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Author Spotlight: Advancements and Challenges in Hepatitis B Virus Detection
Published on: December 15, 2023
HBV-carriers: When is monitoring and surveillance sufficient? (point of view)
1Service d'hépatologie, faculté de médecine Pierre-et-Marie-Curie, hôpital Saint-Antoine, Assistance publique-Hôpitaux de Paris, 184, rue du Faubourg-Saint-Antoine, 75571 Paris cedex 12, France. tony.andreani@orange.fr
Insights
Current hepatitis B virus (HBV) treatments are effective but not curative. Guidelines for treatment initiation vary, necessitating careful patient evaluation based on viral load, transaminases, and age to manage risks like hepatocellular carcinoma.
Area of Science:
- Hepatology
- Virology
- Internal Medicine
Background:
- Hepatitis B virus (HBV) infection management relies on identifying patients needing long-term treatment versus healthy carriers.
- Existing international guidelines for HBV treatment initiation present inconsistencies in cut-off levels for viral load, transaminases, and liver biopsy indications.
- Understanding different phases of HBV infection (immune tolerance, active, inactive) is crucial for appropriate management strategies.
Purpose of the Study:
- To clarify the management of hepatitis B virus (HBV) infection across its different phases.
- To provide guidance on treatment decisions based on viral load, liver enzyme levels, and patient age.
- To address the complexities in managing atypical HBV infection forms and the role of liver biopsy.
Main Methods:
- Analysis of clinical criteria including HBV-DNA viral load, alanine transaminase (ALT) levels, and hepatitis B e-antigen (HBeAg) status.
- Differentiation of HBV infection into immune tolerance, active, and inactive phases.
- Consideration of patient age and presence of cirrhosis in treatment decision-making.
Main Results:
- Immune-tolerant patients with typical forms (HBeAg-positive, normal transaminases, high viral load) generally do not require treatment.
- Immune-tolerant patients over 40, regardless of cirrhosis, should be treated due to increased hepatocellular carcinoma risk.
- Active phase hepatitis and atypical inactive forms with elevated HBV-DNA require careful assessment, often including liver biopsy, to guide treatment.
Conclusions:
- Treatment decisions for HBV infection must be individualized, considering the phase of infection, viral markers, and patient-specific risk factors.
- Standardized guidelines are needed to reconcile differing interpretations of viral load and transaminase cut-offs.
- Early intervention in specific patient groups, such as older immune-tolerant individuals, can mitigate long-term complications like liver cancer.
Abstract:
Medications currently available for the treatment of hepatitis B virus (HBV) infection are highly effective but not curative. The current paradigm is to recognize patients who require long-term treatment (with its inconveniences) among the majority of healthy carriers who do not need treatment. International guidelines have been established to identify patients requiring treatment but differences concerning the cut-off levels for viral load and transaminases, or need for liver biopsy, compromise their interpretation. IMMUNE TOLERANCE PHASE: Patients with strictly defined typical forms (HBeAg-positive, normal transaminases level, very high viral load HBV-DNA more than 2 × 10(6) IU) have very limited liver injury and do not require treatment. Patients with atypical forms (low viral load HBV-DNA less than 2 × 10(6) IU) have a potential risk of more severe histological lesions, but the need for liver biopsy and treatment remains a matter of debate. Immune tolerant patients aged over 40 years should be treated because of the higher risk of hepatocellular carcinoma, even without cirrhosis. ACTIVE PHASE HBEAG-POSITIVE OR NEGATIVE: Typical forms with elevated viral load and transaminases level should be treated. Mild hepatitis with moderately elevated transaminases levels (1-2 times upper limit of normal) can cause variable degrees of liver damage, and liver biopsy is necessary. HBeAg-positive hepatitis with very high transaminases levels have a very high rate of spontaneous HBe seroconversion. Hepatitis with high transaminases levels but low viral (HBV-DNA less than 2000 UI) is possible in HBe-negative patients but unusual in HBe-positive patients. Another cause of liver disease could be involved (hepatitis D, steatosis, alcohol). INACTIVE PHASE: In the typical form, patients have a normal transaminases level and HBV-DNA less than 2000 IU; histological lesions are in general minimal. Treatment is not indicated. Atypical forms with normal transaminases levels but elevated HBV-DNA more than 2000 IU remain problematic. Forms with high-normal transaminases levels have a higher risk of complications. In the event of inactive cirrhosis, treatment is indicated if replication persists, even at a low level.
