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Severe hepatitis B flare and liver failure: current assessment and management
Seng Gee Lim1,2, Maria Buti3, Jordan J Feld4
1Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore. mdclimsg@nus.edu.sg.
Clinical and Molecular Hepatology
|March 18, 2026
Summary
Hepatitis B flares, a complication of Chronic Hepatitis B (CHB), involve rising HBV DNA and ALT levels. Early antiviral treatment significantly reduces mortality, with rescue therapies and liver transplant considered for severe cases.
Area of Science:
- Hepatology
- Virology
- Immunology
Background:
- Hepatitis B flare is a frequent complication of Chronic Hepatitis B (CHB).
- It is characterized by elevated HBV viral load and alanine aminotransferases (ALT) levels (ALT≥5x ULN).
- The immunopathogenesis involves inflammatory responses to increased HBV DNA.
Purpose of the Study:
- To outline the definition, causes, and risks associated with Hepatitis B flares.
- To discuss initial assessment, prognostic scoring (COSSH-ACLF II), and management strategies.
- To review the role of early antiviral therapy, adjunctive treatments, and liver transplantation in managing severe flares and acute-on-chronic liver failure (ACLF).
Main Methods:
- Literature review and synthesis of current understanding on Hepatitis B flares and ACLF.
- Analysis of prognostic models and treatment outcomes, including nucleos(t)ide analogue efficacy.
- Evaluation of adjunctive therapies and the role of liver transplantation.
Main Results:
- Early initiation of nucleos(t)ide analogues reduces mortality in severe HBV flares by 73.6%.
- Salvage therapy with antivirals is challenging once jaundice and coagulopathy develop.
- Adjunctive therapies like corticosteroids and plasma exchange show potential as rescue options but require careful risk-benefit assessment.
Conclusions:
- Hepatitis B flares are serious events that can lead to hepatic decompensation and ACLF.
- Early antiviral treatment is crucial for improving outcomes.
- Liver transplantation remains the ultimate intervention for refractory cases, but rescue strategies should be explored prior to transplant consideration.
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