Clinical Liver Disease

Quantitative Hepatitis B Surface Antigen provides information concerning disease activity over and above an estimation of viral replication. It is an indispensable tool in the clinical assessment and management of chronic hepatitis B viral infection. Drs. Wong and Chan highlight what the clinician needs to know.

Drs. Villamil and Cairo review the best available evidence on managing the HBV patient who has received a solid organ transplantation. For liver transplant patients, the authors address whether there is a role for hepatitis B immunoglobulin, whether antiviral monotherapy sufficient, and how best to manage liver transplantations from antibody to hepatitis B core antigen (anti-HBc) positive donors. In the kidney transplant patient, Drs. Villamil and Cairo discuss kidney transplant in HBsAg-positive patients, as well as kidney transplants from anti-HBc positive donors.

Drs. Vigano and Lampertico weigh in on the nucleos(t)ide analogues (NAs)-pegylated interferon (PEG-IFN) debate, addressing first line therapy selection, monitoring of the patient treated with NAs, and when if ever it is appropriate to stop treatment.

Tram Tran, MD, an Associate Professor of Medicine from Cedars Sinai Medical Center and a CLD author, discusses HBV treatment in a woman of reproductive age. Dr. Tran addresses HBV transmission risk in pregnancy, antiviral therapy in women of childbearing age and treatment in the third trimester, as well as introducing treatment algorithms for the management of HBV in women planning a pregnancy, with an unexpected pregnancy, and during pregnancy.

Although effective therapies for chronic Hepatitis B are available, antiviral drug resistance represents a serious potential complication. With very few new drugs in the development pipeline, providers must make every effort to prevent resistance by following clear indications for therapy, counseling patients repeatedly on adherence, and monitoring closely for the development of virologic breakthrough. Drs. Tana and Ghany explain.

In some clinical situations, Hepatitis B requires immediate treatment. Dr. Perrillo reviews the characteristics of patients who may need prompt or even urgent care..

Treatment can be deferred in chronic HBV patients with inactive or mild liver disease without risk of liver disease progression, while patients with active or advanced liver disease should be treated. Dr. Papatheodoridis reviews approaches to classifying patients and how to determine the most appropriate treatment plans.

Patients with chronic Hepatitis B may also have concomitant infection with hepatitis delta virus (HDV), human immuno-deficiency virus (HIV), and/or hepatitis C virus (HCV). Because of the potential for coinfection, patients who are diagnosed with HBV therefore should be tested for their presence. Drs. Nguyen and Sterling review the essentials of diagnosis and management of the coinfected patient.

Most cases of Hepatitis B that cause long-term morbidity and mortality had their origin during the patient’s childhood, according to Maureen Jonas, MD from Boston Children’s Hospital and Harvard Medical School. Listen to the podcast to better understand the risks of and management strategies for HBV in children, and to review monitoring and treatment algorithms for children with HBV..

This liver biopsy from a patient with markedly active chronic hepatitis B has considerable chronic portal inflammation, predominantly lymphocytes, which migrate out of the portal tract to surround and destroy adjacent hepatocytes. Review this and other histologic features associated with the active immune response to HBV in Dr. Goodman’s review of hepatopathology of HBV.

All newly diagnosed chronic Hepatitis B patients should undergo a complete history, physical assessment, and laboratory assessment in an effort to assess the severity of liver disease and potential need for antiviral therapy. Watch, read, or listen to Dr. Fontana describe recommended testing and markers of HBV replication, as well as other approaches to evaluating the patient.

: HBV is noncytopathic, with hepatic injury occurring as a result of the host immune response against the virus. As a result, the interaction between HBV and the immune system is critical in determining the outcome of infection. Dr. Feld reviews reverse seroconversion, HBV reactivation, prevention, screening, and management strategies.

Both nucleos(t)ide analogues (NAs) and pegylated interferon (PEG-IFN) have proven to be effective, but current guidelines are lacking clear recommendations as to which treatment strategy should be used as first-line therapy. The authors review the best available evidence regarding which patients should be treated with interferon.

The recent development of direct-acting antiviral (DAA) molecules that are active on hepatitis C virus (HCV) has raised the concern that resistance may undermine therapy based on DAAs.

As soon as it was recognized that interferon-based therapy could lead to long-term viral eradication or a sustained virological response (SVR), the search was on for predictors of responses to therapy. With low response rates and the need for prolonged, costly, and difficult therapy, the primary goal was to identify patients who were unlikely to respond to treatment so that fruitless therapy could be avoided.

Treatment failure with pegylated interferon (PEG-IFN)/ribavirin (RBV) dual therapy can be due to either the persistence of hepatitis C virus (HCV) RNA throughout treatment (nonresponse) or the reappearance of the virus after the end of treatment.

The recent approval of two protease inhibitors (telaprevir and boceprevir) and the resultant increase in the sustained virological response (SVR) rate when either of these drugs is added to pegylated interferon (PEG-IFN) and ribavirin (RBV) have led to a flurry of patients with hepatitis C virus (HCV) infection seeking treatment.