New pre-conception immune biomarkers for clinical practice: interleukin-18, interleukin-15 and TWEAK on the endometrial side, G-CSF on the follicular side.

Identification of biomarkers of optimal uterine receptivity to the implanting embryo as well as biomarkers of oocyte competence would undoubtedly improve the efficiency of assisted reproductive technology (ART). Expression of IL-15 and IL-18 has been shown to be different in patients with failed implantation after IVF/ICSI compared with fertile controls and both correlate with local uNK (CD56+) recruitment and angiogenesis. Tumor necrosis factor weak inducer of apoptosis (TWEAK) has been described in mice as a potent early immune regulator able to protect the conceptus. The results of our studies in human suggest that TWEAK modulates the IL-18 related cytotoxicity of uNK cells. Quantification of IL-18, TWEAK and IL-15 mRNA expression by real-time PCR in endometrial tissue collected in mid-luteal phase of non-conception cycles allowed documentation of physiological events that occur at the time of uterine receptivity. Such information may be useful for the physician especially in patients where embryos fail to implant. Cytokine quantification may assist in understanding the mechanisms leading to repeated IVF/ICSI failure: either depletion of cytokines necessary for the apposition-adhesion, or an excess of cytokines leading to local cytotoxicity, may impair the implantation of the embryo. Other new data suggest that a pre-conception dialogue mediated by the oocyte and the follicular fluid and the oocyte may contribute to later implantation success. Follicular concentration of G-CSF appears as a useful biomarker of oocyte competence before fertilization. Moreover both in human and animal models, evidence of a role of the endometrium as a biosensor of the embryo is emerging.

Higher interleukin-18 and mannose-binding lectin are present in uterine lumen of patients with unexplained infertility.

The uterine luminal environment was explored with regard to interleukin-18 (IL-18) and mannose-binding lectin (MBL) and the possibility that the procedure of flushing the uterine cavity would optimize the physiological initial pseudo-inflammatory uterine reaction. Uterine flushings were performed among 175 IVF/intracytoplasmic sperm injection (ICSI) patients at the time of oocyte retrieval and the cycles were compared with a control group matched for age, number of previous attempts and type of assisted reproductive procedure (IVF or ICSI) in which no flushing were performed (n = 175). Samples collected were divided into two groups according to the presence/absence of endometrial cells in samples. IL-18 and MBL expressions were explored by enzyme-linked immunosorbent assay. Implantation rates were significantly higher in those patients who underwent the uterine flushing compared with controls (P = 0.04). Luminal concentrations of IL-18 and MBL were higher if endometrial cells were present in flushings, suggesting endometrial origin of the secretion. Both concentrations of MBL and IL-18 were higher in patients with unexplained infertility compared with patients involved in IVF/ICSI for male or tubal infertility (P = 0.005 and 0.02, respectively). The exploration of the endoluminal environment before oocyte retrieval may enhance pregnancy rates and show distinct features in patients with unexplained infertility.

Cytokines and chemokines in follicular fluids and potential of the corresponding embryo: the role of granulocyte colony-stimulating factor.

BACKGROUND: The cytokine/chemokine levels of individual follicular fluids (FFs) were measured to determine whether a biomarker could be linked to the developmental potential of the derived embryo. METHODS: Fluid was collected from 132 individual FFs that were the source of oocytes subsequently fertilized and transferred. In each, a bead-based multiplex sandwich immunoassay (Luminex) was used to measure 28 cytokines and chemokines simultaneously. RESULTS: Significantly higher levels of interleukin (IL-2) and interferon (IFN-gamma) were detected in FF for embryos that underwent early cleavage. IL-12 was significantly higher in FF corresponding to highly fragmented embryos and the chemokine CCL5 was significantly higher in FF related to the best quality (Top) embryos. The level of granulocyte colony-stimulating factor (G-CSF) in individual FF samples was correlated with the implantation potential of the corresponding embryo. The area under the receiver operating characteristics curve, which distinguished the embryos that definitely led to delivery from those that did not, was 0.84 (0.75-0.90) (P = 0.0001) for FF G-CSF. FF G-CSF was significantly lower in patients older than 36 years compared with those <30-year old. When the FF G-CSF was 20 pg/ml or higher, the ratio between Top and non-Top embryos was significantly higher than for the group with FF G-CSF below 20 pg/ml (45 versus 20.45%, P = 0.007). CONCLUSIONS: Individual FF composition is related to the development of the corresponding in vitro generated embryo and its potential of implantation. Individual FF G-CSF may provide a non-invasive biomarker of implantation that needs to be evaluated together with in vitro observation to select the oocyte, and hence the embryo, to transfer.

[Physiology of implantation]. / Physiologie de l'implantation.

This article explains why we have had to come to a central role for innate immunity rather than the threat of maternal rejection of the foetal allograft. We encompass briefly the role of inflammation in implantation, not only for invasion adhesion, but also to prepare future "tolerance". In this context, we envisage the role of TWEAK and complement.

Detectable levels of interleukin-18 in uterine luminal secretions at oocyte retrieval predict failure of the embryo transfer.

BACKGROUND: Most implantation failures after successful in vitro fertilization-embryo transfer (IVF-ET) result from inadequate uterine receptivity. There is currently no way to predict this receptivity. METHODS: We investigated whether the detection of interleukin-(IL)18 by ELISA in uterine luminal secretions might predict implantation failure. Secretions of 133 patients enrolled in our IVF-ET program were sampled by uterine flushing immediately before oocyte retrieval. We assessed the following outcomes: pregnancy rate, multiple pregnancy rate, and implantation rate per embryo transferred. RESULTS: Interleukin-18 was detected in the flushing fluid of 38 patients (28.6%). Although the two groups were comparable for all other characteristics (age, etiology, ovarian reserve, number of embryos transferred, quality of embryos), all outcome variables differed significantly. The pregnancy rate was 37.9% in the IL-18 - ve group and 15% in the IL-18 + ve group, the multiple pregnancy rate 27.7% and 0%, and the implantation rate per embryo transferred 19.4% and 6.7% (all comparisons, P=0.02). Only embryos meeting good quality criteria were transferred to 65 patients: 50 IL-18 - ve and 15 IL-18 + ve. The pregnancy rate was 51% for the IL-18 - ve group and 20% for the IL-18 + ve group, the multiple pregnancy rate 36% and 0.0%, respectively, and the implantation rate 29% and 8.3% (P = 0.02). CONCLUSION: This non-invasive and simple method predicted inadequate uterine receptivity, independent of embryo quality.

Demonstration of the presence of IL-16, IL-17 and IL-18 at the murine fetomaternal interface during murine pregnancy.

PROBLEM: To determine if interleukin-16 (IL-16), IL-17, and IL-18 are present at the murine fetomaternal interface during pregnancy as a first step towards investigating their roles in fetomaternal relationship. METHODS: Expression of IL-16, IL-17, and IL-18, was assessed by immunohistochemistry (IHC) in the BALB/c x BALB/k (H2d x H2k), and the CBA/J x BALB/c non-abortion prone, and CBA/J x DBA/2 abortion prone matings. Enzyme-linked immunosorbent assay (ELISA) were performed for the two latter cytokines to compare local production in the abortion prone CBA/J x DBA/2 versus the non-abortion prone CBA/J x BALB/c matings. RESULTS: Expression of IL-17 was borderline. The anti-IL-16 staining specifically localized in the uterine stroma and glandular epithelium and was rather low in the placenta. IL-18 staining started in the peri-implantation uterus in the basal proliferative stroma, and was also traced, although weaker, in the glandular epithelium. In the immediate post-implantation period, a weak stromal staining persisted but there was a strong labeling of the ectoplacental cone. Interestingly, when the ectoplacental cone differentiates into placenta having a major histocompatibility complex (MHC) class I + spongiotrophoblast and a (MHC class I-) labyrinth, a very strong transient labeling of uterine natural killer (u-NK) cells was found. Later in gestation, IL-18 was also produced by giant cell and spongiotrophoblast. Finally, we compared by ELISA the production of IL-17/-18 in CBA/J x DBA/2 and CBA/J x BALB/c matings. We detected significantly more IL-18 in the non-abortion prone combination decidua or placenta. CONCLUSION: The three cytokines IL-16, IL-17, and IL-18 were detected at the fetomaternal interface with a tissue specific, stage-dependent distribution. The predominance of IL-18 secretion in the non-resorption prone matings lead us to question the general validity of the classical T-helper (Th)1/2 paradigm.

Concentration of leukaemia inhibitory factor (LIF) in uterine flushing fluid is highly predictive of embryo implantation.

BACKGROUND: There is strong evidence that locally secreted cytokines control the implantation process and can cause implantation failure. Uterine flushing fluids were analysed to determine their concentrations of leukaemia inhibitory factor (LIF) and tumour necrosis factor (TNF). METHODS AND RESULTS: We began by flushing the uterine cavities of 33 infertile patients on day 26 of two consecutive cycles. The concentrations of LIF (by enzyme-linked immunosorbent assay) and TNF (by bioassay) were significantly correlated during these cycles (r = 0.762, P = 0.0001 and r = 0.822, P = 0.001 respectively) and hence reliable. Then, after a reference flushing of 30 infertile patients, we followed the outcome of their first consecutive cycle of ovarian stimulation, which preceded either IVF or intrauterine insemination. A total of 10 patients became pregnant. The median concentration of LIF was 0 pg/ml (range: 0-177) and of TNF was 0 U/ml (range: 0-6.17) among those who became pregnant, and 203 pg/ml (range: 0-1620) and 2.14 U/ml (range: 0-16) respectively among those who did not. The LIF concentration was significantly lower in the pregnant group (P = 0.0013). CONCLUSION: A low concentration of LIF in the uterine flushing fluid at day 26 was predictive of subsequent implantation. Use of this procedure should increase the number of IVF attempts yielding successful pregnancies and also lead to corrective therapies.

Localization of pro-inflammatory (IL-12, IL-15) and anti-inflammatory (IL-11, IL-13) cytokines at the foetomaternal interface during murine pregnancy.

The involvement of some interleukins (ILs) in early and established pregnancy has been convincingly demonstrated, but little is known about the potential role of the more recently discovered ones. However, since many of these have positive or negative regulatory effects on both NK and T cells, it is highly probable that they also have regulatory functions in both implantation and placental development. Therefore, as a first step in tackling this problem, we have investigated whether several recently described pro- (IL-12, IL-15) and anti-inflammatory (IL-11, IL-13) cytokines were expressed at the uteroplacental interface by use of immunohistochemistry at different stages of gestation in mice. Each of these molecules was found at the foetomaternal interface, with specific distributions and patterns of expression depending on both the cytokine itself and the stage of pregnancy. The significance of these data is discussed.

Expression of beta chemokines in explants and trophoblasts from early and term human placentae.

PROBLEM: Implantation of human embryo requires expression of inflammatory cytokines and local attraction of T cells and natural killer (NK) cells. Chemokines are chemoattractants for these cells in classical inflammation. We speculated that they could also be involved in implantation. METHOD OF STUDY: We assessed by enzyme-linked immunosorbent assay (ELISA), reverse transcriptase-polymerase chain reaction (RT-PCR) and immunohistochemistry the presence of three classical beta chemokines Macrophage Inflammatory Protein 1 (MIP1)alpha, MIP1beta and Regulated upon activation, normal T cells expressed and secreted (RANTES) in cultures of placental villi or isolated trophoblasts derived from human first trimester and term placenta. RESULTS: Explant culture assays were positive for these three chemokines, with important quantitative variations between individuals. Half of the highly purified trophoblasts cultures were found by ELISA and RT-PCR to secrete in vitro MIP1alpha and MIP1beta. RANTES was never detected by ELISA in trophoblasts cultures, albeit we could detect a low amount of messenger RNA. Immunohistochemistry experiments show that Hofbauer cells and the trophoblast layer are a secretion site of MIP1beta in term placenta, and that cytotrophoblasts are able to secrete this chemokine in early placenta. CONCLUSION: Human placenta is a site of secretion of chemokines that could be involved in establishment of pregnancy.

Follicular fluid concentration of leukaemia inhibitory factor is decreased among women with polycystic ovarian syndrome during assisted reproduction cycles.

BACKGROUND: The possibility that a specific cytokine profile could be detected in the ovaries of patients with polycystic ovarian syndrome (PCOS) was investigated. METHOD: Enzyme-linked immunosorbent assay (ELISA) or bioassays were used to assess the concentrations of leukaemia inhibitory factor (LIF), tumour necrosis factor, interleukin 11, gamma interferon, progesterone and oestradiol in follicular fluids from preovulatory follicles collected after ovarian stimulation from 15 PCOS patients, 15 infertile control patients with regular cycles, and 8 oocyte donors. RESULTS: LIF and progesterone concentrations were significantly lower in the follicular fluid of PCOS patients (LIF median: 265 pg/ml) compared with controls (LIF median: 816 pg/ml); LIF and progesterone follicular fluid concentrations were correlated (r = 0.720, P = 0.0001). The LH/FSH ratio was negatively correlated with LIF concentrations (r = - 0.714, P = 0.0075). Although the PCOS and control patients did not differ significantly in age, ovarian reserve or IVF indication, the implantation rate was significantly lower among the women with PCOS (IR = 9 versus 21%, P = < 0.01). CONCLUSION: The specific cytokine profile of the PCOS patients is probably related to the lower implantation rate since follicular fluid LIF appears to function as an embryotrophic agent.

Localization of the Th2 cytokines IL-3, IL-4, IL-10 at the fetomaternal interface during human and murine pregnancy and lack of requirement for Fas/Fas ligand interaction for a successful allogeneic pregnancy.

PROBLEM: Th2 cytokines and Fas/Fas ligand interactions are proposed to be part of the placental barrier that contribute to the success of allogeneic pregnancy. To fully understand the role regulation of Th2 cytokines, we must isolate and identify the cells that produce them. We also need to assess the requirement for Fas/Fas ligand interaction in facilitating a successful allogeneic pregnancy. METHOD OF STUDY: To assess the site of production of Th2 cytokines, we used immunohistochemistry sections from placental and decidual tissue obtained at various stages of gestation in mice and humans. We used mice that are genetically deficient in Fas/Fas ligand interactions and raised specific anti-paternal CTLs by anti-paternal immunization of the mother before mating. RESULTS: The detailed results show that in both species the bulk of Th2 production may come from non-lymphoid tissues in the placenta and decidua, with a major role for trophoblasts. This raises questions about the mechanism(s) by which alloimmunization enhances local Th2 cytokine production. This issue is discussed. CONCLUSIONS: The success of allopregnancy in mice with circulating anti-paternal CTLs and deficient Fas/Fas ligand interactions rules out a mandatory role for such a mechanism in ensuring the success of allogeneic pregnancy.

Vertical transmission of HIV: parameters which might affect infection of placental trophoblasts by HIV-1: a review. Biomed Group on the Study of in Utero Transmission of HIV 1.

PROBLEM: To understand the mechanisms preventing and/or facilitating maternofetal transmission of human immunodeficiency virus (HIV)-1 across the placenta during pregnancy. METHODS OF STUDY: Current experimental data were reviewed. RESULTS AND CONCLUSIONS: The data about the production of cytokines by placental cells and explants, taken together with information indicating selective passage of certain HIV-1 variants across the placental trophoblast, suggest an intricate regulatory network operating at the fetomaternal interface. The data show a differential differentiation of early and late trophoblasts, as far as HIV entry routes are concerned. We believe this explains the relative predominance of the early infection window, as far as in utero infection is concerned. Whether such a differentiation state can be transiently induced on term placental trophoblasts by several differentiation agents, including cytokines, is being investigated. Whatever the results may be, it is obvious that infection of placental cells is an excellent model of passage infection by HIV of/through a mucosal barrier.

Insights into the mechanisms of vertical transmission of HIV-1. BIOMED2 Working Group on the in utero transmission of HIV-1.

This paper is a summary of three oral presentations, as well as the ensuing discussion, at the Rijeka/Opatija 3rd Alps Adria Immunology meeting by three members of the European Biomed group on vertical transmission of HIV (G. Chaouat, F. Barre-Sinoussi, G. Scarlatti). This group also involves the laboratories of D. Dormont (CEA, Fontenay aux roses, France), P. Gounon (Electron Microscopy, the Pasteur Institute, France; Irène Athanassakis, University of Crete, Greece; Eva Maria Fenyö, Karolinska Institute, Sweden; and Larry Guilbert, Canada). As such, this paper intends to be neither a review, nor an original article, but rather is an opinion paper discussing the working hypothesis of this network, as well as some of their recent results, which were presented at this meeting. The paper was issued at the request of the organizers of the meeting.

Suppressive effect of hepatitis B virus on the induction of interleukin-1 beta and interleukin-6 gene expression in the THP-1 human monocytic cell line.

The major target organ for Hepatitis B Virus (HBV) is the liver, but extrahepatic sites including monocytes express receptors for HBV and may become infected. Therefore, we investigated the effect of HBV on the in vitro expression of interleukin-beta (IL-1 beta) and interleukin-6 (IL-6) by the monocytoid cell line THP-1, exposed to various stimuli (LPS, PMA or both). Nonstimulated THP-1 cells did not synthesize IL-1 beta and IL-6, even after in vitro exposure to HBV. LPS stimulation alone induced moderate secretion of both IL-1 beta and IL-6 (300 pg/ml). After induction of macrophage differentiation by PMA, THP-1 cells acquired adherence and expressed a higher level of IL-1 beta (up to 2 ng/ml) but did not synthesize IL-6. Treatment of THP-1 cells with PMA and LPS caused the highest production of both IL-1 beta and IL-6 (> 5ng/ml). In vitro exposure of PMA + LPS-stimulated THP-1 cells to HBV resulted in secretion of both HBsAg and preS2Ag which was maintained over 10 days of culture. Southern blot technique was used to study the state of HBV DNA in the cells. Hybridization of non-digested cellular DNA showed only high molecular weight HBV DNA forms. The HindIII restriction pattern revealed bands corresponding to large DNA fragments and the presence of bands at the 3.2 kb position. Under these conditions (PMA + LPS), HBV inhibited the production of IL-1 beta and IL-6 proteins and completely suppressed the IL-1 beta and IL-6 mRNA. Thus, our findings (i) strongly support a relationship between the state of cell differentiation and susceptibility of cells to HBV infection, and (ii) demonstrate that HBV exerts an inhibitory effect on the induction of IL-1 beta and IL-6 genes expression in monocytic THP-1 cells. These results suggest that HBV leads to a fall of pro-inflammatory cytokine production by monocytes/macrophages, which may contribute to impaired host immune response during infection.

Primary cultured normal human hepatocytes for hepatitis B virus receptor studies.

BACKGROUND/AIMS: We analyzed the hepatitis B virus envelope specificities (HBs, preS2 and preS1) involved in virus attachment to normal human hepatocytes, and we performed in vitro hepatitis B virus infection experiments without addition of dimethyl sulfoxide and polyethylene glycol, which may affect cell membrane integrity, in order to study further the early steps of the life cycle of the hepatitis B virus. METHODS: Primary normal human hepatocytes were prepared from surgical biopsies by the two-step collagenase perfusion technique, and cultured in a fetal calf serum-free medium supplemented with 10(-6) M dexamethasone. Cell-binding assays, ligand blotting and immunohistochemistry experiments were carried out using our anti-idiotypic (Ab2) antibodies (Ab2s/preS1, Ab2s/preS2 and Ab2s/HBs). RESULTS: Probing primary normal human hepatocytes, the 35-kDa major preS1-binding protein (preS1-BP35) we have previously identified in human hepatoma HepG2 cells was recognized in blotting, whereas both HBs- and preS1-specificities of the hepatitis B virus envelope interacted strongly with normal human hepatocyte cell membrane in cell-binding assays and immunohistochemistry experiments. Hepatitis B virus infectivity studies confirmed a great inter-experimental variability depending on donors and liver perfusion, and demonstrated a great intra-experimental variability depending on the serum-derived hepatitis B virus isolate used for the inoculation. In our culture conditions, only increased detection of the RC and CCC DNA forms of hepatitis B virus in cells and of hepatitis B virus surface antigens in medium was observed 4 to 8 days after exposure of cells to hepatitis B virus. CONCLUSION: These findings support a potential role for preS1-BP35 as a receptor protein for hepatitis B virus. In our hands, limitation(s) in the hepatitis B virus life cycle may occur at some step after virion binding, and likely result from complex regulation of reverse transcription of the RNA and translation of core protein by extrahepatic host factors or/and by the virus itself. However, the normal human hepatocyte model developed here is available for studying the initial steps in hepatitis B virus entry into cells.

In vitro infection of human hepatoma cells (HepG2) with hepatitis B virus (HBV): spontaneous selection of a stable HBV surface antigen-producing HepG2 cell line containing integrated HBV DNA sequences.

The degree of susceptibility of human hepatoma (HepG2) cells to direct hepatitis B virus (HBV) infection remains unknown. We previously observed a low level of Dane particle production and viral DNA replication after in vitro infection of HepG2 cells with serum-derived HBV. However, this culture system appeared to be affected by variations as human hepatocyte cultures. In the present study, HBV infection of HepG2 cells led to a significant increase in the secretion of three envelope antigens (HBsAg, preS2Ag and preS1Ag) at 4 days post-infection, and Northern blot analysis revealed the presence of both preS1 (2.6 kb) and preS2/S (2.2 kb) transcripts. Expression of preS1Ag and the corresponding viral RNA became undetectable on 21 days post-infection whereas the 2.2 kb RNA species persisted and was associated with secretion of subviral HBs particles expressing preS2-epitopes and banding between 30 and 35% sucrose. At 35 days post-infection (fifth passage), a sudden high level production of HBsAg and preS1Ag was observed, followed by a massive cell death (90%). A stable HBsAg-producing HepG2 cell line, designated HepG2-BV3, grew out of the surviving cells. HepG2-BV3 cells could integrate HBV DNA sequences and produce the three HBV surface antigens. Treatment with dexamethasone increased the HBsAg and preS1Ag secretion. Such a HBsAg-producing HepG2 cell line obtained by in vitro HBV infection seems to mimick events that occur in the naturally occurring persistent chronic infection, and therefore may be an efficient in vitro model for studying the contribution of viral integration in the dysregulation of HBV and liver-specific genes expression.

Significance and relevance of serum preS1 antigen detection in wild-type and variant hepatitis B virus (HBV) infections.

These studies assessed whether the serum expression of preS1 antigen could be a useful HBV marker for monitoring the progress of antiviral therapy in the treatment of chronic active hepatitis B (CAH-B) virus infections. Our findings indicate that: 1) the rearrangements we observed in the preS region of mutated HBV DNA molecules during chronic infection did not effect the preS1 sequence (21-47) critical for HBV infectivity; 2) the persistence or even the rebound of preS1 antigen expression during follow-up in responders to antiviral therapy may indicate virus persistence, suggesting the possibility of relapse through wild-type HBV or the emergence of HBV variants following the immunoelimination phase.

PreS1-specific binding proteins as potential receptors for hepatitis B virus in human hepatocytes.

Cellular receptors play an important role in viral pathogenesis. Until now, there has been no reliable information on the receptor(s) for hepatitis B virus (HBV). Therefore, we attempted to identify specific receptors in human hepatocytes using an immunological approach. Anti-idiotypic (Ab2) antibodies were raised in rabbits against our monoclonal antibody (MAb1) F35.25. MAb1 F35.25 (i) recognized the hepatocyte receptor binding site on HBV (located between amino acid residues 21 and 47 of the preS1 sequence) and (ii) blocked the attachment of preS1-positive HBV particles to human hepatocytes. The presence of Ab2 antibodies in rabbit sera was determined by the ability of antisera to inhibit Id (Ab1)/antigen (HBV) recognition. Affinity-purified Ab2 IgGs to F35.25 represented an internal image for the preS1 domain 12-53. Our present studies indicate that Ab2 IgGs to F35.25 (i) recognized the membrane-associated structure of the preS1-specific HBV receptor in a HepG2 cell binding assay, as visualized by immunoenzymatic staining; (ii) strongly bound to a major 35-kDa component and to three other related proteins of 50, 43, and 40 kDa in extracts of HepG2 cells; and (iii) reacted with several soluble and membrane-associated proteins in normal human liver cells. The binding was insensitive to reduction. All preS1 binding proteins were V8 protease sensitive and endoglycosidase H resistant. The 35-kDa species was trypsin resistant and generated a band of 32 kDa by endoglycosidase F treatment. Together, our results suggest that the identified preS1-specific binding proteins may be involved in the putative complex structure of the hepatocyte receptor for HBV.

PreS antigen expression and anti-preS response in hepatitis B virus infections: relationship to serum HBV-DNA, intrahepatic HBcAg, liver damage and specific T-cell response.

The diagnostic value of preS antigens and anti-preS antibodies during Hepatitis B virus (HBV) infections have not yet been clearly elucidated. Therefore, the objectives of this study were: 1) to better understand the clinical significance of the expression of both preS1 and preS2 antigens (preS1Ag and preS2Ag) in the serum of chronic HBsAg carriers, and 2) to define the respective role of antibody responses to HBs-, preS2- and preS1-specific determinants in the course of acute hepatitis B (AH-B) infections with different outcomes. Our data showed that the serum preS1Ag/HBsAg ratio correlated well with the level of viral replication (serum HBV-DNA as monitored by PCR assay and liver HBcAg), especially in anti-HBe positive chronic carriers. The complete eradication of virions required a persistent antibody response to conformation-dependent HBs-epitopes, temporally associated with a vigorous T cell response to nucleocapsid antigens. Recovery from hepatitis B can be achieved when there is no early antibody response to preS2- and preS1-proteins, which was found to be transient, concomitant with a flare-up of the liver disease, and preceding anti-HBs production. Information on the patterns of preS antigens and their antibodies remained clouded because of the varying specificities and sensitivities of research methods used in studies to date. We have, therefore, developed original Polyclonal-Monoclonal RadioImmunoAssays (PAb-MAb RIAs) by using monoclonal antibodies (MAbs) having previously well-defined specificities. We could thus detect and quantify simultaneously the three distinct antigenicities of the HBV envelope, HBsAg, preS2Ag and preS1Ag, with the same sensitivity. In this way, the preS1Ag/HBsAg and preS2Ag/HBsAg ratios can be calculated to estimate the serum expression of both preS1Ag and preS2Ag in relation to total HBsAg activity during different stages of chronic HBV infection. For optimal management of the state of HBV replication in chronic viral infection, the detection of HBV-DNA in serum was monitored by the Polymerase Chain Reaction (PCR) assay. We extended our work by investigating the clinical significance of antibody response to preS-specific determinants in patients with AH-B showing different outcomes in both natural course or response to alpha-interferon therapy. In a first attempt, we chose to use the Western Immuno-Blotting Assay (WIBA) to obtain a qualitative assessment of the nature of preS antibody responses. Finally, the cell-mediated immune response to HBV antigens was also studied in several patients with self-limited AH-B leading to a relevant finding which may help to clarify the mechanisms responsible for complete clearance of HBV.