[Therapy of problem cases in hepatitis B]

In the management of hepatitis B new therapeutic options have been established in the last years. Patients with fulminant course are rarely observed and should be submitted in a hepatological center. In chronic hepatitis B today we see mainly HBeAg negative/anti-HBe positive patients with replication of HBV-mutants. The tendency is to treat these cases with lamivudine (LAM) for some years. This is also true for HBV-cirrhosis in stage Child A. The progressed cirrhosis (Child B/C) without option for liver transplantation is not an indication for nucleosidanaloga and a contraindication for interferon. However before liver transplantation the viraemia should be diminished lower than 5 pg/ml. That means the HBV-hybridization test should become negative, which can be achieved with LAM in most cases. During and after liver transplantation the HBV-infected patients receive passive immunoprophylaxis with anti-HBs-hyperimmunoglobulin. In the situation of reinfection and hepatitis, nucleosidanaloga are indicated, in the first line LAM. In the case of LAM-resistance, interferon alpha is a further option. Patients after renal transplantation and HBV-infection should also be treated with LAM. In these patients IFN should be avoided, because graft rejection can be induced. Combined infection with HBV plus HDV, HCV or HIV need an individual concept for treatment. Extrahepatic manifestations of HBV-infection with clinical relevance, e.g. panarteriitis or glomerulonephritis are indications for antiviral treatment. If treatment with glucocorticosteroids is necessary in these situations, the steroids should be given only in combination with LAM. In non-cirrhotic patients with normal aminotransferases but quantify-able viraemia the liver histology is helpful for the indication of treatment.