Hepatitis B Reactivation: The Controversies Continue

Hepatitis B virus (HBV) reactivation is a serious but largely avoidable complication of immunosuppressive therapy. The consequences of reactivation range from subclinical increases in HBV DNA to fulminant liver failure, which can be prevented with the appropriate use of prophylactic antiviral therapy. However, which patients need to be screened and whether all patients who test positive for any serological test require antiviral therapy are issues that still remain unclear. Additional issues such as the choice of antiviral and the duration of treatment also need clarification. Some of the confusion comes from the use of varying definitions in the literature to define outcomes. In this review, areas of controversy from definitions of reactivation to management of patients who are hepatitis B surface antigen and lone anti-core antibody positive in different clinical settings are discussed. The recently recognized issue of reactivation in the setting of hepatitis C antiviral therapy is also addressed as well as some recommendations for areas of future research to help clarify best practices.