Scott Letendre, MD (UC San Diego AntiViral Research Center) presents "Impact of HCV on the Brain"

1. AIDS CLINICAL ROUNDS
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2. Impact of HCV on the Brain
A Brief Review
Scott Letendre, M.D.

3. Selected Questions Regarding Impact
of HCV on the Brain
Essential Questions Related Questions
• Does HCV affect the • What are the best
brain? methods to assess
• If so, how does HCV HCV’s impact on the
affect the brain? brain?
• Does HCV-related brain • Can HCV’s effects on
injury respond to the brain be reliably
therapy? distinguished from
• Does HCV infection of those of comorbidities,
the brain limit particularly HIV, liver
treatment success? disease, and drug and
alcohol use?

5. Selected Questions Regarding Impact
of HCV on the Brain
Essential Questions Related Questions
• Does HCV affect the • What are the best
brain? methods to assess
• If so, how does HCV HCV’s impact on the
affect the brain? brain?
• Does HCV-related brain • Can HCV’s effects on
injury respond to the brain be reliably
therapy? distinguished from
• Does HCV infection of those of comorbidities,
the brain limit particularly HIV, liver
treatment success? disease, and drug and
alcohol use?

6. Author Journal Year Size Method People with HCV had…
HCV Serostatus
Clin Microbiol IHDS, Worse IHDS & trend toward worse executive
Thiyagarajan 2010 72
Inf CogState functioning
Hinkin J Addict Dis 2008 118 8 domains Worse learning and memory
Cherner Neurology 2005 430 14 tests Worse functioning in multiple domains
McAndrews Hepatology 2005 83 9 tests Worse learning
Morgello AIDS 2005 137 14 tests Worse executive functioning
Richardson AIDS 2005 220 8 tests More frequent global impairment
Ryan Neurology 2004 116 12 tests Worse executive functioning
Weissenborn J Hepatology 2004 45 10 tests Worse executive functioning and attention
Worse functioning associated with worse liver
Hilsabeck JINS 2003 21 4 tests
fibrosis
Computer- Worse concentration and speed of information
Forton Hepatology 2002 43
based processing
Kramer J Hepatology 2002 100 P300 ERPs Prolonged P300 latencies
HCV Viremia
In fully adjusted GLM, HCV viremia was not
Crystal JAIDS 2012 1338 4 tests
associated with scores on any of the cognitive tests
Clifford Neurology 2009 172 3 tests No difference based on HCV RNA

7. Selected Neurocognitive Findings
McAndrews, Hepatology 2005
Hinkin, J Addict Dis 2008
Cherner, Neurology, 2005

8. CHARTER HCV RNA Data

9. CHARTER HCV RNA Data
X2 = 10.5
p = 0.005

10. CHARTER HCV RNA Data

11. Neuroimaging Investigations
Author Journal Year Size Method People with HCV had…
Nagarajan Int J Hepatol 2012 28 L-COSY Higher myoinositol and glutathione
Gongvatana J Neurovirol 2011 85 DTI Decreased anisotropy & increased diffusivity
J Cerebral Blood MRI Reduced striatal DA and midbrain SERT availability,
Heeren 2011 15
Flow & Metab PET glucose metabolism
Jernigan J Neurovirol 2011 251 sMRI Larger volume of abnormal WM
Forton J Hepatology 2008 25 MRS Higher myoinositol
McAndrews Hepatology 2005 37 MRS Higher choline, lower NAA
Taylor JINS 2004 26 MRS Lower NAA
Weissenborn J Hepatology 2004 45 MRS Lower NAA
Forton Hepatology 2002 17 MRS Higher choline in BG, WM
Forton Lancet 2001 30 MRS Higher choline/creatine ratios

12. Selected Neuroimaging Findings
McAndrews, Hepatology 2005 Nagarajan, Int J Hepatol, 2012

13. Does HCV Affect the Brain?

14. Selected Questions Regarding Impact
of HCV on the Brain
Essential Questions Related Questions
• Does HCV affect the • What are the best
brain? methods to assess
• If so, how does HCV HCV’s impact on the
affect the brain? brain?
• Does HCV-related brain • Can HCV’s effects on
injury respond to the brain be reliably
therapy? distinguished from
• Does HCV infection of those of comorbidities,
the brain limit particularly HIV, liver
treatment success? disease, and drug and
alcohol use?

15. HCV can Infect Cells that are
Relevant to CNS Pathogenesis
• Macrophages/Microglia or Astrocytes
– Letendre et al, J Infect Dis, 2007, 361: 70
– Wilkinson et al, J Virol 2009, 83(3): 1312-9
• Brain Microvascular Endothelial Cells
– Fletcher et al, Gastroenterology 2012, 142: 634-3
• Neuroblastoma and Neuroepithelioma Cells
– Fletcher et al, Gastroenterology 2010, 139: 1365-74
– Bürgel et al, J Viral Hepatitis 2011, 18: 562-70
• Peripheral Blood Mononuclear Cells
• No publications was identified in my non-
exhaustive literature search that demonstrated
infection of neurons

16. Feray C, Gastroenterology. 2012;142(3):428-31

17. Autopsy Data Supports that HCV
can Infect Glial Cells
HCV antigens in brains by heparin columns by WB HCV antigens in astrocytes of HIV+ HCV+ cases
GFAP HCV
HCV-
HCV+
HCV+
Letendre, et al, J Infect Dis, 2007, 361: 70
Slide Courtesy Eliezer Masliah

18. Virologic Evidence that HCV Can
Adapt to the CNS Environment
Author Journal Year Size Finding
Brain HCV RNA found in 7. Brain HCV RNA sequences
Fishman J Infect Dis 2008 13
differed from liver and blood in 4 (57%)
HCV RNA was detected in 5 of 21; sequences in 2 of 5
Bagaglio AIDS 2005 21
differed from plasma and PBMCs
Sequences of brain-derived HCV RNA differed from
other tissues and clustered with lymph node
Forton J Virology 2004 2
sequences; Identified 2 unique brain-derived
mutations
HCV negative RNA strands were detected in brain
Radkowski J Virology 2002 6
tissue from 3 (50%)
HCV sequences were found in 8 CSF specimens and 4
Laskus J Virology 2002 13
of these exhibited differences from other tissues
HCV negative RNA strand sequences differed from
Vargas Liver Transpl 2002 2
consensus serum sequences in both
HCV RNA was detected in 5 of 19 and sequences did
Morsica J Med Virology 1997 19
not differ between CSF and serum

19. Other Mechanisms that May Contribute
to HCV-Associated CNS Injury
• Immune Response
• Glial Activation
– IDO-TRP-KYN-QUIN mediated neurotoxicity*
• Neurotoxic HCV-encoded Proteins
• Altered Blood-Brain Barrier Permeability
Others
• Past or Ongoing Neurotoxic Drug Use
• Liver Disease and Hepatic Encephalopathy
• Cryoglobulin-Associated Vasculitis
*IFN-α can also increase KYN production

20. Additional Relevant Findings
Paulino et al, J Neurovirol Letendre et al, 18th CROI
2011 17:327–340 2011, Abstract 408

21. HCV RNA and HCV Core in CSF

22. Correlates of HCV Core in CSF

23. IL28B and HCV
• Ge et al performed a GWAS predicting SVR in subjects from the
Initiating Dialysis Early and Late (IDEAL) study
• rs12979860 was the most strongly associated SNP in patients of
European ancestry
– 2.5-fold higher relative rate of response among non-Hispanic Caucasian
subjects carrying the C/C genotype. Also associated with better
treatment responses in Hispanics and in African Americans
• Suggested that IL28B variation may influence natural clearance of
HCV since the chronically infected cohort based had a lower
frequency of the C allele than ethnically matched population controls
• Other SNPs Identified:
– rs28416813, rs8103142 were strongly linked to rs12979860
– Another study found associations with rs8099917 and 5 others
Urban et al, Hepatology 2012, 56: 361-6
Ge et al, Nature 2009;461:399-401

24. IL28B and HCV
• IL28B encodes interferon-13, a type III (or λ) IFN, which
bind to a different receptor complex than IFN-α (type I
IFNs)
• IFN-λs have structural and functional similarity to both
interleukins (esp. IL-10) and IFN-αs
• Like other IFNs, IFN-λ activates ISGs via intracellular
signaling pathways but some are non-redundant with
other IFNs
• IFN-λ may result in relatively slower onset and more
prolonged ISG activation than IFN-α
• Expression of IFN-λ receptors appears to be more
restricted, with particularly high expression in the liver
Urban et al, Hepatology 2012, 56: 361-6

25. IL28B and Neurons
• Human neuronal cells expressed endogenous
IFN-λ1 but not IFN-λ2/3. Upon activation of
TLR-3 in the neuronal cells, both IFN-λ1 and
IFN-λ2/3 expression was significantly induced
• Human neurons also expressed functional IFN-
λ receptor complex, IL-28Rα and IL-10Rβ
Urban et al, Hepatology 2012, 56: 361-6
Zhou et al, Neuroscience 2009, 159: 629-37

26. Association of IL28B SNPs with
HCV Seropositivity

27. Association of IL28B SNPs with
HCV Seropositivity & HCV RNA

28. Selected Questions Regarding Impact
of HCV on the Brain
Essential Questions Related Questions
• Does HCV affect the • What are the best
brain? methods to assess
• If so, how does HCV HCV’s impact on the
affect the brain? brain?
• Does HCV-related brain • Can HCV’s effects on
injury respond to the brain be reliably
therapy? distinguished from
• Does HCV infection of those of comorbidities,
the brain limit particularly HIV, liver
treatment success? disease, and drug and
alcohol use?

29. Treatment with Interferon-Ribavirin
Fontana RJ. Dig Dis, 2000; 18: 107-116

30. Treatment-Focused Investigations
Author Journal Year Size Finding
Reductions in basal ganglia Cho/Cr and basal ganglia MI/Cr were
Byrnes J Hepatology 2012 15
observed with SVR, but not in non-responders/relapsers
Pharmacologic KYN markedly rose during treatment, paralleled by a significant
Comai 2011 45
Research increase of the Kyn/Trp ratio, an index of IDO activity
MRS demonstrated lower NAA in the globus pallidus before
Pattullo Liver Intl 2011 40
treatment, which was unchanged with viral clearance
SVR was associated with significant improvements in some
Thein HIV Medicine 2007 34
measures of cognitive function, independent of HRQOL
After viral clearance, macrophage IDO activity, plasma TRP and
Zignego Dig Liver Dis 2007 89 KYN levels returned toward normal values and psychopathology
improved
IFN-α treatment was associated with significant activation in the
Capuron Biol Psychiatr 2005 10
dorsal part of the anterior cingulate cortex on functional MRI

31. UCSD IFN/RBV Project
• 40 HCV+ subjects starting IFN/RBV therapy
• Comprehensive medical, psychiatric, and cognitive
assessment before and 10, 24, 48, and 72 weeks after
treatment initiation
• After 10 weeks, neurocognitive impairment rose from 27.5%
to 47.5% (p < .05)
– Infection with genotype 1 was significantly (p < .05) associated
with decline
• After 72 weeks, 42.5% remained neurocognitively impaired
– Only initial 10-week neurocognitive decline predicted persistent
impairment
– Not viral clearance, severity of liver disease, or depressive
symptoms
Cattie et al, Submitted 2013

32. Demographic and Other Characteristics
Characteristic Mean (SD)
Age (years) 47.8 (8.5)
Education 12.9 (2.0)
Sex (#, % male) 20 (50.0)
N (%) Caucasian 28 (70.0)
Reading literacy (WRAT3) mean (SD) 96.0 (12.5)
Lifetime psychiatric/Substance Disorders
Major depressive disorder # (%) 13 (32.5)
Alcohol 15 (37.5)
Cannabis 15 (37.5)
Methamphetamine 17 (42.5)
Cocaine 16 (40.0)
Opioid 10 (25.0)
Any substance 25 (62.5)
Slide Courtesy Jordan Cattie

33. Baseline Medical Characteristics
Characteristic Mean (SD)
Hemoglobin 14.2 (1.6)
Platelet count 213.0 (77.2)
Albumin 4.0 (0.4)
ALT 85.2 (59.9)
AST 73.2 (48.7)
Bilirubin total 1.0 [0.2]
AST platelet ratio index (APRI) 0.78 (0.52)
log10 HCV RNA 5.8 (0.7)
HCV Genotype (n, %)
1 28 (70.0)
2 6 (15.0)
3 5 (12.5)
4 1 (2.5)
Slide Courtesy Jordan Cattie

34. Summary of Findings

35. Predictors of Neurocognitive Decline
at 10 Weeks
• Multivariable regression identified that worse neurocognitive
decline was associated with:
– Genotype 1
– Depressive symptoms at baseline or lifetime history of
major depression
• Predictors that failed to reach statistical significance:
– Baseline neurocognitive functioning
– Baseline APRI or fibrosis stage

36. Predictors of Neurocognitive Decline
at 72 Weeks
• Multivariable regression identified that worse neurocognitive
decline was associated with:
– Neurocognitive change from baseline to 10 weeks
• Predictors that failed to reach statistical significance:
– Early or Sustained Viral Response
– APRI or fibrosis stage
– Genotype
– Baseline cognitive status
– Current depression status

37. Selected Questions Regarding Impact
of HCV on the Brain
Essential Questions Related Questions
• Does HCV affect the • What are the best
brain? methods to assess
• If so, how does HCV HCV’s impact on the
affect the brain? brain?
• Does HCV-related brain • Can HCV’s effects on
injury respond to the brain be reliably
therapy? distinguished from
• Does HCV infection of those of comorbidities,
the brain limit particularly HIV, liver
treatment success? disease, and drug and
alcohol use?

38. Additional Research Questions
• How well do newer, direct-acting drugs
distribute into tissues other than the liver that
have HCV-infected cells?
• What are the CNS side effects of DAAs and
how can they be best managed?
• Does limited distribution of DAAs into the CNS
contribute to treatment failure?
• Does the blood-brain barrier and the CNS
normalize following successful treatment?

39. Acknowledgements
Study Volunteers
UCSD HNRC National Institutes
• Ronald J. Ellis  Davey Smith of Health
• Igor Grant  Tom Marcotte  …Mental Health
• Allen McCutchan  Cris Achim  …Drug Abuse
• Bob Heaton  Steven Woods  …Neurological
• Edmund Capparelli  Eliezer Masliah Disorders and Stroke
• Brookie Best
Industry
CHARTER and CIT2  Abbott Laboratories
• David Clifford  Christina Marra  GlaxoSmithKline
• Justin McArthur  Susan Morgello  Merck, Inc.
• Ned Sacktor  David Simpson  Janssen
• Ann Collier  Ben Gelman  Gilead Sciences
 Biogen IDEC