Evaluating the individual with chronic HBV infection
- Chronic hepatitis B infection is when HBsAg persists for more than 6 months
- Chronic HBV infection is usually a lifelong infection
- The natural history of chronic HBV infection evolves over decades
- Liver injury is likely due to immune response rather than direct viral injury
- Hepatitis B behaves differently at different stages
- Test results at a single point in time are usually insufficient to accurately predict the subsequent course of HBV infection
- Goals of evaluation
- Assess activity of liver injury: ALT levels, liver biopsy
- Assess severity of liver fibrosis: Platelet count, liver biopsy
- Predict risk of ongoing immune damage if untreated: Age, gender, and viral markers HBeAg, anti-HBe and HBV DNA levels
For a detailed explanation of all these tests, click here
Determine risk of ongoing liver injury based on understanding of natural history
- Hepatitis B is a lifelong infection characterized by different stages
- No single blood test or combination of blood tests at one point in time can be used to accurately predict what will happen in the intermediate future or distant future
- Several readings in time are needed to know if you are stable in one stage or tansitioning from one stage to another, either forwards or backwards!
| HBeAg | HBV DNA (log IU/mL) | ALT | Age | Interpretation |
|---|---|---|---|---|
| POS | >8 | Normal | <40 | Immune tolerance. No evidence supporting treatment |
| POS | 4-8 | Normal | 20-40 | Immune active but with minimal or no liver injury? |
| POS | >4-5 | High | 20-40 | Immune damage. Consider treatment if persists >6+ months. Urgent treatment needed if decompensated cirrhosis (jaundice, ascites, etc.) |
| NEG | <3-4 | Normal | Any | Inactive carrier state - requires persistently normal ALT and persistently low HBV DNA levels. Antiviral therapy not currently recommended if persistently in this state |
| NEG | <3-4 | High | Any | Intermittently active hepatitis B (HBV DNA was higher during ALT flare) vs another cause of liver disease, for example hepatitis C or hepatitis D co-infection, fatty liver, etc. |
| NEG | >3-4 | High | Any | HBeAg negative hepatitis B with ongoing immune damage. Consider treatment |
Unusual hepatitis B test results
Not everyone conveniently fits within the above framework - there are many exceptions. The following are some less common scenarios that can be seen from time to time:
| Serology pattern | Potential interpretations |
|---|---|
|