Children | Adults (AASLD guidance)[1] | |
Definition of immune-tolerant phase | HBV DNA >20,000 IU/mL* ALT <1.5 times ULN | HBV DNA very elevated (typically >1 million IU/mL)* ALT <2 times ULN |
ALT cutoff (ULN) | Males: 35 IU/L Females: 25 IU/L | Males: 30 IU/L Females: 25 IU/L |
Monitoring | Monitor every 6 to 12 months Monitoring includes blood testing (ALT, HBeAg, HBeAb) and surveillance for HCC¶ | Monitor every 6 months |
Fibrosis assessment | Transient elastography (Fibroscan)Δ | |
Liver biopsy | If needed to confirm cirrhosis, or guided biopsy for a suspicious lesion | Liver biopsy in selected patients to assess for inflammation and cirrhosis that might be an indication for treatment (refer below) Candidates include:
|
Treatment | Treatment in immune-tolerant phase is generally not recommended Uncommon exceptions are:
| Treat in immune-tolerant phase is generally not recommended Exceptions are:
|
AASLD: American Association for the Study of Liver Diseases; AFP: alpha-fetoprotein; ALT: alanine aminotransferase; DNA: deoxyribonucleic acid; HBV: hepatitis B virus; HBeAb: hepatitis B antibody; HBeAg: hepatitis B antigen; HCC: hepatocellular carcinoma; IU: international units; ULN: upper limit of normal.
* For HBV DNA, IU/mL = 5 × copies/mL (ie, 20,000 IU/mL = 106 copies/mL).
¶ Surveillance for HCC consists of ultrasonography approximately every 6 months, with serum AFP if practical, but this depends on age and phase of HBV infection. Because the risk for HCC increases with age, we monitor somewhat less frequently (eg, every 2 to 3 years) for young patients in the immune-tolerant phase, provided that the baseline AFP and ultrasound are normal.
Δ Transient elastography is a useful tool for monitoring hepatic fibrosis, but availability and monitoring protocols vary. In our practice, we perform transient elastography at diagnosis and approximately once annually, including during the immune-tolerant phase. More frequent monitoring and/or liver biopsy is appropriate for children with abnormal results.Adapted from: Lee HW, Chan HL. Unresolved issues of immune tolerance in chronic hepatitis B. J Gastroenterol 2020; 55:383.