Hepatitis delta: virological and clinical aspects.

There are an estimated 400 million chronic carriers of HBV worldwide; between 15 and 20 million have serological evidence of exposure to HDV. Traditionally, regions with high rates of endemicity are central and northern Africa, the Amazon Basin, eastern Europe and the Mediterranean, the Middle East and parts of Asia. There are two types of HDV/HBV infection which are differentiated by the previous status infection by HBV for the individual. Individuals with acute HBV infection contaminated by HDV is an HDV/HBV co-infection, while individuals with chronic HBV infection contaminated by HDV represent an HDV/HBV super-infection. The appropriate treatment for chronic hepatitis delta is still widely discussed since it does not have an effective drug. Alpha interferon is currently the only licensed therapy for the treatment of chronic hepatitis D. The most widely used drug is pegylated interferon but only approximately 25% of patients maintain a sustained viral response after 1 year of treatment. The best marker of therapeutic success would be the clearance of HBsAg, but this data is rare in clinical practice. Therefore, the best way to predict a sustained virologic response is the maintenance of undetectable HDV RNA levels.

Hepatitis delta virus: insights into a peculiar pathogen and novel treatment options.

Chronic hepatitis D is the most severe form of viral hepatitis, affecting ∼20 million HBV-infected people worldwide. The causative agent, hepatitis delta virus (HDV), is a unique human pathogen: it is the smallest known virus; it depends on HBV to disseminate its viroid-like RNA; it encodes only one protein (HDAg), which has both structural and regulatory functions; and it replicates using predominantly host proteins. The failure of HBV-specific nucleoside analogues to suppress the HBV helper function, and the limitations of experimental systems to study the HDV life cycle, have impeded the development of HDV-specific drugs. Thus, the only clinical regimen for HDV is IFNα, which shows some efficacy but long-term virological responses are rare. Insights into the receptor-mediated entry of HDV, and the observation that HDV assembly requires farnesyltransferase, have enabled novel therapeutic strategies to be developed. Interference with entry, for example through blockade of the HBV-HDV-specific receptor sodium/taurocholate cotransporting polypeptide NTCP by Myrcludex B, and inhibition of assembly by blockade of farnesyltransferase using lonafarnib or nucleic acid polymers such as REP 2139-Ca, have shown promising results in phase II studies. In this Review, we summarize our knowledge of HDV epidemiology, pathogenesis and molecular biology, with a particular emphasis on possible future developments.

An update on HDV: virology, pathogenesis and treatment.

Hepatitis delta is an inflammatory liver disease caused by infection with HDV. HDV is a single-stranded circular RNA pathogen with a diameter of 36 nm. HDV is classified in the genus Deltavirus and is still awaiting a final taxonomic classification up to the family level. HDV shares similarities with satellite RNA and viroids including a small circular single-stranded RNA with secondary structure that replicates through the 'double rolling circle' mechanism. The HDV RNA genome is capable of self-cleavage through a ribozyme and encodes only one structural protein, the hepatitis delta antigen (HDAg), from the antigenomic RNA. There are two forms of HDAg, a shorter (S; 22 kDa) and a longer (L; 24 kDa) form, the latter generated from an RNA editing mechanism. The S form is essential for viral genomic replication. The L form participates in the assembly and formation of HDV. For complete replication and transmission, HDV requires the hepatitis B surface antigen (HBsAg). Thus, HDV infection only occurs in HBsAg-positive individuals, either as acute coinfection in treatment-naive HBV-infected persons, or as superinfection in patients with pre-existing chronic hepatitis B (CHB). HDV is found throughout the world, but its prevalence, incidence, clinical features and epidemiological characteristics vary by geographic region. There are eight genotypes (1 to 8) distributed over different geographic areas: HDV-1 is distributed worldwide, whereas HDV-2 to 8 are seen more regionally. Levels of HDV viraemia change over the course of HDV infection, being significantly higher in patients with early chronic hepatitis than in cirrhosis. Chronic HDV infection leads to more severe liver disease than chronic HBV monoinfection with an accelerated course of fibrosis progression, an increased risk of hepatocellular carcinoma and early decompensation in the setting of established cirrhosis. Current treatments include pegylated interferon-α and liver transplantation; the latter of which can be curative. Further studies are needed to develop better treatment strategies for this challenging disease.

Assembly of hepatitis delta virus: particle characterization, including the ability to infect primary human hepatocytes.

Efficient assembly of hepatitis delta virus (HDV) was achieved by cotransfection of Huh7 cells with two plasmids: one to provide expression of the large, middle, and small envelope proteins of hepatitis B virus (HBV), the natural helper of HDV, and another to initiate replication of the HDV RNA genome. HDV released into the media was assayed for HDV RNA and HBV envelope proteins and characterized by rate-zonal sedimentation, immunoaffinity purification, electron microscopy, and the ability to infect primary human hepatocytes. Among the novel findings were that (i) immunostaining for delta antigen 6 days after infection with 300 genome equivalents (GE) per cell showed only 1% of cells as infected, but this was increased to 16% when 5% polyethylene glycol was present during infection; (ii) uninfected cells did not differ from infected cells in terms of albumin accumulation or the presence of E-cadherin at cell junctions; and (iii) sensitive quantitative real-time PCR assays detected HDV replication even when the multiplicity of infection was 0.2 GE/cell. In the future, this HDV assembly and infection system can be further developed to better understand the mechanisms shared by HBV and HDV for attachment and entry into host cells.

The nucleolus: reviewing oldies to have new understandings.

The nucleolus is the most prominent compartment in the nucleus and known as the site for ribosome biogenesis in eucaryotes. In contrast, there is no such equivalent structure for ribosome synthesis in procaryotes. This raises two concerns that how does the nucleolus evolve and that whether the nucleolus remains playing a single role in ribosome biogenesis along the evolution. Increasing data support new nucleolus functions, including signal recognition particle assembly, small RNA modification, telomerase maturation, cell-cycle and aging control, and cell stress sensor. Multiple functions of the nucleolus possibly result from the plurifunctionality of nucleolar proteins, such as nucleolin and Nopp140. Proteomic analyses of human and Arabidopsis nucleolus lead a remarkable progress in understanding the evolution and new functions of nucleoli. In this review, we present a brief history of nucleolus research and new concepts and unresolved questions. Also, we introduce hepatitis D virus for studying the communication between the nucleolus and other subnuclear compartments, and Caenorhabditis elegans for the role of nucleolus in the development and the epistatic control of nucleologenesis.

Hepatitis delta virus infection: molecular biology and treatment.

Hepatitis delta virus is a defective human infectious agent which causes severe hepatic damage in hepatitis B virus-infected patients. Although prophylactic steps and the development, in certain countries, of efficient vaccination programs against hepatitis B virus have led to a diminution of the incidence rate of this disease, hepatitis D is still an important health problem. Hepatitis D infection is therefore associated with a worse clinical evolution than hepatitis B infection alone. On the other hand, the different therapeutic strategies being assayed at present including the use of interferon, have shown to be inefficient in the treatment of this disease. In this article, different aspects of the molecular biology and natural history of the infection, specially focused on those unknown aspects of this virus, are discussed. Finally, we have included a revision of the current state of hepatitis D treatment, as well as a comment of the new experimental strategies, like the use of antisense probes and trans-ribozyme activities.

Ribonucleoprotein complexes of hepatitis delta virus.

Human hepatitis delta virus (HDV) is a subviral satellite agent of hepatitis B virus (HBV). The envelope proteins of HDV are provided by the helper virus, HBV, but very little is known about the internal structure of HDV. The particles contain multiple copies of the delta antigen and an unusual RNA genome that is small, about 1,700 nucleotides in length, single stranded, and circular. By using UV cross-linking, equilibrium density centrifugation, and immunoprecipitation, we obtained evidence consistent with the interpretation that delta antigen and genomic RNA form a stable ribonucleoprotein (RNP) complex within the virion. Furthermore, electron-microscopic examination of the purified viral RNP revealed a roughly spherical core-like structure with a diameter of 18.7 +/- 2.5 nm. We also isolated HDV-specific RNP structures from the nuclei of cells undergoing HDV genome replication; both the genome and antigenome (a complement of the genome) of HDV were found to be in such complexes. From the equilibrium density analyses of the viral and nuclear RNPs, we were able to deduce the number of molecules of delta antigen per molecule of HDV RNA. For virions, this number was predominantly ca. 70, which was larger than for the nuclear RNPs, which were more heterogeneous, with an average value of ca. 30.

Sequence and structure of the catalytic RNA of hepatitis delta virus genomic RNA.

Human hepatitis delta virus (HDV) RNA has been shown to contain a self-catalyzed cleavage activity. The sequence requirement for its catalytic activity appears to be different from that of other known ribozymes. In this paper, we define the minimum contiguous sequence and secondary structure of the HDV genomic RNA required for the catalytic activity. By using nested-set deletion mutants, we have determined that the essential sequence for the catalytic activity is contained within no more than 85 nucleotides of HDV RNA. These results are in close agreement with the previous determinations and confirmed the relative insignificance of the sequence at the 5' side of the cleavage site. The smallest catalytic RNA, representing HDV genomic RNA nucleotide positions 683 to 770, was used as the basis for studying the secondary structure requirements for catalytic activity. Analysis of the RNA structure, using RNase V1, nuclease S1 and diethylpyrocarbonate treatments showed that this RNA contains at least two stem-and-loop structures. Other larger HDV RNA subfragments containing the catalytic activity also have a very similar secondary structure. By performing site-specific mutagenesis studies, it was shown that one of the stem-and-loop structures could be deleted to half of its original size without affecting the catalytic activity. In addition, the other stem-and-loop contained a six base-pair helix, and the structure, rather than the sequence, of this helix was required for the catalytic activity. However, the structure of a portion of the stem-and-loop remains uncertain. We also report that this RNA can be divided into two separate molecules, which alone did not have cleavage activity but, when mixed, one of the RNAs could be cleaved in trans. This study thus reveals some features of the secondary structure of the HDV genomic RNA involved in self-catalyzed cleavage. A model of this RNA structure is presented.

Small-form hepatitis B surface antigen is sufficient to help in the assembly of hepatitis delta virus-like particles.

Hepatitis delta virus (HDV) has an envelope composed of large-, middle-, and small-form hepatitis B surface antigens (HBsAgs) provided by the helper hepatitis B virus (HBV). In order to examine the roles of individual HBsAgs in HDV assembly, we constructed plasmids containing each specific HBsAg gene and then cotransfected each plasmid with HDV cDNA into a permissive human hepatoma cell line (HuH-7) to examine the effects on HDV production. Results indicated that the plasmids containing only the HBsAg genes were able to complement HDV cDNA as efficiently as the plasmid containing the complete HBV genome in generating HDV-like particles. Moreover, the small-form HBsAg alone was sufficient for HDV packaging. The particles produced from the cotransfection experiments have density and protein composition characteristics similar to those of naturally occurring HDV. With the electron microscope, they were identified as 36- to 38-nm-diameter particles. It was concluded that only the HBsAgs were able to help in the assembly of HDV-like particles.

The large form of hepatitis delta antigen is crucial for assembly of hepatitis delta virus.

The virions of hepatitis delta virus (HDV) contain two species of HDV-specific protein, a large and a small form of hepatitis delta antigen (HDAg). We examined the role of individual HDAgs in virion assembly in cotransfection experiments. First, we constructed a replication-competent HDV mutant expressing only the small HDAg. When cotransfected with a plasmid expressing hepatitis B virus surface antigens to the HuH-7 cells, the mutant did not produce HDV virions, whereas the wild-type HDV clone did. Therefore, though the small HDAg is important for viral replication and is incorporated into the virus, the small-form delta antigen by itself is insufficient for virion formation. When the system was co-transfected with an additional plasmid providing the large HDAg, the HDV virion was then recovered. There was also evidence suggesting that the large HDAg could be copackaged into the HBsAg particles, without the presence of the HDV genome and the small HDAg. The results indicate a crucial role of the large HDAg in HDV assembly.

Baculovirus-directed high level expression of the hepatitis delta antigen in Spodoptera frugiperda cells.

The hepatitis delta antigen (HDAg) is a multifunctional protein. It forms the core-like structure of the hepatitis delta virus (HDV) but also enhances replication of HDV in the nucleus of the hepatocyte. A cDNA fragment encoding HDAg was inserted adjacent to the polyhedrin promoter of Autographa californica nuclear polyhedrosis virus present in the baculovirus transfer vector pVL941. After transfection of Spodoptera frugiperda (Sf9) cells a recombinant baculovirus Ac delta 1 was isolated and purified using filter hybridization techniques. Sf9 cells infected with Ac delta 1 express the HDAg as a non-fused, non-glycosylated protein with an abundance of up to 25% of the total cellular protein mass. Immunoblot analysis using a human polyclonal anti-HD conjugate identified a 22K and a 24K protein in the nucleus of Ac delta 1-infected Sf9 cells. Electron microscopic studies using immunogold labelling showed that the recombinant HDAg (recHDAg) was associated with the hetero-chromatin of the Sf9 cells. The recHDAg produced by Sf9 cells elicited anti-HD antibodies in chimpanzees when injected intramuscularly.

Hepatitis D virus infection.

The hepatitis D virus (HDV) was first detected in Italy in 1977 and is the etiologic agent of type D hepatitis. A defective RNA virus, HDV depends completely on the hepatitis B virus for its expression and replication. HDV infection can cause a severe form of hepatitis with high mortality rates. In the United States, hepatitis D most commonly affects intravenous drug abusers and hemophiliacs. Diagnosis is based on interpretation of the body's immune response to the hepatitis D antigen. At present, there is no specific treatment for type D hepatitis. Prophylaxis against HDV infection depends entirely on the prevention of hepatitis B. Patients found to have hepatitis D virus infection should be referred to a gastroenterologist for management.

Electron microscopy of ribonucleic acid in nuclear particulate aggregates of hepatitis D using nuclease-gold complexes.

The ultrastructural localization of hepatitis delta antigen (HDAg) and ribonucleic acid (RNA) was investigated by immunoperoxidase electron microscopy and by enzyme electron microscopy of RNase-gold complexes on liver biopsies from seven patients with hepatitis D. HDAg was localized mainly in the nucleus and sometimes in the cytoplasm of hepatocytes. Ultrastructurally, intranuclear HDAg was found on nuclear particulate structures measuring 20 to 30 nm in diameter. Intranuclear RNA visualized with gold particles was found in high amounts in the nucleolus, to a small extent in the chromatin area, and also on nuclear particulate structures. These findings suggest that intranuclear aggregates of irregular granular particulate structures in hepatitis D are the internal component of hepatitis delta virus (HDV) particles in blood.

The size of the hepatitis delta agent.

The size of the hepatitis delta virus was determined by filtration of infectious plasma through polycarbonate membranes and the inoculation of filtrates into chimpanzees. Chimpanzees inoculated with filtrates of 50 nm and 30 nm, but not 15 nm filters, developed delta hepatitis. The minimum size of infectious hepatitis delta virus was estimated to be approximately 30 nm, which is consistent with measurements of particles thought to be the virus.

Intranuclear inclusion bodies in liver of chronic hepatitis B with delta infection.

Seventy-two patients with HBsAg-positive chronic hepatitis were studied for serum antibody to delta antigen (anti-HD) by radioimmunoassay. Delta antigen (HDAg) in liver of the 72 patients was also studied immunohistochemically using peroxidase-labeled anti-HD. In one of the 72 patients, high titers of anti-HD and intrahepatic HDAg were detected. In this patient, HDAg was localized mainly in nuclei and occasionally in the cytoplasm of hepatocytes. By immunoelectron microscopy, HDAg was observed diffusely in some hepatocytic nuclei, but their nucleoli, perichromatin and heterochromatin were devoid of HDAg. Occasionally, inclusion body-like ring-shaped or irregularly shaped aggregates of HDAg were observed in nuclei. At higher magnification, these aggregates consisted of an HDAg-positive amorphous substance and microtubular structures. In their vicinity, scattered HDAg-positive granules were also present. By conventional electron microscopy, similar inclusion bodies composed of a clustered amorphous substance and microtubular structures 10-20 nm in diameter, together with 20-30 nm irregular granules were observed in hepatocyte nuclei, but no core of Dane particles were found. These novel intranuclear structures were not observed in other patients with chronic hepatitis B. It is suggested that they may represent the characteristic ultrastructure associated with delta infection.

Histological and immunohistochemical features in chronic delta hepatitis.

Forty-six liver biopsies from HBsAg Delta/anti-Delta serum positive patients with chronic hepatitis were compared with liver specimens from HBsAg positive Delta/antiDelta negative patients. The results indicate more severe histologic damage and inflammation among subjects who are serum-positive to the Delta system. Specific virus antigen was found in liver cell nuclei of almost all the Delta IR patients (93.5%). The rate of diffusion was directly proportional to the severity of histological lesions, which is in linea with the direct cytopathic effect of the Delta virus as ascertained in various other studies.