Evaluation of patients with chronic HBV infection

Initial evaluation

History and physical examination*

Family history of HBV infection, liver disease, HCC

Laboratory tests to assess liver disease – complete blood counts with platelets, aminotransferase levels, total bilirubin, alkaline phosphatase, albumin, and INR

Tests for HBV replication – HBeAg, anti-HBe, HBV DNA

Tests to rule out viral coinfections – anti-HCV, anti-HDV (in persons from countries where HDV infection is common and in those with history of injection drug use), and anti-HIV^¶

Tests to screen for HCC^Δ – (eg, ultrasound)

Tests to screen for fibrosis^◊ – vibration-controlled transient elastography, serum fibrosis panel, or liver biopsy^§

Suggested follow-up for patients not considered for treatment: HBeAg+, HBV DNA >20,000 international units/mL, and normal ALT without cirrhosis^¥

ALT every 3 to 6 months and HBeAg every 6 to 12 months.

If ALT levels increase between 1 to 2 × ULN:^‡

Recheck ALT every 1 to 3 months and HBeAg every 6 months.
Consider liver biopsy or noninvasive assessment of fibrosis if ALT levels remain persistently elevated, age >40 years, and/or family history of HCC. Recommend treatment if biopsy shows moderate/severe inflammation or significant fibrosis (eg, METAVIR score ≥F2).

If ALT increases to >2 × ULN^‡ for 3 to 6 months and HBeAg+, HBV DNA >20,000 international units/mL, recommend treatment.

Screen for HCC in relevant population.^Δ

Suggested follow-up for patients not considered for treatment: HBeAg-, HBV DNA <2000 international units/mL, and normal ALT without cirrhosis^¥

ALT and HBV DNA every 3 months for 1 year, if persistently normal, ALT and HBV DNA every 6 to 12 months.^†

If ALT increases between 1 to 2 × ULN:^‡

Check serum HBV DNA level and exclude other causes of liver disease.
Monitor ALT and HBV DNA every 3 months.
Consider liver biopsy or noninvasive assessment of fibrosis if ALT remains elevated on serial tests or if HBV DNA persistently ≥2000 international units/mL. Recommend treatment for patients with moderate/severe inflammation or significant fibrosis.

If ALT increases to >2 × ULN, recommend treatment if HBV DNA >2000 international units/mL.

If HBV DNA increases to >2000 international units/mL, recommend treatment if ALT > 2 × ULN. If ALT <2 × ULN, assess liver fibrosis by biopsy or noninvasive tests. Recommend treatment if moderate/severe inflammation or significant fibrosis is present.^§

Screen for HCC in relevant population.

HBV: hepatitis B virus; HCC: hepatocellular carcinoma; INR: international normalized ratio; HBeAg: hepatitis B e antigen; anti-HBe: antibody to HBeAg; HCV: hepatitis C virus; HDV: hepatitis delta virus; ALT: alanine aminotransferase; ULN: upper limit of normal.

* Patient should be evaluated for signs and symptoms of cirrhosis, risk factors for coinfections, alcohol use, and information on vaccination status.

¶ In patients who have not undergone one-time screening and those with ongoing risk factors for HIV-infection.

Δ Refer to the topic that discusses screening of hepatocellular carcinoma.

◊ Refer to the topics in UpToDate that discuss noninvasive assessment of hepatic fibrosis.

§ Liver biopsy can also assess severity of inflammation and help rule out other causes of liver disease, information that will not be provided by noninvasive assessment of liver fibrosis. Refer to the UpToDate topic on management of hepatitis B virus for additional information on the role of liver biopsy.

¥ Cirrhosis is based upon findings from the initial evaluation. Patients with advanced fibrosis determined by noninvasive methods should be evaluated using a second method, and if results are concordant, consider managing the same way as patients with cirrhosis.

‡ The AASLD recommends using an ALT >35 U/L for men and >25 U/L for women as the upper limit of normal rather than local laboratory values.

† If cost is a concern, ALT alone can be monitored.

References:

Terrault NA, Lok ASF, McMahon BJ, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology 2018; 67:1560.

Graphic 62875 Version 13.0

خرید پکیج

Evaluation of patients with chronic HBV infection