 fibrosis stage than the negatives (57% vs 10%, P = 0.0078).


HBV genetic analysis of selected populations, like sub-Saharans infected with HBV-E/A genotypes, will allow identification of subpopulations with risk of HCC development due to accumulation of high-risk HBV variants, thus commanding their increased clinical surveillance.

Keywords: Hepatitis B virus, Hepatocellular carcinoma, PreS deletions, Hepatitis B virus treatment, Grey zone

Core tip: The antiviral treatment in patients with chronic hepatitis B in the “grey zone” of treatment is controversial and not clearly indicated. The genetic analysis of hepatitis B virus (HBV) basal core promoter/precore/core and preS regions has shown a high prevalence and persistence of preS deletions in the sub-Saharan population infected with HBV-E/A genotypes. By contrast, Caucasian patients, who have shown a good clinical evolution in previous studies, were negative for these variants. The recognition of these subpopulations warrant to increase the clinical surveillance in order to minimize the risk of liver cancer development due to accumulation of hepatocellular carcinoma-related HBV genetic variants.