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Asian-Pacific clinical practice guidelines on the

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Article in Hepatology International November 2015
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Hepatol Int
DOI 10.1007/s12072-015-9675-4

GUIDELINES

Asian-Pacific clinical practice guidelines on the management

of hepatitis B: a 2015 update
S. K. Sarin1 M. Kumar1 G. K. Lau2,27 Z. Abbas3 H. L. Y. Chan4
C. J. Chen5 D. S. Chen6 H. L. Chen7 P. J. Chen8 R. N. Chien9
A. K. Dokmeci10 Ed Gane11 J. L. Hou12 W. Jafri13 J. Jia14 J. H. Kim15
C. L. Lai16 H. C. Lee17 S. G. Lim18 C. J. Liu7 S. Locarnini19
M. Al Mahtab20 R. Mohamed21 M. Omata22 J. Park23 T. Piratvisuth24
B. C. Sharma25 J. Sollano26 F. S. Wang28 L. Wei29 M. F. Yuen30
S. S. Zheng31 J. H. Kao32

Received: 20 May 2015 / Accepted: 14 September 2015

 The Author(s) 2015. This article is published with open access at Springerlink.com

Abstract Worldwide, some 240 million people have

chronic hepatitis B virus (HBV), with the highest rates of
infection in Africa and Asia. Our understanding of the
natural history of HBV infection and the potential for
therapy of the resultant disease is continuously improving.
New data have become available since the previous
APASL guidelines for management of HBV infection were
published in 2012. The objective of this manuscript is to

update the recommendations for the optimal management

of chronic HBV infection. The 2015 guidelines were
developed by a panel of Asian experts chosen by the
APASL. The clinical practice guidelines are based on
evidence from existing publications or, if evidence was
unavailable, on the experts personal experience and
opinion after deliberations. Manuscripts and abstracts of
important meetings published through January 2015 have

& S. K. Sarin
[email protected]

12

Department of Infectious Diseases and Hepatology Unit,

Nanfang Hospital, Guangzhou, China

13

Department of Medicine, Aga Khan University, Karachi,

Pakistan

14

Beijing Friendship Hospital, Capital Medical University,

Beijing, China

Department of Hepatology, Institute of Liver and Biliary

Sciences, New Delhi, India

Division of Gastroenterology and Hepatology, Humanity and

Health Medical Centre, Hong Kong SAR, China
15

Department of Hepatogastroenterlogy, Sindh Institute of

Urology and Transplantation, Karachi, Pakistan

Seoul, Korea

16

Institute of Digestive Disease, The Chinese University of

Hong Kong, Hong Kong, China

Department of Medicine, University of Hong Kong,

Hong Kong, China

17

Internal Medicine Asan Medical Center, Seoul, Korea

Division of Gastroenterology and Hepatology, National
University Health System, Singapore, Singapore

Genomics Research Center, Academia Sinica, National

Taiwan University, Taipei, Taiwan

18

Department of Internal Medicine, National Taiwan

University College of Medicine, Taipei, Taiwan

19

Research and Molecular Development, Victorian Infectious

Diseases Reference Laboratory, Melbourne, Australia

Graduate Institute of Clinical Medicine, National Taiwan

University College of Medicine, Taipei, Taiwan

20

Bangabandhu Sheikh Mujib Medical University, Dhaka,

Bangladesh

Department of Internal Medicine, National Taiwan

University Hospital, Taipei, Taiwan

21

Department of Medicine, Faculty of Medicine, University

Malaya, Kuala Lumpur, Malaysia

Liver Research Unit, Chang Gung Memorial Hospital and

University, Chilung, Taiwan

22

Yamanashi Hospitals (Central and Kita) Organization, 1-1-1

Fujimi, Kofu-shi, Yamanashi 400-8506, Japan

10

Department of Gastroenterology, Ankara University School

of Medicine, Ankara, Turkey

23

11

New Zealand Liver Transplant Unit, Auckland City Hospital,

Auckland, New Zealand

Department of Internal Medicine, Institute of

Gastroenterology, Yonsei University College of Medicine,
Seoul, Korea

123

Hepatol Int

been evaluated. This guideline covers the full spectrum of

care of patients infected with hepatitis B, including new
terminology, natural history, screening, vaccination,
counseling, diagnosis, assessment of the stage of liver
disease, the indications, timing, choice and duration of
single or combination of antiviral drugs, screening for
HCC, management in special situations like childhood,
pregnancy, coinfections, renal impairment and pre- and
post-liver transplant, and policy guidelines. However, areas
of uncertainty still exist, and clinicians, patients, and public
health authorities must therefore continue to make choices
on the basis of the evolving evidence. The final clinical
practice guidelines and recommendations are presented
here, along with the relevant background information.

according to the Grading of Recommendations Assessment

Development and Evaluation (GRADE) system (Table 1).
The strength of recommendations reflects the quality of the
underlying evidence, which has been classified into one of
three levels, according to the GRADE system: high (A),
moderate (B) or low (C). The GRADE system offers two
grades of recommendation: strong (1) and weak (2) [1, 2]
(Table 1). Thus, the higher the quality of evidence, the more
likely a strong recommendation is warranted; the greater the
variability in values and preferences, or the greater the
uncertainty, the more likely a weaker recommendation is
warranted. Grades are not provided for definitions.

1 Introduction
Keywords

HBV
Guidelines
Acute hepatitis

Methodology of guideline development

These APASL clinical practice guidelines represent an
update of the last APASL guidelines published in 2012.
The 2015 guidelines were developed by a panel of Asian
experts chosen by the APASL. The clinical practice
guidelines are based on evidence from existing publications or, if evidence was unavailable, on the experts personal experience and opinion after deliberations.
Manuscripts and abstracts of important meetings published
through January 2015 have been evaluated. The evidence
and recommendations in these guidelines have been graded

24

NKC Institute of Gastroenterology and Hepatology, Prince of

Songkla University, Songkhla, Thailand

25

Department of Gastroenterology, G.B. Pant Hospital,

New Delhi, India

26

Department of Medicine, University of Santo Tomas, Manila,

Philippines

27

The Institute of Translational Hepatology, Beijing, China

28

Treatment and Research Center for Infectious Diseases,

Beijing 302 Hospital, Beijing, China

29

Peking University Hepatology Institute, Beijing, China

30

Division of Gastroenterology and Hepatology, Department of

Medicine, University of Hong Kong, Pofulam, Hong Kong

31

32

Department of Hepatobiliary and Pancreatic Surgery,

Collaborative Innovation Center for Diagnosis and Treatment
of Infectious Diseases, Key Laboratory of Combined Multiorgan Transplantation, Ministry of Public Health, First
Affiliated Hospital, Zhejiang University School of Medicine,
Hangzhou 310003, Zhejiang Province, China
Graduate Institute of Clinical Medicine and Hepatitis
Research Center, National Taiwan University College of
Medicine, National Taiwan University Hospital, Taipei,
Taiwan

123

An estimated 240 million persons worldwide are chronically infected with hepatitis B virus (HBV) [3], placing
them at increased risk of developing cirrhosis, hepatic
decompensation, and hepatocellular carcinoma (HCC).
Although most chronically HBV-infected subjects will not
develop hepatic complications, 1540 % will develop
serious sequelae during their lifetime.
Why this update was needed?
New data have become available since the previous
APASL guidelines for management of HBV infection were
published in 2012. These new data and information relate
to new terminology, natural history of hepatitis B, diagnosis, assessment of the stage of liver disease using invasive and noninvasive methods, and the indications, timing,
choice and duration of treatments in noncirrhotic and cirrhotic patients and in special situations like childhood,
pregnancy, coinfections, renal impairment and pre- and
post-liver transplant. In the current guidelines, policy recommendations for support and directions for HBV prevention and eradication in Asian countries have also been
provided. The 2015 guidelines are an update to the 2012
APASL guidelines, and reflect new knowledge and evidence regarding HBV infection.

2 Context of guidelines
2.1 Epidemiology and public health burden
of chronic HBV infection in Asia Pacific
HBV infection is a serious global public health problem. It
is estimated that at least two billion people, or one-third of
the worlds population, have been infected with HBV.
Approximately 240 million people, or about 6 % of the
worlds population, are chronically infected with HBV [3].

Hepatol Int
Table 1 Grading of evidence and recommendations (adapted from the GRADE system) [1, 2]
Notes

Symbol

High quality

Meta-analysis or randomized trials without important limitations or double-upgraded observational

studiesa. Further research is very unlikely to change our confidence in the estimate of effect

Moderate quality

Low

Downgraded randomized trials; upgraded observational studiesa. Further research is likely to have an
important impact on our confidence in the estimate of effect and may change the estimate
Double-downgraded randomized trials; observational studiesa

Very low quality

Triple-downgraded randomized trials; downgraded observational studies; case series/case reportsa

Grading of evidence

Further research is very likely to have an important impact on our confidence in the estimate of effect and
is likely to change the estimate. Any estimate of effect is uncertain
Grading of recommendation
Strong recommendation
warranted

Factors influencing the strength of the recommendation included the quality of the evidence, presumed
patient-important outcomes, and cost

Weaker
recommendation

Variability in preferences and values or greater uncertainty: more likely a weak recommendation is
warranted. Recommendation is made with less certainty; higher cost or resource consumption

Cohort, cross sectional, and casecontrol studies are collectively referred to as observational studies. Limitations that reduce the quality of
evidence of randomized controlled studies include study limitations (such as lack of allocation concealment, lack of blinding, large losses to
follow-up, failure to adhere to an intention-to-treat analysis, stopping early for benefit, or failure to report outcomes), inconsistent results,
indirectness of evidence, imprecision, and publication bias. Factors that can increase the quality of evidence of observational studies include
large magnitude of effect, plausible confounding that would reduce a demonstrated effect, and doseresponse gradient

The prevalence of HBV infection is highly heterogeneous

throughout the world, with an intermediate to high prevalence in the Asia-Pacific region, representing three-quarters
of chronic HBV-positive subjects worldwide [4]. In addition, the Western Pacific region (defined by the World
Health Organization as 37 countries including China,
Japan, South Korea, Philippines, and Vietnam) accounts
for nearly 50 % of all chronic HBV infection globally,
although it has less than one-third of the worlds population
[5].
Prior to implementation of the HBV vaccination program, the Asian-Pacific region was divided into three categories in terms of HBsAg prevalence [6]. High-prevalence
([8 %) regions included mainland China, the Hong Kong
special administrative region (SAR), Taiwan, Korea,
Mongolia, Philippines, Thailand, Vietnam, and the South
Pacific island nations. Intermediate-prevalence (28 %)
regions included central Asia, the Indian subcontinent,
Indonesia, Malaysia, and Singapore. Low-prevalence
(\2 %) regions included Australia and New Zealand,
although prevalence has increased in recent years due to
immigrants from high-prevalence countries [7, 8].
Universal HBV vaccination in newborns has dramatically changed the epidemiology of chronic HBV infection.
A systematic review published by WHO experts in 2012
showed a decrease in prevalence of chronic HBV infection
from 1990 to 2005 in most regions of the world [3].
For example, in Taiwan, where universal vaccination of
newborns was started in 19831985, HBsAg prevalence in
children younger than 15 years of age decreased from
9.8 % in 1984 to 0.7 % in 1999, and was further reduced to

0.5 % in 2004 [9]. This has also resulted in a marked

decline in the incidence of infant fulminant hepatitis,
mortality associated with chronic liver disease and HCC in
those born since advocacy of HBV vaccination began [10].
In mainland China, a national survey of HBV seroepidemiology has already shown a decrease in the general
prevalence of HBsAg, from 9.75 % in 1992 to 7.18 % in
2006, and a decrease in children \5 years of age, from
9.67 % in 1992 to 0.96 % in 2006 [11].
In Korea, the prevalence rates of chronic HBsAg positive subjects were 4.61 % in 1998 and 2.98 % in 2010;
among teenagers (1019 years), it decreased from 2.2 % in
1998 to 0.12 % in 2010 [12].
A study conducted in Taiwan showed relative risk of
HCC of 9.6 % for males who were positive for HBsAg
alone, but the risk increased to 60.2 % in males who were
both HBsAg- and HBeAg-positive [13]. It is estimated that
approximately one-third liver cirrhosis cases and more than
half of the HCC cases in the Asian region are attributable to
HBV [14]. Indeed, chronic HBV infection is the dominant
risk factor for HCC in most areas of Asia-Pacific. More
than 700,000 new HCC cases were diagnosed in 2008, with
an age-adjusted incidence of 10.8 per 100,000 worldwide
[15]. Most HCC cases ([80 %) occur in eastern Asia and
sub-Saharan Africa, where the incidence is [20 per
100,000 individuals [16], and is higher in males than
females. For example, in Korea, the age-standardized
incidence rate of HCC is 47.1 per 100,000 persons for
males and 11.4 per 100,000 persons for females. In Thailand, the annual incidence is 38.6/100,000 persons for
males and 17.2/100,000 persons for females, and in China

123

Hepatol Int

it is 37.9/100,000 and 14.2/100,000 for males and females,

respectively [16].
In India, where a large study in 1987 of approximately
8575 pregnant women had shown a 3.7 % incidence of
HBV infection [17], a recent study of 20,104 pregnant
women revealed a prevalence of around 1.1 %. The precise
reasons for the decreased incidence of HBV infection could
be the introduction of the HBV vaccination [18] and the
wide availability of antiviral drugs to treat the primary
infection in infected subjects. A large number of past
studies have shown a reduction in the prevalence of HBV
infection in the Indian subcontinent.

2.
3.

2.2 Terminology in chronic HBV infection

Various clinical terms relating to HBV infection have been
adopted worldwide for diagnosis, staging of the disease,
natural history, and treatment strategies. These can be
classified into five categories:
1.
2.
3.
4.
5.

Related to HBV infection

Related to natural history of chronic HBV infection
Related to response to antiviral therapy
Related to resistance to nucleo(s)tide analogues (NAs)
Occult HBV infection

Terminologies related to HBV infection

1.

Alanine aminotransferase (ALT) level Determination of serum ALT level is important for starting
antiviral treatment as well as for follow-up of
patients with chronic HBV infection. Serum ALT
level is termed as high normal serum ALT if it is
between 0.5 and 19 the upper limit of laboratory
reference (ULN); as low normal serum ALT if the
level is B0.59 ULN; as minimally raised serum
ALT if between ULN and 29 ULN of ALT level;
and as raised ALT if [29 ULN [19]. Some authors
have suggested lower values be used to define the
ULN for an ALT level of 30 U/l for male and
19 U/l for female [20]. While it would be worthwhile to have the lower ALT values for early
identification of liver injury and treatment of
patients chronically infected with HBV, at present,
the majority of countries in Asia are using ALT of
40 IU/ml as the upper limit of normal. Although
there is data to suggest that patients with ALT
values [0.5 times the upper limit of normal but
\1.0 of ULN still have liver disease [21], there is
little data to show that patients belonging to such a
sub-group, if treated, respond to antiviral therapy.
Due to these reasons, after due deliberations, the
APASL guidelines committee suggested the use of

123

4.

5.

6.

7.

8.
9.

10.

11.

a conventional ALT level of 40 IU/ml rather than

the lowered values of 30 and 19 IU/ml for males
and females, respectively (Table 2).
Chronic HBV infection is defined as HBsAg
seropositive status at 6 months or beyond.
Low replicative chronic HBV infection is defined as
HBsAg(?) anti-HBe(?) with persistent normal
serum ALT (PNALT) and HBV DNA \2000 IU/
ml and no evidence of liver injury. This phase is also
known as inactive carrier and inactive chronic
HBV infection. However, the use of low replicative chronic HBV infection term is preferred, as it
explains the state of HBV infection. The term
inactive carrier should be avoided, as HBV
infection is a dynamic interaction between the host
and the virus, and the inactive state could change at
different time points and gives the individual an
undue false sense of security.
Chronic hepatitis B is defined as chronic necroinflammatory disease of the liver caused by persistent
infection with HBV. It can be subdivided into
HBeAg-positive and HBeAg-negative chronic hepatitis B (CHB).
Resolved hepatitis B is defined as previous HBV
infection with a current state of HBsAg(-) and antiHBs(?)
Acute exacerbation or flare of hepatitis in chronic
HBV-infected patient is defined as intermittent
elevations of serum aminotransferase level to more
than five times the upper limit of normal and more
than twice the baseline value [22].
Reactivation of hepatitis B Reactivation of HBV
replication should be defined as a marked increase in
HBV replication (C2 log increase from baseline
levels or a new appearance of HBV DNA to a level
of C100 IU/ml) in a person with previously stable or
undetectable levels, or detection of HBV DNA with
a level C20,000 IU/ml in a person with no baseline
HBV DNA [22, 23]. In one earlier study, HBV DNA
level of [20,000 IU/ml had a positive predictive
value of 98 % in diagnosing reactivation of reactivation of HBV [23].
HBeAg clearance is defined as loss of HBeAg in a
person who was previously HBeAg positive.
HBeAg seroconversion is defined as loss of HBeAg
and detection of anti-HBe in a person who was
previously HBeAg positive and anti-HBe negative.
HBeAg reversion is defined as reappearance of
HBeAg in a person who was previously HBeAg
negative and anti-HBe positive.
Hepatic decompensation is defined as significant
liver dsyfunction as indicated by raised serum
bilirubin (more than 2.5 times the upper limit of

Hepatol Int
Table 2 Terminologies related to HBV infection
Terminology

Definition

ALT level
High normal

Serum ALT between 0.5 and 19 upper limit of laboratory reference (ULN)

Low normal

Serum ALT B0.59 ULN

Minimally raised
Raised

Serum ALT between ULN and 29 ULN

Serum ALT 29 ULN

Chronic HBV infection

HBsAg seropositive status beyond 6 months

Low replicative chronic HBV infection

HBsAg(?), HBeAg(-) anti-HBe(?) status with persistent normal serum ALT, HBV DNA \2000 IU/
ml and no evidence of liver injury
An asymptomatic individual who has been found to be HBsAg positive on routine blood screening.
Such a subject could have different levels of HBV DNA and could have no evidence of liver disease
to varied stages of liver disease, and hence needs to be worked up

Incidentally detected HBsAg positive

subject (IDAHS)
Chronic hepatitis B

Chronic necroinflammatory disease of liver caused by persistent infection with hepatitis B virus. It can
be subdivided into HBeAg-positive and HBeAg-negative chronic hepatitis B

Resolved hepatitis B infection

Acute exacerbation or flare of hepatitis
B

Previous HBV infection, but now HBsAg(-) and anti-HBs(?)

Intermittent elevations of aminotransferase to more than 5 times the upper limit of normal and more
than twice the baseline value

Reactivation of hepatitis B

Reappearance of active necroinflammatory disease of liver in a patient known to have the inactive
chronic HBV infection state or resolved hepatitis B infection

HBeAg clearance

Loss of HBeAg in a person who was previously HBeAg positive

HBeAg seroconversion

Loss of HBeAg and detection of anti-HBe in a person who was previously HBeAg positive and antiHBe negative

HBeAg reversion

Reappearance of HBeAg in a person who was previously HBeAg negative, anti-HBe positive

Hepatic decompensation

Defined as significant liver dysfunction as indicated by raised serum bilirubin (more than 2.5 times the
upper limit of normal) and prolonged prothrombin time (prolonged by more than 3 s), or INR[1.5 or
occurrence of complications such as ascites and hepatic encepahalopathy

Undetectable serum HBV DNA

Serum HBV DNA below detection limit of a PCR-based assay

12.

normal) and prolonged prothrombin time (prolonged

by more than 3 s), or occurrence of complications
such as ascites and hepatic encephalopathy [24].
Undetectable serum HBV DNA is defined as a serum
HBV DNA level below the detection limit (\12 IU/
ml) of a sensitive validated quantitative PCR-based
assay.

Terminologies related to natural history of chronic HBV

infection
Please refer to the section on natural history below.
Terminologies related to response to antiviral therapy
Responses can be divided into biochemical, serological,
virological and histological responses. All responses can be
estimated at several time points during and after therapy.
The definitions of virological responses vary according to
the timing (on or after therapy) and type of therapy. Two
different types of drugs can be used in the treatment of
CHB: immune modulators such as conventional or

pegylated interferon alpha (IFN or PEG-IFN), and antiviral

agents such as nucleoside/nucleotide analogues (Table 3).
Biochemical response (B) Biochemical response is
defined as normalization of ALT levels. It can be evaluated
at several time points during therapy, and at the end and
after the end of therapy. Since ALT activity often fluctuates
over time, a minimum follow-up of at least 1 year posttreatment with ALT determinations at least every 3 months
is required to confirm sustained off-treatment biochemical
response. The rates of sustained off-treatment biochemical
responses may sometimes be difficult to evaluate, as transient (usually \3 months duration) ALT elevations before
long-term biochemical remission may occur in some CHB
patients within the first year after treatment discontinuation. In such cases, additional close ALT follow-up of at
least 2 years after ALT elevation seems to be reasonable in
order to confirm sustained off-therapy biochemical remission [25]. However, biochemical responses may not correlate with DNA responses.
Serological response for HBeAg Serological response for
HBeAg applies only to patients with HBeAg-positive CHB

123

Hepatol Int
Table 3 Terminologies related to response to antiviral therapy and resistance to NAs
Terminology

Definition

Biochemical response

Normalization of serum ALT level

Serological response
For HBeAg

HBeAg loss and seroconversion to anti-HBe in patients with HBeAg-positive chronic HBV infection

For HBsAg

HBsAg loss and seroconversion to anti-HBs

Virological response on IFN/Peg-IFN therapy

Virological response

HBV DNA levels below 2000 IU/ml

Sustained virological response

HBV DNA levels below 2000 IU/ml for at least 12 months after the end of therapy

Virological response on NA therapy

Primary nonresponse

Reduction of serum HBV DNA \1 log IU/ml at 12 weeks of oral antiviral therapy in an adherent patient

Suboptimal or partial virological

response

Reduction of serum HBV DNA [1 log IU/ml but still detectable at 24 weeks of oral antiviral therapy in an
adherent patient

Virological response

Undetectable serum HBV DNA during therapy

Virological breakthrough

Increase of serum HBV DNA [1 log IU/ml from nadir of initial response during therapy, as confirmed
1 month later

Secondary treatment failure

Viral breakthrough in an adherent patient (due to drug resistance)

Sustained off-treatment
virological response
Complete response

No clinical relapse during follow-up after stopping therapy

Viral relapse

Serum HBV DNA [2000 IU/ml after stopping treatment in patients with virological response

Sustained virological response with HBsAg seroclearance

Clinical relapse

Viral relapse along with ALT [29 ALT

Histological response

Decrease in histology activity index by at least two points and no worsening of fibrosis score compared to
pre-treatment liver biopsy or fibrosis reduction by at least one point by Metavir staging

Drug resistance
Genotypic resistance

Detection of mutations in the HBV genome that are known to confer resistance and develop during antiviral
therapy

Phenotypic resistance

Decreased susceptibility (in vitro testing) to inhibition by antiviral drugs; associated with genotypic
resistance

Cross resistance

Mutation selected by one antiviral agent that also confers resistance to other antiviral agents

and is defined as HBeAg loss and seroconversion to antiHBe.

Serological response for HBsAg Serological response for
HBsAg applies to all CHB patients and is defined as
HBsAg loss and development of anti-HBs (any titers).
Virological responses on IFN/PEG-IFN therapy
Responses to Peg-IFN therapy are defined differently than
responses to NA therapy.
Primary non-response has not been well established.
Virological response is defined as an HBV DNA concentration of \2000 IU/ml. It is usually evaluated at
6 months and at the end of therapy, as well as at 6 and
12 months after the end of therapy.
Sustained off-treatment virological response is defined
as HBV DNA levels below 2000 IU/ml for at least
12 months after the end of therapy.

123

Virological responses on NA therapy

Primary non-response is defined as \1 log 10 IU/ml
decrease in HBV DNA level from baseline at 3 months of
therapy.
Suboptimal or partial virological response is defined as
a decrease in HBV DNA of more than 1 log10 IU/ml, but
with HBV DNA detectable after at least 6 months of
therapy in compliant patients.
Virological response is defined as undetectable HBV
DNA by a sensitive PCR assay. It is usually evaluated
every 36 months during therapy, depending on the
severity of liver disease and the type of NA.
Virological breakthrough is defined as a confirmed
increase in HBV DNA level of more than 1 log10 IU/ml
compared to the nadir (lowest value) HBV DNA level on
therapy (as confirmed 1 month later); it may precede a
biochemical breakthrough, characterized by an increase in
ALT levels. The main causes of virological breakthrough

Hepatol Int

on NA therapy are poor adherence to therapy and/or

selection of drug-resistant HBV variants (resistance).
Sustained off-treatment virological response NA(s) may
be discontinued in some patients. Sustained off-treatment
virological response may be defined as no clinical relapse
during follow-up after stopping therapy.
Viral relapse is defined as serum HBV DNA [2000 IU/
ml after stopping treatment in patients with virological
response.
Clinical relapse is defined as viral relapse along with
ALT [29 ALT.
Complete response is defined as sustained off-treatment
virological response, together with loss of HBsAg.
Histological response is defined as a decrease in histology activity index by at least two points and no worsening of fibrosis score compared to pre-treatment liver
biopsy, or fibrosis reduction by at least one point by
Metavir staging.
HBV resistance to NA(s) is characterized by selection of
HBV variants with amino acid substitutions that confer
reduced susceptibility to the administered NA(s). Resistance may result in primary non-response or virological
breakthrough on therapy.
Genotypic resistance is defined as detection in the HBV
genome of mutations that are known to confer resistance
and develop during antiviral therapy.
Phenotypic resistance is defined as decreased susceptibility (in vitro testing) to inhibition by antiviral drugs
associated with genotypic resistance.
Cross resistance is defined as mutation selected for by
one antiviral agent that also confers resistance to other
antiviral agents.
2.3 Natural history of chronic HBV infection
A number of phases of chronic HBV infection are recognized, reflecting the dynamic interaction between the virus
and the human host immune system. Once HBV infection
has become chronic, its subsequent course largely consists
of four phases of the underlying liver disease, of variable
duration and outcome. All phases have been pathogenetically linked to the level of HBV replication and the
strength and targets of the host immune reactivity against
the replicating HBV. Transition from one phase of
chronicity to the next is not recognizable in all patients,
either because it may not be an obligatory step in the
overall natural course of the infection, or because it is of
very short duration.
Importance of age of acquisition of the virus
Patients who acquire HBV infection either at birth or
within the first 12 years of life (i.e., either vertical or

horizontal transmission) typically have a prolonged

immune-tolerance phase, followed by an often equally
prolonged immune-clearance phase. These individuals
include nearly all Asian and African patients and some
from the Mediterranean countries, accounting for a
majority of the worlds HBV-infected population. About
7085 % of HBeAg seroconverters remain in sustained
remission, but HBeAg-negative hepatitis occurs in the
remaining HBeAg seroconverters; the latter is a critically
important subgroup in which progression of liver disease
often continues [26]. In fact, the majority (75 %) of cirrhosis complications and HCC occur in this population of
HBeAg-negative, chronic HBV-infected people [27]. An
additional complexity is that HBV can cause HCC even in
patients who do not develop cirrhosis.
By contrast, patients who acquire the virus after early
childhood generally do not experience the immune-tolerant
phase. The disease typically becomes quiescent after the
immune-clearance phase, characterized by HBeAg seroconversion to anti-HBe and HBV DNA that remains at a
relatively low level or becomes undetectable.
Phases of chronic HBV infection following vertical
transmission
Immune-tolerant phase In patients with perinatally
acquired HBV infection, the first phase (immune tolerance)
is characterized by the absence of biochemical symptoms
of liver disease (i.e., elevated transaminase levels), despite
evidence of active HBV replication denoted by the presence of HBeAg and HBV DNA in serum. During this
phase, which may last 14 decades in different populations
and individuals, spontaneous and treatment-induced
HBeAg seroconversion is infrequent (\5 %/year). Liver
biopsy during immune tolerance often reveals an absence
of inflammation and scarring.
Diagnosis of immune-tolerant phase The differential
diagnosis of immune tolerance and immune clearance
depends mainly on sequential determinations of serum
ALT levels. However, a slightly increased serum ALT
level, even though it is within the normal range, has been
reported to be significantly associated with risk of liverrelated mortality in the general population [28]. Therefore,
some have proposed lowering the upper limit of normal
(ULN) to 30 IU/l for male and 19 IU/l for female [29],
although this still remains controversial. The immune tolerant phase is defined as persistence of HBeAg-positive
HBV infection without significant ongoing necroinflammatory disease of the liver. Some authors have suggested
that the immune-tolerant phase can be defined as having
HBeAg positivity, persistently normal serum ALT levels,
and serum HBV DNA [2 9 107 IU/ml, with liver biopsy

123

Hepatol Int

examination showing only minimal histological changes

[30, 31]. Two important questions are: (1) What should the
cutoff HBV DNA levels be for considering the patients to
be in the immunotolerant phase of infection; and (2) how to
predict histology without liver biopsy, based on ALT and
HBV DNA levels? In two studies on HBeAg-positive
patients with normal ALT and HBV DNA [2 9 106 IU/
ml, including 57 and 40 Asian patients, liver biopsy
showed only mild disease in all, and no patient had a
histological fibrosis score of [1 [32, 33]. However, in a
Korean study, 28 % of HBeAg-positive patients with normal ALT and HBV DNA [2 9 104 IU/ml had significant
histology [34]. Also, in an Indian study of 73 HBeAgpositive patients with persistently normal ALT, 40 % had
significant fibrosis. Of these patients, 23 had HBV DNA
levels of C2 9 106 IU/ml and 50 had HBV DNA levels of
\2 9 106 IU/ml. The median (range) of fibrosis scores
among HBeAg-positive patients with persistently normal
ALT was comparable between patients with HBV DNA
levels C2 9 106 IU/ml [1.0 (0.03.0)] and HBV DNA
levels of \2 9 106 IU/ml [1.0 (0.04.0); p = 0.649]. The
area under ROC curve (AUROC) to determine whether
there is a HBV DNA level that could differentiate patients
with fibrosis from without any fibrosis on liver biopsy was
0.424, indicating that HBV DNA is a poor surrogate for
fibrosis on liver biopsy [21, 35]. Thus, liver fibrosis cannot
be predicted based on HBVDNA levels and ALT alone
[35].
More important than defining the immune-tolerant phase
is to identify patients with histological evidence of liver
disease. Recent studies have found an association between
even low levels of HBV DNA and CHB complications,
especially in Asian patients who acquire the virus early in
life [36].
The duration of the immune-tolerant phase is variable.
In vertical HBV transmission from HBeAg-positive
mothers, it may last for more than three decades, while
under other conditions, such as in horizontal HBV spread
among children, it appears to be very short and is hardly
recognizable.
A study from Taiwan followed 240 patients (54 % male,
mean age 27.6 years) who presented in this phase, and
found that only 5 % progressed to cirrhosis and none to
HCC during a follow-up period of 10.5 years [26]. These
findings indicate that prognosis is generally favorable for
patients who are in the immune-tolerant phase.
Transition from immune tolerance to immune clearance
phase Spontaneous HBeAg seroconversion generally
occurs before 40 years of age in more than 90 % of HBsAg
positive patients [37]. However, loss of immune tolerance
occurs at a rate of 1015 %/year, and patients who progress
to the immune-clearance phase often face disease

123

progression [33]. The duration of the immune tolerance

phase is related to such factors as age of infection
(younger [ older), mode of infection (vertical [ horizontal), immune status (suppressed [ competent), ethnicity
(Asians [ non-Asians), HBV genotype C [ B, D [ A,
baseline biochemical and histological activity (higher [ lower), and ALT flare during follow-up (present [ absent) [30].
Immune-reactive phase During the immune-reactive
phase (also known as immune active/immune clearance/
HBeAg-positive CHB/HBeAg clearance phase), symptoms of liver disease may appear for the first time, as the
host immune response leads to hepatocyte lysis with a
flare in aminotransferase levels. Increased immune pressure on the virus during this phase is reflected by suppression of serum HBV DNA levels and accelerated
clearance of HBeAg with seroconversion to anti-HBe
positivity. This phase is characterized by the presence of
HBeAg, high or fluctuating serum HBV DNA levels,
persistent or intermittent elevation in serum aminotransferases, and active inflammation on liver biopsy. These
flares may precede HBeAg seroconversion, but many
flares only result in transient decreases in serum HBV
DNA levels without loss of HBeAg, and some flares may
lead to hepatic decompensation. More typically, the flare
subsides after a variable period of time, although the
associated liver injury may not regress and fibrosis can
result [38]. The annual rate of spontaneous HBeAg
clearance in this phase ranges from 3 to 12 %. Factors
associated with higher rates of spontaneous HBeAg
seroconversion include older age, higher aminotransferase
levels, and HBV genotypes (A, B, D, F, B [ C) [39, 40].
Genotype C is also associated with more liver injury at
the time of seroconversion [41]. In a study from Alaska, it
was found that after losing HBeAg, those with genotypes
C and F were more likely to revert to the HBeAg-positive
state as compared to those with other genotypes (A, B, D)
(p \ 0.001) [40].
This phase may end not only in HBeAg seroconversion,
but also in HBsAg clearance and seroconversion to antiHBs. However, in a number of patients, HBV replication
continues despite HBeAg loss and the development of antiHBe antibodies. The duration of this phase, and the frequency and severity of the flares, correlates with the risk of
cirrhosis and HCC [42]. Recurrent flares occur more
commonly in males and may explain why HBV-related
cirrhosis and HCC are more common in males than in
females.
HBsAg titer has been found to be higher during the
immune tolerance phase than during the immune clearance
phase, as well as being higher in HBeAg(?) than in
HBeAg(-) patients [43, 44].

Hepatol Int

Low replicative phase Although the previous phase of

immune reactivity against HBV may have unfavorable
outcomes, with progression of the underlying liver
necroinflammation and fibrosis to cirrhosis and even to
development of HCC and death, it largely terminates
sooner or later in HBeAg clearance and transition to a low
replicative phase. This phase is characterized by absence of
HBeAg, presence of anti-HBe, persistently normal
aminotransferase levels, and low or undetectable serum
HBV DNA. Liver biopsy usually shows mild hepatitis and
minimal fibrosis, but inactive cirrhosis may be observed in
patients who had accrued severe liver injury during the
preceding immune clearance phase. However, in
4565 % of cases, ALT activity can fluctuate with long
periods of normal ALT levels. This phase has also been
referred to as the inactive HBsAg carrier state, but this is
an erroneous label for a fair proportion of patients, given
that the potential for further disease flares exists and other
complications such as HCC can supervene. Indeed, for
patients with infection acquired at an early age, the
majority of complications occur after HBeAg
seroconversion.
HBV DNA levels in HBeAg-negative patients with normal
ALT It has traditionally been believed that patients who
are HBeAg negative with normal ALT have low HBV
DNA levels. However, recent studies have shown that this
may not always be true. Among 414 HBeAg-negative
Taiwanese CHBV-infected patients with persistently normal serum ALT levels, compared to CHBV-infected
patients with lownormal ALT (\0.59 ULN), those with
high-normal ALT (0.519 ULN) had a greater frequency
of serum HBV DNA levels [2000 IU/ml and a higher
prevalence of core promoter mutations [45]. In another
study from India, 35 % of HBeAg-negative patients with
persistently normal ALT for at least 1 year had HBV DNA
C2 9 106 IU/ml. Even when the recently updated ULN
values (30 IU/l for male and 19 IU/l for female) were used,
42 % of such patients had HBV DNA C2 9 106 IU/ml
[21].
Histology in HBeAg-negative patients with normal
ALT Elevated ALT has been considered to be associated
with active liver disease on histology, while normal ALT
has been considered to be associated with inactive histology. Many initial studies showed that among patients with
chronic HBV infection with normal ALT, about 5090 %
had either minimal or mild changes (chronic persistent
hepatitis) on biopsy [4648]. Recent studies have described
higher prevalence of liver injury in such patients. Among
58 Indian HBeAg-negative patients with persistently normal ALT who were biopsied, median (range) HAI was 3.0
(1.010.0), fibrosis score was 1.0 (0.03.0) and 14 % had

significant fibrosis (F C2). In patients with persistently

normal ALT as defined by updated criteria, HAI was 3.0
(1.081), fibrosis score was 1.0 (0.02.0), and distribution
of fibrosis stages (0/1/2/3/4) were 35/46/19/0/0 %,
respectively. Twenty-one percent of HBeAg-negative
patients with persistently normal ALT (PNALT) and HBV
DNA \2 9 104 IU/ml had histologically active liver disease [histological activity index (HAI) C3 and/or fibrosis
stage C2]. Of the 58 patients who had baseline initial liver
biopsy, 28 underwent repeat liver biopsy after median
50 months (range 3668). The median change in the
Hepatic Activity Index (HAI) from initial biopsy was 2.0
(range 04). Six (21 %) subjects had no change in HAI,
eight (29 %) had a one-point change, six (21 %) had a twopoint change, six (21 %) had a three-point change, and two
(7.1 %) had a four-point change. The median change in
fibrosis score from initial biopsy was 1 (01). Eight (29 %)
subjects had no change in fibrosis score and 20 (71 %) had
a one-point change [21, 49, 50]. Spontaneous ALT flares
occurred at 4.3 %/year among patients who were HBeAg
negative with persistently normal ALT, so that cumulative
probability for ALT flare was 47 % at 10 years [50]. Other
studies have also found that 3040 % of patients who
exhibited normal serum ALT for more than 6 months had
significant histological findings [51, 52].
Long-term prognosis of HBeAg-negative patients with
normal ALT Many studies have shown that although the
rate of liver disease progression was associated with higher
ALT levels, most cases of cirrhosis and HCC occurred in
patients with ALT \45 U/l [5355]. In another study of
3233 Chinese patients with chronic HBV infection who
were grouped on the basis of ALT at presentation and
followed for 4 years, it was found that the group with ALT
values that were one to two times the ULN (range of
comparison 0.56 U/l times the ULN) was at highest risk of
complications of cirrhosis and HCC. However, the risk of
cirrhosis and HCC was greater for the group of patients
with ALT [0.5U/l9 ULN than for the group with ALT
\0.5 U/l9 ULN. More than two-thirds of the patients who
experienced complications were already HBeAg negative
when the complications occurred [27]. In a report from
REVEAL study group, 1932 HBsAg-seropositive and
HBeAg seronegative participants with low serum levels of
HBV DNA (\2 9 104 IU/ml) and 18,137 HBsAgseronegative and anti-HCV-seronegative participants were
compared. All of them had serum ALT levels \45 U/l and
no HCC or cirrhosis diagnosed before or within 1 year after
study entry. The multivariate-adjusted hazard ratio (95 %
confidence interval) was 4.6 (2.58.3) for HCC incidence
and 2.1 (1.14.1) for liver-related death for those with low
replicative chronic HBV infection compared to controls
[36].

123

Hepatol Int

Reactivation phase The previous anti-HBe-positive low

replicative phase is not always equivalent to a permanent
termination of replication and of HBV-induced chronic
liver damage. Although many patients remain in the low
replicative phase for a long period of time and may also
lose HBsAg (around 2 %/year), others retain or redevelop,
over time, significant HBV replication and progressive
liver damage [18, 19, 25]. This state of HBV-induced liver
damage was first referred to as the reactivation phase, or
HBeAg-negative/anti-HBe positive chronic hepatitis B
[54]. In one study of 283 Taiwanese patients followed for a
median of 8.6 years after spontaneous HBeAg seroconversion, 67 % had sustained remission, 4 % had HBeAg
reversion, and 24 % had HBeAg-negative CHB. Cirrhosis
developed in 8 % and HCC in 2 %, the risk being higher in
those who had active hepatitis after HBeAg seroconversion
[55].
It is important to differentiate patients in the low
replicative phase from patients who remain at risk of progressive disease. Differentiation between these two categories of patients has been based on a HBV DNA cutoff of
2000 IU/ml [56, 57]. However, this level remains controversial. In a recent study, it has been shown that HBsAg
C1000 IU/ml could be used to identify patients with high
risk of reactivation [58]. In one Asian study, it was reported
that in patients with HBV DNA \2000 IU/ml, a HBsAg
level below 1000 IU/ml was associated with a 2 % incidence of HCC at 20 years, which increased to 8 % with an
HBsAg level above 1000 IU/ml. This association between
HBsAg and the development of HCC is not observed if
HBV DNA is above 2000 IU/ml [59]. It is therefore
worthwhile to reconsider whether terminologies such as
inactive HBV carrier are appropriate or should be
abandoned.
The reactivation phase is characterized by negative or
positive HBeAg, positive anti-HBe, detectable HBV DNA,
elevated aminotransferases, and continued necroinflammation. Whereas most patients reach this phase after a
variable duration of low replicative state, some progress
directly from HBeAg-positive chronic hepatitis to HBeAgnegative chronic hepatitis. Patients in this phase are usually
older and have more advanced liver disease, as this represents a later phase in the course of chronic HBV infection. Serum HBV DNA levels are lower than in HBeAgpositive patients, but may be high. The high levels of serum
HBV DNA result from a spontaneous mutation in the core
or core promoter region of the viral genome [60]. The
precore mutation produces a stop codon in a region of the
HBV genome that prevents the formation of HBeAg,
whereas the basal core promoter (BCP) mutation affects
HBeAg transcription. These mutations, either singly or in
combination, permit HBV replication in the absence of
HBeAg. The hallmark of this phase is its fluctuating

123

course. In a study of 164 anti-HBe-positive patients who

were monitored at monthly intervals for a median period of
21 months, 64 % had fluctuating ALT levels, including
44 % whose ALT levels were intermittently normal [61].
Several investigators have attempted to define cutoff HBV
DNA levels that would differentiate patients with HBeAgnegative chronic hepatitis from inactive carriers, but in
view of the fluctuating course, serial testing is more reliable than a single test [62].
A recent study found that reactivation of hepatitis B
following HBeAg seroconversion correlated significantly
with genotype C (p = 0.003), male sex (p = 0.03), ALT
levels [59 upper normal limit during the HBeAg-positive
phase (p = 0.02), and age at HBeAg seroconversion
C40 years (p = 0.002) [63].
HBeAg-negative CHB was originally reported in
Mediterranean countries, but has now been reported in all
parts of the world. Currently, HBeAg-negative CHB represents the most common type of CHB, particularly in
European, African and Middle East countries of the
Mediterranean Basin.
Spontaneous HBsAg seroclearance has been reported to
occur at a rate of 0.51 %/year in patients with chronic
HBV infection [64]. HBsAg seroclearance is generally
accompanied by undetectable serum HBV DNA, normalization of liver biochemistries, and improved liver histology [65]. However, HCC has been reported in a small
percent of patients, the risk being higher in those with
cirrhosis, HCV coinfection, or older age at the time of
HBsAg seroclearance [66].
HBsAg levels are important in predicting HBsAg loss
during follow-up. One Asian study found that in
HBeAg(-) patients with persistently normal ALT, a
decline C1 log10 IU/ml during a 2-year time period or a
single measurement below 200 IU/ml are the best predictors of HBsAg loss [positive predictive value (PPV)
100 %] [66]. Also, a threshold of HBsAg decline C0.3
log10 IU/ml/year identifies patients with high probability
of HBsAg loss with a negative predictive value (NPV) of
95 % and a PPV of 85 % [58].
Phases of chronic HBV infection following horizontal
transmission
Horizontally acquired disease also evolves through a
number of phases with active replication and hepatic
necroinflammatory activity in the early months and years
of chronic HBV infection. With time, replication often
diminishes and host immune pressure results in HBeAg/
anti-HBe seroconversion. This is followed by a quiescent
phase of infection with lessened liver injury and evolution
into an inactive HBV infection state. Certain patients
appear to suffer little morbidity after HBeAg

Hepatol Int

seroconversion. For instance, studies of HBsAg-positive

Italian patients in the inactive infection state, who were
initially identified when they were rejected as blood
donors, showed that these individuals experienced no
appreciable increase in liver-related morbidity over many
years [64]. This observation reflects the benefit of HBeAg
seroconversion following adult acquisition of HBV; that is,
this event typically leads to a durable decrease in viral
activity and liver damage.
Predictors of disease progression in chronic HBV infection
Chronic HBV infection and cirrhosis The annual incidence of cirrhosis has been estimated to be 26 % for
HBeAg-positive and 810 % for HBeAg-negative patients.
The higher rate of cirrhosis among HBeAg-negative
patients is related to older age and more advanced liver
disease at presentation. Among HBeAg-positive patients,
the rate of cirrhosis development is higher in those who
remained HBeAg positive during follow-up. Additional
factors have been identified to be associated with progression to cirrhosis: habitual alcohol intake, concurrent
infection with hepatitis C virus (HCV) or human immunodeficiency virus (HIV), high levels of HBV replication,
and patients who had HBeAg reversion, HBV genotype
(C [ B) [67, 68] and a higher proportion ([45 %) of BCP
mutataion [69]. In one study of 3774 HBsAg chronic HBVinfected subjects aged 3065 years, the adjusted relative
risk of cirrhosis for patients with baseline serum HBV DNA
[104 and [106 copies/ml was 2.3 (95 % CI 1.63.5) and
9.3 (95 % CI 6.513.1), respectively [70]. Collectively,
these data suggest that persistent high levels of HBV
replication (with accompanying hepatitis) increase the risk
of cirrhosis, but the prognostic significance of a high serum
HBV DNA level at a single time point in a young HBVinfected subject (\30 years old) is unclear.
Chronic HBV infection and HCC The annual incidence
of HCC has been estimated to be \1 % for noncirrhotic
chronic HBV-infected patients and 23 % for patients with
cirrhosis. Additional risk factors for HCC include coinfection with HCV, a family history of HCC [71], habitual
alcohol intake, high levels of HBV replication HBV
genotype C [ B) [72], and core promoter mutations [73],
as well as obesity, diabetes, and smoking [74].
2.4 Clinical significance of HBV genotypes
and common mutants

Saharan Africa, Northern Europe, India and Western Africa.

Genotypes B and C are common in Asia. Genotype C mainly
exists in East and Southeast Asia. Genotype D is prevalent in
Africa, Europe, the Mediterranean region and India. Genotype E is restricted to West Africa. Genotype F is found in
Central and South America. Genotype G has been reported in
France, Germany, and the United States. Genotype H is
found in Central America [75]. Geographic distribution of
HBV genotype may correlate with the modes of transmission. For example, genotypes B and C are prevalent in highly
endemic areas where perinatal or vertical transmission plays
an important role in the viral spreading, whereas the
remaining genotypes are frequently found in areas where
horizontal transmission is the main mode of transmission.
In a study from Japan, the persistence of HBV infection
after acute hepatitis B was higher in patients with genotype A
(23 %) than in those with genotype B (11 %) or C (7 %)
infection [76]. The rate of chronicity after acute genotype D
infection has also been reported to be relatively high [77].
HBV genotype C patients may experience delayed
HBeAg seroconversion and a lengthier period of active
HBV replication than genotype B patients. With these
unfavorable features, genotype C patients are more prone
to develop advanced fibrosis, cirrhosis, and even HCC than
genotype B patients [7880].
Compared with genotypes C and D patients, genotype A
and B patients had a higher rate of spontaneous HBsAg
seroclearance [81, 82].
Genotype C infections conferred a higher frequency of
BCP A1762T/G1764A mutation than genotype B, and
HBV viral load was higher in genotype C than in genotype
B patients [72]. Similarly, genotype D-infected patients
who had more progressive liver disease had a higher
prevalence of BCP A1762T/G1764A mutation than those
with genotype A infection [83]. Frequency of pre-S deletion was significantly higher in genotype C patients than in
genotype B patients, and pre-S deletion is associated with
higher risk for HCC development [84].
HBV genotype A has better responses to IFN-a treatment
than genotype D patients, regardless of HBeAg status. Further, HBV genotype B has a higher response rate to IFN-a
treatment than genotype C in HBeAg-positive patients [85].
There is no significant association between HBV genotype and response to nucleos(t)ide analogues [85].

3 Guidelines
3.1 Screening for chronic HBV infection

Based on the extent of divergence in the entire HBV genomic

sequence, at least ten HBV genotypes (AJ) and several
subtypes have been identified: [8 % for genotypes and
48 % for subtypes. Genotype A is highly prevalent in sub-

The impact of vaccination has been profound in reducing

the global burden of HBV, particularly in children and
young adults, but millions of chronic HBV-infected

123

Hepatol Int

patients remain. Seroprevalence studies have been widely

performed and show that chronic HBV infection continues
to be a major health problem; a representative case was that
of China, where the seroprevalence rate in 1992 was 9.8 %
and was reduced to 7.2 % in 2006 after vaccination. While
these optimistic trends do indicate an eventual eradication
of the virus, this would appear to be many decades away. In
the interim, there is good established treatment for patients
chronically infected with HBV that can reduce liver-related
outcomes [86], although HBsAg clearance is still not a
realistic goal. With the World Health Organization (WHO)
resolution on viral hepatitis, the WHO has launched a
number of initiatives [87], which include the Global
Hepatitis Network and a Framework for Action, in order to
tackle these issues. It is recognized that one of the major
obstacles to action remains the large burden of undiagnosed
cases of chronic HBV infection around the globe. However,
estimates of such a hidden burden of disease are poorly
documented. In a large cross sectional study screening for
hepatitis B amongst Asian Americans in San Francisco
(n = 3163), 65 % of those who tested HBsAg positive were
unaware they had had chronic HBV infectioneither they
had never been tested before or had not been previously
diagnosed [88]. In a US-based insurance cohort study, the
difference in the proportion of patients who tested positive
for HBsAg compared to the expected number estimated
from the NHANES study was 21 % [89]. A study from Italy
showed that based on HBV prevalence data of 1.29 % from
the Ligurian region, there should be 20,438 chronically
infected patients, but only 445 (2.2 % of the estimated
chronic HBV infection population) were actually chronically infected on follow-up [90]. European estimates indicate that three-quarters of those infected with chronic HBV
infection are unaware of their infection [91]. In Asia, a
Japanese study on HBV and HCV prevalence examined
patients, such as first time blood donors and those having a
periodic health examination, who were unaware of their
hepatitis status. The prevalence of HBV in this population
was estimated to be 0.63 % or 68,792 persons [92]. In
general, there are few studies that examine this issue of
under-diagnosis of chronic HBV infection, and approaches
that can resolve the issue. It is estimated that 45 % of people
living with CHB remain undiagnosed, resulting in poor
health outcomes and risk of transmission [93].
Principles of screening
In a key article published over 40 years ago, the World
Health Organization established several principles for
health screening [94]. In this article, the criteria were:
1.

Screening should be directed towards an important

health problem

123

2.
3.
4.
5.

6.

7.

8.

9.

There should be a simple, safe, precise and validated

screening test
Treatment started at an early stage should be of more
benefit than treatment initiated later
There should be evidence that the screening test is
effective in reducing mortality and morbidity
The benefit of screening should outweigh the physical
and psychological harm caused by the test, diagnostic
procedures and treatment
The opportunity cost of the screening program should
be economically balanced in relation to expenditure on
medical care as a whole
There should be a plan for managing and monitoring
the screening program and an agreed set of quality
assurance standards
Potential screening participants should receive adequate information about benefits and disadvantages of
participation
Case finding should be a continuing process and not a
once-and-for-all project

Chronic HBV infection clearly falls into this category;

consequently, screening to detect those with CHB infection
is a justifiable exercise.
Screening and linkage to care
A large number of studies of epidemiology of chronic HBV
infection only examine those who are detected to be
HBsAg seropositive, but little is known of screening uptake
(% of patients who agree to take the test), and of these, how
many were referred and evaluated as requiring therapy.
Consequently, screening to detect seropositive patients is
insufficient as a management strategy, without proper
linkage to care. The Institute of Medicine recommendations [95], while specific to the US, can be broadly applied
to many other countries as well. They found that the US
infrastructure for management of chronic viral hepatitis
was poor, and broadly recommended three important initiatives: increased disease surveillance, improved provider
and community education, and integration and enhancement of viral hepatitis services. In particular, the viral
hepatitis services should encompass five core elements in a
coordinated and comprehensive manneroutreach and
awareness; prevention of new infections; identification of
infected people; social and peer support; and medical
management of infected people, as otherwise newly diagnosed patients will be lost and will not receive the benefit
of potential therapy that may be lifesaving.
Consequently, the logistic chain of screening begins
with information and education, followed by agreement
to undergo testing, testing itself, and then evaluation; it
ends with treatment in those who need it. A good

Hepatol Int

example of the approach to screening and linkage to care

is the Hepatitis Outreach Network, which combines the
expertise and resources of the Mount Sinai School of
Medicine, the NYC Department of Health and Mental
Hygiene, and community-based organizations [96]. A
similar study was undertaken in Sheffield in the UK [97].
Consequently, many stakeholders need to come together
and coordinate efforts and resources in order for this
strategy to be effective. However, screening itself is a
major exercise.
Evidence for screening
While it seems sensible and rational to perform screening
for chronic HBV infection, a screening strategy needs to
have evidence of efficacy, based on evidence that
screening reduces mortality or complications of disease.
Some screening strategies are potentially harmful, particularly in the case of cancer screening, when there are
false negative or positive results, adverse events of
labeling or early diagnosis and adverse effects of treatment or investigation [98]. Consequently, proof of efficacy relies on randomized control trials of screening
using one of two designs [98]the first is randomized to
screening versus no screening, with treatment of those
screened and found to be suitable for therapy; the second
is where all participate in screening and those with
positive test results are randomized to treatment or no
treatment. In both scenarios, a significant difference in
outcome (e.g., liver cancer, cirrhosis or mortality) then
favors the screening arm. Unfortunately, no such studies
have been performed in chronic HBV infection, and it
would seem that such studies are unlikely, since the lead
time to development of such complications would take
many decades. Secondly, the second screening strategy
of not treating if there is a positive result may be ethically difficult to carry out, if patients fulfill treatment
criteria. Consequently, evidence for screening is largely
based on observational data. In the REVEAL study [53],
164 cases of HCC were detected during follow-up. In
evaluation of cirrhosis, during the initial screening, 436
cases of cirrhosis were found, and a further 365 cases
were discovered during follow-up [99]. There was also a
significant increase in liver-related mortality [100]. Most
screening studies did not examine clinical outcomes, but
rather, the number of patients screened and the number
of positive HBsAg cases found. As the largest and most
comprehensive screening program, the BFreeNYC program reached 11,000, screened approximately 9000
people, and diagnosed and managed six cases of HCC
and 22 of end-stage liver failure [101]. These studies
show that screening does pick up significant cases of
advanced liver disease and their complications. While

screening may potentially detect such complications,

whether screening followed by treatment would prevent
such complications has not yet been demonstrated.
Treatment for chronic HBV infection has reduced outcomes in patients with significant liver fibrosis or
advanced liver disease, and treatment of chronic HBV
infection for those without cirrhosis has shown to
improve surrogate markers such as LFTs, liver histology
and HBeAg seroconversion [102]. While cancer screening programs can have potentially harmful consequences
due to nonspecificity of tests (leading to anxiety and
unnecessary testing), this does not appear to be the case
with screening for hepatitis B. In addition, in the
screening test for hepatitis B, HBsAg has a high level of
sensitivity and specificity [103], making false positives or
negatives extremely low. However, social issues,
including discrimination and stigmatization of the
patients, need to be addressed adequately before
embarking on screening programs.
Types of screening
There are several types of screening: mass screening or
population screening involves screening a large population,
multiphasic health screening involves a battery of screening tests on the same occasion, and opportunistic screening
refers to screening offered to patients who attend a health
practitioner for some other reason.
Population-based screening is where a test is offered
systematically to all individuals in the defined target group
within a framework of agreed policy, protocols, quality
management, monitoring and evaluation. This involves
considerable infrastructure and protocols. Such a
scheme does not appear to have been established for
chronic HBV infection in most countries. Establishment of
a screening strategy then requires deliberation on the mode
in which the strategy is delivered. Such interventions have
to be tested in randomized control trials to determine which
have the best outcomes in terms of proportion of patients
taking up screening, proportion of patients that test positive
and proportion who require treatment.
Opportunistic screening is less organized and generally
less effective, as it relies on the healthcare worker to
remember to initiate the process, to provide information
and education, and to inform about the testing process
and consequences if tested positive, and options for
therapy, all of which involve considerable time and
effort. In an excellent systematic review of community
screening strategies for chronic HBV infection, Robotin
and George [104], reviewed strategies that specifically
excluded screening conducted by state and local public
health departments. They categorized programs into four
models:

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Hepatol Int

(A)

(B)

(C)
(D)

Community clinic model with screening integrated

into routine primary care services. Screening is
based on risk factors and doctors provide counseling
and testing referrals
Community outreach model, which involves screening in community settings (e.g., health fairs) and
volunteers providing logistic support
Partnership and contract model, where screening is
outsourced to a general health screening company
Outreach and partnership model, which contains
elements of (B) and (C), where screening occurs in
community setting with a community organization
that has direct links to the target community

detect and evaluate stage of the liver disease and extent

of liver damage;
plan antiviral therapy which can delay or reverse the
progression of liver disease;
permit ultrasound surveillance to detect HCC at a
potentially treatable stage;
counsel to avoid excessive alcohol use;
take measures to reduce risk of transmission to others;
avoid unnecessary vaccination, as vaccination is not
beneficial for persons already chronically infected and
is unnecessary for persons already immune (either
through prior vaccination or a previous resolved acute
infection;
vaccinate unprotected individuals.

The systematic review found that screening uptake was

highest for programs using an outreach and partnership
model (C), while the community outreach model (B) had
less uptake, and screenings offered by clinical experts had
low uptakes (12 %). Successful linkage to care was
offered by some programs, but many programs had high
dropout rates. No data on the proportion of patients
requiring treatment or referral for treatment was provided.
The overall evaluation was that these screening programs
had at best screened modest numbers of patients, considering the global burden of disease. The authors felt that the
most successful programs achieved significant buy-in from
target communities, delivering culturally appropriate educational initiatives and offering comprehensive care packages, not just screening alone.
Whichever screening strategy is employed, the logistics of
implementation need to be established. A key aspect of this is
the consent and information to be provided to the patient.
Counseling is crucial to educate and inform patients about
chronic HBV infection, the consequences and sequelae of
chronic infection and the treatment options available. Also,
advice on what is to be done if the test is positive and the
linkage to care need to be established. Aids such as flyers,
leaflets, websites, trained counselors and trusted community
contacts can be used to help patients understand this better.
Proper clinical studies are needed to test whether such
methods are useful in increasing screening uptake.

The prevalence of HBV varies markedly between different countries of the Asia Pacific region. The prevalence
of chronic infection ranges from 10 % of the population in
China to \2 % in Australia [6]. So there are areas of high,
medium, and low endemicity based on a prevalence of
HBsAg positivity of C8, 27, and \2 %, respectively
[106].
In countries with high endemicity, [90 % of new
infections occurred among infants and young children as
the result of perinatal or household transmission, while in
countries of low endemicity (i.e., HBsAg prevalence of
\2 %), the majority of new infections occur among adolescents and adults as a result of sexual and injection-drug
use exposures. In countries of intermediate HBV
endemicity, multiple modes of transmission operate, i.e.,
perinatal, household, sexual, injection-drug use, and
health-care related.
Screening of the general population may be cost effective in finding new cases in countries with high prevalence,
but it is not in regions with low prevalence. In countries
with intermediate prevalence, it would depend upon the
socioeconomic status. However, it is worth doing screening
of high-risk groups irrespective of prevalence and
socioeconomic status.
The following groups should be tested for HBV infection [7, 107110]:

Risk factor screening

Certain groups are at higher risk of acquisition of HBV and

of becoming chronically infected. There is a need for targeted screening for HBV infection in high-risk individuals
because the infection remains asymptomatic in a vast
majority of infected individuals, especially those who
acquire infection at birth or during childhood. Moreover,
chronic infection leads to the development of cirrhosis,
liver failure, or HCC. Identification of a HBV-infected
person is helpful to [7, 105]:

123

Persons with liver disease

Persons needing immunosuppressive or cancer
chemotherapy
Injection drug users (IDU)
Persons who have received unsafe injections (used
syringes or needles)
Men who have sex with men (MSM)
Persons with multiple sexual partners or history of
sexually transmitted infection
Family members, household contacts and sex partner of
a person with hepatitis B
Inmates of correctional facilities

Hepatol Int

Dialysis patients
HCV- or HIV-infected individuals
Pregnant female (preferably during the first trimester to
vaccinate unprotected mothers)
Infants born to females with chronic HBV
Blood or organ donors
Health care workers

Screening in special populations

Antenatal screening for hepatitis B in pregnant females to
identify newborns who require prophylaxis against perinatal
infection is a well-established, evidence-based standard of
practice [111]. This has become even more important, as new
strategies to even further reduce perinatal transmission using
nucleos(t)ide analogues in the last trimester of pregnancy
haves been established through randomized control trials
[112, 113]. However, the effectiveness of such screening
programs in real life is not ideal. In a large prospective study
[114], the impact of the GAVI project on reducing perinatal
HBV infection was evaluated. This included a proportion of
pregnant females screened for HBV. Between 2002 and
2009, using a cluster sampling methodology in Eastern,
Central and Western regions of China, 244 facilities were
assessed with 71,694 live births in 2002 and 125,874 live
births in 2009. The HBV screening rate increased from 64 %
in 2002 to 85 % in 2009. Consequently, there is still room for
improvement. With regard to blood safety, this is clearly an
important area to ensure high compliance. A recent report in
Morbidity and Mortality Weekly Report (MMWR) [115]
indicates that the number of countries in Africa and subSaharan Africa testing at least 95 % of donations for HBV
increased from 76 to 94 %. Nucleic acid testing (NAT) is not
widely available in the developing world [116], and is now
considered a standard of care in blood safety. In Asia, there
are few audits of blood safety measures in developing
countries; consequently, it is unclear to what extent is blood
safety is established.
Tests used for screening Screening tests are inexpensive
and cost effective in populations at higher prevalence, as
cost per case identified decreases, and they have the
potential to reduce HBV-associated morbidity and mortality [117]. The individuals found to be negative during
the screening should be vaccinated, and cases identified
should be counseled and treated.
The HBsAg test is the primary way to definitively
diagnose chronic HBV infection. The anti-HBs test will tell
if your patient is protected against HBV. Anti-HBs antibody can be produced in response to vaccination, recovery
from an acute hepatitis B infection, or the presence of less
common pre-S mutants [118].

The total hepatitis B core antibody (total anti-HBc) test

tells if a person has been previously exposed to HBV [119].
The test by itself does not indicate whether immunity or
chronic infection has developed as a result of exposure.
This test can be utilized for screening, but anti-HBc positive individuals should be further tested for both HBsAg
and anti-HBs to differentiate infection from immunity.
However, both HBsAg and ant-HBs may be negative. In
such a case, patients with immunity show anamnestic
response after one dose of HBV vaccine, while patients
with occult infection do not [120]. This test may be falsepositive in low prevalence areas. Patients with false-positive results will need a full course of vaccine to have an
immune response. Anti-HBc antibody is also positive
during the window phase of acute hepatitis B, i.e., after the
disappearance of HBsAg and before the anti-HBs develop.
Individuals with past HBV infection (anti-HBc reactive)
should not donate blood even if they have recovered.
3:1

Recommendations (screening for chronic HBV

infection).
3:1:1

3:1:2

3:1:3
3:1:4
3:1:5
3:1:6

Screening for hepatitis B infection is an

important tool to discover new cases of
chronic infection (A1).
There is insufficient evidence to recommend
any specific screening strategy for CHB and
further research is needed in this crucial area
(C1).
Existing screening strategies in antenatal care
and blood supply should be strengthened (A1).
Screening in high-risk populations should
continue to be a high priority (A1).
Strategies to enhance screening acceptance
and uptake should be undertaken (C1).
High-risk persons who are most likely to be
infected with HBV and should be tested for
chronic HBV infection include (B1):
Persons with liver disease
Family members, household contacts,
infants, sex partners of a person infected
with hepatitis B
Persons needing immunosuppressive or
cancer chemotherapy
Injection drug users (IDU)
Persons who receive unsafe injections (used
syringes or needles)
Persons who have sex with males (MSM),
with multiple sexual partners, STDs
Inmates of correctional facilities
Dialysis patients
HCV- or HIV-infected individuals

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Hepatol Int

Pregnant females (preferably during the first

trimester, to vaccinate unprotected mothers)
Health care workers
Blood or organ donors
3:1:7

3:1:8

Testing should include a serological assay for

HBsAg (A1), anti-HBs (B2) and total antiHBc (B2).
Screening should be linked to appropriate
counseling and referral for further care including clinical evaluation, need for treatment and
vaccination (if found to be negative for HBV
infection) (C1).

3.2 Counseling and prevention of transmission

of hepatitis B from individuals with chronic HBV
infection
Patients with chronic HBV infection should be counseled
regarding lifestyle modifications and prevention of transmission, as well as the importance of lifelong monitoring.
No specific dietary measures have been shown to have
any effect on the progression of CHB. However, heavy
use of alcohol ([20 g/day in female and [30 g/day in
male) may be a risk factor for the development of cirrhosis [121].
Persons chronically infected with HBV should be
counseled regarding transmission to others (Table 4).
Household members and steady sexual partners are at
increased risk of HBV infection and therefore should be
vaccinated if they test negative for HBV serological
markers. For sex partners who have not been tested or have
not completed the full immunization series, barrier protection methods should be employed.
The risk of infection after blood transfusion and transplantation of nonhepatic solid organs (kidneys, lungs,
heart) from persons with isolated anti-HBc is low: 013 %
[122]. The risk of infection after transplantation of liver
from HBsAg-negative, anti-HBc-positive donors has been
reported to be as high as 75 % and is related to the HBV

immune status of the recipients [123]. If anti-HBc-positive

donor organs are used for HBV seronegative recipients,
antiviral therapy should be administered to prevent de novo
HBV infection. While the optimal duration of prophylactic
therapy has not been determined, a limited duration, such
as 612 months, may be sufficient for transplantation of
non-hepatic solid organs. For transplantation of livers, lifelong antiviral therapy is recommended, but whether HBIG
is necessary is unclear [124].
HBsAg-positive female who are pregnant should be
counseled to make sure they inform their providers so that
appropriate decisions regarding administering hepatitis B
immune globulin (HBIG) and hepatitis B vaccine can be
made for their newborn immediately after delivery. HBIG
and concurrent hepatitis B vaccine have been shown to be
95 % efficacious in the prevention of perinatal transmission of HBV; the efficacy is lower for mothers with very
high serum HBV DNA levels ([78 log10 IU/ml) [125,
126]. In a recent analysis comparing the cost-effectiveness
of HBV control strategies combining universal vaccination
with hepatitis B immunoglobulin (HBIG) treatment for
neonates of chronically HBV-infected mothers, it was
concluded that HBIG treatment for neonates of HBsAg
positive mothers is likely to be a cost-effective addition to
universal vaccination, particularly in settings with adequate
health care infrastructure. Targeting HBIG to neonates of
higher risk, HBeAg-positive mothers may be preferred
where willingness to pay is moderate. However, in very
resource-limited settings, universal vaccination alone is
optimal [127].
Transmission of HBV from infected health care workers
to patients may occur in rare instances (see 3.13.4 Health
care workers section).
3:2

Recommendations: counseling and prevention of

transmission of hepatitis B from individuals with
chronic HBV infection:
3:2:1

Chronic HBV-infected persons should be

counseled regarding prevention of transmission of HBV (Table 4) (A1).

Table 4 Recommendations for infected persons regarding prevention of transmission of HBV to others
Have sexual contacts vaccinated
Use barrier protection during sexual intercourse if partner not vaccinated or naturally immune
Do not share toothbrushes or razors
Cover open cuts and scratches
Clean blood spills with detergent or bleach
Do not donate blood, organs or sperm
Can participate in all activities including contact sports
Children should not be excluded from daycare or school participation and should not be isolated from other children
Can share food, utensils, or kiss others

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Hepatol Int

3:2:2

3:2:3
3:2:4

3:2:5

Sexual and household contacts of chronic

HBV-infected persons who are negative for
HBV seromarkers should receive hepatitis B
vaccination (A1).
Abstinence of alcohol is recommended in
chronic HBV-infected subjects (A1).
Chronic HBV-infected subjects should not be
discriminated and stigmatized in the society or
in their work place (A1).
HBV-infected children should not be isolated
in the educational and social environment
(A1).

3.3 Assessment of persons with chronic HBV

infection
The initial evaluation of an individual with HBV infection should include a detailed history and physical
examination. Alcohol consumption, family history of
HBV and HCC, and assessment of risk factors to
determine the likely mode of HBV acquisition and
possible superinfection with other hepatitis virus(es)
should be part of the history taking. Comorbidities such
as obesity, diabetes mellitus and metabolic syndrome
should be assessed. Hepatic steatosis in individuals with
CHB is related to co-existent metabolic factors rather
than being virally induced [128, 129]. The physical
examination focuses on identifying presence of cirrhosis
or decompensated liver disease, as it has an impact on
prognosis. A complete blood count, biochemical tests,
serological and virological markers of HBV, and hepatic
ultrasound should be part of the initial evaluation. The
biochemical tests include ALT, AST, GGT, alkaline
phosphatase, serum albumin and prothrombin time. The
virological assessment consists of HBeAg, anti-HBe
antibodies and Hepatitis B DNA measurement, the latter
being the best marker of viral replication [130]. A realtime PCR quantification assay should be used to measure
serum HBV DNA levels [131, 132].
Other causes of chronic liver disease should be systematically looked for, including coinfections with HDV,
HCV and/or HIV. Comorbidities, including alcoholic,
autoimmune, and metabolic liver disease with steatosis or
steatohepatitis should be assessed.
In addition, all first-degree relatives and sexual partners
of patients with chronic HBV infection should be advised
to get tested for HBV serological markers (HBsAg, antiHBc, anti-HBs) and to be vaccinated, if they are negative
for these markers.
In subjects with chronic HBV infection, accurate
assessment of the extent of hepatic fibrosis and/or the
severity of necroinflammatory activity is essential for

choosing therapeutic strategies and for monitoring the

responses to anti-viral or anti-fibrotic treatment. Knowledge of the underlying histology can help guide therapeutic
decisions when patients do not meet the clinical practice
guidelines and treatment may be helpful. Aminotransferase
levels may fluctuate with time, and single measurements of
ALT and AST do not indicate disease stage. Usually, the
ALT concentrations are higher than those of AST, but with
disease progression to cirrhosis, the AST/ALT ratio may be
reversed. A progressive decline in serum albumin concentrations, rise in bilirubin and prolongation of the prothrombin time are characteristically observed as
decompensated cirrhosis develops. In chronic HBV infection, a liver biopsy is usually recommended to determine
the stage of fibrosis and/or the grade of activity in patients
with a high viral load and high-normal or minimally raised
ALT levels and in those older than 30 years without clinical evidence of cirrhosis. Liver biopsy is considered the
reference standard for the histological evaluation of liver
disease. However, it is important to remember that a liver
biopsy represents just *1/50,000 of the entire liver, and
that liver injury is typically irregularly distributed in the
liver. Thus, liver biopsy is an imperfect reference standard;
taking into account a range of accuracies of the biopsy,
even in the best possible scenario, an area under the
receiver operating characteristic (AUROC) [0.90 cannot
be achieved even for a perfect marker of liver disease
[133]. The diagnostic accuracy of liver biopsy decreases
because it is often subject not only to sampling error, but
also to intra- and inter-observer variability in histological
interpretation [134]. Moreover, even if it is generally
accepted to be a safe procedure, it is invasive and can be
associated with rare but potentially serious complications,
including hemorrhage, pneumothorax, and procedure-related mortality. Thus, although there is still an important
role for liver biopsy among chronic HBV infection, there is
an obvious need to develop and use noninvasive, accurate,
and reproducible tests for detecting liver injury. For
example, noninvasive tests are helpful in assessing the
stage of fibrosis in chronic HBV infection with no clear
indication for a liver biopsy, or in those who require follow-up assessment of the stage of fibrosis during or after
treatment.
Several noninvasive tests based on serum fibrosis
markers or radiographic techniques have been introduced,
and they are being increasingly used to assess the severity
of liver disease in clinical practice. These include serum
biochemical parameters, such as the ratio of aspartate
aminotransferase (AST) to ALT, the fibrosis score-4 (FIB4), the AST to platelet ratio index (APRI), the age-spleenplatelet index, the Forns index, and the Hui index. Specialized tests include Fibrotest, Hepascore, the enhanced
liver fibrosis test and, for elasticity imaging, magnetic

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resonance (MR) elastography and transient elastography

(TE) [135, 136].
The APRI is a simple test that is readily available, is
inexpensive, does not require particular expertise in interpretation, and can be performed in an outpatient setting.
APRI uses two cutoff points for diagnosing specific fibrosis
stages, as the use of a single cutoff would result in suboptimal sensitivity and specificity. A high cutoff with high
specificity is used to diagnose persons with a particular
stage of fibrosis, and a low cutoff with high sensitivity (i.e.,
fewer false-negative results) is used to rule out the presence
of a particular stage of fibrosis. Some persons will fall in
the indeterminate range of test results (i.e., their score will
be between the low and the high cutoff) and will need
future re-testing and evaluation. Most commonly reported
cutoff values for APRI for the detection of significant
fibrosis and cirrhosis are as follows: For significant fibrosis
(METAVIR CF2), low and high cutoffs for APRI are 0.5
and 1.5; and for cirrhosis (METAVIR F4), low and high
cutoffs for APRI are 1.0 and 2.0. Sensitivity, specificity,
PPV and NPV for diagnosing significant fibrosis (METAVIR CF2) were 7184, 5069, 5261 and 7684 % for
APRI low cutoff; and 2845, 9095, 6881 and 6572 %
for APRI high cutoff. Sensitivity, specificity, PPV and
NPV for diagnosing cirrhosis (METAVIR F4) were 5573,
7080, 1828 and 9397 % for APRI low cutoff; and
2249, 8194, 1934 and 9194 % for APRI high cutoff
[137].
Emerging technologies utilizing ultrasound and MR
imaging platforms, such as acoustic radiation force
impulse imaging and diffusion-weighted MR imaging
have been developed as well. These approaches make up
for the weak points in the liver biopsy by improving the
histology results, but they also reduce the need for liver
biopsy.
Liver stiffness measurement using TE (Fibroscan) was
first developed in 2003 and is the most extensively evaluated method of this type. Following vigorous validations in
many studies, TE was shown to be a reliable and accurate
surrogate for liver biopsy in assessing the severity of liver
fibrosis [138140]. In recent years, many patients in AsiaPacific countries have been evaluated by TE, resulting in
extensive accumulated experience. The performances of
TE in diagnosing significant fibrosis (CF2 stage) and cirrhosis (F4 stage) are good, with AUROC of 0.810.95 and
0.80.98, respectively. Most studies report estimated cutoff
ranges of 6.37.9 and 9.013.8 kPa for the diagnosis of
significant fibrosis and cirrhosis, respectively. However,
although TE has displayed reliable diagnostic accuracy in
this setting, it can be influenced by factors such as
necroinflammation, edema, food intake, and cholestasis,
resulting in an overestimation of TE values. Because of the
complex natural history of chronic HBV infection, which

123

frequently presents as fluctuating patterns associated with

necroinflammatory activity, serum levels of ALT and
bilirubin must be considered as a potential confounder
when interpreting the TE values of chronic HBV-infected
patients.
Liver fibrosis is a dynamic process. Beyond the crosssectional studies, recent evaluations of noninvasive tests
have focused on their ability to predict the risk of disease
progression or liver-related death, and on their use in
monitoring the treatment response during long-term, follow-up longitudinal assessments [141, 142]. A major
advantage of noninvasive tests is that they allow repeated
serial measurements of liver fibrosis. Indeed, the role of
noninvasive tests is no longer confined to the detection of
the severity of liver fibrosis; rather, noninvasive approaches provide a surveillance tool that predicts clinical outcome and long-term prognosis, thus helping to determine
treatment strategies. Furthermore, to improve the overall
diagnostic performance, the advantages of combining TE
and serum markers have been established in several studies
[143145], but further validation is still required.
Neither noninvasive testing nor liver biopsy alone is
sufficient to make a definitive decision in clinical practice, and regardless of specific methodological advances,
all of the available clinical and biological data must be
taken into account in therapeutic decision-making. The
utilization of noninvasive tests for assessing liver histology can significantly reduce, but not completely
replace, the need for liver biopsy and should be seen as
a complementary tool in the management of chronic
HBV-infected patients.
Use of risk calculators
Chronic HBV infection remains an important cause of
HCC development. HCC causes poor quality of life and
shortened survival, and is thus regarded as a major health
challenge. The risk of CHB progressing to HCC may be
reduced by antiviral therapy [146], and surveillance with
abdominal ultrasonography and serum alpha-fetoprotein
tests can be used to screen patients for early HCC treatment. Although, the global number of individuals infected
with CHB is extensive, especially in endemic areas such as
Asian-Pacific and sub-Saharan African regions, only a
small number of patients develop end-stage liver diseases.
Therefore, the identification and triage of patients who are
at high risk of HCC development is important. Several
factors, such as gender, age, family history of HCC, presence of hepatic inflammation/fibrosis, alcohol consumption, elevated viral load, hepatitis Be antigen (HBeAg)
positivity, and specific HBV genotypes (e.g., genotype C),
have been identified to be independently associated with
elevated risk of HCC development [13, 67, 147]. These

Hepatol Int

factors, including patient, viral, and environmental factors,

interact with one another and lead to HCC development in
patients with chronic HBV infection. From the individualized medicine point of view, these factors should be used
to reveal the future risk of HCC progression in patients
with viral hepatitis so that preventive measures can be
applied to those at high risk [148].
Risk calculators for HCC in chronic HBV-infected patients
without antiviral treatment Many Asian study groups
established prediction models that incorporated several
clinical variables to estimate HCC risk for chronic HBVinfected patients. These included IPM from Korea (hospital
based using gender, HCV infection, HBV infection, AFP
levels, chronic hepatitis, cirrhosis, alcohol use and ALT
levels) [149]; GAG-HCC risk score from Hong-Kong
(hospital based using gender, age, HBV DNA levels, core
promoter mutations and cirrhosis) [150]; CUHK clinical
scoring system from Hong-Kong (hospital based using age,
albumin, bilirubin, HBV DNA levels and cirrhosis) [151];
and REVEAL nomograms from Taiwan (community based
using gender, age, ALT levels, family history of HCC,
alcohol consumption, HBV DNA levels, HBeAg and HBV
genotype) [152]. The most important issue with these was
the lack of external validation. All these groups then collaborated to develop a HCC risk score (REACH-B)
incorporating gender, age, serum alanine transaminase
(ALT) concentration, HBeAg status, and serum HBV DNA
level as the predicting parameters [153]. This study derived
a 17-point risk model from 3584 treatment-free and cirrhosis-free CHB patients in a community-based Taiwanese
cohort (REVEALHBV), and validated its use in a composite hospital-based cohort (n = 1505) from Hong Kong
and Korea. This risk score could predict HCC with a wide
range of risks, ranging from 0.0 to 23.6 % at 3 years, 0.0 to
47.4 % at 5 years, and 0.0 to 81.6 % at 10 years for
patients with the lowest through the highest scores.
Although the derivation and validation cohorts were quite
different in their distributions of sex, age, HBeAg
serostatus, ALT concentration, HBV DNA level, and cirrhosis, the risk score developed from the derivation cohort
accurately and reliably estimated the HCC risk at 3, 5 and
10 years of follow-up in the validation cohort. The area
under the receiver operating characteristic curve (AUROC)
and the corresponding 95 % CI were 0.811 (0.7900.831),
0.796 (0.7750.816), and 0.769 (0.7470.790), respectively, in predicting 3-, 5- and 10-year HCC risk, indicating
a fair discriminatory capability. The performance of the
risk score was improved when cirrhotic patients were
excluded from the validation cohort [153].
With recent studies showing utility of quantitative serum
HBsAg levels (which are reproducible and low cost) in
providing additional predictability of HCC, especially in

patients with low levels of HBV DNA (\2000 IU/ml)

[154], the original REVEAL nomograms were upgraded by
incorporating qHBsAg into the HCC risk prediction model
[155]. In addition to HCC, this study also provided a prediction model for predicting the long-term development of
cirrhosis. The risk prediction model for HCC included age,
sex, family history of HCC, and a combined variable
encompassing HBeAg serostatus, serum HBV DNA and
ALT levels, quantitative serum HBsAg level, and HBV
genotype as the predicting parameters. The projected 5-,
10-, and 15-year HCC risk for each score was pre-calculated and depicted in a nomogram. This upgraded HCC risk
calculator was internally validated using a third of the
population from which the model was derived, and showed
excellent prediction accuracy and discriminatory ability.
Since serum HBV DNA measurement is relatively
expensive compared to all other risk predictors in the risk
calculator, a risk calculator might be generated in which
quantitative serum HBsAg levels can be used in lieu of
serum HBV DNA levels.
The REACH-B scoring system has been used to classify
anti-viral treatment eligibility of CHB patients according to
the 2012 Asian Pacific Association for the Study of the
Liver (APASL) treatment guidelines [156]. In this study, a
total of 904 noncirrhotic CHB patients were enrolled, and it
showed that for patients to be eligible for anti-viral treatment, the minimal REACH-B score should be 7 and 6,
respectively, for HBeAg-seropositive and HBeAgseronegative patients. Additionally, in HBeAg-seronegative patients, the REACH-B score could predict treatment
eligibility, with an adjusted OR (95 % CI) of 1.78
(1.611.98). In HBeAg-seropositive patients, however, this
same score-dependent eligibility of treatment was not
observed. In this study, the authors also showed that the
REACH-B score was excellent in discriminating treatment
eligibility for young (\40 years) HBeAg-seropositive
patients (AUC 0.903) and in both young (\45 years; AUC
0.907) and older (C45 years; AUC 0.883) HBeAgseronegative patients; but the discriminatory capability for
older (C40 years) HBeAg-seropositive patients was poor
(AUC 0.664). They also found that 46.4 % of HBeAgseropositive patients older than 40 years of age with high
risk of HCC, as estimated by a REACH score C11, would
be erroneously excluded from treatment, mainly because
their ALT levels never exceeded 29 ULN, even after
frequent blood tests during follow-up.
These risk calculators can be used for evidence-based
decisions during clinical management of chronic HBV-infected patients. Based on patients personalized HCC risks,
their follow-up intervals, surveillance patterns, and referral
strategies can be tailored. Also, timely antiviral therapy in
high-HCC-risk patients may lead to improvement in quality of life and prolonged survival. The potential cutoff risk

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Hepatol Int

and corresponding management strategies still remain an

issue.
Although the risk calculators are easy-to-use and the
REACH-B predictive score was externally validated to be
an applicable tool for HCC risk estimation, several precautions are warranted. Because surveillance strategies
derived from a Taiwanese population might not apply
globally, further validation is still needed in patients of
different ethnicities, geographical areas, ages at infection,
genetic background, HBV genotypes or species, comorbidities, and exposures to environmental factors such as
aflatoxin and alcohol [157]. It has been shown that the
applicability and predictability of HCCrisk scores developed in Asians are poor or modest in Caucasian CHB
patients, for whom different risk scores are required [158].
Since current HCC risk prediction tools were generated
from a natural history cohort without history of antiviral
therapy, the inference of predicted risks under circumstances of antiviral therapy should theoretically be inappropriate; although these risk calculators have been also
used for predicting HCC risk among patients on anti-virals
[159].
Besides HCC, several other clinical outcomes and
milestones of chronic HBV infection, such as cirrhosis, and
liver-related mortality, as well as the seroclearance of
HBeAg, HBsAg, and HBV DNA, can also be suitable for
the development of risk prediction tools.
3:3

Recommendations (assessment of persons with

chronic HBV infection)
3:3:1

3:3:2

3:3:3

3:3:4

123

The initial evaluation of an individual with

HBV infection should include assessment of
the level of viremia, degree of inflammation
and the presence and stage of liver disease. A
detailed history to investigate the possible
source of HBV transmission, as well as
physical examination, biochemical tests [including aspartate aminotransferase (AST)
and ALT, gamma-glutamyl transpeptidase
(GGT), alkaline phosphatase, bilirubin, and
serum albumin and globulins, and prothrombin time], complete blood count and hepatic
ultrasound should be performed (A1).
Measurement of HBV DNA is essential for
the diagnosis, assessment for initiating treatment and subsequent monitoring of infected
subjects (A1).
Other causes of chronic liver disease should
be looked for, including coinfections with
HDV, HCV and/or HIV (A1).
Comorbidities, including alcoholic, autoimmune, metabolic liver disease with steatosis
or steatohepatitis should be assessed (A1).

3:3:5

3:3:6

3:3:7

3:3:8

3:3:9

3:3:10

Accurate assessment of the degree of fibrosis

is essential not only to determine prognosis,
but also to identify patients who require
antiviral treatment (AI).
A liver biopsy is recommended to determine
the stage of fibrosis and/or the grade of
activity in patients with a high viral load and
high-normal or minimally raised ALT levels
without clinical evidence of cirrhosis (AI).
Noninvasive tests such as transient elastography can be a useful, reliable and practical
tool for the diagnosis, and for decisionmaking for treatment and monitoring clinical
outcome (BI).
Transient elastography is especially useful in
the assessment of liver fibrosis in patients
with normal ALT and bilirubin levels (AI). In
a patient infected with hepatitis B, a liver
stiffness measurement \6 generally excludes
a significant liver disease, above 8 indicates
significant fibrosis (F C2 by METAVIR
fibrosis score) and above 11 raises suspicion
of cirrhosis. These cutoffs may have regional
and population variations (A1).
Risk calculators may be used to assess HCC
risk in chronic HBV-infected patients and
make decisions to manage such patients (B2).
Specific risk calculators need to be developed
and validated in patients of different ethnicities, geographical areas, ages at infection,
genetic backgrounds, HBV genotypes,
comorbidities, and exposures to environmental factors such as aflatoxin and alcohol (B1).

3.4 Goals and endpoints of therapy in chronic HBV

infection
Goal of therapy
The ultimate goal is global eradication of HBV infection by
various strategies, including vaccination, treatment and
prevention of transmission. The goal of therapy for chronic
HBV infection is to improve quality of life and survival of
the infected person by preventing progression of the disease to cirrhosis, decompensated cirrhosis, end-stage liver
disease, HCC and death; and prevention of transmission of
HBV to others. This goal can be achieved if HBV replication can be suppressed in a sustained manner. Then, the
accompanying reduction in histological activity of CHB
lessens the risk of cirrhosis and decreases the risk of HCC,
particularly in noncirrhotic patients. However, chronic
HBV infection cannot be completely eradicated due to the

Hepatol Int

persistence of covalently closed circular DNA (cccDNA) in

the nucleus of infected hepatocytes, and also, the HBV
genome integrates into the host genome and might favour
oncogenesis and the development of HCC [160].
Endpoints of therapy
Therapy must ensure a degree of virological suppression
that will lead to biochemical remission, histological
improvement and prevention of complications. The ideal
endpoint in both HBeAg-positive and HBeAg-negative
patients is sustained off-therapy HBsAg loss, with or
without seroconversion to anti-HBs. This is associated with
a complete and definitive remission of the activity of CHB
and an improved long-term outcome. This endpoint, however, is infrequently achievable with the currently available
anti-HBV agents. A more realistic endpoint is the induction
of sustained or maintained virological remission [25].
Induction of sustained off-therapy virological response in
both HBeAg-positive (with sustained anti-HBe seroconversion) and HBeAg-negative patients is a satisfactory
endpoint, because it has been shown to be associated with
improved prognosis. If sustained off-therapy response not
achievable, then a maintained virological remission (undetectable HBVDNA by a sensitive PCR assay) under
long-term antiviral therapy in HBeAg-positive patients
who do not achieve anti-HBe seroconversion and in
HBeAg-negative patients is the next most desirable
endpoint.
Health-related quality of life (HRQOL) is significantly
affected in CHBV patients, particularly in those with more
severe forms of the disease. Prevention of disease progression with early treatment or liver transplantation can
certainly improve HRQOL. Even though some antiviral
medications decrease HRQOL during the acute treatment
period, the HRQOL of CHBV patients improves after
completion of antiviral treatment [161]. In order to
improve HRQOL of CHB patients, attention should be paid
to the reduction of patients treatment cost burden and the
provision of early health education accompanied with
proper treatments [162]. A recent Chinese study evaluated
the effect of comprehensive intervention on health-related
quality of life and provided guidance on improving
HRQOL for patients with CHB. Comprehensive intervention included government support, technical guidance from
the Chinese Center for Disease Control and Prevention,
standardized medical care, and community involvement.
HRQOL before and 1 year after intervention was measured
with the Short Form 36 and HBV-specific health surveys.
After comprehensive intervention, the HRQOL in patients
with CHB showed significant improvements in body pain,
vitality, social functioning, and mental as well as physical
and mental component score (p \ 0.05). Family and social

support increased, and financial concerns decreased

(p \ 0.05) [163].
3:4

Recommendations: goals and endpoints of therapy in

chronic HBV infection
3:4:1

3:4:2

3:4:3

3:4:4

3:4:5

The overall goal is global eradication of HBV

infection by various strategies including vaccination, treatment and prevention of transmission (A1).
The goal of therapy for CHB is to improve
quality of life and survival of the infected
person by preventing development of disease,
progression of the disease to cirrhosis, decompensated cirrhosis, end-stage liver disease,
HCC and death; and by prevention of transmission of HBV to others (A1).
The ideal endpoint in both HBeAg-positive
and HBeAg-negative patients is sustained offtherapy HBsAg loss, with or without seroconversion to anti-HBs (A1).
Induction of sustained off-therapy virological
response in both HBeAg-positive (with sustained anti-HBe seroconversion) and HBeAgnegative patients is a satisfactory endpoint
(A1).
If sustained off-therapy response is not achievable, then a maintained virological remission
(undetectable HBV DNA by a sensitive PCR
assay) under long-term antiviral therapy in
HBeAg-positive patients who do not achieve
anti-HBe seroconversion, and in HBeAg-negative patients, is the next most desirable
endpoint (A1).

3.5 Indications of therapy in chronic HBV infection

The indications for treatment are generally based mainly on
the combination of three criteria: serum HBV DNA levels,
serum ALT levels and severity of liver disease (assessed by
clinical evaluation, liver biopsy or noninvasive methods).
Indications for treatment should also take into account age,
health status, family history of HCC or cirrhosis and
extrahepatic manifestations (Table 5).
Patients
with
decompensated
cirrhosis
and
detectable HBV DNA require urgent antiviral treatment
with NA(s). Significant clinical improvement can be
associated with control of viral replication [164, 165].
However, antiviral therapy may not be sufficient to rescue
all decompensated patients and they should be considered
for liver transplantation at the same time (Fig. 1).
Patients with compensated cirrhosis and HBV DNA
[2000 IU/ml should also be considered for treatment even

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Hepatol Int
Table 5 Treatment indications for chronic HBV-infected patients
HBsAg positive patient

HBV DNA
(IU/ml)

ALT

Treatment

Decompensated
cirrhosis

Detectable

Any

Treat. Histology not needed. Consider LT of no stabilization

Compensated cirrhosis

[2000

Any

Treat. Histology should be obtained or assess fibrosis noninvasivelya

Severe reactivation of
chronic HBV

Detectable

Elevated

Treat immediately

Noncirrhotic HBeAgpositive chronic

hepatitis B

[20,000

[29 ULN

Observation for 3 months if no hepatic decompensation concerns.

Treat. Histology should be obtained or assessed noninvasivelya

129 ULN

Assess fibrosis noninvasively. Monitor every 3 months. Biopsy if

noninvasive tests suggest evidence of significant fibrosis, ALT is
persistently elevated, age [35 years or family h/o HCC or cirrhosis.
Treat if moderate to severe inflammation or significant fibrosisa

Persistently normal (age

\30) (immune tolerant
phase)

Assess fibrosis noninvasively. Monitor every 3 months. Biopsy if

noninvasive tests suggest evidence of significant fibrosis, or there is a
family h/o HCC or cirrhosis. Treat if moderate to severe inflammation
or significant fibrosisa

200020,000

Any ALT

Rule out other causes of elevated ALT.Assess fibrosis noninvasively.

Monitor every 3 months. Biopsy if noninvasive tests suggest evidence
of significant fibrosis, age [35 years, ALT is persistently elevated, or
there is a family h/o HCC or cirrhosis. Treat if moderate to severe
inflammation or significant fibrosisa

\2000

\ULN

Assess fibrosis noninvasively. Monitor every 3 months. Biopsy if ALT

becomes elevated, noninvasive tests suggest evidence of significant
fibrosis, age [35 years or with family h/o HCC or cirrhosis. Treat if
moderate to severe inflammation or significant fibrosis

[ULN

Rule out other causes of elevated ALT. Assess Fibrosis noninvasively.

Monitor every 3 months. Biopsy if noninvasive tests suggest evidence
of significant fibrosis, ALT is persistently elevated, age [35 years or
with family h/o HCC or cirrhosis. Treat if moderate to severe
inflammation or significant fibrosisa

[29 ULN

Observation for 3 months if no hepatic decompensation concerns.

Treat. Histology should be obtained or assess fibrosis noninvasively

129 ULN

Rule out other causes of elevated ALT.Assess fibrosis noninvasively.

Monitor every 3 months. Biopsy if noninvasive tests suggest evidence
of significant fibrosis, age [35 years, ALT is persistently elevated, or
there is a family h/o HCC or cirrhosis. Treat, if moderate to severe
inflammation or significant fibrosisa

Persistently normal

Assess fibrosis noninvasively. Monitor every 3 months. Biopsy if ALT

becomes elevated, noninvasive tests suggest evidence of significant
fibrosis, age [35 years or with family h/o HCC or cirrhosis. Treat if
moderate to severe inflammation or significant fibrosisa

[ULN

Rule out other causes of elevated ALT. Assess fibrosis noninvasively.

Monitor every 3 months. Biopsy, if noninvasive tests suggest
evidence of significant fibrosis, ALT is persistently elevated, age
[35 years or with family h/o HCC or cirrhosis. Treat if moderate to
severe inflammation or significant fibrosisa

Persistently normal

Assess Fibrosis noninvasively. Monitor ALT every 36 months and/or

DNA every 612 months. Biopsy if noninvasive tests suggest
evidence of significant fibrosis, ALT becomes elevated, age
[35 years or with family h/o HCC or cirrhosis. Treat if moderate to
severe inflammation or significant fibrosisa

Noncirrhotic HBeAgnegative chronic

hepatitis B

[2000

\2000

a
Moderate to severe inflammation on liver biopsy means either hepatic activity index by Ishak activity score[3/18 or METAVIR activity score
A2 or A3; significant fibrosis means F C2 by METAVIR fibrosis score or Ishak fibrosis stage C3. Significant fibrosis by noninvasive markers
means liver stiffness C8 kPa (by Fibroscan) or APRI C1.5. Cirrhosis by noninvasive markers means liver stiffness C11 kPa (by Fibroscan) or
APRI C2.0

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Hepatol Int
Fig. 1 Treatment indications
for chronic HBV-infected
patients with cirrhosis or
reactivation of chronic HBV
infection

Chronic HBV Infected Paent

Decompensated Cirrhosis

HBV DNA Detectable

Treat
Histology not needed
Consider LT of no
stabilizaon

Compensated Cirrhosis*

HBV DNA > 2000 IU/ml

if normal ALT,

HBV DNA detectable if

elevated ALT

Treat
Histology should be
obtained or assess
brosis noninvasively.*

Severe reacvaon of
Chronic HBV

Treat
immediately

* Cirrhosis by non-invasive markers means Liver sness 11 kPa (by Fibroscan) or APRI 2.0

if ALT levels are normal. Liver biopsy is recommended,

but noninvasive assessment of fibrosis is another option
(Fig. 1).
Treatment may be started in pre-cirrhotic chronic HBVinfected patients if they have persistently elevated ALT
levels [2 times the upper limit of normal (ULN) (at least
1 month between observations) and HBV DNA
[20,000 IU/ml if HBeAg positive and [2000 IU/ml if
HBeAg negative. In such patients, liver biopsy may provide additional useful information, especially in those with
doubtful causes of hepatic necroinflammation. A noninvasive method for the estimation of the extent of fibrosis is
useful in patients who start treatment without liver biopsy.
There is lack of sufficient data to start antiviral therapy
in the sub-groups of patients where there is significant
fibrosis, but the ALT levels are normal or minimally elevated or the DNA levels are below the defined limits.
These group of patients are not uncommon and the experts
deliberated on the treatment options for them. It was
unanimously agreed that these patients do merit antiviral
therapy, in order to prevent further progression of fibrosis
and other complications of liver disease. In addition,
therapy might help in stabilizing their disease or even
regression of fibrosis. In these cases, serial noninvasive
assessment of fibrosis and bio-chemical assessment of
inflammation and disease severity should be done.
Patients with a rising trend in ALT or bilirubin may be
developing an exacerbation, and even severe hepatitis or
hepatic decompensation. They should be monitored closely
with weekly or biweekly serum ALT, bilirubin, and prothrombin time measurement. Such exacerbations, particularly in patients with declining serum HBV DNA level,
may also precede spontaneous HBeAg seroconversion, and

may be followed by disease remission. Thus, it is reasonable to delay treatment for an observation period of
3 months, if there is no concern about hepatic
decompensation.
Patients with severe reactivation of chronic HBV
infection [reactivation with the presence of coagulopathy
with prolonged prothrombin time (prolonged by more than
3 s) or INR increased to [1.5] with impending or overt
hepatic decompensation should be treated immediately
with antiviral agents to prevent the development or deterioration of hepatic decompensation (see Treatment of
patients with reactivation of chronic HBV infection
including those developing acute on chronic liver failure
section) (Fig. 1).
Available information suggests that patients with persistently normal alanine aminotransferase levels (PNALT)
or minimally raised ALT levels (12 times the ULN)
respond poorly, in terms of HBeAg seroconversion, when
treated with currently available drugs. A recent article
evaluating the effects of tenofovir disoproxil fumarate
(TDF) in HBeAg-positive patients with normal levels of
ALT and high levels of HBV DNA in a double-blinded
way was reported. The authors demonstrated that both TDF
monotherapy and the combination of TDF and emtricitabine are effective in the suppression of HBV DNA in
patients with normal ALT and high viral load. However,
only 5 % of patients achieved HBeAg seroconversion after
192 weeks of therapy with combination of TDF and
emtricitabine [166]. Therefore, no drug treatment is recommended for this group of patients unless they have
evidence of significant fibrosis, cirrhosis, or are under a
protocol. One recent meta-analysis showed that nearly half
(48 %) of the 683 CHB patients with minimally increased

123

Hepatol Int

Non-cirrhoc HBeAg posive Chronic HBV infected paent

VIRAL
LOAD

HBV DNA
<2000IU/mL

HBV DNA
2000 -20,000IU/mL

ALT

Any

Any

Fibrosis

If elevated ALT, exclude

other causes
Assess brosis
noninvasively
Monitor 3 monthly
Individualize liver
biopsy@
Treat if moderate to
severe inammaon or
signicant brosis. $

If elevated ALT,
exclude other causes
Assess brosis
noninvasively
Monitor 3 monthly
Individualize liver
biopsy@
Treat if moderate to
severe inammaon or
signicant brosis.$

HBV DNA
>20,000 IU/mL

ALT1-2x ULN or N

ALT>2x ULN

Assess brosis
noninvasively
Monitor 3 monthly
Individualize liver
biopsy@
Treat if moderate to
severe inammaon
or signicant brosis.$

Observe for 3 months,

if no concerns of
hepac
decompensaon
Treat if no
seroconversion
Obtain histology or
assess brosis noninvasively.$

@ Biopsy if non-invasive tests suggest evidence of signicant brosis, ALT persistently elevated, Age >35 yr. or family h/o HCC or cirrhosis.
$
Moderate to severe inammaon on liver biopsy means either Hepac acvity index by Ishak acvity score >3/18 or METAVIR acvity score A2 or A3
Signicant brosis on liver biopsy means F2 by METAVIR brosis score or Ishak brosis stage 3
Liver sness 8 kPa ( by Fibroscan) or APRI 1.5 indicates signicant brosis; Liver sness 11 kPa (by Fibroscan) or APRI 2.0 indicates cirrhosis

Fig. 2 Treatment indications for noncirrhotic HBeAg-positive chronic HBV-infected patients

Non-cirrhoc HBeAg negave Chronic HBV infected paent

VIRAL
LOAD

ALT

Fibrosis

HBV DNA <2000IU/mL

ALT > ULN

If elevated ALT, exclude
other causes
Assess brosis
noninvasively
Monitor 3 monthly
Individualize liver
biopsy@
Treat if moderate to
severe inammaon or
signicant brosis.$

HBV DNA>2000 IU/mL

Persistently normal

ALT1-2x ULN or N

Assess brosis
noninvasively
Monitor ALT 3-6
monthly and DNA 6-12
monthly
Individualize liver
biopsy@
Treat if moderate to
severe inammaon or
signicant brosis.$

Assess brosis
noninvasively
Individualize liver
biopsy@
Treat if moderate to
severe inammaon
or signicant brosis*

ALT>2x ULN
Observe for 3
months, if no
concerns of hepac
decompensaon
Treat if no
seroconversion
Obtain histology or
assess brosis noninvasively.$

@ Biopsy if non-invasive tests suggest evidence of signicant brosis, ALT persistently elevated, Age >35 yr. or family h/o HCC or cirrhosis.
$
Moderate to severe inammaon on liver biopsy means either Hepac acvity index by Ishak acvity score >3/18 or METAVIR acvity score A2 or A3
Signicant brosis on liver biopsy means F2 by METAVIR brosis score or Ishak brosis stage 3
Liver sness 8 kPa ( by Fibroscan) or APRI 1.5 indicates signicant brosis; Liver sness 11 kPa (by Fibroscan) or APRI 2.0 indicates cirrhosis

Fig. 3 Treatment indications for noncirrhotic HBeAg-negative chronic HBV-infected patients

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Hepatol Int

ALT levels (levels 12 times the ULN) from nine recruited

studies had stage 2 or higher fibrosis (95 % CI 3661 %).
A subgroup of HBeAg-positive and HBeAg-negative
patients showed similar rates of fibrosis (41 vs. 47 %;
p = nonsignificant) [167]. Another study tried to explore
the hepatic histological changes after long-term antiviral
therapy in CHB patients with persistently normal ALT
levels and advanced hepatic fibrosis [168]. The authors
compared paired liver biopsies before and after lamivudine
treatment in CHB and normal ALT levels. Of them, 82.4 %
of patients had a baseline fibrosis score of 4 by Scheuer
scoring system and this was reduced to 17.6 % after a
median duration of 44.5 months of therapy.
If patients are not considered for treatment, they should
be followed up every 36 months. HBeAg-positive patients
with serum HBV DNA [20,000 IU/ml and PNALT should
also be followed up every 3 months. A liver biopsy should
be considered in viremic patients older than 3540 years,
especially those with high normal or minimally raised ALT
levels or family history of HCC or cirrhosis, with intent to
identify the group of patients with significant fibrosis
requiring treatment (Fig. 2).
Patients with active HBV replication (HBV DNA
[2000 IU/ml) and minimally elevated (129 ULN) or
persistently normal ALT should have liver fibrosis assessed. Liver biopsy may be needed before therapy to assess
the necroinflammatory grade, determine the fibrotic stage,
and exclude other possible causes of raised ALT levels as a
guide for consideration of antiviral treatment. Treatment
should be instituted if moderate to severe hepatic
necroinflammation or significant fibrosis is found. If liver
biopsy is not feasible, noninvasive assessment of liver
fibrosis should be considered as an alternative.
Immunotolerant patients need special attention. HBeAgpositive patients under 30 years of age with persistently
normal ALT levels and a high HBV DNA level, without
any evidence of liver disease and without a family history
of HCC or cirrhosis, generally do not require immediate
therapy. In these cases, noninvasive assessment of liver
fibrosis should be done. Follow-up should be done at least
every 36 months. A liver biopsy should be considered if
significant fibrosis is suspected or if there is family history
of HCC or cirrhosis.
HBeAg-negative patients with persistently normal
ALT levels (ALT determinations every 3 months for at
least 1 year) and HBV DNA levels below 2000 IU/ml,
without any evidence of liver disease, do not require
immediate therapy. Evaluation of the severity of fibrosis
by a noninvasive method might be useful as the first
screening test in such cases. A suspicion of significant
fibrosis should help identify patients for liver biopsy.
There is however, limited data using such an algorithmic
approach in CHB. Follow-up with ALT and alpha-

fetoprotein determinations every 36 months and ultrasonography and/or HBV DNA every 612 months is
needed (Fig. 3).
3:5

Recommendations: indications of therapy in chronic

HBV infection
3:5:1

3:5:2

3:5:3

3:5:4

3:5:5

3:5:6

HBsAg positive patients with decompensated

cirrhosis and detectable HBV DNA require
immediate antiviral treatment with NA(s).
Liver transplantation should be considered if
patients do not stabilize with medical management (A1).
Patients with compensated cirrhosis and HBV
DNA [2000 IU/ml should be considered for
treatment even if ALT levels are normal (A1).
Patients with compensated cirrhosis should be
treated irrespective of the ALT and HBV DNA
levels (C2).
Patients with suspected severe reactivation
[reactivation with the presence of coagulopathy with prolonged prothrombin time (prolonged by more than 3 s) or INR increased to
[1.5] of chronic HBV infection should be
started on antiviral therapy immediately after
sending tests for quantitative HBV DNA, but
without waiting for the results (B1).
Treatment may be started in pre-cirrhotic
chronic HBV-infected patients if they have
persistently elevated ALT levels [2 times
upper limit of normal (ULN) (at least 1 month
between observations) and HBV DNA
[20,000 IU/ml if HBeAg positive and
[2000 IU/ml if HBeAg negative (B1).
Patients with high HBV DNA levels
([20,000 IU/ml if HBeAg positive and
[2000 IU/ml if HBeAg negative) but ALT
\29 ULN should obtain assessment of fibrosis noninvasively, and should be monitored
every 3 months. Biopsy should be considered
if noninvasive tests suggest evidence of significant fibrosis, ALT becomes persistently
elevated, if age is [35 years or there is family
h/o HCC or cirrhosis. They should be considered for treatment if biopsy shows moderate to
severe inflammation or significant fibrosis
(B1).
HBeAg-positive patients with HBV DNA
\20,000 IU/ml, should be evaluated for other
causes if ALT is elevated, should obtain
assessment of fibrosis noninvasively, and
should be monitored every 3 months. Biopsy
should be considered if noninvasive tests
suggest evidence of significant fibrosis, ALT

123

Hepatol Int

3:5:7

3:5:8

3:5:9

becomes persistently elevated, if age is

[35 years or there is family h/o HCC or
cirrhosis. They should be considered for
treatment if biopsy shows moderate to severe
inflammation or significant fibrosis (B1).
HBeAg-negative patients with HBV DNA
\2000 IU/ml, should be evaluated for other
causes if ALT is elevated, should obtain
assessment of fibrosis noninvasively, and
should be monitored every 3 months if ALT
is elevated (if ALT is normal, monitoring
should be done with ALT every 36 months
and with DNA every 612 months). Biopsy
should be considered if noninvasive tests
suggest evidence of significant fibrosis, ALT
remains persistently elevated, if age is
[35 years or there is family h/o HCC or
cirrhosis. They should be considered for
treatment if biopsy shows moderate to severe
inflammation or significant fibrosis (C1). More
long-term data using antiviral therapy is
needed for these groups of patients.
Noninvasive methods for the estimation of the
extent of fibrosis are useful in selecting
patients for liver biopsy. Patients with the
suggestion of significant fibrosis by noninvasive markers [mean liver stiffness C8 kPa (by
Fibroscan) or APRI C1.5] should be considered for liver biopsy followed by treatment, if
biopsy shows moderate to severe inflammation
or significant fibrosis (C1) (Table 5). Patients
with suspected significant fibrosis but unwilling to undergo liver biopsy may be considered
for treatment (C2) or should be kept on regular
follow-up (B1).
Patients who are not considered for treatment
should be followed up regularly by measurement of ALT levels, HBV DNA, AFP, ultrasonography and fibrosis assessment (Table 5)
(B1).

3.6 Results of currently available therapies,

predictors of response to therapy, follow-up
and stopping rules during therapy in chronic HBV
infection
3.6.1 Results of and predictors of response to nucleos(t)ide
analogues
Lamivudine, adefovir dipivoxil, entecavir, telbivudine and
tenofovir disoproxil fumarate have been approved in most
Asia Pacific countries. Clevudine has been approved in

123

Korea and the Philippines, while its development has been

stopped in others countries due to myopathy.
L-Nucleoside

analogues Lamivudine In the Asian

lamivudine (LAM) trial and a multi-center trial in China,
HBeAg seroconversion was achieved in approximately
4447 % after 45 years of therapy [169]. In a long-term
follow-up study among 95 CHB patients (43 HBeAg-positive) on lamivudine for at least 10 years with maintained
viral suppression (HBV DNA \2000 IU/ml), seven (10 %)
patients had HBsAg seroclearance. Baseline HBsAg
\1000 IU/ml and on-treatment reduction of HBsAg
[0.166 log IU/ml were optimal cutoffs to predict HBsAg
seroclearance (negative predictive values 98.1 and 97.8 %,
respectively), but in general, the HBsAg decline was slow
at 0.104 log IU/ml/year [170].

In a Korean study including 178 patients with HBeAg

seroconversion and discontinued lamivudine, the relapse
(defined as HBV DNA [140,000 copies/ml) rate after
12-month consolidation was 8.7 % in 5 years, in contrast to
61.9 % in those with consolidation therapy \12 months
[171]. In another study including 101 patients from Taiwan
and Hong Kong, longer consolidation of lamivudine was
associated with a higher combined response (HBeAg
seroconversion and undetectable HBV DNA) 6 months
post-treatment; 25.6, 39.0 and 71.4 % with consolidation
therapy for \12, 1218 and [18 months, respectively
[172]. A study among 83 Taiwanese patients found that
HBsAg level \300 IU/ml at the end of lamivudine treatment could predict HBsAg seroclearance after stopping
lamivudine (five of nine patients, 55.5 %) at a median
follow-up of 4 years [173]. More data is needed for the use
of HBsAg level to guide treatment cessation.
In HBeAg-negative patients, studies among Chinese
patients who stopped LAM after a minimum of 24 months
of treatment with at least three results of undetectable HBV
DNA 6 months apart showed a post-treatment relapse
(HBV DNA C104 copies/ml) rate of 3750 % at 1 year
[174, 175]. A study from Hong Kong including 53 HBeAgnegative patients treated with LAM for a mean of 34
(1276) months and stopped LAM therapy for
47 35 months showed that end-of-treatment HBsAg
B100 IU/ml plus reduction by [1 log from baseline could
predict sustained response (HBV DNA B200 IU/ml) of
100 % (five of five patients) at 12 months and HBsAg loss
at 5 years post-treatment [176]. Another Taiwanese study
including 107 HBeAg-negative patients treated by LAM
for 93 35 months showed that end of treatment HBsAg
\120 and \200 IU/ml were associated with HBsAg loss
(19 of 24 patients, 79.2 %) and sustained response (HBV
DNA \2000 IU/ml; 28 of 30, 93.3 %) at a median of
4 years post-treatment [177].

Hepatol Int

LAM is well tolerated, even in patients with decompensated cirrhosis or in pediatric patients [178]. The key
LAM resistant mutant is at the YMDD locus in the catalytic domain of the HBV polymerase gene (rtM204I/V/S),
which may confer cross-resistance to other drugs in the Lnucleoside group, such as telbivudine and entecavir. The
compensatory mutation, rtL180M, is frequently associated
with rtM204V/S and will reduce the susceptibility to
entecavir. Another LAM resistant mutation, rtA181T/V,
may confer cross-resistance to adefovir and telbivudine,
and has partial resistance to tenofovir. Compensatory
codon substitutions that increase viral replication may also
be found, such as rtL80V/I, rtV173L, rtT184S/G [179]. The
incidence of rtM204V/I substitution increased from 24 %
in 1 year to 70 % in 5 years. Undetectable HBV DNA at
week 24 was associated with 9 and 5 % of LAM resistance
at 2 years among HBeAg-positive and HBeAg-negative
patients, respectively [180].
Although prolonged lamivudine (LAM) therapy is
associated with the emergence of LAM-resistant mutations,
it is still a commonly used therapy in many Asian countries
because of its established long-term safety and low cost. In
one recent multicenter study on 838 patients, an individual
prediction model for lamivudine treatment response in
HBeAg-positive CHB patients was suggested. In the multivariate analysis, age [odds ratio (OR) 0.974, p \ 0.001],
baseline alanine aminotransferase level (OR 1.001,
p = 0.014), and baseline HBV DNA level (OR 0.749,
p \ 0.001) were independent factors for HBeAg seroconversion. Based on the predictors, an IPM was established.
Patients were classified into high ([50 %), intermediate
(3050 %), or low (B30 %) response groups based on their
probability of HBeAg seroconversion according to the
IPM. The cumulative HBeAg seroconversion rate at
6 years for the high, intermediate, and low response groups
was 66.0, 48.5, and 21.8 %, respectively (p \ 0.001). This
model may allow screening of LAM responders prior to the
commencement of antiviral treatment, but needs further
validation [181].
Telbivudine Telbivudine (LdT) 600 mg daily has been
shown to have more potent HBV DNA suppression than
LAM and ADV [182, 183]. After excluding patients who
had drug resistance at year 2 in the GLOBE study, continuation of LdT until year 4 was associated with undetectable HBV DNA in 76 % of HBeAg-positive and 86 %
of HBeAg-negative patients, HBeAg seroconversion in
53 % of HBeAg-positive patients, and HBsAg loss in
1.9 % of HBeAg-positive patients and 0.6 % in HBeAgnegative patients [184]. Among the 61 patients who had
telbivudine stopped because of HBeAg loss for [6 months
and HBV DNA \5 log copies/ml (98 % had HBV DNA
\300 copies/ml), 50 (82 %) had sustained HBeAg

seroconversion, 28 (46 %) had HBV DNA \4 log copies/

ml (14 patients had undetectable HBV DNA), and four
(6.5 %) had HBsAg loss [184].
The most common LdT resistant substitution is rtM204I,
and rtA181T/V [179]. The 2-year risk of LdT resistance
was 25.1 % in HBeAg-positive patients and 10.8 % in
HBeAg-negative patients, which is lower than that of
lamivudine [180]. In the subgroup that had no genotypic
resistance at year 2 and received LdT up to year 4, the
cumulative virological breakthrough/resistance rate was
18.8/10.6 % for HBeAg-positive and 15.9/10.0 % for
HBeAg-negative patients [184].
In a multi-centered Chinese study among HBeAg-positive patients on LdT, patients who had HBV DNA C300
copies/ml at week 24 were randomized to add-on adefovir
treatment versus continuation of telbivudine until week
104. The add-on adefovir group had a higher chance of
HBV DNA \300 copies/ml (76.7 vs. 61.2 %), a lower risk
of genotypic resistance (2.7 vs. 25.8 %) and comparable
rate of HBeAg seroconversion (23.7 vs. 22.7 %) compared
to the continued LdT group at week 104 [185]. In a real-life
cohort in Hong Kong, among the 25 patients who had
detectable HBV DNA but \2000 IU/ml after 612 months
of telbivudine, 24 (96 %) could achieve undetectable HBV
DNA after switching to entecavir for a median follow-up of
2 years [186]. LdT is generally well tolerated, including in
patients with decompensated liver cirrhosis [178]. Based
on the databases of the GLOBE study as well as other
studies including compensated and decompensated
patients, LdT was found to improve renal function, as
measured by calculated eGFR after 24 weeks of therapy,
and this benefit was seen among patient who were aged
[50 years and those with eGFR B90 at baseline [187]. The
improvement in eGFR was confirmed in another Korean
study with 43 patients on LdT and adefovir combination
therapy for 24 weeks [188]. Among patients who received
LdT for 4 years, creatine kinase increase was reported in
10.1 % of patients and muscle symptoms in 6.1 % of
patients (myopathy and myositis in 0.6 %) [187].
Acyclic nucleotide phosphonates Adefovir dipivoxil In
HBeAg-positive patients, HBeAg seroconversion can be
achieved in 3037 % after 35 years of adefovir (ADV)
treatment [189, 190]. In HBeAg-negative patients, 67 % of
patients had HBV DNA \200 IU/ml and 75 % had fibrosis
regression after 240-week treatment with ADV [191].
The safety profile of 10 mg ADV daily was similar to
placebo in patients with compensated CHB. Reversible
increase in serum creatinine of more than 0.5 mg/dl
(maximum 1.5 mg/dl) was reported in up to 3 % of patients
when the therapy is extended to 5 years [191].

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Hepatol Int

The primary drug resistance mutations against ADV are

rtA181V/T and rtN236T. The cumulative incidence of
genotypic resistance to ADV was 29 % after 5 years of
therapy in HBeAg-negative patients [191]. The substitution
rtN236T has partial cross-resistance to tenofovir, but it is
sensitive to LAM, LdT and entecavir [179].
ADV is effective in suppressing HBV DNA in patients
with rtM204I/V HBV substitution. In a 5-year follow-up
cohort of 165 LAM-resistant patients, add-on ADV therapy
resulted in undetectable HBV DNA in 74 % and genotypic
ADV resistance in 10.2 % of patients [192]. Undetectable HBV DNA at month 6 is the best predictor of
maintained HBV DNA suppression; 87100 % of patients
with undetectable HBV DNA at month 6 had undetectable HBV DNA at 35 years on continuous ADV addon therapy [193, 194].
Tenofovir disoproxil fumarate Tenofovir disoproxil
fumarate (TDF) is an acyclic adenine nucleotide analogue
effective for both HBV and HIV. Five-year continuous
TDF therapy was associated with HBV DNA \400 copies/
ml in 65 % of HBeAg-positive and 83 % of HBeAg-negative patients; HBeAg seroconversion in 40 % and HBsAg
loss in 10 % (all but one were HBeAg-positive; 96 % HBV
genotype A and D) patients [195]. On paired liver biopsy at
5 years, 87 % of the 348 patients had histological
improvement and 74 % of the 96 cirrhotic patients had
regression of liver cirrhosis [195]. Patients who had high
viral load ([9 log copies/ml) took a longer time to reach
HBV DNA \400 copies/ml than those with lower baseline
HBV DNA levels, but overall, 96.9 % of patients who
completed 240 weeks of therapy could achieve HBV DNA
\169 copies/ml [196]. Among immune-tolerant patients
(HBeAg-positive, HBV DNA [1.7 9 107 IU/ml, normal
ALT), a combination of tenofovir with emtricitabine was
associated with a higher rate of undetectable HBV DNA
than tenofovir monotherapy (76 vs. 55 %) after treatment
for 4 years, but the overall rate of HBeAg seroconversion
was only 5 % (all in patients on combination therapy)
[166]. Among the 52 patients who stopped treatment after
4 years, 51 of them had rapid increase in HBV DNA within
4 weeks and one patient had an ALT flare within 24 weeks.
TDF is generally well tolerated, including in patients
with decompensated liver disease [165]. Reduction of
creatinine clearance to \50 ml/min is extremely uncommon among patients with normal baseline renal function
(\1 %) after 35 years of continuous TDF treatment [197,
198]. Approximately 1 % of patients developed
hypophosphatemia (\2 mg/dl or 0.65 mmol/l), and most of
them resolved without dosage modification, treatment
interruption or phosphate supplementation. In a multicentered study comparing TDF (n = 141) with TDF and
emtricitabine (n = 139) in lamivudine-resistant CHB,

123

there was a small decline in the bone mineral density of the

spine (-1.4 %) and hip (-1.8 %) at week 96 of treatment
[198]. Rare cases of Fanconi syndrome that readily
resolved with cessation of tenofovir have been reported
[199].
No TDF resistance has been reported up to 7 years
[200]. Tenofovir monotherapy is sufficient in the treatment
of rtM204V/I rtL180M HBV variants; 89.4 % patients
on TDF versus 86.3 % patients on a combination of TDF
and emtricitabine achieved undetectable HBV DNA
(\69 IU/ml) after 96 weeks of treatment [198]. In vitro
studies showed that a single mutation of the ADV resistant
mutations, A181T/V or N236T, had little reduced susceptibility to TDF. On the other hand, presence of the double
mutant rtA181V/T ? rtN236T had low level, reduced
susceptibility to TDF [201]. In a post hoc analysis of a
multi-center study comparing TDF versus TDF and
emtricitabine combination among ADV refractory patients,
patients with rtN236T showed a similar decline in HBV
DNA as of those with wild-type HBV in the initial
24 weeks by either regime [202]. Another European multicenter study showed that TDF monotherapy and TDF/
emtricitabine combination were equally effective in suppressing the HBV DNA to \400 copies in 168 weeks (82
and 84 %, respectively) among ADV refractory patients,
and there was no difference in the response with regard to
the baseline LAM/ADV resistance profile [197]. In a case
series of 57 patients who failed to achieve complete HBV
DNA suppression by antiviral drugs including entecavir or
TDF due to the presence of multi-drug resistant HBV, a
combination of TDF and entecavir (0.5 mg for nave or
1 mg for LAM experienced patients daily) could achieve
undetectable HBV DNA (\80 IU/ml) in 90 % of patients
after treatment for a median of 21 months [203].
D-Cyclopentanes

Entecavir Entecavir (ETV) is a cyclopentyl guanosine

analogue with potent selective inhibition of the priming,
DNA-dependent synthesis, and reverse transcription functions of HBV polymerase. In Asian cohorts treated with
ETV 0.5 mg daily, approximately 8392 % patients had
undetectable HBV DNA, 2649 % patients had HBeAg
seroconversion and \1 % of patients had HBsAg seroclearance at year 3 of treatment [204, 205]. Among 222
treatment-nave patients treated with entecavir in Hong
Kong, 97.1 % patients had undetectable HBV DNA,
66.9 % had HBeAg seroconversion and only one patient
achieved HBsAg seroclearance after 5 years [206]. The
rate of HBsAg decline is approximately 0.125 log IU/ml/
year, which explains the need for long-term therapy and
low rate of HBsAg clearance in ETV-treated patients [206].
Among HBeAg-positive patients with high viral load ([108

Hepatol Int

IU/ml), a combination of tenofovir and entecavir could

achieve a higher rate of undetectable HBV DNA than
entecavir monotherapy at week 96 (78.8 vs. 62.0 %,
respectively) [207]. However, this study lacks the tenofovir
monotherapy arm for comparison.
In a Korean study, approximately 1416 % of treatment-nave patients had primary nonresponse as defined by
AASLD (\2 log reduction in HBV DNA at month 6) or
EASL (\1 log reduction in HBV DNA at month 3), but all
primary non-responders could achieve undetectable HBV
DNA after 54 months of treatment [208]. On the other
hand, partial virological response (detectable HBV DNA at
month 12) was predictive of a lower probability of complete HBV DNA suppression and higher risk of virological
breakthrough. Approximately 1826 % of treatment-nave
patients had partial virological response on entecavir; the
cumulative rate of virological response (undetectable HBV
DNA) at year 3 is 4558 % and virological breakthrough is
5.16.3 % [205, 209]. For some of these patients, virological breakthrough might be related to poor drug
adherence.
Long-term cohort studies among entecavir-treated
patients compared with historic untreated controls in Japan
and Hong Kong demonstrated reduction in mortality, liverrelated complication and HCC, especially among patients
with liver cirrhosis [210212]. Patients who achieved
undetectable HBV DNA during treatment had better
prognosis [213, 214]. Over 97 % of treatment-nave
patients could achieve maintained HBV DNA suppression
on entecavir after 23 years, while most patients who
failed to achieve undetectable HBV DNA were exposed to
previous antiviral agents [214]. Among patients who failed
to have complete HBV DNA suppression with entecavir,
switching or add-on tenofovir was associated with
97100 % undetectable HBV DNA after 12 months [215,
216].
In a retrospective Taiwanese study among 95 HBeAgnegative patients who discontinued ETV therapy after
undetectable HBV DNA had been documented on three
occasions, each 6 months apart, the cumulative clinical
relapse (ALT[2 time upper limit of normal and HBV DNA
[2000 IU/ml) was 45.3 % in 1 year [217]. Nine patients
had spontaneous remission while the remaining 34 patients
were retreated by ETV with good HBV DNA suppression.
In another prospective study from Hong Kong, ETV was
stopped in 184 HBeAg-negative patients, fulfilling the
same stop treatment criteria. The cumulative rate of virological relapse (HBV DNA [2000 IU/ml) was 72.4 % at
6 months and 91.2 % at 1 year; 25.8 % of patients had
elevated ALT level before ETV retreatment was recommenced [218]. No baseline or on-treatment factors were
found to be consistently predictive of post-treatment
relapse after stopping ETV.

ETV is well tolerated. The US Food and Drug Administration (FDA) requires all approved NAs to carry the
black box warning for the potential development of
lactic acidosis as a result of mitochondrial toxicity. Most of
the reports of lactic acidosis for LAM and TDF have been
when they were used in combination with other antiretroviral agents in HIV-infected patients. Isolated cases have
been reported for TEL and ADV in HBV patients [219,
220]. Reports of cases have also been observed in patients
treated with ETV, in particular those with impaired liver
function and high model for end-stage liver disease
(MELD) score [221, 222]. Interestingly, only the MELD
and not the ChildPugh score was correlated with the
development of lactic acidosis, suggesting that renal
impairment may be an important contributor. In a series of
11 patients treated with ETV before liver transplant for
acute flares of CHB with decompensation, none had evidence of lactic acidosis [223]. This highlights the importance of appropriate dose adjustment of NAs according to
the calculated CrCl. Lactic acidosis is rarely reported
among Asian patients with decompensated cirrhosis [164].
Although it is likely to be a rare event, clinical vigilance
must be adopted for this potentially fatal complication,
especially for those who are receiving combination therapy, and for those with impaired liver function and multiorgan failure.
ETV has a high genetic barrier to resistance. Drug
resistance requires at least three codon substitutions,
including rtL180M, rtM204I/V, plus a substitution at one
of the following amino acids: rtT184S/G, rtS202I/G and/or
rtM250V [179]. Among treatment-nave patients, ETV
resistance is very rare. In the long-term follow-up of the
international trial on HBeAg-positive and HBeAg-negative
patients and in a long-term follow-up study in Hong Kong,
the cumulative probability of ETV resistance was 1.2 %
after 5 years of ETV treatment [218].
ETV is effective in the treatment of ADV resistance
[179]. Switching to ETV monotherapy (1 mg daily) in
LAM resistant patients is associated with a [50 % cumulative risk of ETV, as rtM204I/V and rtL180M reduce the
genetic barrier of resistance to ETV [224]. Among lamivudine resistant patients who had HBV DNA[2000 IU/ml
on LAM and ADV combination therapy, a combination of
entecavir 1 mg daily and ADV could achieve undetectable HBV DNA (\60 IU/ml) in 29 % in 1 year and
42 % in 2 years [225].
Other direct antiviral agents Clevudine is an L-nucleoside pyrimidine analogue with potent antiviral activity
against HBV. With clevudine 30 mg daily, the cumulative
rate of undetectable HBV DNA is 6783 % and HBeAg
seroconversion is 2331 % after 23 years [226, 227].
Virological breakthrough occurs in approximately 25 % of

123

Hepatol Int

patients, and is primarily related to rtM204I rtL180M

mutants. Myopathy was reported in up to 13 % of patients
after being treated for a mean of 14 (range
9.323.5) months, but it was resolved spontaneously after
stopping clevudine [226]. The global development of clevudine was terminated in 2009 because of case reports of
serious myopathy related to myonecrosis.
Besifovir (LB80380) is an acyclic nucleotide phosphonate with chemistry similar to ADV and TDF. In a phase
IIb, open-label, multicenter study among 114 treatmentnave patients randomized to besifovir 90 mg daily, besifovir 150 mg daily and entecavir 0.5 mg daily for
48 weeks, undetectable HBV DNA was found in 63.6, 62.9
and 58.3 %, and HBeAg seroconversion was found in 11.1,
15 and 9.5 %, respectively [228]. No drug resistance or
elevated serum creatinine was found among patients on
besifovir. Ninety-four percent of patients on besifovir had
reduced serum L-carnitine, but the L-carnitine levels
returned to normal with supplement.
Tenofovir alafenamide fumarate (TAF) is a nucleotide
reverse transcriptase inhibitor and a novel prodrug of
tenofovir. Closely related to the commonly used reversetranscriptase inhibitor tenofovir disoproxil fumarate, it has
greater plasma stability than tenofovir disoproxil fumarate,
and provides efficient delivery of active drug to hepatocytes at reduced systemic tenofovir exposures. In a recent
study, noncirrhotic, treatment-nave subjects with CHB
were randomized (1:1:1:1:1) to receive tenofovir alafenamide 8, 25, 40, or 120 mg, or tenofovir disoproxil
fumarate 300 mg for 28 days and were assessed for safety,
antiviral response, and pharmacokinetics, followed up by
off-treatment for 4 weeks. Tenofovir alafenamide was safe
and well tolerated; declines in HBV DNA were similar to
tenofovir disoproxil fumarate at all doses evaluated.
Tenofovir alafenamide 25 mg has been selected for further
hepatitis B clinical development [229].
Combination of NAs De novo combination of lamivudine
and adefovir does not improve viral suppression over
lamivudine alone, although this reduces, but does not
abolish, lamivudine resistance. Furthermore, adefovir
resistance was not reported in this study. Combining telbivudine and lamivudine does not achieve greater reduction in HBV DNA than telbivudine monotherapy, but may
even increase the risk of telbivudine resistance [230]. This
suggests that NAs with the same resistance pattern should
not be combined.
In one meta-analysis evaluating the effectiveness and
resistance of de novo combination of lamivudine and
adefovir dipivoxil compared with entecavir monotherapy
for nucleos(t)ide-naive patients with chronic HBV infection (five studies, 328 patients), it was found that at

123

48 weeks, the combination group had superior virological

response rates compared to the ETV group (90.0 vs.
78.9 %, p = 0.01). At week 96, LAM ? ADV was more
effective than ETV in ALT normalization [RR 1.11, 95 %
CI (1.02, 1.21), p = 0.01] and HBeAg seroconversion [RR
2.00, 95 % CI (1.26, 3.18, p = 0.003)], and no significant
difference was found in the virological response
(p = 0.23). No viral resistance occurred in combination
therapy and six patients in the ETV group were experienced with viral breakthrough [231]. In a recent clinical
trial, 379 treatment-nave patients were randomized to
receive entecavir monotherapy (n = 186) or entecavir plus
tenofovir (n = 198) [232]. By week 96, 76 % in the
monotherapy arm and 83 % in the combination arm had
HBV DNA below 50 IU/ml (p = 0.088). In a post hoc
subgroup analysis, combination therapy was superior to
entecavir monotherapy in patients with positive HBeAg
and baseline HBV DNA over 8 log IU/ml. However,
because the subgroup analysis was not planned a priori, the
findings can only be considered exploratory and have to be
confirmed in another study focusing on patients with high
viral load. The efficacy of tenofovir monotherapy and
higher dose entecavir (1.0 mg) has to be evaluated before
combination therapy can be recommended for this group of
patients.
Monitoring treatment and guidance for stopping therapy
in chronic HBV-infected patients treated with nucleos(t)ide
analogues
Efficacy and safety of NA therapy should be monitored
regularly. Primary non-response, defined as\1 log10 IU/ml
decline in HBV DNA level from baseline at month 3 of
therapy, is rare with NA therapy [233]. Checking patients
compliance is recommended in patients with primary nonresponse. Virological response at 6 months of lamivudine
or telbivudine therapy and at 12 months of adefovir therapy is associated with the risk of emergence of drug
resistance and virological and serological response with
long-term therapy [234, 235]. HBV DNA level should be
measured at month 3 and 6 of therapy and then every
36 months if agents with low genetic barrier are used
(lam, Adefo, telbivudine), and every 6 months in patients
treated with a high genetic barrier to resistance, such as
entecavir or tenofovir. Serum ALT and HBeAg and antiHBe (in patients with HBeAg-positive CHB) should be
monitored every 3 months.
Checking compliance and testing for genotypic resistance should be done in patients with virological breakthrough during NA therapy. Due to potential
nephrotoxicity, monitoring serum creatinine and serum
phosphate levels should be done every 3 months during
adefovir or tenofovir therapy [236, 237]. Muscle symptoms

Hepatol Int

or muscle weakness should be monitored during telbivudine or clevudine therapy [180, 238]. A decline of
HBsAg level during therapy may predict HBeAg or HBsAg
loss with long-term telbivudine, entecavir or tenofovir
therapy [239241]. However, more data is needed to confirm the results before making a recommendation.
In HBeAg-positive CHB patients who achieve HBeAg
seroconversion with undetectable HBV DNA, the relapse
rates depend on the duration of consolidation therapy
[242]. One recent study described 94 patients who stopped
NA after at least 1 year of therapy. Patients could be
HBeAg-positive or HBeAg-negative at the start of therapy,
but all were HBeAg-negative and had undetectable HBV
DNA (\200 IU/ml) at the time of discontinuation. Consolidation therapy was defined as treatment duration
between the first undetectable HBV DNA (in case of
HBeAg-positive patients after HBeAg loss) and NA discontinuation. Relapse was defined as HBV DNA
[2000 IU/ml measured twice 6 months apart within
1 year, or retreatment after an initial HBV DNA elevation.
At the start of therapy, 35 patients were HBeAg-positive
and 59 were HBeAg-negative. The cumulative relapse rate
was 33 % at 6 months, 42.7 % at 1 year, and 64.4 % at
5 years. Patients with at least 3 years of consolidation
therapy (n = 37) had a 1-year relapse rate of 23.2 %
compared to 57.2 % for 13 years of consolidation therapy
(n = 32), and 55.5 % for \1 year of consolidation therapy
(n = 20) (p = 0.002). For each additional year of consolidation therapy, patients were 1.3-fold more likely to lose
HBsAg (hazard ratio 1.34; 95 % CI 1.021.75). Consolidation therapy of at least 3 years decreased the rate of
relapse and increased the rate of HBsAg loss significantly
[243].
Due to the high relapse rate after NA treatment discontinuation in patients with HBeAg-negative chronic
hepatitis, treatment until HBsAg loss is generally recommended [218]. HBsAg levels may be a potential marker to
guide treatment cessation. HBsAg levels of\2 log10 IU/ml
at the end of treatment are associated with a lower relapse
rate at 12 years post-treatment discontinuation (15 vs.
85 % in those with HBsAg level [2 log10 IU/ml at end of
treatment) [244]. In one recent study to assess the outcome
of patients withdrawing from NA therapy after HBsAg
clearance, 27 (5 %) out of 520 CHB patients who received
NA for prolonged periods ultimately lost serum HBsAg
and were followed for 44 (12117) months thereafter. It
was concluded that patients reaching the therapeutic endpoint of HBsAg clearance can be safely withdrawn from
NA following either anti-HBs seroconversion or at least
12 months of a post-clearance consolidation period [245].
However, in one recent meta-analysis including 22 studies
with a total of 1732 HBeAg-negative patients (median
duration of therapy, consolidation therapy and off-therapy

follow-up ranged from 6 months to 8 years, 496 weeks

and 680 months, respectively, and patients were monitored with serum ALT and HBV DNA monthly in the first
13 months and every 36 months thereafter in most
studies), the 1-year off-therapy virological relapse (HBV
DNA [2000 IU/ml)and clinical relapse (HBV DNA
[2000 IU/ml ? ALT elevation) occurred in \70 % and
\50 % of the patients, respectively, and \40 % of the
patients received re-treatment. These rates were higher in
patients with shorter treatment, shorter consolidation therapy (\2 years) and those treated with less potent
nucleos(t)ide analogues. Off-therapy severe flares were
rare and hepatic decompensation was reported in only one
patient with cirrhosis. Biochemical relapse reflecting
enhanced immune-mediated hepatocyte killing may lead to
a higher chance for off-therapy HBsAg seroclearance and
possibly be desirable. Thus, with an appropriate stopping
rule and a proper off-therapy monitoring plan, cessation of
long-term nucleos(t)ide analogue therapy prior to HBsAg
seroclearance in HBeAg-negative CHB is a feasible alternative to indefinite treatment [246].
Hepatitis relapse with hepatic decompensation and death
is an important issue after cessation of NAs therapy in
cirrhotic patients. The advantages of stopping NA therapy
are a finite duration of treatment, with improved adherence
and retention in care, reduced costs, and minimization of
renal and bone toxicity. The disadvantages are the risk of
reactivation of suppressed disease with discontinuation of
therapy, resulting in an unpredictable worsening of disease
and possible development of fulminant hepatitis and acuteon-chronic liver failure, as well as the risk of developing
resistance with stopstart therapy. Cirrhotics have much
less hepatic reserve for life-threatening hepatic decompensation after an exacerbation. However, one recent metaanalysis suggested that NAs withdrawel is safe even in
cirrhotics, that off-therapy severe flares were rare and that
hepatic decompensation was rarely observed in patients
with cirrhosis [246].
3:6:1

Recommendations (results of currently available

therapies, predictors of response to therapy, followup and stopping rules during NA therapy in patients
with chronic HBV infection)
3:6:1:1

3:6:1:2
3:6:1:3

Treatment-nave patients can be treated

with TDF 300 mg daily (A1), ETV 0.5 mg
daily (A1), ADV 10 mg daily (A2), LdT
600 mg daily (A2) or LAM 100 mg daily
(A2).
TDF or ETV are the preferred NAs and
should be used as first-line therapy (A1).
During NA therapy, HBeAg, anti-HBe (in
patients with HBeAg-positive) and ALT
should be monitored every 3 months (A1).

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Hepatol Int

3:6:1:4

3:6:1:5

3:6:1:6

3:6:1:7

3:6:1:8

3:6:1:9

3:6:1:10

The HBV DNA level should be measured

at month 3 and 6 of therapy and then every
36 months if agents with a low genetic
barrier are used (lamivudine, adefovir,
telbivudine), and every 6 months in
patients treated with a high genetic barrier
to resistance, such as entecavir or tenofovir (A1).
Renal function and bone profile should be
monitored at least every 3 months if TDF
or ADV is used (A1).
Muscle symptoms and muscle weakness
should be monitored during telbivudine or
clevudine therapy (A1).
For HBeAg-positive patients without liver
cirrhosis, the optimal duration of NA
therapy is unknown, and the therapy can
be stopped after at least 1 year (A1), but
preferably after 3 years (C1) of additional
therapy after HBeAg seroconversion with
undetectable HBV DNA by PCR and
persistently normal ALT levels.
The optimal duration of NA therapy is
unknown in patients with HBeAg-negative
CHB. In patients without liver cirrhosis,
the treatment can be withdrawn (1) after
HBsAg loss following either anti-HBs
seroconversion or at least 12 months of a
post-HBsAg clearance consolidation period (B1), or (2) after treatment for at least
2 years with undetectable HBV DNA
documented on three separate occasions,
6 months apart (B1).
After stopping of NAs, patients should be
monitored monthly for the initial 3 months
and then every 36 months thereafter for
relapse (A2).
The stopping of NA therapy may also be
considered in cirrhotic patients with a
careful off-therapy monitoring plan (A1).

3.6.2 Results of and predictors of response

to therapy with interferons
Currently, conventional interferon-alfa (IFN), lamivudine,
adefovir, entecavir, telbivudine, tenofovir and pegylated
interferona2a (Peg-IFN-2a) have been approved for the
treatment of CHB globally. Table 1 shows the comparison
between these two treatment strategies (immune control vs.
viral control). Peg-IFN-2b has been approved for the
treatment of chronic HBV infection in a few countries.
Thymosin a1 has also been licensed in some Asian

123

countries. However, clevudine was only approved in Korea

and the Philippines.
Immunomodulatory agents include conventional interferon-a (IFN), pegylated interferon (Peg-IFN), and thymosin a1. These agents have dual actions: enhancing host
immunity to mount a defense against HBV and modest
antiviral action. Over the past two decades, IFN-based
therapy has been the mainstay of CHB treatment
worldwide.
Conventional interferon
HBeAg-positive chronic hepatitis B Meta-analyses of
controlled trials in HBeAg-positive patients showed that
treatment with conventional interferon-alfa (IFN) at a dose
of 5 MU daily or 10 MU three times weekly for
46 months achieved higher HBeAg loss (33 vs. 12 %),
HBV DNA suppression (37 vs. 17 %) and ALT normalization than untreated controls with a risk difference of
around 25 % for each parameter. The rate of HBsAg
seroclearance was also higher (7.8 vs. 1.8 %) in IFNtreated patients, with a risk difference of 5.6 %. Asian
patients with elevated baseline ALT have IFN response
rates comparable to Western patients. The efficacy of IFN
treatment in children with elevated ALT was also similar to
that in adults. Re-treatment of patients who failed previous
IFN therapy could achieve HBeAg loss in 2040 % of
cases. A study of tailored regimen of IFN in 247 HBeAgpositive patients showed a higher sustained response than
fixed 6-month treatment (40.5 vs. 28.3 %, p = 0.013).
HBeAg seroconversion is durable in over 90 % and
delayed HBeAg seroconversion could occur in 1015 % at
12 years post-therapy, and there was up to a 15-year
cumulative incidence of 75 % HBeAg seroconversion (vs.
52 % in control). In addition, IFN-treated patients have a
lower likelihood of cirrhosis and HCC development, as
well as better overall survival, especially among responders
[19].
HBeAg-negative chronic hepatitis B A 12-month IFN
therapy showed the end-of-treatment biochemical and
virological response rates in 6090 %; however, sustained
response rate was only 22 %. Extending IFN treatment for
24 months in Italian patients induced sustained response in
30 % and HBsAg clearance in 18 % at 6 years post-therapy. IFN treatment improved long-term outcomes, including reduction of HCC and survival and hepatic
complication-free survival in patients with sustained
response [19].
Compensated cirrhosis Previous studies showed that
compensated cirrhosis patients treated with IFN had comparable or even better response and a similar side effect

Hepatol Int

profile as those without cirrhosis, with reduced risk of

hepatic decompensation, HCC and prolonged survival in
responders. However, IFN is contraindicated in patients
with overt decompensated cirrhosis because it can precipitate hepatic decompensation, resulting in fatal complications [19]. Long-term follow-up studies showed that IFN
treatment increased HBsAg seroclearance over time in
patients with HBeAg loss. Two meta-analysis studies have
confirmed these long-term benefits of IFN treatment in
reducing liver disease progression to cirrhosis and HCC
[247].
Pegylated interferon alfa alone Pegylation of interferona (Peg-IFN) improves its pharmacokinetic and prolongs its
half-life, which allows weekly injection. Two types of PegIFN have been developed: Peg-IFN a-2a (40 KD) and PegIFN a-2b (12 KD). In an early phase 2 study on Asian
HBeAg-positive patients, the combined sustained viral
response (SVR) (HBeAg loss, HBV DNA suppression, and
ALT normalization) of Peg-IFN a-2a was twice that with
conventional IFN a-2a (24 vs. 12 %; p = 0.036) at
24 weeks post-therapy [248]. A previous study of 24-week
Peg-IFN a-2b in Chinese HBeAg-positive patients also
confirmed a higher HBeAg loss rate than conventional IFN
a-2b [249].
HBeAg-positive chronic hepatitis B Two large phase 3
trials on HBeAg-positive patients showed that 1 year of
Peg-IFN a-2a and Peg-IFN a-2b monotherapy resulted in
HBeAg seroconversion in 32 % and 29 % of patients at
6 months post-therapy, respectively. The virological
response based on HBV DNA suppression was found to be
modest with Peg-IFN. HBV DNA suppression to \400
copies/ml was only obtained in 14 % of patients with PegIFN a-2a and 7 % with Peg-IFN a-2b, respectively.
However, HBsAg seroconversion was achieved in 35 %
of patients at 6 months post-therapy [250, 251]. In an
analysis of the long-term effects of Peg-IFN, 83 % of 150
Asian HBeAg-positive patients treated with Peg-IFN a-2a
for 48 weeks who achieved HBeAg seroconversion at
6 months post-therapy had sustained seroconversion at
12 months. Furthermore, 38 % of the patients who
achieved HBeAg seroconversion at 12 months post-therapy had serum HBV DNA levels \400 copies/ml [252].
Moreover, long-term (mean follow-up of 3 years) sustained
negativity of HBeAg and HBsAg in 172 European HBeAgpositive patients treated with Peg-IFN a-2b was 37 and
11 %, respectively. In particular, sustained negativity of
HBeAg and HBsAg was observed in 81 and 30 % of 64
patients with an initial serological response (HBeAg negativity at 26 weeks post-therapy) [253]. Of note, most of
the patients who cleared HBsAg were infected by HBV
genotype A.

A recent prospective study with mostly Asian patients

compared the treatment response of different doses and
durations of Peg-IFN a-2a in HBeAg-positive patients
[254]. The data showed that 180 lg/week of Peg-IFN a-2a
for 48 weeks was superior to regimens with shorter duration or lower dose. Therefore, the currently recommended
dose and duration of Peg-IFN a-2a therapy is 180 lg/week
for 48 weeks. The recommended dose of Peg-IFN a-2b
therapy is 1.5 lg/kg/week for 48 weeks.
HBeAg-negative chronic hepatitis B With 1 year of PegIFN a-2a therapy, the data revealed that HBV DNA
\4000 IU/ml occurred in 43 % of patients and HBsAg loss
was reported in 4 % at 6 months post-therapy [255]. After
3 years of follow-up, 28 % of HBeAg-negative patients
had HBV DNA \2000 IU/ml, and HBsAg clearance rate
increased to 8.7 % [256]. In addition, the two studies using
Peg-IFN a-2a therapy also found that Peg-IFNbased
therapy was superior to lamivudine alone in inducing
HBeAg seroconversion in HBeAg-positive patients and in
suppressing viral replication in HBeAg-negative patients.
All three studies showed that the therapeutic efficacy was
comparable between Peg-IFN monotherapy and combination therapy of Peg-IFN plus lamivudine. A recent study on
120 Caucasian HBeAg-negative patients with genotype D
infection explored whether longer treatment duration could
lead to a better response, and the results showed that
extending treatment duration to 96 weeks increased
response rate (HBV DNA level \2000 IU/ml at 1 year
post-therapy) from 11.8 to 28.8 % [257].
Chronic hepatitis B with cirrhosis A prior study on 24
HBeAg-positive patients with well-compensated cirrhosis
treated with 52 weeks of Peg-IFN a-2b with or without
lamivudine showed a higher rate of HBeAg serconversion
and HBV DNA \10,000 copies/ml at 26 weeks post-therapy than those without cirrhosis (30 vs. 14 %, p = 0.02)
[258]. In addition, improvement of liver fibrosis was found
more frequently in patients with advanced fibrosis than in
those without (66 vs. 22 %, p \ 0.001). The side effects
were comparable between patients with and without
advanced fibrosis.
Combination therapy of IFN and NAs
With current antiviral agents, most CHB patients fail to
obtain HBsAg seroclearance, which is the ultimate goal of
HBV therapy. Furthermore, relapse is common during post
NA therapy follow-up. Therefore, combination therapy
could be considered the ideal treatment for CHB. There are
three approaches for administering combination therapy:
NA followed by addition of Peg-IFN and continuation of
NA; starting with Peg-IFN followed by addition of NA; or

123

Hepatol Int

simultaneous administration of NA and Peg-IFN. There is

lack of data to recommend one over the other. However,
most investigators have used the first approach and scientifically prefer the basis of viral load reduction followed by
immune modulation as a logical step. The three approaches
have been used with different NAs and Peg-IFN with
improved results compared to monotherapy with either
group of drugs.
Combination of Peg-IFN with lamivudine However, in
both HBeAg-positive and HBeAg-negative subjects,
simultaneous commencement of Peg-IFN and LAM tends
to provide a more profound treatment effect on viral suppression without superior sustained virological off-treatment response, compared with Peg-IFN monotherapy [250,
251, 255].
A study on 36 treatment-naive HBeAg-positive patients
who received LAM 100 mg per day for 4 weeks before
adding Peg-IFN for the following 24 weeks showed that
they achieved higher sustained (6 months after end of
treatment) virological responses compared with the 27
patients who received Peg-IFN from the start (undetectable HBV DNA and HBeAg losses 50 vs. 15 %;
p = 0.028; 39 vs. 15 %; p = 0.05, respectively) [259].
However, another study found no difference in efficacy
between32-week Peg-IFN started simultaneously with
LAM and that started 8 weeks before LAM or 8 weeks
after commencement of LAM, 24 weeks after the end of
therapy. All patients received lamivudine until week 104
[260].
Combination of Peg-IFN with adefovir In a multicenter
prospective study, 160 HBeAg-positive patients were randomized to Peg-IFNa-2a monotherapy or to individualized
combination therapy with Peg-IFNa-2a ? adefovir dipivoxil (ADV) based on the baseline features and treatment
response. At week 96, combined response (ALT normalization and undetectable HBV DNA), HBeAg clearance,
and seroconversion rates were higher in those patients
treated with the combination than in those treated with PegIFNa-2a alone [261]. An Italian multicenter study in 60
HBeAg-negative patients showed a similar sustained
virological response (i.e., HBV DNA \2000 IU/ml
24 weeks) after the EOT among those treated with a
48-week combination of Peg-IFNa-2a ? ADV or PegIFNa-2a alone (23 vs. 20 %, p = 0.75), with only one
patient (3 %) in the combination group achieving HBsAg
loss [262].
Combination of Peg-IFN with telbivudine A study in 159
HBeAg-positive patients reported that a combination of
Peg-IFNa-2a and telbivudine (LdT) led to a higher rate of

123

undetectable HBV viral load and greater reductions in

HBeAg and HBsAg levels than either drug alone [263].
Another study compared the efficacy and safety of two
sequential regimens: Peg-IFN for 24 weeks followed by
LdT for 24 weeks (Peg-IFN first), or vice versa (LdT first),
in 30 HBeAg-negative patients. At the end of follow-up
(week 72), more patients treated with LdT first had HBV
DNA \2000 IU/ml (47 vs. 13 %, p = 0.046). Sequential
treatment with Peg-IFN followed or preceded by 24 weeks
of LdT was safe; only one patient dropped out because of
myalgia [264]. However, presently the combinations of
Peg-IFN with LdT should be avoided, as a high risk of
severe polyneuropathy development was reported in those
treated with the combination therapy, leading to an early
discontinuation of one study [263].
Combination of Peg-IFN with entecavir One recent study
(the OSST study) reported on 100 Chinese HBeAg-positive
patients with maintained virological response on ETV who
switched to a finite course of Peg-IFN a-2a and achieved
significantly higher rates of HBeAg seroconversion and
HBsAg clearance than 100 patients who continued ETV
[265].
Another global randomized trial (the ARES study) was
conducted in European and Chinese HBeAg-positive
patients. In this open-label, multicenter randomized trial,
HBeAg-positive CHB patients with compensated liver
disease started on ETV monotherapy (0.5 mg/day) and
were randomized in a 1:1 ratio to either Peg-IFN add-on
therapy (180 lg/week) from week 24 to 48 (n = 85), or to
continue ETV monotherapy (n = 90). Response was
defined as HBeAg loss with HBV DNA \200 IU/ml at
week 48. Responders discontinued ETV at week 72. All
patients were followed until week 96. Response was
achieved in 16/85 (19 %) patients allocated to the add-on
arm versus 9/90 (10 %) in the monotherapy arm
(p = 0.095). Adjusted for HBV DNA levels prior to randomized therapy, the Peg-IFN add-on was significantly
associated with response (OR 4.8, 95 % CI 1.614.0,
p = 0.004). Eleven (13 %) of add-on treated patients
achieved disease remission after ETV cessation, versus
2/90 (2 %) of patients treated with monotherapy
(p = 0.007), which was 79 % (11/14) versus 25 % (2/8) of
those who discontinued ETV (p = 0.014). At week 96, 22
(26 %) patients assigned add-on versus 12 (13 %) assigned
monotherapy
achieved
HBeAg
seroconversion
(p = 0.036). Peg-IFN add-on led to significantly more
decline in HBsAg, HBeAg and HBV DNA (all p \ 0.001).
Add-on therapy resulted in more viral decline and appeared
to prevent relapse after stopping ETV. Hence Peg-IFN addon therapy may facilitate the discontinuation of nucleos(t)ide analogues [266].

Hepatol Int

Combination of Peg-IFN with tenofovir In one study on

HBeAg-positive CHB, raised ALT (48200 IU/ml)
patients, all patients received tenofovir (300 mg/day for
12 weeks), followed by randomization to tenofovir plus
peg-interferon a2b 1.5 mcg/kg/weekly for 24 weeks (sequential therapy; n = 30) or tenofovir monotherapy
(n = 30). Daily tenofovir was continued thereafter until
HBsAg loss. At 48 weeks, 60 % in the sequential therapy
group and 30 % in tenofovir monotherapy had normal ALT
(p = 0.02). Patients receiving sequential therapy had
higher HBV DNA loss (80 vs. 53 %; p = 0.028), mean
HBV DNA reduction [6.70 1.64 vs. 4.43 2.44 log10
(p \ 0.001)], and HBeAg seroconversion (53.3 vs. 23.3 %;
p = 0.017), compared to the tenofovir monotherapy group.
Two patients on sequential therapy had HBsAg loss by
48 weeks compared with none in tenofovir monotherapy
[267].
In a recent open-label study (Study 149), a total of 740
CHB patients (60 % positive for HBeAg) without
advanced bridging fibrosis or cirrhosis were randomly
assigned to receive tenofovir ? pegylated interferon for
48 weeks, tenofovir ? pegylated interferon for 16 weeks,
continuing on Tenofovir alone through week 48, tenofovir
monotherapy for 120 weeks (continuous monotherapy) or
pegylated interferon monotherapy for 48 weeks. At the
end of treatment, HBsAg levels declined most in the
48-week tenofovir plus pegylated interferon arm (-1.1
log10), followed by interferon monotherapy (-0.8.1
log10), the 16-week tenofovir combination regimen (-0.5
log10) and tenofovir monotherapy (-0.3 log10). At
48 weeks, 7.3 % of patients taking the 48-week tenofovir
plus pegylated interferon regimen showed HBsAg loss.
Response rates were substantially lower in the 16-week
tenofovir combination arm and interferon monotherapy
arm (both 2.8 %). None taking tenofovir alone experienced HBsAg loss. By 72 weeks, the rate of HBsAg loss
rose to 9.0 % in the 48-week tenofovir plus pegylated
interferon group, while remaining the same in the other
three arms. A total of seven patients experienced HBsAg
seroreversion, or reappearance after loss (four in the
48-week combination arm and three in the 16-week
combination arm) [268].
Taken together, simultaneous combination of Peg-IFN
plus tenofovir or sequential combination therapy using
entecavir first followed by Peg-IFN shows promising
results; however, future large studies are needed to confirm
these results.
Peg-IFN add-on treatment in NAs responders
Because it has been observed that during effective NAs
therapy, HBsAg decline is very slow and may require
decades to achieve undetectable levels, an alternative use

of Peg-IFN in chronic HBV-infected patients is to add on

Peg-IFN to NAs responders to accelerate the HBsAg
decline. One study reported HBsAg kinetics in 12 patients
(nine HBeAg-negative) having undetectable HBV DNA
(\116 copies/ml) for more than 6 months on NAs
(LAM = 1,
LAM ? ADV = 2,
ETV = 7,
ETV ? TDF = 2), and who additionally received PegIFN as an individualized therapy. After add-on of
PegIFN, a rapid decline of HBsAg occurred in two
patients, to HBsAg levels of 0.14 and 0.02 IU/ml at week
48, respectively (corresponding to a maximal reduction of
2.9 log10 and 4.25 log10). Three patients discontinued
Peg-IFN early due to side effects, whereas seven patients
withdrew from treatment after a mean of 16 weeks due to
a suboptimal HBsAg response (decline of 0.09 log10
only) [269]. In one randomized controlled trial (PEGON
study) conducted in Europe and China, 82 HBeAg-positive patients with compensated liver disease were treated
for at least 12 months with entecavir (ETV) or tenofovir
(TDF) with subsequent HBV DNA \2000 IU/ml at randomization. Patients were randomized to 48 weeks of
Peg-IFN addition, or 48 weeks of continued NA
monotherapy. Response (HBeAg seroconversion with
HBV DNA \200 IU/ml) was assessed at week 48.
Responders will discontinue treatment after 24 weeks
consolidation treatment (week 72), with subsequent offtreatment follow-up until week 96. Week 48 results were
presented at AASLD 2014. Ninety-six percent of patients
were of Asian ethnicity, with an average age of 33 years.
Response, as well as HBeAg seroconversion alone, was
achieved in 17 % of patients who received Peg-IFN addon compared to 5 % of patients who continued NA
monotherapy (p = 0.15). HBeAg loss was achieved in
33 % of patients who received Peg-IFN add-on compared
to 18 % in the NA monotherapy group (p = 0.14). PegIFN add-on resulted in significantly more HBsAg decline
at week 48 (0.59 vs. 0.29 log IU/ml, p = 0.021). HBsAg
decline [1 log IU/ml was achieved in 19 % of the PegIFN add-on group compared to 0 % in the NA
monotherapy group (p = 0.005). One patient who
received Peg-IFN add-on had clearance of HBsAg at
week 48 [270]. Preliminary results of the multicenter,
randomized controlled phase III trial ANRS-HB06
PEGAN study presented at AASLD 2014 suggested that
addition of a 48-week course of Peg-IFN alfa-2a to oral
anti-HBV therapy in HBeAg-negative CHB patients with
undetectable serum HBV DNA for at least 1 year results
in a low rate of HBsAg clearance (6.6 %), and that low
baseline HBs Ag titers and a history of HBeAg seroconversion, either spontaneously or under HBV therapy,
may increase HBsAg clearance rate [history of HBeAg
seroconversion prior to randomization (23.5 vs. 3.3 %)
(p = 0.0185)] [271].

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Hepatol Int

Baseline and on-treatment predictors of response to PegIFN (Table 6)

Lower serum HBV DNA level and elevated ALT levels In
CHB patients receiving IFN or Peg-IFN treatment, lower
HBV DNA level and higher ALT level are known as
baseline predictors for a better response. For HBeAg-positive patients receiving Peg-IFN-based treatment, a pooled
analysis showed that a lower level of HBV DNA (\9 log10
copies/ml) and an elevated ALT level ([2 times of upper
limit of normal) were associated with a higher sustained
response rate (HBeAg loss and HBV-DNA level
\2000 IU/ml at 6 months post-therapy) [272]. For
HBeAg-negative patients, a lower HBV DNA level and a
higher ALT level were both associated with a higher
treatment response to Peg-IFN-based therapy [256].
HBV genotype In a pooled analysis on two large clinical
trials with HBeAg-positive patients who received
12-month Peg-IFN-based therapy, Buster et al. [272] found
that patients with genotype A infection had the best
response, followed by genotypes B and C, which had
similar responses, while those with genotype D had the
worst response. These results lend support to the recommendation that Peg-IFN therapy is suitable for patients
with genotype A rather than genotype D infection. In
patients with genotype B or C infection, Asian studies
reported that in a shorter 6-month Peg-IFN treatment,
response was better in genotype B infection compared to
genotype C infection [273, 274]. However, the HBeAg
seroconversion rate is similar between genotypes B and C
after 12-month Peg-IFN-based treatment, which is the
current standard of care. When HBsAg clearance is defined
as treatment endpoint in HBeAg-positive patients, subgroup analysis from the clinical trial using Peg-IFN a-2b

showed that genotype A had the highest rate of HBsAg loss

compared to other genotypes [272]. For HBeAg-negative
patients, the data comparing the sustained response among
patients receiving Peg-IFN a-2a lamivudine showed that
there was no difference between genotypes A and D or
genotypes B and C after a long-term follow-up of 3 years
[256].
Taking these lines of evidence together, it is concluded
that with a standard 12-month Peg-IFN treatment, HBeAgpositive patients infected with genotype A have the best
response, followed by genotypes B and C, who have a
similar response, while those infected with genotype D
have the lowest response. For HBeAg-negative patients,
the role of HBV genotype may be minimal.
HBeAg level, precore and basal core promoter mutants A
retrospective analysis on 271 HBeAg-positive patients who
received 48-week Peg-IFN a-2a lamivudine showed that
HBeAg seroconverters have a lower baseline and ontreatment levels of HBeAg [275]. However, thus far, there
is no commercial assay available for measuring HBeAg
concentrations in clinical practice. Two Asian studies
indicated that pre-therapy BCP mutations could increase
HBeAg clearance rate in patients receiving Peg-IFN
treatment [273, 276]. These results highlight that further
studies are needed to confirm the predictive value of
HBeAg-associated factors in HBeAg-positive patients with
Peg-IFN therapy. A recent study quantified the proportion
of precore (PC) and BCP mutants at baseline and during
IFN or Peg-IFN treatment in 203 HBeAg-positive patients,
and found a dose response relationship between the proportion of PC/BCP mutants and HBeAg seroconversion
rate [277]. These data suggested that both PC and BCP
mutants were qualitatively and quantitatively associated
with a higher response rate to IFN or Peg-IFN therapy in

Table 6 Baseline predictors and stopping rules of 48-week pegylated interferon therapy in Asian and Caucasian chronic hepatitis B patients
HBeAg-positive
Asian

HBeAg-negative
Caucasian

Asian

Caucasian

Lower HBV DNA level

Better response

Better response

Not clear

Not clear

Higher ALT level

Better response

Better response

Not clear

Not clear

Genotype

B and C are
comparable

A is better than D

B and C are comparable

Not clear

Precore stop codon (PC) and

basal core promoter (BCP)
mutants

Mutant better
than wild type

Wild type better

than mutant

Not clear

Not clear

IL28b SNP

No predictive
value

Controversial

Not clear

Controversial

Lower level HBeAg

Better response

Better response

Not applied

Not applied

Stopping rule at 12-weeks

No decline of
HBsAg level at
week 12

HBsAg level
[20,000 IU/ml
at week 12

No rule could achieve

95 % of negative
predictive value

Only in genotype D patients: without

HBsAg decline and with \2log HBV
DNA decline

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Hepatol Int

Asian HBeAg-positive patients. However, a European

study with 214 HBeAg-positive patients receiving Peg-IFN
a-2b lamivudine showed that the presence of either PC
or BCP mutants lowered the rate of sustained response
(wild-type vs. presence of mutant: 34 vs. 11 %) [278].
Taken together, PC and BCP mutant may play different
roles in Asians and Caucasians, which may be
attributable to different HBV genotypes.
Quantitative serum HBsAg level Since serum HBsAg
level varies depending on the balance between viral
replication and host immunity, it is hypothesized that
HBsAg may serve as a biomarker to predict treatment
response to Peg-IFN. A French study first reported that a
decline in serum HBsAg level of 0.5 log10 IU/ml at week
12 could differentiate sustained responders from relapser in
HBeAg-negative patients [279]. From then on, several
retrospective studies proposed the role of HBsAg level as a
stopping rule at week 12 of Peg-IFN treatment in both
HBeAg-positive and HBeAg-negative patients. However,
further prospective studies are still required to validate
these findings.
In a study enrolling 202 HBeAg-positive Caucasian
patients with genotype A or D infection [280], only 3 % of
patients without decline of HBsAg level at week 12 could
achieve sustained response [negative predictive value
(NPV) of 97 %]. However, this was not validated well in
another study with 399 HBeAg-positive Asian patients
with genotype B or C infection (NPV of 82 %) [281].
Instead, the Asian study proposed an alternate stopping
rule, HBsAg [20,000 IU/ml at week 12. To investigate
which stopping rule was more universally applicable across
HBV genotypes, data from three large-scale clinical trials
were pooled, and it was concluded that if treatment
response was defined as sustained response, then the
12-week stopping rule can be defined as no decline of
HBsAg level for genotype A and D, but HBsAg level
[20,000 IU/ml for genotype B and C patients; while
HBsAg [20,000 IU/ml at 24 week could be applied to all
patients as the 24 week stopping rule, irrespective of HBV
genotype [282].
Most data regarding HBeAg-negative patients included
genotype D infection. When using HBV DNA level
\2000 IU/ml combined with normal ALT level at
6 months post-therapy as the treatment endpoint, the
stopping rule of no HBsAg decline plus \2 log HBV DNA
decline at week 12 had NPV of 100 % [283]. For patients
with non-genotype D infections, HBsAg decline of 10 %
has been shown to predict treatment response at 1-year
post-therapy (47.2 and 16.4 % for HBsAg decline C10 vs.
\10 %, respectively) [284]. In summary, a stopping rule
for Peg-IFN therapy at week 12 or 24 is clinically useful in
HBeAg-positive patients. For HBeAg-negative patients

with genotype D infection, a week 12 stopping rule is also

clinically applicable. However, for HBeAg-negative
patients with non-genotype D infection, more studies are
warranted.
Quantitative serum anti-HBc level Quantitative serum
anti-HBc level has been reported to reflect host immune
status and hepatitis activity. However, its clinical significance in CHB therapy remains limited. In a retrospective
cohort study consisting of 231 and 560 patients enrolled in
two phase IV, multicenter, randomized, controlled trials
treated with Peg-IFN or NA-based therapy, the role of
quantitative serum anti-HBc level in predicting HBeAg
seroconversion was evaluated. The data showed that at the
end of trials, 99 (42.9 %) and 137 (24.5 %) patients
achieved HBeAg seroconversion in the Peg-IFN and NA
cohorts, respectively. Baseline anti-HBc level of 4.4 log10
IU/ml was the optimal cutoff value to predict HBeAg
seroconversion for both Peg-IFN and NA. Patients with
baseline anti-HBc C4.4 log10 IU/ml and baseline HBV
DNA \9 log10 copies/ml had 65.8 % (50/76) and 37.1 %
(52/140) rates of HBeAg seroconversion in the Peg-IFN
and NA cohorts, respectively. In pooled analysis, other
than treatment strategy, the baseline anti-HBc level was the
best independent predictor for HBeAg seroconversion (OR
2.178; 95 % CI 1.5773.009; p \ 0.001). Therefore,
baseline anti-HBc titer may serve as a useful predictor of
Peg-IFN and NA therapy efficacy in HBeAg-positive CHB
patients, which could be used for optimizing the antiviral
therapy of CHB [285].
Quantitative hepatic HBsAg level In addition to serum
HBsAg level, the relationship between hepatic HBsAg
level and treatment response of IFN-based therapy has
been explored in 45 HBeAg-positive patients, and there
was a positive correlation between baseline serum HBsAg
level and hepatic HBsAg level [286].
Interleukin-28B
genotype Several
interleukin-28B
(IL28B)-associated single nucleotide polymorphisms
(SNPs), including CC genotype of rs12979860 and TT
genotype of rs8099917, are associated with a higher
response rate in Peg-IFN-based treatment for chronic
hepatitis C. Whether the IL-28B SNPs could also predict
Peg-IFN-based treatment response in CHB has been
actively investigated. Nevertheless, the results remain
controversial. The first study enrolled 115 patients receiving 6-month Peg-IFN treatment, and there was no correlation noted between IL28B SNPs and treatment response
[273]. In contrast, a multicenter study, which enrolled 205
HBeAg-positive patients receiving Peg-IFN lamivudine
from 11 European and Asian centers, yielded contradictory
results [287]. In this study, around 65 % of the patients

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were of Asian descendants. They found that the CC

genotype of rs12979860 was highly associated with
HBeAg seroconversion. However, this is the only study
showing a positive correlation in HBeAg-positive patients.
Most of the subsequent studies failed to confirm these
findings [288]. With regard to HBeAg-negative patients,
only one retrospective study has been reported. The authors
included 101 Caucasian patients receiving IFN or Peg-IFN
for 24 months and were followed for a median of 11 years
[289]. They found that the CC genotype of rs12979860 was
associated with higher rates of SVR (HBV DNA level
\2000 IU/ml) and HBsAg clearance. In summary, most
studies involving Asian patients failed to identify IL28B
genotype as a possible predictor for HBV treatment
response. In Caucasian patients, further investigations are
needed.
SNPs near HLA-DP region Two SNPs near HLA-DP
regions rs3077 and rs9277535 were shown to play a role in
spontaneous HBsAg clearance in patients with chronic
HBV infection. Since spontaneous clearance of HBsAg is a
result of host immune activity, which could be enhanced by
Peg-IFN treatment, it seems reasonable to investigate the
association between the HLA-DP SNPs and the treatment
response to Peg-IFN. In fact, it has been shown that rs3077
GG genotype was associated with a better treatment
response in HBeAg-positive patients receiving Peg-IFN
therapy in Asian studies [290]. Although both were retrospective and small-scale studies, these encouraging data
still suggested that the role of HLA-DP SNPs in Peg-IFN
therapy are worthy of further studies.
Side effects of IFN-based therapy
The most frequently reported side effects of IFN-based
therapy are flu-like symptoms, headache, fatigue, myalgia,
alopecia, and local reaction at the injection site. IFN and
Peg-IFN have myelosuppressive effects; however, neutropenia \1000/mm3 and thrombocytopenia \500,000/
mm3 are not common unless patients already have cirrhosis
or low cell counts prior to IFN-based treatment. Neutropenia and thrombocytopenia induced by IFN or Peg-IFN
do not significantly increase the risk of infection and
bleeding, except in patients with cirrhosis or immunosuppression. Although IFN and Peg-IFN have many side
effects, they are well tolerated. Premature discontinuation
due to patients intolerability has been reported in 28 % of
patients treated with Peg-IFN.
Therapy with pegylated interferon: overall conclusions
Currently, monotherapy with a potent NA or Peg-IFN is
recommended as the first-line therapy. However, Peg-IFN

123

is not recommended for patients who have hepatic

decompensation, immunosuppression or medical or psychiatric contraindications. Peg-IFN is more appropriate for
young patients, those who can better tolerate side effects
and those who are reluctant to receive indefinite treatment.
During treatment, Peg-IFN could be stopped at week 12 or
24 if the patients are found to be primary non-responders,
which is defined by the genotype-specific HBsAg stopping
rule. Finally, useful and reliable viral and host factors
predictive of treatment outcomes need further exploration
to guide individualized Peg-IFN therapy in the future.
Monitoring treatment and guidance for stopping
therapy in chronic HBV-infected patients treated
with interferons
The currently recommended dose and duration of Peg-IFN
a-2a therapy for both HBeA-positive and HBeA-negative
CHB is 180 lg/week for 48 weeks. In patients receiving
Peg-IFN therapy, full blood cell counts and serum ALT
levels should be monitored monthly and thyroid function
should be monitored every 3 months. All patients should
be monitored for safety through 12 months of treatment.
In HBeAg-positive patients, HBeAg, anti-HBe antibodies and serum HBV DNA levels should be checked at 6
and 12 months of therapy and at 6 and 12 months posttherapy. Sustained HBeAg seroconversion together with
ALT normalization and serum HBV DNA below 2000 IU/
ml post-therapy is the desired therapeutic endpoint.
HBeAg-positive patients who develop HBeAg seroconversion with Peg-IFN therapy require long-term follow-up
because of the possibility of HBeAg seroreversion or
progression to HBeAg-negative CHB. HBsAg should be
checked at 12-month intervals after HBeAg seroconversion
if HBV DNA is undetectable, as the rate of HBsAg loss
increases over time. Patients who become HBsAg seroclearance should be tested for anti-HBs antibodies. Patients
treated with Peg-IFN who achieve significant decline of
HBV DNA and/or HBsAg levels through 3 or 6 months of
therapy have an increased likelihood of treatment response.
In contrast, HBeAg-positive patients treated with Peg-IFN
who fail to achieve serum HBsAg levels below 20,000 IU/
ml or any decline in serum HBsAg levels by month 3 have
a low likelihood of HBeAg seroconversion [274]. Thus,
cessation of Peg-IFN therapy may be considered.
In HBeAg-negative patients, serum HBV DNA levels
should be checked at 6 and 12 months of therapy and at 6
and 12 months post-therapy. A sustained virological
response with HBV DNA \2000 IU/ml post-therapy is
generally associated with the remission of disease activity.
HBsAg should be checked at 12-month intervals if HBV
DNA remains undetectable during the follow-up. Patients
who become HBsAg seroclearance should be tested for

Hepatol Int

anti-HBs antibodies. HBeAg-negative patients who

achieve sustained response at 12 months post-therapy still
require long-term follow-up because of the risk of future
disease reactivation. HBeAg-negative patients, especially
those with genotype D infection, who fail to achieve any
decline in serum HBsAg levels and a [2 log10 IU/ml
decline in serum HBV DNA levels by month 3 of Peg-IFN
therapy, have a very low likelihood of treatment response
[274, 291, 292]. Thus, cessation of Peg-IFN therapy should
be considered.
3:6:2

3:6:2:7

Recommendations: results of currently available

therapies, predictors of response to therapy, followup and stopping rules during interferon therapy in
chronic HBV infection
3:6:2:1

3:6:2:2

3:6:2:3

3:6:2:4

3:6:2:5

3:6:2:6

Treatment-nave patients can be treated with

Peg-IFN-a2a 180 lg weekly or Peg-IFN-a2b
11.5 lg/kg weekly (A1).
For Peg-IFN, the recommended duration is
48 weeks for both HBeAg-positive and
negative patients (A1).
In patients treated with Peg-IFN, full blood
counts and serum ALT levels should be
monitored monthly and TSH should be
monitored every 3 months. All patients
should be monitored for safety through
12 months of treatment (A1).
In regions endemic for HBV genotype A and
D infection, HBV genotyping should be done
among patients being considered for IFN
therapy (A1).
In HBeAg-positive patients, HBeAg and
anti-HBe antibodies and serum HBV DNA
levels should be checked at 6 and 12 months
of treatment and at 6 and 12 months posttreatment (A1). HBsAg levels should be
checked every 3 months (A1).
For HBeAg-positive patients treated with
Peg-IFN who fail to achieve serum HBsAg
levels below 20,000 IU/ml (genotype B and

3:6:2:8

C infection), or any decline in serum HBsAg

levels (genotype A and D infection) by week
12 and serum HBsAg levels below
20,000 IU/ml by week 24 (genotype AD
infection), stopping Peg-IFN therapy should
be considered (B2).
In HBeAg-negative patients, serum HBV
DNA levels should be measured at 6 and
12 months of treatment and at 6 and
12 months post-treatment (A1). HBsAg
levels should be checked every 3 months
(A1).
For HBeAg-negative patients, especially
those with genotype D infection, who fail
to achieve any decline in serum HBsAg
levels and a [2 log10 IU/ml decline in
serum HBV DNA levels by month 3 of
Peg-IFN therapy, discontinuation of Peg-IFN
therapy should be considered (B2).

3.7 Treatment strategies for first-line therapy in precirrhotic chronic hepatitis B: nucleos(t)ide
analogues or interferons or a combination
The two therapeutic approaches available for the suppression of HBV replication include antiviral agents [nucleos(t)ide analogues, NAs] and immune-based therapies
(IFN-a or pegylated-IFN-a) (Table 7).
The main theoretical advantages of Peg-IFN are the
absence of resistance and the potential for immune-mediated control of HBV infection with an opportunity to obtain
a sustained virological response off-treatment, and a
chance of HBsAg loss in patients who achieve and maintain undetectable HBV DNA, and thus potential of finite
treatment duration. Peg-IFN-induced HBeAg seroconversion might be more durable than NA-induced HBeAg
seroconversion. Frequent side effects and subcutaneous
injection are the main disadvantages of (PEG-) IFN treatment. (PEG-) IFN is contraindicated in patients with

Table 7 Comparison of two treatment strategies for chronic hepatitis B

Pegylated interferon

Nucleos(t)ide analogues

Strategy

Sustained off-therapy response (immune control)

Maintained on-treatment response (viral control)

Goal

Low HBV DNA level (\2000 IU/ml) and normal ALT

level

Undetectable HBV DNA level and normal ALT level

Duration

Finite

Prolonged or indefinite

Effectiveness

Sustained response in *30 % of patients after

48 weeks of therapy

Successful suppression of viral replication with continued

treatment, but high relapse rate after stopping the treatment

Contraindication

Hepatic decompensation, immunosuppression,

pregnancy, psychiatric or medical contraindications

Nil

123

Hepatol Int

decompensated HBV-related cirrhosis or autoimmune disease, in patients with uncontrolled severe depression or
psychosis, and in female patients during pregnancy. Orally
administered NAs are well tolerated, but the rate of viral
relapse is common once the treatment is ceased, which
necessitates long-term or even life-long treatment. Current
data show that long-term ETV or TDF therapy is relatively
safe and has minimal risk of drug resistance. Therefore,
Peg-IFN should be highly considered in young people who
are planning to have babies and patients with a high chance
of achieving sustained off-therapy response, such as
HBeAg-positive patients who have high pre-treatment ALT
levels, genotype A infection or those with more favorable
predictors.
Finite-duration treatment with (PEG-) IFN This strategy
is intended to achieve a sustained off-treatment virological
response. Peg-IFN, if available, has replaced standard IFN
in the treatment of CHB, mostly due to its easier applicability (once weekly administration). A 48-week course of
Peg-IFN is mainly recommended for HBeAg-positive
patients with the best chance of HBeAg seroconversion. It
can also be used for HBeAg-negative patients, as it is
practically the only option that may offer a chance for
sustained off-treatment response after a finite duration of
therapy. Full information about the advantages, adverse
events and inconveniences of Peg-IFN versus NAs
(Table 7) should be provided so the patient can participate
in the decision. Simultaneous combinations of Peg-IFN
with NAs such as entecavir and tenofovir have been shown
to be safe with promising results. Sequential combination
therapies using viral load reduction followed by addition of
Peg-IFN have been found to be safe with improved seroconversion rates compared to monotherapies. These
approaches need to be confirmed in larger studies before
they are recommended.
Finite-duration treatment with a NA This strategy can be
is feasible for HBeAg-positive patients who seroconvert to
anti-HBe on treatment. However, treatment duration is
unpredictable prior to therapy, as it depends on the timing
of HBeAg seroconversion and the treatment continuation
post-HBeAg seroconversion. HBeAg seroconversion may
not be durable after NAs discontinuation, at least with less
potent agents, in a substantial proportion of these patients
requiring close virological monitoring after treatment
cessation.
An attempt for finite NA treatment should use the most
potent agents with the highest barrier to resistance, to
rapidly reduce levels of viremia to undetectable levels and
avoid breakthroughs due to HBV resistance. Once HBeAg
seroconversion occurs during NA administration, treatment
should be prolonged for at least 1 year and preferably an
additional 3 years to try to achieve a durable off-treatment
response. Consolidation therapy of at least 3 years

123

decreases the rate of relapse and increases the rate of

HBsAg loss significantly [243].
Long-term treatment with NA(s) This strategy is necessary for patients who are not expected to or fail to achieve a
sustained off-treatment virological response and require
extended therapy, i.e., for HBeAg-positive patients who do
not develop HBeAg seroconversion and HBeAg-negative
patients. This strategy is also recommended in patients with
cirrhosis, irrespective of HBeAg status or anti-HBe seroconversion on treatment. The most potent drugs with the
optimal resistance profile, i.e., tenofovir or entecavir,
should be used as first-line monotherapies.
There are as yet no data to indicate an advantage of de
novo combination treatment with NAs in NA naive patients
receiving either entecavir or tenofovir.
3:7

Recommendations: treatment strategies for first-line

therapy in pre-cirrhotic CHB: nucleos(t)ide analogues or interferons or a combination
3:7:1

3:7:2

3:7:3

3:7:4

3:7:5

A course of Peg-IFN may be the most

appropriate first-line treatment strategy when
the purpose of treatment is to achieve a
sustained response after a defined treatment
course compared with NAs requiring longterm administration (B2).
A 48-week course of Peg-IFN is mainly
recommended for HBeAg-positive patients
with the best chance of HBeAg seroconversion (B1). It can also be used for HBeAgnegative patients, as it is practically the only
option that may offer a chance for sustained
off-treatment response after a finite duration
of therapy (B2).
Despite the tolerability and the higher rates
of off-therapy response compared to NAs, the
benefits of Peg-IFN are restricted to a
subgroup of patients, especially with raised
ALT and low to moderate levels of serum
HBV DNA. To increase the rates of patients
who may benefit from this treatment while
minimizing the adverse events, a careful
patient selection and individualized treatment
decisions to achieve treatment optimization
are required (A1).
Full information about the advantages,
adverse events and inconveniences of PegIFN versus NAs should be provided, so that the
patient can participate in the decision (A1).
Simultaneous combinations of Peg-IFN with
NAs such as lamivudine, entecavir and
tenofovir have been shown to be safe, but
safety needs to be confirmed in larger studies
before recommendation (B2).

Hepatol Int

3:7:6

3:7:7

3:7:8

3:7:9

3:7:10

Sequential combination therapies using viral

load reduction followed by addition of PegIFN or add-on Peg-IFN after response to NAs
have been found to be safe with improved
seroconversion rates compared to monotherapies (B2). These approaches need to be
confirmed in larger studies.
Finite-duration treatment with a NA is
achievable for HBeAg-positive patients who
seroconvert to anti-HBe on treatment. However, treatment duration is unpredictable prior
to therapy, as it depends on the timing of
HBeAg seroconversion and the treatment
continuation post anti-HBe seroconversion
(A1).
Strategy of long-term treatment with NA(s) is
necessary for patients who are not expected
to or fail to achieve a sustained off-treatment
virological response and require extended
therapy, i.e., for HBeAg-positive patients
who do not develop HBeAg seroconversion
and HBeAg-negative patients (A1).
The most potent drugs with the optimal
resistance profile, i.e., tenofovir or entecavir,
should be used as first-line long-term
monotherapies (A1).
As of yet, there are no data to indicate an
advantage of de novo combination treatment
with two NAs in NA-naive patients receiving
either entecavir or tenofovir (C2).

3.8 Treatment failure to therapy and its

management in chronic HBV infection
The goals of hepatitis B treatment are to eliminate or
permanently suppress viral replication, normalize serum
ALT levels and improve liver histology, thereby reducing
the risk of disease progression in patients chronically
infected with hepatitis B and reducing the long-term risk of
liver-related complications such as HCC, decompensation
and death. In recent years, the treatment of chronic hepatitis has greatly improved with the development of new
therapeutic options. To date, two immunomodulators,
interferon alpha and pegylated interferon, and five
nucleos(t)ide analogues (NA), lamivudine, adefovir, entecavir, telbivudine and tenofovir (not all countries), are
approved therapies for HBV.
The long term efficacy of NAs is determined by the
ability to achieve and maintain viral suppression. Treatment failure may be either primary virological failure or
secondary viral breakthrough. Primary virological failure
may be either primary nonresponse or partial (suboptimal)

virological response. Primary nonresponse is defined as \1

log reduction in plasma HBV DNA levels after 24 weeks
of therapy. In the absence of noncompliance, primary
nonresponse is rare and is now only observed during adefovir therapy due to suboptimal efficacy of this agent. The
appropriate action is to switch to a more potent drug (entecavir in treatment-nave patients, tenofovir in treatmentexperienced patients). Partial virological response is
defined as detectable HBV DNA in plasma after 24 weeks
of therapy. Partial virological response may be encountered
with all available NAs, especially in those patients with
high baseline viraemia. The previous APASL HBV Management Guidelines recommended that treatment be modified (switch or add a second, more potent drug without
cross-resistance) if HBV DNA remained detectable after
24 weeks. However, this Roadmap Approach really only
pertains to patients receiving lamivudine or telbivudine
(drugs with a low genetic barrier to resistance), and should
become obsolete with the shift towards primary therapy
with more potent drugs with a high genetic barrier to
resistance. In patients receiving entecavir or tenofovir
monotherapy with detectable HBV DNA after 24 weeks,
continuation of the same treatment is recommended, given
the steady rise in rates of virological response over time
and the very low risk of resistance with both of these agents
[213].
Viral breakthrough is either due to noncompliance or the
emergence of drug resistance. Because antiviral therapy
with NA does not completely inhibit the replication of the
virus, the emergence of HBV drug resistance is almost
inevitable with long-term monotherapy. Like HIV, the
HBV reverse transcriptase lacks a proofreading function,
which allows for viral mutations to occur spontaneously
during viral replication. This results in a pool of viral
quasi-species that coexist in different proportions depending on their relative replicative fitness. The dominant
species at any one time is the fittest virus, capable of
replicating in the presence of selection pressure provided
by the antiviral therapy. Factors that may impact the risk of
selecting resistant HBV variants during antiviral therapy
include the baseline viral load and diversity, the replicative
fitness of variants and the number of specific mutations that
are required to confer resistance, which is the genetic
barrier of that antiviral agent to resistance.
There are five NAs approved for clinical use, and a sixth
agent, clevudine, which is approved in Korea but development elsewhere, has been halted because of risk of
myopathy. All NAs target the active site of the HBV
reverse transcriptase of the HBV polymerase and have
potent antiviral activity, with between 4 and 6 log IU
reduction in HBV DNA levels over 12 weeks. Single
amino acid substitutions within the reverse transcriptase
domain can significantly reduce NA binding and antiviral

123

Hepatol Int
Fig. 4 Reverse transcriptase
mutations associated with drug
resistance

Terminal
Protein
1

Spacer
183

I(G)

POL/RT

RNaseH

349 (rt1)

II(F)

692 (rt 344) 845 a.a.

F__V__LLAQ_YMDD
B
C

L-Nucleoside Resistance
rtA181T/V rtM204V/I
LMV
L-dT
rtA181T/V
rtM204I
Acyclic Phosphonate Resistance
rtA181T/V
rtN236T
ADV/TFV
D-Cyclopentane Resistance
rtL180M plus rtM204V/I
ETV
rtI169 rtT184
rtS202

Fig. 5 Cumulative incidence of

antiviral resistance in long-term
studies of NA therapy

Year 1

Year 2

Year 3

Year 4

Year 5

rtM250

Year 6 Year 8

72
Weeks
LAM1
23%

46%

55%

71%

80%

0%

3%

11%

18%

29%

5%

25%

29%

35%

TDF4

0%

0%

0%

0%

0%

0%

ETV*5

<1%

<1%

1.2%

1.2%

1.2%

1.2%6

ADV1
LdT2,3

efficacy, whilst preserving replication capacity. The longterm benefit of these agents is lost following the selection
of these resistant mutants, resulting in viral breakthrough
and subsequent treatment failure.
Viral breakthrough due to drug resistance is defined as
an increase in HBV DNA levels (C19 log10 IU/ml) in
patients who initially responded to antiviral therapy and are
compliant with therapy [293]. This will lead to ALT elevations with occasional hepatitis flares and clinical
decompensation. Occasionally, the emergence of drug
resistance may result in acute liver failure and death, even
in patients with minimal liver disease. Antiviral resistance
is also associated with loss of long-term efficacy of
antiviral therapy, with reduced HBeAg seroconversion and
histological progression. Other potential consequences of

123

0%

NA resistance include changes to the overlapping envelope

region, resulting in altered HBsAg antigenicity, possible
surface escape mutants, reduced binding to HBIG and
associated increased risk of HBV recurrence following
liver transplantation.
Primary resistance mutations have been identified for
five out of the six currently approved NAs (Fig. 4).
Although all five currently available NAs target the
same active site of the reverse transcriptase, they exhibit
very different genetic barriers to resistance rates in longterm follow-up studies of each (Fig. 5).
Lamivudine: L-nucleoside analogue The first approved
NA for HBV. Lamivudine has potent antiviral efficacy, but
also has the lowest barrier to resistance. The cumulative
rate of emergence of lamivudine resistance is 1520 %/

Hepatol Int

year, and it plateaus around 60 % after 5 years. Higher

baseline viral load, HBeAg positivity and immunosuppression are all factors associated with increase rate of
resistance, whilst HBV genotype and fibrosis stage are not.
The primary mutations associated with lamivudine resistance are the rtM204I and rtM204V mutations
(rtL180M).
Telbivudine: L-nucleoside analogue Tenfold more
potent than lamivudine. Slower rate of drug emergence
than LAM, around 10 %/year in HBeAg-positive and 5 %/
year in HBeAg-negative patients. In the Globe study, at the
end of 2 years, resistance was observed in 21.6 % of
HBeAg-positive patients and 8.6 % of HBeAg-negative
patients. The primary mutations associated with telbivudine resistance are the rtM204I and rtM204V mutations. Therefore, lamivudine resistance is assumed to
confer cross-resistance with telbivudine.
Adefovir: acyclic nucleoside phosphonate The first
approved NA for the rescue of lamivudine resistance. It is
also effective against telbivudine and entecavir resistance.
Unfortunately, the dose-limiting nephrotoxicity of this
agent has resulted in suboptimal dosing (10 mg) with
reduced antiviral potency compared to other NAs. Around
20 % of patients have primary treatment failure to this
agent. Factors that contribute to primary nonresponse
include the inadequate dose of 10 mg, individual differences in ADV metabolism and prior lamivudine resistance.
In treatment-nave patients who had an adequate primary
virological response, the rate of adefovir resistance is
around 35 % per annum. This is increased to almost 10 %
per annum in patients with prior lamivudine resistance (i.e.,
sequential monotherapy). The primary mutations associated with adefovir resistance are rt N236T rtA181V/T.
The latter also confers cross resistance to lamivudine.
Entecavir: deoxyguanosine analogue 100-fold more
potent than LAM and has a very high genetic barrier to
resistanceonly 1 % over 5 years in treatment-nave
patients. Much higher rates of resistance in LAM-experienced (refractory) patients, around 10 % per annum. This
difference reflects the pathway to resistance for entecavir.
The primary mutations are those associated with lamivudine resistanceL180M ? m204I/V. However, secondary
mutations are needed to confer resistance to entecavir.
These include rtT184G rtS202I rtM250V. It has no
cross resistance to adefovir, so entecavir monotherapy can
be used to treat adefovir resistance.
Tenofovir Acyclic nucleoside phosphonate: 1000-fold
more potent than adefovir and has a very high barrier to
resistance. This is the only approved NA without any
associated clinical resistance. Although reduced susceptibility to tenofovir has been produced in vitro with sitedirected mutagenesis, no primary mutations associated
with tenofovir resistance have been detected in any patient

receiving up to 8 years continuous tenofovir therapy. In

addition, no tenofovir resistance has been observed in
patients with prior lamivudine resistance in studies of
tenofovir salvage therapy. In a large Phase IIb study, 280
patients with documented resistance to lamivudine were
randomized to either tenofovir monotherapy or the fixeddose combination of tenofovir plus emtricitabine (an Lnucleoside analogue similar to lamivudine) for 96 weeks
[198]. Both treatments were safe and well tolerated. The
addition of emtricitabine did not improve efficacyHBV
DNA levels were suppressed below LOQ in 86 % of the
combination group and 89 % of the monotherapy group.
No tenofovir resistance was observed in either treatment
group. Prior exposure or documented resistance to entecavir or adefovir was documented at baseline in 12 % and
22 %, respectively, all of who achieved and maintained
complete viral suppression on tenofovir emtricitabine.
In a second Phase IIb study, 105 patients with documented
resistance to adefovir were randomized to tenofovir
monotherapy or to tenofovir plus emtricitabine for
168 weeks [197]. Again, adding emtricitabine did not
improve efficacy, with HBV DNA levels were suppressed
below LOQ in 84 % of the combination group and 82 % of
the monotherapy group maintaining HBV DNA levels
below LOQ at the end of 168 weeks. The baseline genotypic resistance mutations did not predict responsein
particular, the presence of lamivudine and/or adefovir
resistance-associated mutations at baseline had no impact
on long-term treatment response.
Because all the NAs share the same target (HBV polymerase), cross resistance is a major issue (Table 8), and
therefore the emergence of resistance may limit future
treatment options (Fig. 5). Therefore, the optimal first-line
treatment will be with an NA with high antiviral potency
and a high barrier to resistance. Unfortunately, in many
countries within the Asia-Pacific region, the less expensive
NAs with low barrier to resistance have remained as firstline therapies because of cost and access barriers. As
patients receive and fail sequential monotherapy, multidrug resistant HBV variants are becoming more prevalent,
for which there are very limited salvage options available.
Combining two or more of these older NAs with low
barriers to resistance from different classes may help delay
or prevent the emergence of antiviral resistance to each
drug (e.g., LAM plus ADV) [294]. However, such a
strategy is associated with increased cost and nonadherence.
Summary
The best first-line strategy will always be selection of an
agent with both a high barrier to resistance (requires multiple mutations before emergence of resistance) and high

123

Hepatol Int
Table 8 Cross-resistance profiles amongst the five NAs [332]
Pathway
L-Nucleoside

(LAM/LdT)

HBV variants
Wild-type

LAM
S

LdT
S

ETV
S

ADV
S

TDF
S

M204 l/V

Acyclic phosphonate (ADV)

N236T

Shared (LAM, LdT, ADV)

A181T/V

Double (ADV, TDF)

A181T/V ? N236T

D-Cyclopentane

L181M ? M204V/I I169 T184 S202 M250

A181T ? N236T ? M204V

(ETV)

Multi-drug resistance

Table 9 Strategies to manage treatment failurefirst and second line

LAM/LdT resistance

3:8:2

Switch to TDF
Add ADV

LAM then ETV resistance

Switch to TDF
Add ADV

ADV resistance (no previous LAM)

3:8:3

Switch to ETV
Switch to TDF

ADV resistance (previous LAM/LdT)

Switch to TDF
Switch to LAM/TDF

ETV resistance (no previous LAM/LdT)

Switch to TDF
Add ADV

Multidrug resistance

Switch to ETV/TDF
Switch to Peg-IFN

antiviral potency (achieves complete viral suppression

within the first 6 months). Patient education and monitoring is also important to prevent treatment interruption.
The availability of tenofovir and entecavir as first line
drugs has made the two previous APASL recommendations(1) that combination of NAs without cross-resistance should be used in highest risk patients (those who
have already failed one class, those with highest viral load
and those on immunosuppression), and (2) that the treatment be modified (switch or add a second agent) after
24 weeks, if HBV DNA is still detectable (so-called
Roadmap Approach)invalid.
In patients receiving long-term therapy with lamivudine,
telbivudine and adefovir monotherapy, appropriate virological monitoring should be performed to detect viral
breakthrough and genotypic resistance. Early detection and
modification of antiviral therapy should optimize long-term
outcomes (Table 9).
3:8

Recommendations: treatment failure to therapy and

its management in chronic HBV infection
3:8:1

123

The best strategy for drug resistance is

prevention through patient education on compliance and selection of an agent with high
potency and high barrier to resistance (entecavir and tenofovir) (A1).

3:8:4

3:8:5

3:8:6

3:8:7
3:8:8

Regular monitoring for viral breakthrough

should be performed in patients receiving an
agent with low barrier to resistance (lamivudine, telbivudine and adefovir) (A1).
Patients with viral breakthrough evident by
more than 1 log IU/ml increase of HBV DNA
from the nadir should be counseled about
compliance. In the compliant patient, appropriate testing to confirm genotypic drug resistance should be performed with a validated
test. Rescue therapy should be instituted as
early as possible in case of drug resistance
(A1).
For patients who develop drug resistance while
on LAM or LdT, switching to TDF is indicated
(A1).
For patients who develop drug resistance while
on ADV therapy, without prior lamivudine
exposure, switching to either ETV or TDF
monotherapy is indicated (A1).
For patients who develop drug resistance while
on ADV rescue therapy for prior lamivudine/
telbivudine resistance, switching to TDF
monotherapy is indicated (B1).
For patients who develop drug resistance while
on ETV, switching to TDF is indicated (B1).
For patients who develop drug resistance
associated with multidrug resistant mutations
(A181T ? N236T ? M204V), combination
ETV plus TDF is indicated (C2).

3.9 Treatment of patients with chronic HBV

infection with severe liver disease
3.9.1 Treatment of patients with compensated cirrhosis
Peg-IFN in regimens similar to those used in CHB can be
used for the treatment of well-compensated cirrhosis [258].
Among NAs, monotherapies with tenofovir or entecavir are
preferred because of their potency and minimal risk of
resistance. Close monitoring of HBV DNA levels every

Hepatol Int

3 months during the first year of therapy and until HBV

DNA undetectability is important, as exacerbations of
hepatitis B may occur in patients with cirrhosis requiring
urgent management. Thus, patients with cirrhosis require
long-term therapy, with careful monitoring for resistance
and flares.
Clinical studies indicate that prolonged and adequate
suppression of HBV DNA can stabilize patients and prevent the progression to decompensated liver disease [86].
Regression of fibrosis and even reversal of cirrhosis have
been reported in patients with prolonged suppression of
viral replication [295].
Nonetheless, long-term monitoring for HCC is mandatory despite virological remission under NA(s), since there
is still a risk of developing HCC [296, 297].
NA therapy should usually be continued for life in cirrhotic patients.

closely monitored in this setting. The dose of all NAs needs

to be adjusted in patients with low creatinine clearance
(\50 ml/min).
Patients with decompensated cirrhosis may show slow
clinical improvement over a period of 36 months under
NA(s) and then transplantation may be avoided. In such
cases, life-long treatment is recommended. The HCC risk
is high in these patients even under effective NA therapy,
and therefore long-term HCC surveillance is mandatory
[299]. Some patients with advanced hepatic disease with a
high ChildPugh or MELD score may have progressed
beyond the point of no return, and may not benefit, thus
requiring liver transplantation. In that situation, treatment
with NA(s) inducing HBV DNA undetectability at transplantation will decrease the risk of HBV recurrence in the
graft (see 3.12 Prevention and treatment of recurrent
hepatitis B after liver transplantation section).

3:9:1

3:9:2

Recommendations: treatment of patients with compensated cirrhosis

3:9:1:1

3:9:1:2
3:9:1:3
3:9:1:4

Peg-IFN in regimens similar to those used

in CHB can be used for the treatment of
well-compensated cirrhosis (A1). However,
extra caution and monitoring is recommended to prevent and diagnose hepatic
decompensation (A1).
Among NAs, monotherapies with tenofovir
or entecavir are preferred (A1).
NA therapy should usually be continued for
life in cirrhotic patients (B1).
Monitoring for HCC is mandatory despite
virological remission under NA(s) (A1).

Recommendations (treatment of patients with

decompensated cirrhosis)
3:9:2:1

3:9:2:2

3:9:2:3
3:9:2:4

3.9.2 Treatment of patients with decompensated cirrhosis

Patients with decompensated cirrhosis should be treated in
specialized liver units, as the application of antiviral therapy is complex, and these patients may be candidates for
liver transplantation. Antiviral treatment is indicated irrespective of HBV DNA level, in order to prevent reactivation. Peg-IFN is contraindicated in this setting. Entecavir or
tenofovir should be used. The licensed entecavir dose for
patients with decompensated cirrhosis is 1 mg (instead of
0.5 mg for patients with compensated liver disease) once
daily.
Recent studies have shown that both drugs are not only
effective, but are generally safe in these patients [164,
298].
Lactic acidosis has been reported to develop with some
NAs, particularly entecavir, in treated patients with
advance decompensated cirrhosis (MELD score [20).
Therefore, clinical and laboratory parameters should be

3:9:2:5

3:9:2:6
3:9:2:7

Patients with decompensated cirrhosis

should preferably be treated in specialized
liver units, as the application of antiviral
therapy is complex, and these patients may
be candidates for liver transplantation (A1).
Antiviral treatment is indicated in all
HBsAg positive cirrhotic patients with
hepatic decompensation, irrespective of
HBV DNA levels (A1).
Peg-IFN is contraindicated in decompensated cirrhosis (A1).
Among NAs, monotherapies with tenofovir
or entecavir are preferred (A1). The antiviral treatment should not be delayed while
waiting for the HBVDNA results.
The dose of all NAs needs to be adjusted in
patients with low creatinine clearance
(\50 ml/min) (A1).
NA therapy should usually be continued for
life in decompensated cirrhotic patients (B1).
Monitoring for HCC is mandatory, despite
virological remission under NA(s) (A1).

3.10 Treatment of patients with reactivation

of chronic HBV infection including those developing
acute on chronic liver failure
Upon exposure to HBV, individuals with a vigorous and
broad immune response to the virus develop an acute selflimited infection that may result in acute hepatitis. Individuals who do not mount a broad and vigorous immune
response do not clear the virus, but develop persistent

123

Hepatol Int

infection and become chronically infected with HBV. HBV

persists in the body even after serological recovery from
acute hepatitis B; so individuals who have been exposed to
HBV are at risk for reactivation of hepatitis B replication
when the immune imbalance occurs, which can lead to
flare or exacerbation of hepatitis [300]. The severity of the
flare depends on the state of underlying liver disease and
may range from mild flare of hepatitis to acute on chronic
liver failure. As patients suffering from severe acute
exacerbation of CHB may not have underlying liver cirrhosis, they may recover to a relatively normal liver
function, in contrast to those suffering from end-stage liver
cirrhosis. It is therefore important to recognize this
important clinical presentation of CHB.
Reactivation of chronic HBV infection has two components, i.e., reactivation of HBV replication and flare (or
exacerbation) of hepatitis. Reactivation of HBV replication
should be defined as a marked increase in HBV replication
(C2 log increase from baseline levels or a new appearance
of HBV DNA to a level of C100 IU/ml) in a person with
previously stable or undetectable levels or detection of
HBV DNA with levelss C20,000 IU/ml in a person with no
baseline HBV DNA [22, 300]. The types of reactivation
should be described as follows: exacerbation of CHB or
reactivation of past hepatitis B. The latter can be further
defined as reverse HBsAg seroconversion (reappearance of
HBsAg), or appearance of HBV DNA in serum in the
absence of HBsAg.
This reactivation of HBV replication may lead to flare
(or exacerbation) of hepatitis, which is characterized by an
abrupt elevation of the serum ALT level, although there is
no consensus definition or diagnostic criterion. It usually
refers to an abrupt increase in serum ALT to [5 times the
upper limit of normal and more than twice the baseline
value [23, 301]. Severe hepatitis flare means reactivation
with the presence of coagulopathy with prolonged prothrombin time (prolonged by more than 3 s) or INR
increased to[1.5. Severe hepatitis flare may lead to ACLF.
Flare (or exacerbation) of hepatitis in CHB infected
patients is common and may be caused by a number of
factors (Table 10).

Spontaneous reactivation hepatitis B

Spontaneous reactivation of hepatitis B can occur in both
HBeAg-positive and -negative patients [302, 303]. Spontaneous reactivation of chronic HBV infection can occur in
the immune clearance phase affecting 4050 % of HBeAgpositive patients, and can be prolonged when there is
repeated unsuccessful clearance of HBeAg [304]. Reactivation of chronic HBV infection at the HBeAg-negative
phase is seen in 1530 % of HBeAg-negative patients, and
is occasionally associated with HBeAg seroreversion
[301].
In Far Eastern regions, 2338 % of patients have been
reported to develop jaundice and hepatic decompensation
(acute on chronic liver failure) during biochemical exacerbation of CHB [305, 306]. These exacerbations may be
associated with significant mortality.
Pathogenesis of spontaneous reactivation of hepatitis B
virus infection
Acute hepatitis flare is precipitated by the reactivation of
HBV infection. The reasons for reactivated infection are
unknown, but are likely explained by changes in the
immunological control of viral replication.
Influence of HBV genotypes on reactivation has also
been assessed. There is a possibility that the immunogenicity of the different genotypes is different. Genotype B
HBV may associate with more vigorous immune response
that leads to a higher chance of successful immune clearance, but also a higher risk of hepatic decompensation
during the hepatitis flare. On the contrary, genotype C
HBV is associated with less vigorous and prolonged,
abortive immune clearance, which is more likely to cause
progressive liver damage, and eventually, liver cirrhosis
and HCC [307].
Several HBV mutant strains, including mutations in
precore, core promoter, and deletion mutation in pre-S/S
genes, have been reported. Viral populations in the immune
tolerance phase mostly consist of exclusively wild-type
virus or HBeAg-positive strains with little or no

Table 10 Causes of acute hepatitis flares of hepatitis in chronic hepatitis B virus infected patients
Spontaneous reactivation of hepatitis B virus replication
Due to immunosuppressive medications: cancer chemotherapy, antirejection drugs, corticosteroids
Cessation of anti-viral agents
Emergence of drug resistance
Due to antiviral therapy: interferon, corticosteroid withdrawal
Due to superimposed infections with other hepatotropic viruses: hepatitis A/E virus, hepatitis C virus, hepatitis delta virus
Caused by interaction with HIV infection: reactivated hepatitis, effect of immune reconstitution therapy
Other hepatotropic insults: drugs, alcohol

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Hepatol Int

precore/core promoter mutants or HBeAg-negative strains

[308]. Spontaneous reactivation of CHB may also occur in
response to HBV genotypic variation. Chronic infection
with precore mutant is often associated with multiple flares
interspersed with periods of asymptomatic infection [309].
It is possible that the absence of HBeAg in patients harboring precore mutant HBV may permit a more vigorous
immunological response to core peptides expressed on the
surface of hepatocytes. Episodic flares have been attributed
to increases in the concentration of precore mutants and
changes in the proportion of precore to wild-type HBV
[310]. It has been suggested that disease exacerbations are
uncommon during the earliest phase of chronic HBV at a
time when wild-type HBV predominates, and that flares
become common with the gradual emergence of the precore variant [310]. These flares have been thought to subside with time as the genetic heterogeneity disappears and
patients become exclusively infected with precore HBV
[311]. Multiple exacerbations of hepatitis due to reactivated HBV infection have been described in patients with
BCP mutation, either alone, or in association with precore
mutation [312, 313].
Reactivation seems to occur more commonly in male
homosexuals, patients who are infected with human
immunodeficiency virus (HIV), concurrent with bacterial
infections or surgery, and when there is emotional or
physical stress [314]. Pregnancy and postpartum may also
be a risk factor [315]. Liver injury during these spontaneous flares appears to be mediated by expanded numbers
of T cells that are reactive to HBeAg and HBcAg which
are cross-reactive at the T cell level. Measurement of
lymphocyte proliferation in response to these viral antigens has shown that increased T-cell responses occur in
the early phase of acute flares and subside after recovery
from acute exacerbation and HBeAg seroconversion
[316].
Once acute on chronic liver failure (ACLF) develops,
the immunological changes seen in the inflammatory process are very similar to those of severe sepsis [317]. As the
ACLF progresses, the resulting inflammatory responses in
the liver and its associated cellular immune dysfunction
can result in multi-organ failure.
Diagnosis
The typical presentation of severe spontaneous reactivation
in a patient with CHB is a short onset of jaundice and very
high ALT level, sometimes preceded by prodromal constitutional symptoms. If signs of chronic liver disease are
present, the diagnosis could be easy, however, some
patients presenting with severe acute reactivation of CHB
may not have had an earlier diagnosis of chronic HBV
infection. In countries with intermediate and high

endemicity, the possibility of reactivation of chronic HBV

infection is high, which may be the first presentation of
CHB or compensated cirrhosis, which was asymptomatic
before exacerbation. Hence, a possibility exists that a
proportion of patients with suspected acute hepatitis B
might actually be suffering from CHB and manifesting
clinically for the first time during a period of severe reactivation [23]. In areas of intermediate to high HBV
endemicity, endemic for chronic HBV infection, reactivation (flare or exacerbation) accounts for 2770 % of presumed acute hepatitis [23, 317, 318].
The symptoms and biochemical parameters of severe
acute reactivationof CHB can be very similar to those of
acute hepatitis B [23]. Hence, severe acute reactivation of
CHB might be misdiagnosed as acute hepatitis B in some
cases. Patients with severe spontaneous acute reactivation
of CHB can have positive IgM anti-HBc, which may again
be confused with the diagnosis of acute hepatitis B. Levels
[600 PaulEhrlich units/ml or IgM anti-HBc ([1:1000)
suggest an acute HBV infection with high inflammatory
activity. In all other situations, concentrations are lower or
undetectable [23, 319]. One study suggests that a low titer
of IgM anti-HBc (\1:1000) and high HBV DNA level
([0.5 pg/ml, which equals *141,500 copies/ml) are useful
to identify severe acute reactivation (flare or exacerbation)
of CHB from acute hepatitis B [23]. However, HBV DNA
may sometimes become undetectable at the peak of the
biochemical exacerbation due to vigorous immune clearance. The presence of BCP mutation and precore stop
codon mutations have been suggested to differentiate severe acute exacerbation of CHB from acute hepatitis B in
Japanese series, but its use in clinical practice needs further
validation [319].
A previous history of CHB or a positive family history
of CHB may suggest reactivation (flare or exacerbation);
whereas recent history of at-risk blood, percutaneous or
sexual exposure may suggest acute hepatitis B.
Liver biopsy showing evidence of chronicity may suggest chronic infection.
In uncertain cases of acute hepatitis B versus severe
reactivation of CHB, one can manage these patients as
severe reactivation cases and repeat hepatitis B surface
antigen testing (HBsAg) 6 months later. In over 95 % of
acute hepatitis B acquired in adulthood, HBsAg will be
cleared on the follow-up testing; however, a small percentage of patients with acute reactivation of chronic HVB
infection may also clear HBsAg.
As CHB infected patients still can acquire another viral
infection that causes acute hepatitis, other viral hepatitis
(A, C, D and E) must be excluded by serological assays. If
suspected, other etiologies (Table 1) should also be
excluded before a diagnosis of spontaneous reactivation of
CHB is made.

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Hepatol Int

Outcome
The clinical presentation of acute spontaneous reactivation
of CHB infection depends on the underlying severity of
liver disease and other factors.
In a Chinese study on evaluation of prognostic factors in
severe reactivation (flare or exacerbation) of chronic HBV
infection, at admission the following parameters were
independently associated with adverse outcome: pre-existing cirrhosis, high ChildPugh score, low albumin level,
high bilirubin level, prolonged PT and low platelet count.
For the subsequent stay in the hospital, these factors were
as follows: high peak bilirubin level, long peak PT, long
duration to reach the peak PT, development of
encephalopathy, and presence of ascites. There was also a
trend for a longer time to reach peak bilirubin level to be an
independent factor associated with adverse outcome [320].
In one study from Taiwan on HBeAg-positive noncirrhotic patients with acute exacerbation, 5.1 % of the
exacerbation episodes resulted in hepatic decompensation,
and serum HBV DNA level was the only significant risk
factor (p = 0.003). A serum HBV DNA cutoff value of
1.55 9 109 copies/ml predicted decompensation with a
sensitivity of 85.7 %, a specificity of 85.5 %, a negative
prediction value of 99.1 %, and a positive prediction value
of 24.0 % [321].
Owing to their limited hepatic reserve, cirrhotic patients
are expected to recover more slowly from the hepatic insult
and are more prone to complications including sepsis,
gastrointestinal bleeding and acute renal failure. Many
studies have found that patients with pre-existing liver
cirrhosis and more serious hepatic dysfunction (prolonged
prothrombin time, elevated serum bilirubin and high
ChildPugh score) have a higher risk of mortality [322,
323].
Once the disease reaches the stage of acute on chronic
liver failure (ACLF), the prognosis is extremely poor, with
3-month mortality rates without liver transplantation
reported to be around 5055 % [324]. Different predictive
models have been used in prognosticating acute-on-chronic
liver failure due to reactivation of CHB. MELD is the most
commonly used prediction model. MELD score has been
found in many studies to be more objective when compared
to ChildPugh score in predicting survival in chronic HBV
infection patients with ACLF [325, 326]. It has been found
that a MELD score of[30 is associated with high mortality
([90 % despite using antivirals), a MELD \2023 is
associated with low mortality with use of antivirals
(1617 %) and MELD in between these ranges is associated with intermediate mortality (4451 %) with antiviral
treatment [327, 328].
A number of logistic regression models based on both
laboratory parameters and organ dysfunction have also

123

been described. One regression model, using the presence

of hepatorenal syndrome, liver cirrhosis, positive HBeAg,
low albumin and prolonged PT, was found to be superior to
the MELD score in predicting 3-month mortality [329].
Another model based on the presence of hepatic
encephalopathy, hepatorenal syndrome, positive HBeAg,
liver cirrhosis and prolonged PT was also found to be
superior to both the MELD and ChildPugh score [325]. In
a recent study from China compared a logistic regression
based model (based on presence of hepatic encepahalopathy, hepatorenal syndrome, cirrhosis, HBeAg status,
Prothrombin time and age) with ChildTurcottePugh
(CTP) classification, Kings College Hospital (KCH) criteria, model for end-stage liver disease (MELD), MELD
combined with serum sodium (Na) concentration
(MELDNa), and integrated MELD (iMELD) for predicting
short-term prognosis of patients with HBV-related acuteon-chronic liver failure (ACLF). It was found that the
regression model, MELD, MELDNa and iMELD had
similar accuracy in predicting the short-term prognosis in
patients with liver cirrhosis, while regression model was
superior to MELD, MELDNa and iMELD in predicting the
short-term prognosis of HBV-ACLF patients without liver
cirrhosis. CPT score and KCH criteria fared poorly [330].
Further studies to externally validate these models would
be needed.
Acute Physiology and Chronic Health Evaluation
(APACHE) II and III, Simplified Acute Physiology Score
(SAPS) II, and Mortality Prediction Model II, SOFA and
its modifications have been used to prognosticate critically
ill patients with liver failure [331, 332].
Treatment
Patients need intensive supportive care, including close
monitoring and treatment of complications.
In severe spontaneous reactivation of CHB when
immune activity is already excessive, interferon-based
treatment may aggravate the hepatic decompensation, and
is thus contraindicated. Oral nucleos(t)ide analogs are the
treatment of choice.
In initial case series or cohort studies of Lamivudine in
patients with severe acute exacerbation, some showed
dramatic effects [333], whereas others could not demonstrate any survival benefit of lamivudine treatment [323,
334, 335], possibly related to the delayed commencement
of lamivudine. A study from Taiwan suggests that the
beneficial effect of antiviral therapy on short-term survival
depends on the timing of treatment. Among consecutive
CHB patients with severe acute exacerbation treated with
lamivudine, all 25 patients who had baseline bilirubin
below 20 mg/dl survived. Among patients with low
(\20 mg/dl) baseline serum bilirubin level, lamivudine

Hepatol Int

treatment has definite survival benefit as compared to historic controls who did not receive lamivudine (5/20
patients died, 20 %, p = 0.013). On the other hand, the
mortality rate of the patients who received lamivudine
when bilirubin was above 20 mg/dl (23/35, 67 %) was
similar to that of the untreated historical controls (9/11,
82 %) [336]. A more recent study found a survival benefit
in lamivudine-treated patients when compared to controls
in patients with a MELD score of 30 or less; however,
those treated with lamivudine still had a 3-month mortality
of 50.7 %. A low pre-treatment HBV DNA and a rapid
decline in viral load were predictors of good outcome
[337].
Once ACLF develops, the prognosis of spontaneous
reactivation of HBV infection is poorer as compared to
patients who dont develop features of ACLF. In one metaanalysis of antiviral therapy in ACLF due to spontaneous
reactivation of HBV infection that included 11 randomized
controlled trials (including 654 patients; 340 treated with
NAs such as lamivudine entecavir, telbivudine, or tenofovir disoproxil fumarate, and 314 treated with NAs or
placebo), it was found that nucleoside analogues significantly improved 1-month [OR 2.10; 95 % CI (1.29, 3.41);
p = 0.003], 3-month [OR 2.15; 95 % CI (1.26, 3.65);
p = 0.005] and 12-month survival [OR 4.62; 95 % CI
(1.96, 10.89); p = 0.0005] [338]. Another meta-analysis of
five studies on nucleos(t)ide analogues in ACLF due to
spontaneous reactivation of HBV infection concluded that
antiviral treatment with nucleos(t)ide analogues significantly lowered 3-month mortality [44.8 vs. 73.3 %, RR
0.68, 95 % CI (0.54, 0.84), p \ 0.01] as well as incidence
of reactivation [1.80 vs. 18.4 %, RR 0.11, 95 % CI (0.03,
0.43), p \ 0.01] compared to those who did not. There was
no significant difference in the prognosis of patients treated
with entecavir or lamivudine [36.4 vs. 40.5 %, RR 0.77,
95 % CI (0.45, 1.32), p = 0.35] [339].
Several studies have found that despite a faster suppression of HBV replication, entecavir treatment was either
not associated with improved short-term survival as compared to patients receiving no treatment [340], or had
higher overall mortality as compared to lamivudine treatment [341], or higher mortality when treatment was started
early but with high DNA levels (bilirubin \15 mg/dl and
HBV DNA higher than 105 copies/ml) compared with
lamivudine [342]. Lactic acidosis has been hypothesized as
a possible cause of increased mortality with entecavir
[341]. This finding needs further confirmation. However,
other studies have found comparable efficacy of entecavir
and lamivudine in the short term [329, 343, 344], and long
term [345], or better long-term (52 weeks) survival but not
short-term survival as compared to lamivudine [346]. One
meta analysis found that there was no significant difference
in the prognosis of patients treated with entecavir or

lamivudine [36.4 vs. 40.5 %, RR 0.77, 95 % CI (0.45,

1.32), p = 0.35] [339]. One study has found entecavir to
have similar survival benefit as compared to telbivudine,
although telbivudine had a better renoprotective effect
[347].
One RCT from India found improved 3-month survival
with tenofovir (57 %) in comparison to placebo (15 %)
among patients with acute exacerbation of chronic HBV
infection presenting as acute-on-chronic liver failure. A
more than 2-log reduction in HBV DNA levels at 2 weeks
was found to be an independent predictor of survival [348].
In one study, 69 patients of severe spontaneous reactivation of hepatitis B were randomized to receive either
tenofovir monotherapy or dual therapy of tenofovir plus
telbivudine. Of all patients, 25 patients had ACLF (13
patients received tenofovir and 12 received tenofovir plus
telbivudine). Patients with ACLF receiving tenofovir plus
telbivudine against tenofovir alone had significant
improvement in MELD score at week 4 and week 12 and
improvement in acute kidney injury compared to baseline.
Of the 69 patients enrolled into study, 11 patients died at
the end of the 3-month follow-up period. Among ten deaths
in ACLF, eight had received tenofovir alone (p = 0.02). A
predictor of mortality in univariate analysis in ACLF-B at
2436 weeks of follow-up was presence of septic shock,
tenofovir monotherapy, e antibody positivity and high
baseline MELD score [349].
The definitive treatment for severe reactivation (flare or
exacerbation) with ACLF is liver transplantation. Both
deceased and living donor transplants are viable and very
useful options with very good results [350]. Liver transplantation results from the East in patients with HBV
reactivation have shown successful 5-year survival above
90 % [350, 351].
In a DDLT setting, the availability of the organ becomes
a major concern. In living donor transplant cases, there are
no waiting list constraints, and survival has been shown to
be comparable to DDLT.
Recently, a lot research has been conducted in an
attempt to improve the dreadful outcome in HBV ACLF.
One randomized placebo-controlled trial found that the
administration of granulocyte-colony stimulating factor
improved survival after 2 months [352]. Use of bioartificial
liver support systems is controversial and the results of a
randomized controlled multicenter study in ACLF patients
failed to identify any survival benefit [353]. Corticosteroids, based on their anti-inflammatory activity, have
been used in chronic HBVinfection with ACLF. In a recent
study, 56 patients received intravenous dexamethasone
10 mg daily for 5 days, together with continuous lamivudine. When compared with controls, dexamethasone
treatment was an independent factor influencing survival,
with a rapid decline in serum bilirubin in the first 5 days

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Hepatol Int

being predictive of survival [354]. In a more recent study,

corticosteroid treatment in combination with nucleotide
analogue has sufficient virological effect against severe
acute exacerbation of chronic HBVinfection, and a rapid
decline of HBV DNA is conspicuous in survived patients
[355].
3:10

Recommendations: treatment of patients with reactivation of chronic HBV infection, including those
developing acute on chronic liver failure
3:10:1

3:10:2

3:10:3

3:10:4

3:10:5

3:10:6

3:10:7

Reactivation of HBV replication should be

defined as a marked increase in HBV
replication (C2 log increase from baseline
levels or a new appearance of HBV DNA
to a level of C100 IU/ml) in a person with
previously stable or undetectable levels or
detection of HBV DNA, with levels
C20,000 IU/ml in a person with no baseline HBV DNA (B1).
Flare (or exacerbation) of hepatitis usually
refers to an abrupt increase in serum ALT to
[5 times the upper limit of normal and
more than thrice the baseline value (B1).
Other causes of hepatitis flares, such as
superimposed hepatotropic viruses, toxins or
drugs, should be excluded (Table 10) (A1).
The severity of such reactivation depends
on the severity of underlying liver disease,
and once ACLF develops, the prognosis is
very poor (A1).
Nucleos(t)ide analogs should be started
immediately without delay or waiting for
the HBV DNA results (A1).
Liver transplantation should be considered
among patients with severe liver failure
(e.g., MELD [30) (B1).
Assessment of reduction of HBV DNA
level at week 2 after nucleos(t)ide analogs
should be done; if there is a \2 log
reduction, it suggests poor prognosis and
the patient should be considered for liver
transplantation (B1).

3.11 HCC screening in chronic HBV infection

HCC screening and surveillance in patients with HBV
infection have been covered in detail in APASL consensus
recommendations on HCC [356].
More than 50 % of HCC cases worldwide and 7080 %
of those in HBV-endemic regions are attributable to
chronic HBV infection [357]. The relative risk of HCC in
chronic HBV-infected subjects was about 100223 times

123

that of normal population [358]. As a result, surveillance

for HCC has been widely applied in patients with chronic
HBV infection.
An important issue related to the surveillance program is
cost-effectiveness. In many Western countries, interventions that can be achieved at a cost of\$50,000/year of life
gained are considered cost-effective [359]. Obviously, this
threshold cost is not applicable in most Asian countries,
and should be determined depending on the economic situation of each country. As a matter of course, the efficacy
of surveillance unambiguously depends on the incidence of
HCC in the target population.
Who should be screened?
In determining the target population for surveillance, two
points should be taken into consideration: the incidence of
HCC, and the degree of benefit from a treatment in terms of
patients survival. According to several cost-effectiveness
models, surveillance becomes cost-effective when the risk
of HCC is 1.5 %/year or greater in patients with cirrhosis
[359, 360]. However, surveillance with USG and AFP
becomes cost-effective once the incidence of HCC exceeds
0.2 %/year in hepatitis B infected subjects without cirrhosis [361].
All patients with HBV-related cirrhosis should be
screened for HCC. However, the benefit of surveillance
seems to be absent or minimal in ChildPugh class C
patients. Trevisani et al. [362] reported that a surveillance
program could prolong the patients survival in ChildPugh
class B patients. However, in ChildPugh class C patients,
although cancer stage and treatment distribution were
better in those under a surveillance program than those
without it, there was no difference in overall survival (7.1
vs. 6.0 months). The anticipated survival benefit from early
detection of HCC was offset by a high incidence of liverfailure-related mortality.
Defining the population who should be screened among
chronic HBV-infected subjects without cirrhosis is somewhat complicated. As mentioned above, surveillance
becomes cost-effective in chronic HBV-infected subjects
without cirrhosis, if the cutoff cost-benefit is $50,000/year
of life gained and the incidence of HCC exceeds 0.2 %/
year. However, each Asian country differs greatly in the
economic situation, and therefore the result of cost-effectiveness analysis performed in a specific country is not
applicable to other countries. Since the cost-effectiveness
greatly depends on the incidence of HCC, the threshold
incidence of HCC for surveillance should be determined
individually in each country.
Outcome calculators for predicting HCC Until now,
several prediction scores have been developed and

Hepatol Int

validated to calculate the risk of HCC in patients with

chronic HBV infection in the community and clinic
settings.
3:11:3
Liver stiffness as predictor of HCC development Liver
stiffness, measured by transient elastography, has been
used to assess the degree of liver fibrosis and it correlates
well with liver fibrosis stage. Jung et al. [363] reported that
the incidence rates of HCC are significantly associated with
the degree of elevated liver stiffness measurement (LSM).
The discordance rate in the diagnosis of cirrhosis between
clinical criteria and LSM was 13.4 %, and the incidence of
HCC was higher in patients without clinical cirrhosis who
showed LSM [13 kPa than in those with clinical cirrhosis
who showed LSM B13 kPa. These results strongly suggested that LSM can be a complement or alternative to the
clinical diagnosis of cirrhosis in developing models for the
prediction of HCC. However, LSM per se was not useful in
determining the subgroup of patients for surveillance in
this study population. The observed incidence of HCC was
0.54 %/person-year even in patients with the lowest LSM
value (\8 kPa), which is much higher than the threshold
incidence (0.2 %/year) for surveillance in noncirrhotic
chronic HBV-infected subjects. Recently, Wong et al.
[364] modified their CUHCC score with LSM (LSM
HCC score), and the AUROCs of LSMHCC score were
higher than those of CUHCC score (0.830.89 vs.
0.750.81). By applying the cutoff value of 11, the score
excluded future HCC with high negative predictive value
(99.4100 %) at 5 years.
Modalities and frequency for screening
USG, AFP, des-c-carboxyprothrombin (DCP, prothrombin
induced by vitamin K absence-II), Lens culinaris agglutinin-reactive fraction of AFP (AFP-L3), or their combinations have long been used as surveillance tests for HCC
in Asian countries. Detailed review on the diagnostic performance of each test as a surveillance test is beyond the
scope of this guideline for the management of CHB. They
were well summarized in APASL consensus recommendations on HCC [356].
The APASL consensus recommendations on HCC recommended USG and AFP every 6 months as surveillance
tests for HCC [356].
3:11

Recommendations: HCC screening in chronic HBV

infection
3:11:1

3:11:2

Surveillance for HCC is recommended in

high-risk populations with chronic HBV
infection (B2).
Current HCC risk prediction scores can
accurately stratify the risk of HCC in

3:11:4
3:11:5

3:11:6

3:11:7

patients with chronic HBV infection and

be used to determine the target population
for surveillance (B1).
The threshold incidence of HCC for
surveillance should be determined individually based on the economic situation of
each country (B1).
Surveillance for HCC should be performed
by USG and AFP (B2).
Surveillance by USG and AFP should be
performed every 6 months (B2), and
preferably every 3 months in cirrhotics
and those at high risk of HCC (C2).
Contrast enhanced CT and MRI should be
used regularly for confirmation of suspicious
lesions on US screening (A1). Their use is
also recommended in the screening of
patients with advanced cirrhosis with high
suspicion of development of HCC (C2).
A baseline CECT or CEMRI should be
obtained in all cirrhotics at presentation (B1).

3.12 Prevention and treatment of recurrent hepatitis

B after liver transplantation
Antiviral therapy using newer nucleos(t)ide analogues with
lower resistance rates such as entecavir or tenofovir could
suppress HBV replication, improve liver function, and
delay or obviate the need for liver transplantation in some
patients. Antiviral therapy before LT may prevent HBV
recurrence after LT by reducing the level of viremia to
extremely low levels. After LT, the primary goal of
antiviral therapy is to prevent HBV recurrence and to
prevent graft loss.
Diagnosis, mechanisms, and risk factors for HBV
recurrence after LTRecurrence of HBV infection after LT is defined as the
reappearance of circulating hepatitis B surface antigen
(HBsAg) with or without detectable HBV DNA. However,
only patients who develop persistently detectable HBV
DNA are shown to be at risk for clinical disease and graft
loss [365]. HBV reinfection is the consequence of an
immediate reinfection of the graft by circulating HBV
particles, or a later reinfection from HBV particles coming
from extrahepatic sites such as peripheral blood mononuclear cells, or both.
There is a direct relationship between HBV viral load at
transplantation (i.e., [105 copies/ml) and the rate of HBV
recurrence [366]. Thus, antivirals should be used before
transplantation to achieve undetectable HBV DNA levels

123

Hepatol Int

to reduce the risk of HBV recurrence. Other factors associated with low rates of recurrence include surrogate
markers for low levels of viral replication (including
HBeAg-negative status, fulminant HBV, and HDV coinfection). In addition, HCC at LT, HCC recurrence, or
chemotherapy used for HCC are independently associated
with an increased risk of HBV recurrence [367].
Prevention of HBV recurrence after LTPrior to the availability of effective HBV prophylaxis in the
1980s, LT for CHB was a relative contraindication. High
rates of graft reinfection leading to severe flares and loss of
graft occurred in the absence of antiviral therapy. The use
of hepatitis B immune globulin (HBIG) after LT was the
first major milestone in the prevention of post-transplant
HBV recurrence. HBIG monotherapy reduced HBV
recurrence by a rate of approximately 70 % [368]. The
advent of antiviral therapy further changed the landscape of
post-LT prophylaxis. Several meta-analyses have shown
that combination prophylaxis was significantly superior to
antivirals or HBIG alone in preventing HBV recurrence
[369371].
HBIG containing prophylaxis regimens In conventional
protocols, HBIG is used at high dose to neutralize HBsAg
during the anhepatic phase and the first postoperative week
(i.e., generally 10,000 IU/day) . In the early post transplant
period, some studies reported that high IV HBIG dosage
(C10,000 IU/day)
versus
low
HBIG
dosage
(\10,000 IU/day) was associated with a lower frequency
of HBV recurrence [368]. In medium-term and long-term
follow-up, IV HBIG has been administered in two different
ways: at a frequency dictated by the maintenance of
specific anti-HBs levels, or on a fixed schedule. The latter
approach is simpler and requires less monitoring, but is
more expensive [372]. The target levels for anti-HBs titers
vary with time after LT: generally, anti-HBs levels are
maintained at [500 IU/l during 13 months, [250 IU/l
until 612 months, and at [100 IU/l thereafter.
The use of IV HBIG has limitations; namely, the high
cost, parenteral administration, limited supply, need for
frequent clinic visits and laboratory monitoring, lower
effectiveness in patients with high levels of HBV replication before LT, and the potential selection of HBsAg
escape mutants. Alternative approaches have been studied,
which include the use of low-dose intramuscular (IM)
HBIG, subcutaneous HBIG, withdrawal of HBIG after a
finite period or prophylaxis regimens without HBIG. The
ability to achieve undetectable HBV DNA before LT in the
majority of patients using potent antivirals allows the use
of prophylaxis regimens that minimize the dose or duration
of HBIG. However, a more cautious approach to a

123

prophylaxis regimen is necessary for those patients with a

high risk of HBV recurrence: high pretransplant HBV
DNA levels, those with limited antiviral options if HBV
recurrence occurs (i.e., HIV or HDV coinfection, preexisting antiviral drug resistance), those with a high risk of
HCC recurrence, and those with a risk of noncompliance to
antiviral therapy [373].
Combination prophylaxis with low-dose IM HBIG
(400800 IU IM) plus lamivudine decreases costs by more
than 90 % compared to an IV regimen, with a recurrence
rate as low as 4 % at 4 years [374]. Subcutaneous regimens
of HBIG administered 6 months after LT have also been
shown to be effectivel, with some advantage in tolerability
and the possibility of self-administration by patients at
home [375]. In one study on 183 patients receiving combination prophylaxis with antiviral therapy (mostly LAM
monotherapy) plus HBIG given either IV high-dose
(10,000 IU monthly), IV low-dose (30006000 IU
monthly), IM low-dose (10001500 IU every 12 months),
or for a finite duration (median duration 12 months).
Cumulative rates of HBV recurrence at 1, 3, and 5 years
were 3, 7, and 9 %, respectively. Multivariate analysis
showed that positivity for HBeAg and high viral load at
transplant, but not the post transplant HBIG regimen, were
associated with HBV recurrence [376]. Also, the combination of HBIG and a newer nucleos(t)ide analogue
(tenofovir or entecavir) was shown to be superior to the
combination of HBIG and LAM in reducing the risk of
HBV recurrence in one systematic review (1 vs. 6.1 %,
p = 0.0004) [371].
Indefinite combination therapy with HBIG plus a
nucleos(t)ide analogue may not be required in all liver
transplant recipients. Strategy of HBIG withdrawal after a
defined period of combination prophylaxis has been studied. In a study of 29 patients, high-dose HBIG and LAM
were used in the first month, after which the patients were
randomized to receive either LAM monotherapy or LAM
plus IMHBIG at 2000 IU monthly [377]. None of the
patients developed HBV recurrence during the first
18 months, but later recurrences developed in four patients
after 5 years of follow-up, which was related to poor LAM
compliance [378]. An alternative approach is to switch
after HBIG withdrawal to a combination of LAM/ADV
[379] or a combination of emtricitabine/TDV [380] or
entecavir [381].
HBIG-free prophylactic regimens LAM, when used as a
prophylactic monotherapy (started before transplantation
and continued after transplantation without HBIG), showed
a 10 % recurrence rate at 1 year, but 2241 % at 3 years
after LT, due to the emergence of escape mutations in the
YMDD motif of the polymerase gene [382]. Recurrence
was observed mainly in patients with a high level of HBV

Hepatol Int

replication prior to drug exposure [382]. In a study on 61

LAM-resistant patients treated with ADV on the wait-list
who underwent LT (40 % of these patients received ADV
plus/minus LAM prophylaxis without HBIG), no patient
had recurrent HBV infection [383]. In another study on use
of a combination prophylaxis using LAM and ADV without BIG in 18 patients who had HBV DNA below 3 log
10 IU/ml before LT, no cases of HBV recurrence were
observed after a median follow-up of 22 months [384].
The availability of more potent antivirals with a higher
barrier to resistance could increase the proportion of
patients with undetectable HBV DNA before transplantation and decrease the risk of recurrent disease after transplantation. In a study investigating the efficacy of ETV as
monoprophylaxis in 80 patients, there were no episodes of
HBV flares or graft loss secondary to recurrent HBV
infection. A total of 18 patients (22.5 %) had persistent
HBsAg positivity after transplant without seroclearance
(n = 8) or reappearance of HBsAg after initial seroclearance (n = 10). One of these patients had a very low HBV
DNA level. The pre-LT HBsAg level was significantly
higher in those who had HBV recurrence/persistence
compared with those who did not [223]. A recent large
long-term cohort study of 362 CHB post-LT patients
receiving only NAs without HBIG showed that at year 8
after LT, 98 % had undetectable HBV DNA. Moreover, the
survival was excellent at 83 % at 8 years, with no mortality
related to HBV recurrence [385]. This clearly shows that
HBIG-free regimen is safe and effective, and many studies
have also demonstrated the efficacy of this therapeutic
approach [386, 387].
However, HBIG remains part of the antiviral prophylaxis in many transplant centers. The use of HBIG is likely
to result in a higher rate of HBsAg negativity due to the
fact that the passive anti-HBs antibodies will bind with
HBsAg, leading to a further reduction in detection rate
when compared with HBIG-free protocols. HBV DNA
persists in serum, liver, or peripheral blood mononuclear
cells even 10 years after LT in a proportion of HBV
transplanted patients who are HBsAg-negative. These
reservoirs may serve as a source of HBV reinfection in the
future, supporting the use of long-term prophylactic therapy in most patients [388, 389]. Therefore, life-long
antiviral therapy is currently the standard of care after LT
for CHB. In the early post transplant period, some studies
reported that a high IV HBIG dosage (C10,000 IU/day)
versus a low HBIG dosage (\10,000 IU/day) was associated with a lower frequency of HBV recurrence [369].
Patients with undetectable HBV DNA levels at the time of
transplant can be considered for HBIG free regimens by
using high potency NAs [tenofovir or entecavir]. However,
HBIG free prophylaxis should not be used for those
patients with high pretransplant HBV DNA levels, those

with limited antiviral options if HBV recurrence occurs

(i.e., HIV or HDV coinfection, pre-existing drug resistance,
or intolerance), those with a HCC at LT, and those with a
risk of noncompliance to antiviral therapy [373]. Among
them, HBIG withdrawal may be considered if high potency
NAs are used. The timing of HBIG withdrawal is still
controversial; however, 1-year post-transplantation seems
to be safe and feasible [379, 390]. A recent study from
India included 176 patients (at least [12 months followup) with HBV cirrhosis/HCC who received secondary
prophylaxis with indefinite entecavir/tenofovir after livingdonor LT. All patients received 10,000 IU intravenous
HBIG in anhepatic phase followed by 6001000 IU intramuscularly daily for 7 days, weekly for 3 weeks, and then
monthly, to keep antiHBs levels [100 mIU/ml for 1 year.
Thirty-five patients (19.8 %) had HBV DNA [2000 IU/ml
before LT. After LT, patients received entecavir (n = 126,
71.5 %), tenofovir (n = 20, 11.3 %), or a combination of
entecavir and tenofovir (n = 30, 17 % for 3 months, followed by entecavir alone). During follow-up of 43
(12117) months, two patients (including one with noncompliance) had HBV recurrence [391].
3:12

Recommendations: prevention and treatment of

recurrent hepatitis B after liver transplantation
3:12:1

3:12:2
3:12:3

Antivirals (tenofovir or entecavir) should

be used before transplantation to achieve
undetectable HBV DNA levels to reduce
the risk of HBV recurrence (A1).
A lifelong prophylactic therapy is needed
(A1).
Among low risk patients (i.e., with undetectable HBV DNA levels at the time of
transplant), HBIg free regimens can be used.
High potency NAs (entecavir or tenofovir)
should be used for life (B1) (Fig. 6).

Assess risk status

Low-risk paents
-Undetectable HBV DNA levels at LT

High-risk paents
- Detectable HBV DNA levels at LT
- Presence of drug-resistant HBV
- HIV /HDV coinfecon
- HCC at LT
- Poor compliance to anviral therapy

No HBIg

10,000 IU IV HBIG in an-hepac phase

followed by 600-1000 IU
intramuscularly/ IV daily for 7 days,
weekly for 3 weeks, and then monthly,
to keep an-HBs levels >100 mIU/mL
for 1 year

High potency NAs[ Tenofovir or

Entecavir]

High potency NAs [Tenofovir or

Entecavir]

Fig. 6 Prophylaxis for prevention of HBV graft recurrence following

LT

123

Hepatol Int

3:12:4

Among high-risk patients (detectable HBV

DNA levels at LT, presence of drugresistant HBV, HIV or HDV coinfection,
HCC at LT or poor compliance to antiviral
therapy) 10,000 IU IV HBIG in anhepatic
phase should be given, followed by
6001000 IU intramuscularly/IV daily for
7 days, then weekly for 3 weeks, and then
monthly, to keep antiHBs levels[100 mIU/
ml for 1 year. After 1 year, HBIg may be
discontinued. High potency NAs (entecavir
or tenofovir) should be continued
simultaneously.

3.13 Treatment of chronic HBV infection in special

patient groups
3.13.1 Coinfection with HBV and HIV
Approximately 1525 % of the HIV infected population in
Asia and Africa has concurrent chronic HBV infection,
with coinfection more common in areas of high prevalence
for both viruses [392] and rates approaching 25 % in
countries where the viruses are highly endemic [393]. In
areas where HBV is less endemic (North America, Europe,
and Australia), the overall prevalence of chronic HBV
infection among HIV-infected persons is estimated to be
614 % [394396].
A persistent state of immune activation in patients with
chronic HBV infection could upregulate HIV replication.
Early prospective cohort studies of HIV/HBV-coinfected
patients revealed a 3.6-fold6.8-fold relative risk of progression to AIDS compared to those without coinfection
[397, 398]. However, other reports failed to confirm these
results [399]. This discrepancy was likely related to the
duration of HIV infection. To minimize the influence of
duration of HIV infection, a prospective observational
cohort of adult patients with primary HIV infection (seroconversion window B6 months) has shown that HBV
coinfection (adjusted hazards ratio 3.46; 95 % CI
1.1610.32) was an independent predictor of immunological progression that was defined as the occurrence of a
CD4 cell count \350 cells/ll 3 months or more after
diagnosis of primary HIV infection [400]. In another study
examining the interactions of HBV and HIV using the
composite endpoint of AIDS defining illnesses and death
among HIV-infected individuals who had a seroconversion
window of B3 years in a large cohort, it was found that the
hazards ratio for an AIDS or death event was almost double
(adjusted hazards ratio 1.80; 95 % CI 1.202.69) for those
with HBV coinfection [401]. In the Swiss HIV Cohort
Study, patients who tested positive for HBsAg had

123

significantly impaired CD4 recovery during the first

3 years of HAART, despite similar virological effectiveness of antiretroviral therapy compared to patients without
HBV infection [504 cells/ll (95 % CI 496511) vs. 449
cells/ll (95 % CI 428469)] [402].
Compared to HIV-uninfected subjects, patients with
HIV infection have a higher risk of chronicity after acute
HBV infection [403]. Clinical observational studies have
demonstrated that HIV/HBV-coinfected patients may have
faster progression of hepatic fibrosis and a higher risk of
cirrhosis, end-stage liver disease, and HCC than HBVmonoinfected patients [395, 404]. Similarly, compared
with HIV-monoinfected patients, those with HIV/HBV
coinfection, especially HBV genotype B, had a higher risk
of acute hepatitis, hepatic decompensation, and liver-related mortality [405]. Superinfection or coinfection with
hepatitis D virus may further exacerbate the complications
in patients with HIV/HBV coinfection [406].
Treatment of HIV may lead to flares of hepatitis B due
to immune reconstitution, but the risk of developing cirrhosis is negligible in HBV/HIV coinfected patients on
long-term tenofovir combined with emtricitabine or lamivudine therapy [407].
Given the faster progression of liver disease in HIV
HBV coinfected patients, there is a strong rationale for
early dual anti-HIV and anti-HBV therapy, irrespective of
immunological, virological or histological considerations
[408]. Most coinfected patients should be simultaneously
treated for both HIV and HBV de novo [409]. Lamivudine
(LAM), emtricitabine (FTC) and and tenofovir (TDF) have
both anti-HBV and anti-HIV activities. For most patients,
the best option is triple combination of antiretrovirals,
including two reverse transcriptase inhibitors with antiHBV activity. Tenofovir combined with emtricitabine or
lamivudine plus a third agent active against HIV are indicated [409, 410] (Fig. 7).
Other NAs, such as adefovir (ADV) or telbivudine
(LdT) therapy, do not fit in the HIV setting due to the lack
of or residual activity of these molecules against HIV and
their relatively weak activity against HBV. Treatment with
entecavir (ETV) may be needed in case TDF cannot be
used, mostly due to kidney toxicity. Because ETV displays
weak activity against HIV and may select for resistance
mutations, it should be administered only in the context of
a fully suppressive HIV treatment [411].
Lamivudine, entecavir and tenofovir have activity
against both HIV and HBV, and are contraindicated as
single agents for hepatitis B in coinfected patients because
of the risk of HIV resistance. Thus, all HBsAg-positive
patients should be screened for HIV before these drugs are
used in the treatment of HBV infection.
Among patients with CD4 count [500/ml who are
unwilling to start HAART, HBV can be treated before the

Hepatol Int
Fig. 7 Treatment of CHB
infection in HIV infected
individuals

HIV/HBV Co-infecon

Among paents with CD4 count

>500/ml unwilling to start
HAART, HBV can be treated
before the instuon of anHIV therapy; PEGIFN,*
Adefovir# and Telbivudine#,
which are not proven to be
acve against HIV, should be
used.

Consider early dual an-HIV and an-HBV

therapy, irrespecve of immunological,
virological or histological consideraons

Lamivudine naive

HAART including
Tenofovir plus
Lamivudine or
Emtricitabine

Lamivudine
experienced
Add or Substute
one NRTI with Tenofovir
as part of HAART

* Peg-IFN may be used if genotype A, low HBV-DNA and high ALT

# However, if Adefovir or Telbivudine use does not lead to the goal of undetectable HBV DNA aer 12 months of
therapy, treatment of HIV infecon should be considered.

institution of anti-HIV therapy; PegIFN, adefovir and telbivudine, which are not proven to be active against HIV,
should be preferred [409]. Peginterferon (Peg-IFN) alpha
could be considered as therapy for CHB in coinfected
patients in very specific situations, such as in patients
unwilling to start HAART who have normal CD4 counts
[500, HBeAg(?), low HBV-DNA, elevated ALT, and
lack of decompensated cirrhosis. However, if any of these
two NAs (adefovir and telbivudine) with a low barrier to
resistance do not reach the goal of undetectable HBV DNA
after 12 months of therapy, treatment of HIV infection
should be envisaged.
Oral anti-HBV drugs may select changes at the HBV
polymerase, leading to loss of susceptibility to the corresponding drug and cross-resistance to other antivirals.
Changes in M204 I or V are usually responsible for LAM,
FTC, and LdT resistance, whereas more changes (L180M
plus M204V plus T250) are usually needed for ETV
resistance. Accordingly, cross-resistance is almost universal with LAM, FTC, LdT, and to a lesser extent, with ETV.
There is some cross-resistance to ADV in the presence of
A181S plus M204 I mutations in patients who have failed
LAM therapy. No mutations have been uniformly associated with significant loss of susceptibility to TDF in vivo,
although anecdotal reports have pointed out that A194T in
the context of LAM resistance mutations might account for
TDF resistance in HBV [412].
Resistance to LAM in HBV is more common and
develops more quickly in HIV-HBV coinfected patients
[413]. Selection of LAM resistance in CHB is associated
with poor outcomes, including the occurrence of liver
enzyme flares, which occasionally may be life-threatening, and preclude the success of rescue antiviral

interventions due to cross-resistance with other antivirals.

Additionally, because of overlapping polymerase and
envelope genes in the HBV genome, LAM resistance
mutations may result in changes in the HBsAg, causing
diminished HBs antigenantibody binding. This may
translate into failure in diagnostic tests, vaccine escape, or
both [414]. Transmission of drug-resistant HBV strains
has also been reported [415].
HIV-infected adults without protective HBsAb titers
should be vaccinated. The response rate and durability of
the vaccine are poorer in HIV infected persons compared
with HIV-negative persons, and they are influenced by
both CD4 counts and plasma HIV-RNA levels [416,
417]. Accordingly, in patients with low CD4 counts
(\200 cells/ml) and uncontrolled HIV replication, the
success of HBV immunization is low. In these individuals, previous antiretroviral therapy for at least 6 months
may increase HBV vaccine response rates. An initial
conventional HBV vaccination schedule should be used;
in the case of lack of achievement of protective anti-HBs
titers ([10 mIU/ml) revaccination using double-dose and/
or 34 injections (months 0, 1, 6, and 12) is recommended [418]. Some protection from HBV vaccine may
be expected even in the case of anti-HBs titers dropping
to \10 mIU/ml.
3:13:1

Recommendations: coinfection with HBV and HIV

3:13:1:1

In HIV/HBV-coinfected patients, HBV

coinfection accelerates immunological
and clinical progression of HIV infection
and increases the risk of hepatotoxicity
when combination antiretroviral therapy
is initiated, while HIV infection increases

123

Hepatol Int
Fig. 8 Treatment of HBV
HCV coinfected patients

HBsAg-posive
&
An-HCV-posive

Acve HCV /
Inacve HBV
Treat HCV: P+R
Observe HBV
reacvaon

P: Peg-IFN
R: ribavirin
NUC: nucleos(t)ide analogue

3:13:1:2

3:13:1:3

3:13:1:4
3:13:1:5

3:13:1:6
3:13:1:7
3:13:1:8

123

the risk of hepatitis events, cirrhosis, and

end-stage liver disease related to chronic
HBV infection (A1).
Given the faster progression of liver
disease in HIV-HBV coinfected patients,
early dual anti-HIV and anti-HBV therapy should be considered, irrespective of
immunological, virological or histological considerations (B1).
Tenofovir combined with emtricitabine
or lamivudine plus a third agent active
against HIV should be used (A1).
Peg-IFN can be used in a highly selected
group of coinfected patients (B1) (Fig. 5).
Lamivudine, entecavir and tenofovir
have activity against both HIV and
HBV and are contraindicated as single
agents for hepatitis B in coinfected
patients because of the risk of HIV
resistance (A1). Thus, all HBsAg-positive patients should be screened for HIV
before these drugs are used in the treatment of HBV infection (A1).
Adefovir and telbivudine should not be
used in coinfected patients (A1).
HIV-infected adults without protective
HBsAb titers should be vaccinated (A1).
In HBV-HIV coinfected patients, an
initial conventional HBV vaccination
schedule should be used; in the case of
lack of achievement of protective antiHBs titers ([10 mIU/ml), revaccination
using double-dose and/or three to four
injections (months 0, 1, 6, and 12) is
recommended (B1).

Acve HCV /
Acve HBV

Treat HCV: P+R

Observe HBV
response & reacvaon
Or
Treat HCV & HBV:
P+R+NUC

Acve HBV /
Inacve HCV

Inacve HCV /
Inacve HBV

Treat HBV: P or NUC

Observaon

3.13.2 Coinfection with HBV and HCV

Most patients with chronic hepatitis C have a hepatitis C
virus (HCV) monoinfection. However, in areas where the
HBV is endemic, a substantial proportion of the patients
are coinfected with hepatitis C and B [419]. If the prevalence of anti-HCV positivity worldwide is approximately
14 % in the general population, the number of individuals
with HCV/HBV coinfection among the 320 million chronic
HBV positive subjects would be approximately 3.212.8
million. Moreover, HCV/HBV coinfections can also be
found in people at risk of parenteral hepatotropic viral
transmissions, such as people who use intravenous drugs,
patients with thalassemia, and patients with hemophilia.
In patients with dual chronic hepatitis B and C, the
disease outcomes, including the development of liver cirrhosis (LC) and HCC, are generally more severe than those
in patients with either hepatitis B or hepatitis C [420, 421].
In addition to cross-sectional data, a long-term communitybased study finding supported the effect of HCV/HBV
coinfection on the cumulative incidences of HCC [422].
Therefore, patients dually infected with hepatitis C and B
need attention and require effective antiviral treatments.
Treatment goals and strategies The primary goal of the
treatment of HCV and HBV coinfection is to eliminate or
permanently suppress both viruses [419]. Simultaneously,
the long-term goal is to reduce or terminate hepatic
necroinflammation, prevent progression to cirrhosis and the
development of HCC, and ultimately prolong the survival
of patients.
These goals can be achieved by eradicating both viruses
after providing an effective antiviral therapy for dually
infected patients. Accumulating data exist to reach firm
conclusions on the management of patients with HCV

Hepatol Int

coinfection. It is generally agreed that the dominant virus

should be identified before designing a therapeutic strategy
(Fig. 8) [423]. HBV and HCV replicate in the same hepatocyte without interference [424]. A proportion of coinfected patients may have fluctuating serum HBV DNA
levels, thus indicating the need for longitudinal evaluation
of viral loads before starting any antiviral therapy, in order
to clarify the respective pathogenic role of each virus
[423]. HBV DNA levels are often low or undetectable and
HCV is usually responsible for the activity of chronic
hepatitis in most patients. If HBV is dominant, treatment
should be aimed toward this virus. If HCV is dominant,
Peg-IFN therapy in combination with ribavirin can achieve
a sustained HCV clearance rate comparable to that in HCV
mono-infection [425428]. This has been demonstrated in
an open-label, comparative, multicenter study involving
321 Taiwanese patients with active HCV infection, in
which patients with HCV genotype 1 infection received
Peg-IFN alfa 2a 180 lg weekly and ribavirin
(10001200 mg) daily for 48 weeks [426]. Patients with
HCV genotypes 2 or 3 received Peg-IFN alfa 2a 180 lg
weekly and ribavirin 800 mg daily for 24 weeks. The
sustained virological response in HCV genotype 1-infected
patients was comparable between 161 HBV/HCV patients
and 160 HCV mono-infection patients (72.2 vs. 77.3 %).
For patients with HCV genotype 2/3 infections, the sustained virological response values were 82.8 and 84.0 %,
respectively. The HCV sustained virological response
(SVR) was durable in approximately 97 % of the patients
during a 5-year post-treatment follow-up [427]. Furthermore, approximately 30 % of dually infected patients lost
HBsAg within 5 years after the start of Peg-IFN-based
therapy. The benefit of anti-HCV therapy in dually infected
patients was further confirmed in another large populationbased survey in Taiwan [429]. Compared with the patients
in an untreated dually infected cohort, the risk of developing HCC, all-cause mortality, and liver-related mortality
decreased by 35, 62, and 59 %, respectively, in patients
who received active anti-HCV therapy.
3:13:2

Recommendations: coinfection with HBV and

HCV
3:13:2:1

3:13:2:2

It is important to determine the viral

loads of individual viral infections and
which virus is dominant before designing
the treatment strategy, and then to treat
the patients accordingly (B1) (Fig. 6).
In HBVHCV coinfected patients who
are HCV viremic, antiviral treatment may
be selected using the same criteria as for
those patients with HCV mono-infection
(A1).

3.13.3 Coinfection with HBV and HDV

Although HDV can only infect HBsAg positive patients
and HBV vaccine has been available for a long time, the
prevalence of HDV has not shown a significant decline.
Recent studies also confirm that even in countries like
United States, Australia and some European countries, the
prevalence of HDV is showing an increasing trend [430].
In the coinfected host, it is generally HDV which is the
dominant virus because it suppresses HBV through replication, but can cause severe liver injury that may result in
fulminant hepatic failure and rapid progression to cirrhosis
and hepatic decompensation, as well as an increased risk of
liver cancer [431]. Chronic infection after acute HBVHDV hepatitis is less common, while chronic delta hepatitis develops in 7090 % of patients with HDV superinfection [430]. Active coinfection with HDV is confirmed
by detectable HDV RNA, immuno-histochemical staining
for HDV antigen, or IgM anti-HDV [432]. However,
diagnosis of active HDV infection may be difficult, as
HDV RNA assays are not standardized and HDV antigen
and IgM anti-HDV assays are not widely available.
Peg-IFN is effective against HDV. The efficacy of PegIFN therapy can be assessed during treatment (after
36 months) by measuring HDV RNA levels. Weekly
injection of pegylated interferon is currently used for
1218 months [433]. More than 1 year of therapy may be
necessary, as there may be some benefit from treatment
prolongation [434]. However, the optimal duration of
therapy is not well defined [432]. So long as the hepatitis B
surface antigen stays positive, HDV patients remain
infective even if the HBV or HDV viral titers are low or
undetected.
Around 2540 % of treated patients have a sustained
off-treatment virological response with undetectable HDV
RNA and accompanying improvement in histology, while
some also lose HBsAg [430, 432].
Although late relapses have been documented, in a study
performed by Hedrich and colleagues in patients who were
HDV RNA negative 6 months after pegylated interferon
treatment, pegylated interferon alfa 2a treatment was given
for 48 weeks with or without adefovir and resulted in 28 %
of the patients having undetectable HDV RNA 6 months
post-treatment [435]. In long-term follow-up of patients for
approximately 4 years, a significant number of patients
were tested HDV RNA positive at least once during further
follow-up, and it was also concluded by the investigators to
closely monitor patients post-Peg interferon therapy, even
those who are HDV RNA negative 6 months after therapy
with interferon alfa 2a therapy.
When standard interferon was used at nine million units
compared to no treatment or low dose at three million units
given three times a week for 48 weeks, 50 % of the high-

123

Hepatol Int

dose group had a complete biochemical response defined

by normalization of ALT, in addition to virological
response negative HDV RNA at the end of the treatment,
compared to no complete responses in any of those in the
low-dose or no treatment group. The long term follow-up
up to 12 years demonstrated significantly improved survival and liver histology for the high dose treatment group,
although most of them relapsed after clearance of HDV
RNA [436].
Although no head-to-head comparison trials have been
carried out, two major reviews have not been able to definitely show that either type of interferon therapy is superior to the other. However, one recent systematic review of
randomized trials found that 1 year of high dose interferon
alfa monotherapy achieved higher levels of undetectable HDV RNA and normalization of ALT at the end of
treatment when compared with pegylated interferon alfa 2a
monotherapy. However levels of HDV RNA suppression
24 weeks after the end of therapy were not significantly
different [437]. A systematic review by Alavian and colleagues comparing standard and pegylated interferon alfa
found sustained virological response rates in 19 and 29 %
of patients, respectively [438]. In a study from Turkey
using entecavir for chronic hepatitis D, after 1 year of
entecavir treatment, it was found to be ineffective in CHD.
It was also concluded from the study that any beneficial
effect of nucleosidenucleotide analogue treatment may
necessitate prolonged treatment [439]. In a recent study
from Pakistan, sustained virological response, which was
defined as negative HDVRNA at 24 weeks post-treatment,
was seen in 23.1 % for virological and biochemical
responses and in only 12.5 % as a combined response
[440]. A Cochrane review concluded that interferon alfa
does not seem to cure Hepatitis D in most patients. It was
also concluded from this review that more randomized
trials with large sample sizes and less risk of bias were
needed before interferon can be recommended or refuted
[441]. In a recent study from Germany by Nikongolo [442],
it was suggested that HBV and HDV entry via sodium
taurocholate co transporting polypeptide is inhibited by
cyclosporine A. In the future, this drug may help reduce the
incidence of HBV and HDV after more studies demonstrate
its usefulness and where it would actually fit in the management of HBV and HDV coinfection. Myrcludex-B, a
myristoylated a preS/248my2 peptide, has been shown to
limit the establishment of HDV infection in vivo and
delayed the increase in HBV viremia. The real role of its
use is yet to be determined in HBV-HDV management
[443].
Lamivudine, adefovir and entecavir have been found to
be ineffective in the management of Hepatitis D alone or in
combination with interferon; however, Wedemeyer, in his
study using pegylated interferon and adefovir, showed

123

significant decline in HBsAg titers using adefovir [444],

which could be significant as a predictor for successful
treatment of HBeAg-positive CHB [280]. Case reports
have appeared in which successful treatment of HBV and
HDV have been reported using pegylated interferon and
entecavir [445] and pegylated interferon and tenofovir and
emtricitabine [446]. Thus, NAs treatment might be considered in some patients who have active HBV replication
with persistent or fluctuating serum HBV DNA levels
above 2000 IU/ml [447].
3:13:3

Recommendations: coinfection with HBV and

HDV
3:13:3:1

In patients with coinfection of HBV and

HDV, it is important to determine which
virus is dominant and the patient should be
treated accordingly with pegylated interferon alfa for 1218 months. Patients
should be monitored for 6 months posttreatment and beyond (A1).

3.13.4 Health care workers

HBV can survive in dried blood outside the body for up to
7 days, and is significantly more infectious than either
hepatitis C or HIV, with a reported transmission rate of up
to 30 % from needlestick injuries. This rate seems to correlate with serum HBV DNA concentrations. The concentration of HBV varies across body fluids, with blood,
serum and wound exudates carrying the highest concentrations; semen, vaginal fluid and saliva carrying moderate
concentrations; and urine, feces, sweat and breast milk
containing the lowest concentrations, which translates into
the lowest risk of HBV transmission. Percutaneous injuries
sustained by health-care workers during certain surgical,
obstetrical, and dental procedures provide a potential route
of HBV transmission to patients as well as to heath care
workers (HCWs). Therefore, it is important to prevent
operator injuries and blood exposures during exposureprone surgical, obstetrical, and dental procedures.
Chronic HBV infection in itself should not preclude the
practice or study of medicine, surgery, dentistry, or allied
health professions. Standard precautions should be adhered
to rigorously in all health-care settings for the protection of
both patient and provider [448].
HCWs and students of surgery, dentistry, medicine, or
allied health fields should be screened for HBV infection.
Testing should include a serological assay for HBsAg, antHBs and Total anti-HBc. All noninfected health-care providers and students should receive hepatitis B vaccine.
Vaccination (three-dose series) should be followed by
assessment of hepatitis B surface antibody to determine

Hepatol Int

vaccination immunogenicity, and providers who do not

have protective concentration of anti-HBs ([10 mIU/ml)
should undergo, revaccination [448].
Exposure of a HCW to the blood of an HBV-infected
patient in the performance of any procedure, should be
handled with standard post-exposure prophylaxis. Exposure of a patient to the blood of an HBV-infected healthcare provider, in the performance of any procedure, should
be handled with post-exposure prophylaxis and testing of
the patient in a manner similar to the reverse situation (i.e.,
prophylaxis for providers exposed to the blood of an HBVinfected patient) [449].
Transmission of HBV by HCWs to patients In the health
care setting, transmission may occur via several routes, but
the most frequent route leading to establishment of HBV
infection is through needlestick injury. Invasive surgical
procedures are another route of HBV transmission; in fact,
surgeons represent the largest group of HCWs involved in
provider-to-patient HBV transmission [450].
It is the regular performance of an exposure-prone
procedure (EPP) that is mainly of concern. EPPs are
defined as procedures in which there is a risk that injury to
the physician may result in the exposure of the patients
open tissues to the blood of the physician. Any type of
invasive surgery is, thus, an EPP, wherein the affected
physicians gloved hand is in constant contact with sharp
instruments, needle tips or sharp tissues (spicules of bone
or teeth) inside a patients open body cavity. Surgery
performed within a confined anatomical space, where the
hands or fingertips may not always be completely visible,
also carries an elevated risk of transmission, given the
paucity of surgical precision and control in this context. A

procedure is considered to be non-exposure-prone (NEPP)

when the hands and fingertips of the physician are visible
and outside the patients body throughout, even when there
is handling of sharp instruments. A NEPP can become an
EPP if a patient is uncooperative [451].
Retrospective studies have evaluated the rate of HBV
transmission from affected physicians through blood contact during specific types of EPPs. Percutaneous injuries
have been reported to occur in 6.9 % of operations, and in
32 % of these instances, the instigating sharp instrument
touches the patient wound once again [452]. The risk of
HBV transmission is not negligible; the rate in cardiothoracic surgery is reported to be 613 % [453, 454], up to
9 % in gynecological surgery [455, 456], and 2 % in
general surgery [457, 458]. The proportion of patients
infected with HBV secondary to transmission from an
infected HCW is between 0.5 and 13.1 % [459].
CDC has classified patient care procedures into two
categories (Table 11).
Most effective transmissions have occurred when the
HCW carried HBV DNA [1.9 9 105 IU/ml (106 copies/
ml, with conversion factor of 5.26 copies/IU). Establishing
a threshold for the limitation of EPPs would have to
account for a 3 log10 safety margin to account for assay
variability [452]. HCWs who are HBsAg positive should
be tested for HBeAg and anti-HBe and for HBV viremia.
HCWs, and medical and dental students who are
HBsAg-positive, who do not perform exposure-prone
procedures but who practice non- or minimally invasive
procedures (Category II, table) should not be subject to any
restrictions of their activities or study. They do not need to
achieve low or undetectable levels of circulating HBV
DNA, hepatitis e-antigen negativity, or have review and

Table 11 Classification of patient care procedures

Procedures known or likely to pose an increased risk of percutaneous
injury to a HCW that have resulted in provider-to-patient
transmission of hepatitis B virus (HBV)

Category IIall other invasive and noninvasive procedures

These procedures are limited to major abdominal, cardiothoracic, and

orthopedic surgery, repair of major traumatic injuries, abdominal and
vaginal hysterectomy, caesarean section, vaginal deliveries, and
major oral or maxillofacial surgery (e.g., fracture reductions).
Techniques that have been demonstrated to increase the risk for
health-care provider percutaneous injury and provider digital
palpation of a needle tip in a body cavity and/or the simultaneous
presence of a health care providers fingers and a needle or other
sharp instrument or object (e.g., bone spicule) in a poorly visualized
or highly confined anatomic site

These and similar procedures are not included in Category I as they

pose low or no risk for percutaneous injury to a health-care provider,
or, if a percutaneous injury occurs, it usually happens via provider-topatient blood exposure. These include surgical and obstetrical/
gynecological procedures that do not involve the techniques listed for
Category I; and providers hands are outside a body cavity (e.g.,
phlebotomy, placing and maintaining peripheral and central
intravascular lines, administering medication by injection,
performing needle biopsies, or lumbar puncture)

Category I procedures, especially those that have been implicated in

HBV transmission, are not ordinarily performed by students fulfilling
the essential functions of a medical or dental school education rectal
examination; and procedures that involve external physical touch
(e.g., general physical or eye examinations or blood pressure checks)

Dental procedures other than major oral or maxillofacial surgery

Insertion of tubes (e.g., nasogastric, endotracheal, rectal, or urinary
catheters)
Endoscopic or bronchoscopic procedures
Internal examination with a gloved hand that does not involve the use
of sharp devices (e.g., vaginal, oral)

123

Hepatol Int

oversight by an expert review panel, as recommended for

those performing exposure-prone procedures. However,
they should receive medical care for their condition by
appropriate clinicians [460].
HCWs who perform exposure-prone procedures, i.e.,
those listed under Category I activities (Table 11), should
be guided by an institutional expert review panel regarding
the procedures that they can perform and prospective
oversight of their practice [461]. Confidentiality of the
health-care providers or students HBV serological status
should be maintained. HBV-infected HCWs can conduct
exposure-prone procedures if a low or undetectable HBV
viral load is documented by regular testing at least every
6 months unless higher levels require more frequent testing; for example, as drug therapy is added or modified,
testing is repeated to determine if elevations above a
threshold are transient [460]. An HBV DNA level of
1000 IU/ml or its equivalent is an appropriate threshold to
adopt [460]. Spontaneous fluctuations of HBV DNA levels
and treatment failures might both present as higher-thanthreshold (1000 IU/ml) values. This will require the HBVinfected HCW to abstain from performing exposure-prone
procedures, while subsequent retesting occurs, and if needed, modifications or additions to the health-care providers drug therapy and other reasonable steps are taken
[460].
Hospitals, medical and dental schools, and other institutions should have written policies and procedures for the
identification and management of HBV-infected healthcare providers, students, and school applicants.
Treatment of HCWs for reduction of Infectivity Healthcare workers also need special attention regarding starting
antiviral therapy, as they may require antiviral therapy
even if they do not fulfill the typical indications for treatment, to reduce direct transmission during exposure-prone
procedures to patients.
Published evidence for the efficacy of antiviral therapy on the transmission rate to patients is limited. One
Dutch study reported reduction of viremia to \1000
copies/ml in 18 HCPs with either interferon-a or various
NAs [462].
DNA levels \1000 IU/ml are reached more often and
much faster in HBeAg-negative chronic HBV-infected
subjects, because they have lower baseline levels of viremia and possibly a higher turnover of HBV-containing
hepatocytes, as compared to HBeAg-positive subjects. The
immunotolerant HBeAg-positive subjects typically have
baseline viremia levels [108 IU/ml. The mean reduction of
viremia obtained in HBeAg-positive patients with entecavir within 1 year was reported to be 6.9 log10 copies/ml
[463]. One study on tenofovir therapy showed that the
mean value in patients with moderately high viremia fell

123

from 7.3 to 3.7 log10 copies/ml within approximately

12 weeks, while patients with [9.0 log10 baseline level
needed roughly 52 weeks [196]. In a direct comparison of
tenofovir and entecavir, decreases of -4.0 or -4.5
log10 units/ml, respectively, were found after 3 months of
therapy [464]. Thus, viremia can be suppressed to acceptable levels in the majority HCWs by 3 months of entecavir
or tenofovir therapy. HCWs with very high viremia
[108 IU/ml may need longer therapy, but most of them
will reach acceptable or even undetectable levels within
1 year [465].
3:13:4

Recommendations (health care workers)

3:13:4:1

3:13:4:2

3:13:4:3

3:13:4:4

3:13:4:5

3:13:4:6

Chronic HBV infection in itself should

not preclude anyone from the practice or
study of medicine, surgery, dentistry, or
allied health professions (A1). Such
HCWs should not be isolated or discriminated, but should be encouraged to be
investigated and treated (A1).
HCWs and students of surgery, dentistry,
medicine, or allied health fields should be
screened for HBV infection. Testing
should include a serological assay for
HBsAg, anti-HBs and total anti-HBc (A1).
All non-infected health-care providers
and students should receive hepatitis B
vaccine and their immunization status be
confirmed (A1).
Standard precautions should be adhered
to rigorously in all health-care settings
for the protection of the patient and the
provider (A1).
HCWs who perform exposure-prone procedures, i.e., those listed under Category
I activities (Table 11), should be guided
by an institutional expert review panel
regarding the procedures that they can
perform and prospective oversight of
their practice (B1). The status of the
individual could vary depending on the
response to therapy.
HBV-infected HCWs can conduct exposure-prone procedures if a low
(\1000 IU/ml) or undetectable HBV
viral load is documented by regular
testing at least every 6 months (B1).

3.13.5 Chronic HBV infection and pregnant females

When females in the childbearing age require antiviral
therapy, the issue of pregnancy must be discussed before

Hepatol Int

starting treatment. If pregnancy is planned in approaching

years, IFN-based therapy is preferable for its finite duration
of treatment. Pregnancy is discouraged during IFN therapy
because of IFNs anti-proliferative effect. Contraception is
suggested during IFN treatment. In pregnant females with
chronic HBV infection who need antiviral therapy, or in
females who have unexpected pregnancy during antiviral
treatment, the treatment plan should be fully discussed,
considering risks and benefits for the mother and fetus on
issues regarding risks of maternal disease progression,
maternal ALT flares, fetal development, vertical transmission of HBV, long-term plan for treatment and next
pregnancy [466, 467]. Among the currently available NAs,
LdT and TDF are classified as category B drugs (no risk in
animal studies, but unknown in humans), whereas LAM,
ADV, and ETV are classified as category C drugs (teratogenic in animals, but unknown in humans) by the US
FDA. Category B NAs (LdT and TDF) may be considered
for mothers indicated for antiviral treatment during the first
through third trimester of pregnancy. TDF has more safety
data in HIV-positive females, and the least chance of viral
resistance. Safety data from the Antiretroviral Pregnancy
Registry has demonstrated no increased rates of birth
defects (2.8 % 46/1982) with TDF exposure during the first
trimester [468]. Despite postnatal active/passive immunization of the newborns, mother-to-infant transmission of
HBV still occurs; major risk factors are maternal HBeAg
and high viral load [469, 470]. For prevention of motherto-infant transmission that occurrs during theperinatal
period, short-term maternal NAs used in mothers of
stable liver disease, starting from the second or third trimester, has been documented to reduce maternal viral load
and decrease perinatal mother-to-infant transmission. The
results are based on non-randomized, open label clinical
studies using either LAM, LdT or TDF [471478]. The
target population for short-term NAs treatment for pregnant females to reduce maternal HBV transmission is
maternal HBV viral load above 67 log10 IU/ml [469]. The
starting point of maternal treatment in most studies is
2832 weeks of gestation, after careful examination to
exclude maternal systemic disorder and fetal anomalies.
Cessation of NAs therapy (at delivery or 412 weeks after
delivery) is recommended in females without ALT flares
and without pre-existing advanced liver fibrosis/cirrhosis.
Continuation of NAs treatment after delivery may be
necessary according to maternal liver disease status.
Breastfeeding is not discouraged in mothers with chronic
HBV infection if newborns have received appropriate
postnatal immunoprophylaxis. However, breastfeeding is
not generally encouraged during NAs therapy because of
uncertainty of safety to newborns [479, 480]. There has
been insufficient data regarding maternal ALT flare rates
before and after delivery, especially after cessation of NAs

postpartum. Some studies reported increased rates of ALT

flares in the LdT or LAM treated group [476], and other
studies using TDF reported comparable or possibly beneficial effects for the mothers [472, 481]. Several issues are
still not well understood, such as the long-term safety of
the mothers and child beyond 1 year post delivery, optimal
large-scale screening methods, and cost-effectiveness of
such prevention strategy for the population.
3:13:5

Recommendations: chronic HBV infection and

pregnant female
3:13:5:1

3:13:5:2

3:13:5:3

3:13:5:4

The issue of pregnancy and maternal

fetalchild health should be notified in
chronically HBV-infected female in the
childbearing age, especially when antiviral treatment is considered. The treatment
plan should be fully discussed with the
patient and relatives, especially regarding
the risks of maternal liver disease status,
fetal development, vertical transmission
of HBV, long-term plan for treatment and
pregnancy. Maternal HBeAg, HBV DNA
status, and ALT level should be checked
during pregnancy (A1).
In pregnant females with chronic HBV
infection who need antiviral therapy,
tenofovir is the drug of choice for
mothers indicated for antiviral treatment
during the first through third trimester of
pregnancy. It is a pregnancy category B
drug with adequate safety data in HIVpositive females and least chance of viral
resistance (B1).
For reduction of risk of mother-to-infant
transmission that occurs during perinatal
period, short-term maternal NAs starting
from 28 to 32 weeks of gestation is
recommended using either tenofovir or
telbuvidine for those mothers with HBV
DNA above 67 log10 IU/ml (B2). Since,
the HBV transmission could occur even
with lower maternal HBV DNA levels,
NAs could be administered after discussion with the patient, even in patients
with lower DNA levels. The NAs could
be stopped at birth and when breastfeeding starts, if there is no contraindication
to stopping NAs (B2).
Breast-feeding is discouraged during
maternal NAs treatment. For those with
ALT flares detected during the treatment
period,
continuation
of
antiviral

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Hepatol Int

treatment according to maternal liver

disease status may be indicated (B2).
3.13.6 Chronic HBV infection in patients with CKD,
on dialysis and in renal transplant patients
Chronic HBV infection has a pivotal influence on
patients with CKD undergoing haemodialysis and renal
transplant with complex issues [482]. Patients with renal
disease should be screened for HBV infection and
though vaccine responsiveness is impaired, HBV
seronegative patients should be vaccinated. In particular,
renal patients under anti-HBV therapy should be followed not only for the treatment efficacy, but also the
stage of liver disease and the renal disease status. PegIFN or NAs can be used for chronic HBV infection
patients with renal dysfunction. However, NAs represent
the first-line treatment option for chronic HBV-infected
patients with any level of renal dysfunction and renal
replacement therapy. Physicians should be aware of the
necessary drug dose adjustments according to creatinine
clearance as well as the potential nephrotoxicity and
long-term drug efficacy.
In general, entecavir, an agent without signs of
nephrotoxicity, and telbivudine, an agent with promising
data for even improvement in creatinine clearance, seem
to be the preferred options for NA-naive patients with
any renal dysfunction, depending on the HBV viremia
levels and the severity of renal dysfunction. Although,
there are no definite conclusions about the risk of
tenofovir-associated nephrotoxicity, most clinicians are
concerned and therefore avoid using this agent in this
setting. However, tenofovir remains the agent of choice
for patients with renal dysfunction and prior resistance to
other NAs.
HBsAg positive patients who undergo renal transplantation and receive immunosuppressive agents should
receive anti-HBV prophylaxis with NAs. However, PegIFN should be avoided in renal transplant patients because
of the risk of rejection.
3:13:6

Recommendations: chronic HBV infection in

patients with CKD, on dialysis and renal transplant patients
3:13:6:1

3:13:6:2

123

NAs (entecavir or telbivudine) represent

the first-line treatment options for chronic
HBV-infected patients with any level of
renal dysfunction and renal replacement
therapy. NAs should be dose adjusted
based on creatinine clearance rates (A1).
Peg-IFN should be avoided in renal
transplant patients because of the risk of
rejection (A1).

3.13.7 Extrahepatic manifestations of chronic hepatitis B

Several extrahepatic conditions have been described during
acute and chronic HBV infection. While the pathogenesis
remains controversial, it is largely attributed to an immunemediated injury of organs other than the liver. Viral antigeninduced induction and deposition of immune complexes,
reaction with tissue antigens by HBV-induced auto antibodies, or a direct viral reaction may occur in extrahepatic
tissues such as the skin, muscles, joints and kidneys.
Glomerulonephritis The incidence of HBV-related
glomerulonephritis is from 0.1 to 25 % and may present
clinically in three forms, i.e., membranous, membranoproliferative, and IgA nephropathy. Membranous glomerulonephritis (MGN) is the most common type, especially in
areas endemic for HBV infection, and usually presents as
nephrotic syndrome, with proteinuria, edema and hypertension. Immune complexes are deposited only in the basement
membrane where HBV antigens, i.e., HBsAg, may be identifiable in the glomerular capillary wall. In children, up to
60 % may experience spontaneous remission, usually associated with HBeAg seroconversion. However, in adults it can
lead to chronic renal failure in up to 3050 % of cases [483,
484]. Membranoproliferative glomerulonephritis (MPGN)
is characterized by deposition of HBsAg in both the
mesangial and capillary walls; HBeAg and HBcAg have also
been identified in the glomeruli. In chronic HBV infection,
the heightened immune response results in increased
amounts of circulating immune complexes containing HBV
antigens, complement components, immunoglobulins, etc.,
which are deposited in sites outside the liver [485]. HBVrelated IgA nephropathy is a less severe form of renal disease
and usually evolves with an indolent course, although an
aggressive course with progression to acute renal failure has
been reported. Tubulo-reticular inclusions in the endoplasmic reticulum of endothelial cells of the glomerular and
peritubular capillaries have been identified on electron
microscopy [486]. It has been suggested that both humoral
and cellular immune injury, mediated by HBAg-HBAb
immune complexes in the former and by HBV originating
from renal cells in the latter, may be involved in the pathogenesis of IgA nephropathy [487]. Remission of clinical and
laboratory manifestations of nephropathy with successful
antiviral treatment have been demonstrated [488491].
Polyarteritis nodosa Polyarteritis nodosa (PAN) is a generalized necrotizing vasculitis, and HBV-associated PAN
(HBV-PAN) represents a typical form of classic PAN. The
pathogenesis HBV-PAN is largely attributed to immunecomplex deposition (with antigen excess) in the vessel walls
of the skin, kidneys, heart and nervous system. A recent study
of 348 patients with PAN revealed that patients with HBV-

Hepatol Int

PAN had more frequent peripheral neuropathy, abdominal

pain, cardiomyopathy, orchitis, and hypertension compared
to patients with non-HBV-related PAN. PAN is observed
more frequently in European and North American patients,
but rarely in Asian patients [492]. Constitutional symptoms
include malaise, anorexia, weakness, fever, and weight loss.
Erythematous skin lesions and palpable purpura and nodules
are not uncommon. Prior reports have estimated the incidence of HBV infection in PAN patients to be between 30
and 70 %; however, in the West, these figures have declined
remarkably in parallel with those of HBV infection [493].
Antiviral therapy, combined with corticosteroids and plasma
exchanges, has demonstrated good efficacy in the management of HBV-PAN [494, 495].
Cryoglobulinemia Patients with chronic HBV infection
may present with mixed cryoglobulinemia, i.e., type II
(monoclonal IgM and polyclonal IgG) and type III (polyclonal IgM and monoclonal IgG). The prevalence of HBVassociated cryoglobulinemia ranges from 0 to 15 % [496,
497]. Clinically, it may present with protracted purpura,
with or without ulcerative skin lesions, arthralgia, and
weakness. It may be associated also with the sicca syndrome, Raynaud phenomenon, as well as renal and neurological complications. When nephritis is present, the
clinical course can rapidly be fatal. Effective treatment of
the underlying chronic HBV infection with currently
available nucleos(t)ide analogues generally leads to clinical
and serological resolution of cryoglobulinemia [498, 499].
Serum sickness-like syndrome A transient serum sickness-like arthritisdermatitis syndrome occurs in
approximately 1020 % of patients during the prodrome of
acute hepatitis B [500]. The pathogenesis is related also to
circulating immune complexes, and during the acute phase,
high concentrations of HBsAg have been detected in the
synovial fluid with associated reduction in complement
levels. The manifestations can range from fever, myalgia,
polyarthralgia or overt arthritis with joint swelling and
edema of small joints of the hands and feet, as well as large
joints of the knees, ankles and wrists. The polyarthritis is
characteristically asymmetrical and is often associated with
erythematous skin lesions. Morning stiffness and a gel
phenomenon are present; thus, it can be mistaken for acute
rheumatoid arthritis. However, it typically disappears when
jaundice sets in and leaves no demonstrable permanent
joint destruction. The resolution of arthritic lesions parallels those of HBsAg clearance. This serum sickness-like
syndrome ends abruptly with the onset of clinical hepatitis
with few significant sequelae, and does not recur [501].
Dermatological manifestations The skin rashes in
patients with chronic HBV infection are usually related to

immune complex deposition, neutrophilic infiltration and

small vessel necrosis. They present typically as palpable
purpura. Lichen planus, a chronic recurrent rash composed
of small, flat-topped, polygonal bumps that may coalesce
together into rough, scaly plaques on the skin and mucous
membranes, has been found to be highly prevalent in
Turkish patients who are seropositive with HBsAg [502].
The Gianotti-Crosti syndrome, or papular acrodermatitis of
childhood, is characterized by small, flat, erythematous,
papular or papulovesicular rash that occurs in the face and
distal extremities of infants and young children. Other than
HBV, the EpsteinBarr virus, hepatitis A virus, cytomegalovirus, coxsackie, adenovirus, enterovirus, HIV are also
implicated as etiological agents. While the association of
this syndrome with HBV infection was reported as early as
1976, this association remains controversial [503].
GuillainBarre
syndrome GuillainBarre syndrome
(GBS) is a rare extrahepatic involvement associated with
both acute and chronic HBV infection. While both HBsAg
and HBV DNA have been detected in cerebrospinal fluid, it is
unclear whether the virus itself or an immune-mediated
assault or a vasculitis-related injury to the myelin sheath is
responsible for these symptoms of the central nervous system
[504]. A recent case report described a patient with GBS
associated with acute hepatitis B responding to nucleoside
analogue and intravenous immunoglobulin treatment [505].
3:13:7

Recommendations: extrahepatic manifestations of

CHB
3:13:7:1

3:13:7:2

3:13:7:3
3:13:7:4

Extrahepatic manifestations may be associated with both CHB infection

(glomerulonephritis, polyarteritis nodosa,
mixed cryoglobulinemia, and skin manifestations) and acute HBV infection
(GuillainBarre syndrome and, a serum
sickness-like syndrome) (B1).
HBsAg positive patients with extra-hepatic
manifestations and active HBV replication
may respond to antiviral therapy (B1).
Peg-IFN may worsen some immune mediated extra-hepatic manifestations (B1).
Plasmapheresis, corticosteroids or IVIG
can be useful in addition to NA therapy in
severe immune-mediated cases (C2).

3.13.8 Patients before and/or after curative or local

regional therapy of HCC
Once HCC develops, treatment for HBV will depend on the
stage of disease. Mostly patients will be on antiviral therapy, as the majority will have underlying cirrhosis.

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Hepatol Int

For non-surgical patients, a high viral load prior to

chemotherapy or locoregional therapy results in higher
rates of severe hepatitis during chemotherapy [506].
Longer survival has been shown in patients receiving
TACE with the additional of antiviral therapy [507].
For the overwhelming majority of patients with HCC,
surgical removal of the tumor by resection or LT is the only
curative option. HCC recurrence occurs in up to 4150 %
of patients within 2 years after resection (early recurrence)
and in up to 20 % of patients more than 2 years later (late
recurrence) [508]. Most early recurrence appears to reflect
diffusion of primary tumors, while most late recurrence
stems from de novo tumors spontaneously arising in the
remnant diseased liver. Antiviral therapy is important for
patients undergoing resection, as the hepatic reserves will
be limited and compromised in the post-operative period.
Therefore, flares of hepatitis may lead to decompensation
for untreated patients [509]. Surgery and anesthesia may
also impart a state of immunosuppression in the early postoperative period, thereby increasing the risk of HBV
reactivation [510]. A high pre-operative viral load has been
associated with worse overall and recurrence free survivals
after curative resection [511]. There is also the potential
increased risk of recurrent HCC due to the process of
necrosis and regeneration of remaining hepatocytes, which
may induce DNA mutations and instability. Upregulation
of adhesion molecules on cells lining sinusoids may
increase the risk of distant metastasis [512].
Viral load and hepatic inflammatory activity have been
associated with late recurrences after HCC resection [513].
A cohort of 72 resected patients with HBV-relatedHCC
showed that the absence of antiviral treatment was a risk in
tumor recurrence [514]. An HBV DNA of [2000 IU/ml at
the time of resection was a significant risk factor (RR 22.3,
95 % CI 3.3150.5, p = 0.001).
Routine prophylactic NA therapy for HCC patients with
HBV-DNA levels \2000 IU/ml before liver resection may
also be considered. The aim is to prevent HBV reactivation
after liver resection, which occurs in as many as 19 % of
patients within the first 1 year, and which can severely
reduce liver function and survival [515].
Since NAs cannot completely eradicate HBV, lifelong
treatment should be pursued as long-term therapy may help
prevent hepatitis flare-ups and inhibit hepatocarcinogenesis
to the greatest extent [516].
Various studies have found that antiviral therapy
decreases HCC recurrence after resection. In a nationwide
cohort study from Taiwan of 4051 untreated versus 518
NA-treated CHB patients with resected HCC, even though
there was a higher rate of cirrhosis in the latter (38.7 vs.
48.6 % respectively, p \ 0.001), the risk of HCC recurrence was lower in the NA-treated patients (43.6 vs.
20.5 % respectively, p \ 0.001) [517]. NA use was

123

independently associated with a significantly lower HCC

recurrence risk (HR 0.67, 95 % CI 0.550.81, p \ 0.001).
A meta-analysis also demonstrated the beneficial effects of
antiviral therapy with regards to HCC recurrence (OR 0.59,
95 % CI 0.350.97, p = 0.04), and liver-related mortality
(OR 0.13, 95 % CI 0.020.69, p = 0.02) [518]. Two recent
meta-analyses including 20 studies demonstrated that the
presence of high viral load significantly increased overall
HCC recurrence risk after curative therapy, whereas
antiviral therapy had potential beneficial effects in preventing recurrence [519, 520].
There is also improvement in recurrence-free survival
and overall survival with NAs treatment among patients
undergoing resection for HBV-related HCC. In a recent
systematic review of 19 studies, the NA group (1468
patients) showed a median recurrence-free survival of
85.0 % (range 19.790.0 %) at 1 year, 57.0 % (range
11.490.0 %) at 3 years, and 54.0 % (range 42.681.3 %)
at 5 years. These median survival rates were significantly
higher than the corresponding values in the non-NA group
(5541 patients): 78.0 % (range 4.586.6 %) at 1 year,
56.0 % (range 056.0 %) at 3 years, and 47.0 % (range
047.0 %) at 5 years (all p \ 0.001) [521]. In the same
review on 15 studies reporting overall survival, the overall
median survival in the NA group (1468 patients) was
94.0 % (range 24.0100.0 %) at 1 year, 81.0 % (range
60.0100.0 %) at 3 years, and 73.0 % (range 59.089.7 %)
at 5 years. These values were significantly higher than the
corresponding ones for the non-NA group (5200 patients):
91.0 % (range 0100.0 %) at 1 year, 74.0 % (range
085.0 %) at 3 years, and 62.0 % (range 070.0 %) at
5 years (all p \ 0.001) [521].
Thus, use of antiviral therapy improves the long-term
post-hepatectomy recurrence and survival in patients with
HBV-related HCC. With a better liver function reserve at
the time of recurrence, a greater proportion of patients in
the antiviral group could receive curative treatment for
recurrence [522].
Interferon treatment as tertiary prevention of HBV-related HCC recurrence remains controversial [523525].
Use of interferon treatment in HCC patients may be complicated and even risky, as these patients are more vulnerable to the development of hepatic decompensation with
life-threatening
complications
such
as
hepatic
encephalopathy and ascites. In contrast, nucleos(t)ide
analogues are, in general, safer and better tolerated than
interferon.
HBV recurrence after liver transplantation has always
been a major problem for HBV-related HCC. Pre-transplant HBV DNA level and antiviral treatment was a major
risk factor associated with HBV recurrence after liver
transplantation [526]. For all recipients with high load of
HBV DNA, a potent, high resistance NAs should be given

Hepatol Int

as early as possible before transplantation. HBIG should be

given during the anhepatic phase. NAs in combination with
low dose HBIG have been proved to reduce HBV recurrence after transplantation [527]. The most recent data
showed entecavir or tenofovir were more effective NAs
using this strategy [528] (see 3.12 Prevention and treatment of recurrent hepatitis B after liver transplantation
section).
3:13:8

Recommendations: patients before and/or after

curative or localregional therapy of HCC
3:13:8:1

3:13:8:2

3:13:8:3

NAs treatment should be given to

patients with HBV-related HCC (at least
12 weeks before, during and after
chemotherapy, locoregional therapies,
resection or LT), if they have
detectable serum HBV-DNA (B1).
Because NA therapy cannot completely
eradicate HBV, lifelong treatment is
needed (B2).
HBIG should be given to recipients with
high viral loads in anhepatic phase,
followed by combination therapeutic
modalities with NAs and low-dose HBIG
after LT to prevent HBV recurrence (B1).

3.13.9 Chronic HBV infection in children

The Oxford dictionary states that A young human being
below the age of puberty or below the legal age of majority
should be regarded as child. On the other hand, The
Nations Convention defines child as a human being below
the age of 18 years [529]. The UN convention has been
ratified by 192 of 194 member countries. However, different countries may have different age settings for children in medical set-up. Also, the age of voting rights differ
in different countries, ranging from 18 to 20 years. The
definition of child is of utmost importance for the treatment of chronic HBV-infected patients, as the pathogenesis
of HBV takes critical clinical turns in child, especially
around 1618 years of age. Transmission modalities for
HBV infection vary between different regions of the world.
In highly endemic areas, most infections are transmitted
from mother to child vertically/perinatally (mainly in Asian
countries) or through horizontal transmission from child to
child during early childhood (mainly in African countries)
[530]. In countries of intermediate endemicity, HBV
infection occurs in all age groups, whereas in areas of low
endemicity, infection occurs primarily in adult life through
sexual or parenteral transmission (e.g., drug use). In these
countries, surgery, dental care, tattooing, and body piercing
may be relevant sources of infection, while transfusion-

related infections have become very rare because of

improved blood screening [531]. The age at the time of
HBV acquisition is the major determinant of chronicity, as
about 90 % of newborns who acquire HBVperinatally
develop chronic HBV infection In contrast, only 2550 %
of children who acquire the virus in the first 6 years of life
and 5 % of adults become chronically infected [532].
Natural history of chronic HBV infection in children The
vast majority of children infected at birth are immunetolerant with high HBV DNA levels in serum and the
presence of HBeAg for years, typically into late childhood
or adolescence. Generally, in this phase, despite the highlevel HBV replication, the host T-cell response is suppressed, and infected hepatocytes are therefore not
attacked. Alanine aminotransferase (ALT) levels are frequently normal or slightly increased, and histological
changes are minimal. Transplacental transfer of maternal
HBeAg can induce tolerance of helper T cells of newborns
to HBeAg [309]. The affected children are usually
asymptomatic and have normal growth.
The immune-active phase is characterized by elevation
of aminotransferase and fluctuating serum HBV-DNA
levels. This phase may lead to seroconversion. Spontaneous seroconversion rates (loss of HBeAg and development of anti-HBe) in these perinatally infected children are
low, occurring in fewer than 2 %/year of children younger
than 3 years and in 45 % of children older than 3 years
[533]. These rates are much lower than those (1416 %/
year) observed in children infected horizontally after the
perinatal period [534, 535].
After achievement of anti-HBe seroconversion, serum
HBsAg persists, but aminotransferase levels return to
normal and HBV DNA becomes very low or undetectable.
This state is the low replicative phase, and in this phase,
liver disease progresses very slowly. Available data on
long-term follow-up of children in low replicative phase
without signs of cirrhosis at the time of seroconversion
have demonstrated no progression to cirrhosis over about
30 years [536, 537]. The complete resolution of HBV
infection is characterized by loss of HBsAg and appearance
of anti-HBs. This spontaneous vent is rarely observed in
children (0.61 %/year) [538]. Although in children and
adolescents, chronic HBV infection is generally a mild
disease with a benign course, 15 % of HBeAg-positive
children develop cirrhosis [536, 537].
Between 0.01 and 0.03 % of children with chronic HBV
infection develop HCC during childhood (32 per 100,000
person-year) [538, 539]. Children developing HCC are
more likely to be males (70 %), with cirrhosis (80 %), and
to have undergone early seroconversion (suggesting that
necroinflammation during seroconversion to anti-HBe may
be severe enough to lead to cirrhosis and HCC) [538]. In

123

Hepatol Int

adult patients, the long-term risk of both HCC and cirrhosis

is directly correlated to serum HBV DNA levels and
HBeAg positivity, but no conclusion can be drawn from
pediatric studies because of the rarity of HCC during
childhood. The role of viral genotype in the risk of
developing HCC is still to be clarified in the pediatric
population. The risk of HCC is higher in individuals with a
family history of HCC [71].
Indications of treatment in children with chronic HBV
infection Decision to treat must take into account the
mild evolution of the disease during childhood, the risk of
disease progression later in life, the development of severe
complications in few, not yet well-identified children, the
efficacy of current antivirals, their side effects, and the
limited number of drugs labelled for use in this age group
[540].
The need for treatment should be evaluated at each
follow-up visit, in order to initiate antiviral drugs at the
earliest signs of liver damage. Currently, decision to start
treatment is based on ALT levels, HBeAg positivity, HBV
DNA levels, assessment of liver disease severity (either
histology and/or noninvasive methods), family history of
HCC, and co-existing liver diseases (Table 12).
As the upper limit of normal (ULN) for ALT levels in
pediatric age has not yet been established, it is advised that
the normal limit should be as per the local laboratory ULN.
In the presence of high ALT levels, assessment of serum
HBV DNA levels is important, as high HBV DNA values
warrant antiviral treatment, whereas low levels should
instigate investigations to exclude other causes of liver
disease.
As response to currently available antivirals in children
is partial and limited to specific subgroups, histological
assessment of the degree of inflammation and of the stage
of fibrosis is recommended before considering treatment in
certain groups (Table 12). Response to both interferon
(IFN)-a and NA is more likely when at least moderate
necroinflammation or moderate fibrosis is found at liver
histology [541, 542]. Although the benefit of treatment has
not been established for children with mild inflammation or
fibrosis, a family history of HCC may warrant treatment
even in children with mild histological changes, as they are
at increased risk of developing HCC [71]. Although still
not fully validated, noninvasive methods to assess the
degree of hepatic fibrosis, such as FibroScan, could prove
useful to avoid liver biopsy, especially during follow-up.
However, sufficient data is lacking in children, and at
present, these noninvasive methods cannot substitute for
liver biopsy in the decision to treat a child or an adolescent
with CHB, as these methods evaluate more fibrosis than
necroinflammatory activity.

123

In HBeAg-positive children with elevated serum ALT

levels ([19 upper normal limit), an observation period of
12 months is recommended, as raised ALT levels and
variable levels of HBV-DNA may indicate imminent
seroconversion that would not require treatment.
In HBeAg-negative children, ALT and HBV DNA
levels should be measured every 3 months within the first
year to rule out HBeAg-negative hepatitis. After confirmation of the low replicative phase (normal ALT and HBV
DNA \2000 IU/ml), patients should be monitored with
ALT every 3 months and HBV DNA every 612 months.
HCC surveillance with liver ultrasound and AFP should
be done every 6 months, as in adults.
Treatment options for children with chronic HBV infection The US Food and Drug Administration (FDA)
approved five medications for treatment of children with
CHB: IFN-a, lamivudine, adefovir, entecavir, and recently,
tenofovir. IFN-a can be used in children older than
12 months of age, lamivudine starting at 3 years of age,
adefovir and tenofovir in children aged 12 years and older,
and entecavir starting from 16 years of age.
IFN-a Results of a large, multinational, randomized,
controlled trial of IFN-a in children with HBV infection
showed a virological response (defined as negativeHBeAg
and HBV-DNA) in 26 % of treated patients versus 11 % of
controls (p = 0.03) after 24 weeks of therapy. Loss of
HBsAg occurred in 10 % of treated patients versus 1.2 %
of controls [542]. Various studies have shown that factors
associated with response to treatment are elevated ALT
levels ([29 upper normal limit), low-serum HBV-DNA
levels, female gender, and age \5 years [543, 544].
However, long-term follow-up studies suggest that
untreated children may have similar rates of HBeAg
seroconversion as IFN-a-treated children, although the
seroconversion may lag by 13 years [545, 546]. With
respect to nucleoside analogs, IFN-a has the advantages of
a long-lasting response and no risk of mutants induction;
however, major disadvantages are the high-cost, frequent
side-effects, and the need for thrice-weekly injections. The
latter could be reduced by the use of pegylated IFN-a,
which requires a single weekly administration because of
its prolonged half-life. It is not yet approved for use in
children, although studies in adults HBV patients have
shown a higher efficacy with respect o IFN-a. In summary,
HBeAg seroconversion occurs earlier in IFN-a-treated
children with elevated ALT levels at the time of starting
therapy compared with controls. It remains to be established whether shifting the time to seroconversion by
1236 months reduces long-term damage to the liver [531].
Lamivudine A large multicenter trial of LAM in children
[547] showed that 23 % of the children in the treatment

Hepatol Int
Table 12 Indications of treatment in children with chronic HBV infection
HBV DNA
(IU/ml)

ALT

Treatment

Decompensated
cirrhosis

Detectable

Any

Treat. Histology not needed. Consider LT of no stabilization

Compensated
cirrhosis

Detectable

Any

Treat

Severe reactivation
of chronic HBV

Detectable

Elevated

Treat immediately

Noncirrhotic
HBeAg-positive
CHB

[20,000

[29 ULN

Follow-up for 1 year to see for spontaneous seroconversion. Treat if no

seroconversion. Histology not t needed

129 ULN

Follow-up for 1 year to see for spontaneous seroconversion. If no

seroconversion, assess severity of liver disease by biopsy. Treat if moderate
to severe inflammation or significant fibrosisa

Persistently normal
(immune tolerant
phase)

Monitor every 3 months. Biopsy if ALT persistently elevated or family h/o

HCC or cirrhosis. Treat if moderate to severe inflammation or significant
fibrosisa

200020,000

Any ALT

\2000

\ULN

Rule out other causes of elevated ALT if normal ALT. Monitor every 3 months.
Biopsy if ALT persistently elevated, or with family h/o HCC or cirrhosis.
Treat if moderate to severe inflammation or significant fibrosisa
Monitor every 3 months. Biopsy if ALT persistently elevated or with family h/o
HCC or cirrhosis. Treat if moderate to severe inflammation or significant
fibrosisa

Noncirrhotic
HBeAg-negative
CHB

[2000

\2000

[ULN

Rule out other causes of elevated ALT. Monitor every 3 months. Biopsy if ALT
persistently elevated, or with family h/o HCC or cirrhosis. Treat if moderate
to severe inflammation or significant fibrosis

[29 ULN

Treat. Histology not needed

129 ULN

Rule out other causes of elevated ALT. Monitor every 3 months. Biopsy if ALT
persistently elevated, or with family h/o HCC or cirrhosis. Treat if moderate
to severe inflammation or significant fibrosisa

Persistently normal

Monitor every 3 months. Biopsy if ALT persistently elevated, or with family

h/o HCC or cirrhosis. Treat if moderate to severe inflammation or significant
fibrosisa
Rule out other causes of elevated ALT. Monitor every 3 months. Biopsy if ALT
persistently elevated, or with family h/o HCC or cirrhosis. Treat if moderate
to severe inflammation or significant fibrosisa

[ULN

Persistently normal

Monitor ALT every 3 months and DNA 612 monthly. Biopsy if ALT
persistently elevated, or with family h/o HCC or cirrhosis. Treat if moderate
to severe inflammation or significant fibrosisa

A family history of HCC may warrant treatment even in children with mild histological changes, as they are at increased risk of developing
HCC

group cleared HBV-DNA and HBeAg, compared to 13 %

in the placebo group.
The response to treatment was especially in children
with higher ALT values and histological activity (among
children with ALT greater than five times the upper limit of
normal, HBeAg loss occurred in 50 % vs. 24 % in the
placebo group). However, 19 % of children developed
LAM resistant mutants. Other smaller studies of LAM
treatment in children have confirmed both the efficacy in
reducing serum HBV DNA and the high mutation rate
[548, 549].

Adefovir ADV dipivoxil is approved for the treatment

of adolescents ([12 years) with CHB, but not in
younger children after beneficial virological effects were
not observed in children between 2 and 12 years of age
in the primary efficacy, multicenter, randomized trial
where 23 % of adolescents reached a virological
response after 12 months of ADV treatment compared
with 0 % in the placebo group [550]. ADV is safe and
well tolerated in children, and no important resistanceassociated mutations have been observed in the pediatric
setting [551].

123

Hepatol Int

Entecavir ETV is more effective than LAM and ADV in

the treatment of CHB in adults. On the basis of these
encouraging results and a good safety profile, ETV has
been approved by the FDA for treatment of adolescents
over the age of 16. Clinical trials in children younger than
16 years are ongoing.
Tenofovir In a recent double-blind, placebo-controlled
trial on the use of tenofovir (300 mg once daily for
72 weeks vs. placebo) in CHB adolescents 12 to\18 years
of age, a virological response in 89 % of treated patients
was seen regardless of previous HBV therapies [552].
Normalization of ALT levels occurred in 74 % of treated
patients. No resistance to tenofovir developed through
week 72. Tenofovir therefore appears to be a promising
agent for the treatment of CHB in adolescents, although
long-term studies are needed to evaluate the rate of seroconversion and the impact on the development of HCC.
Treatment strategy for chronic HBV infection in children
Currently, a finite-duration IFN-a therapy remains the
treatment strategy of choice for HBeAg-positive children
with elevated ALT levels, as seroconversion to anti-HBe
is the main aim in this patient population. IFN-a is the
only available treatment offering a chance of sustained
off-treatment response. It is likely that, as soon as results
of trials using Peg-IFN in children are available, it will
become the recommended drug. The recommended regimen is 510 million units per square meter, three times
weekly for 6 months. For Peg-IFN, studies in adults show
the highest HBeAg seroconversion rate with 48-week
treatment schedules. IFN-a is the only treatment licensed
for treating children younger than 3 years of age, who,
however, rarely require therapy. In case of non-response
at the end of IFN treatment, wait for at least 12 months
before considering other therapies, as response may be
achieved during the 6 months following the end of IFN-a
treatment.
The recent FDA approval of tenofovir and entecavir,
which have high genotypic barriers to resistance, has made
them the first-line NA treatments for adolescents. In
patients older than 12 years of age, tenofovir (or entecavir
for patients [16 years old) is the best choice, as response
rate is high and resistance is less likely. The recommended
dose for tenofovir is 300 mg once daily, and for entecavir
is 0.5 mg once daily (for nucleoside-nave patients).

Although not yet approved for the treatment of CHB

inpatients \12 years of age, the use of tenofovir might be
safe in younger children, as it is already widely used (and
FDA licensed) for patients older than 2 years of age with
HIV infection. Since the approval of tenofovir for adolescents, adefoviris is no longer recommended because of the
higher risk of resistance and the lower response rate.
A finite-duration treatment with tenofovir or entecavir is
possible if seroconversion to anti-HBe is achieved on
treatment. Duration of treatments with NA has not been
established, but the recommendations should be as for the
adults. Patients should be monitored after discontinuation
because of the possibility of post-treatment flares.
Patients who do not undergo HBeAg seroconversion on
treatment, the rare children with HBeAg-negative chronic
hepatitis and cirrhotic patients need long-term treatment
with NA.
Tenofovir or entecavir, if allowed by the age, are the
first choice. Lamivudine is the only NA currently approved
for younger children. Its use should be limited to the rare
young children unresponsive to IFN-a and requiring
immediate treatment, and to special populations with
contraindications to IFN. The recommended treatment dose
for lamivudine is 3 mg/kg/day (maximum 100 mg/day),
administered orally once daily.
Treatment failure and antiviral resistance
The basic principles remain the same as for adults. Because
of the low number of effective drugs that are approved,
when resistance to an NA develops in children, the decision
of therapy adjustment is based on the patients age
(Table 13).
3:13:9

Recommendations: chronic HBV infection in

children
3:13:9:1
3:13:9:2

3:13:9:3

Any person up to the age of 18 years

will be considered as a child (A1).
The need for treatment should be evaluated at each follow-up visit, in order to
initiate antiviral drugs at the earliest
signs of liver damage (C2).
Children with decompensated cirrhosis
and detectable HBV DNA require urgent
antiviral treatment with NA(s). Liver
transplantation should be considered if

Table 13 Management of antiviral resistance in children with chronic HBV infection

Lamivudine
resistance

Switch to tenofovir (for [12 years old)

Adefovir
resistance

If the patient was NA-naive before adefovir, switch to entecavir (for [16 years age) or tenofovir (for [12 years age);
entecavir for ([16 years age) may be preferred in such patients with high viremia

123

Switch to IFN (\12 years of age)

Hepatol Int

3:13:9:4

3:13:9:5

3:13:9:6

3:13:9:7

3:13:9:8

3:13:9:9

3:13:9:10

3:13:9:11

3:13:9:12

patients do not stabilize with medical

management (A1).
Patients with moderate to severe activity
or significant fibrosis with any ALT
level should be considered for treatment
(A1).
Children with severe reactivation of
chronic HBV infection should be treated
without delay and irrespective of HBV
DNA levels (A1).
As the upper limit of normal (ULN) for
ALT levels in pediatric age has not yet
been established, it is advised that the
normal limit should be as per the local
laboratory ULN (C2).
In HBeAg-positive children with elevated serum ALT levels ([19 upper
normal limit), an observation period of
12 months is recommended, as raised
ALT levels and variable levels of HBVDNA may indicate imminent seroconversion that would not require treatment
(C1).
In HBeAg-negative children, ALT and
HBV DNA levels should be measured
every 3-months within the first year to
rule out HBeAg-negative hepatitis.
After confirmation of the low replicative
phase (normal ALT and HBV DNA
\2000 IU/ml), patients should be monitored with ALT every 3 months and
HBV DNA every 612 months (B1).
Treatment may be started in pre-cirrhotic chronic HBV-infected patients if
they have persistently elevated ALT
levels [2 times upper limit of normal
(ULN) (at least 1 month between observations) and HBV DNA [20,000 IU/ml
if they are HBeAg-positive and
[2000 IU/ml if HBeAg-negative, even
without a liver biopsy (B1).
Patients with compensated cirrhosis and
detectable HBV DNA should be considered for treatment even if ALT levels
are normal (B1).
Patients who are not considered for
treatment should be followed up regularly (Table 13) (B1).
Although the benefit of treatment has
not been established for children with
mild inflammation or fibrosis, a family
history of HCC may warrant treatment
even in children with mild histological

3:13:9:13

3:13:9:14

3:13:9:15

3:13:9:16

3:13:9:17

3:13:9:18

3:13:9:19

changes, as they are at increased risk of

developing HCC (B2).
No sufficient data are available for use
of noninvasive markers in children and,
at present, these noninvasive methods
cannot substitute for liver biopsy in the
decision to treat a child or an adolescent
with CHB, as these methods evaluate
more fibrosis than necroinflammatory
activity (C2).
The US FDA approved five medications
for treatment of children with CHB:
IFN-a, lamivudine, adefovir, entecavir,
and recently, tenofovir. IFN-a can be
used in children older than 12 months of
age, lamivudine starting at 3 years of
age, adefovir and tenofovir in children
aged 12 years and older, and entecavir
starting from 16 years of age (A1).
Currently, a finite-duration IFN-a therapy remains the treatment strategy of
choice for HBeAg-positive children
with elevated ALT levels (A1).
In case of no response at the end of IFN
treatment, at least 12 months should
elapse before considering other therapies, as response may be achieved
during the 6 months following the end
of IFN-a treatment (B1).
Patients who do not undergo HBeAg
seroconversion on treatment, the rare
children with HBeAg-negative chronic
hepatitis and cirrhotic patients need
long-term treatment with NA (B1).
The recent FDA approval of tenofovir
([12 years of age) and entecavir (for
[16 year of age), which have high
genotypic barriers to resistance, has
made them the first-line NA treatments
for adolescents (A1).
Although not yet approved for the
treatment of CHB in patients \12 years
of age, the use of tenofovir might be
safe in younger children, as it is already
widely used (and FDA-licensed) for
patients older than 2 years of age with
HIV infection (B1).

3.14 Treatment of acute HBV infection

The natural course of HBV infection is determined by the
interplay between virus replication and the hosts immune

123

Hepatol Int

response. Upon exposure to HBV, individuals with a vigorous and broad immune response to the virus develop an
acute self-limited infection that may result in acute hepatitis; an aberrant response can lead to fulminant hepatitis.
Individuals who do not mount a broad and vigorous
immune response do not clear the virus, but develop persistent infection and become chronically infected with
HBV.
Clinical manifestations
During the acute phase of hepatitis B (AVH-B), manifestations range from subclinical or anicteric hepatitis to
icteric hepatitis, and in some cases, fulminant hepatitis.
Approximately 70 % of patients with acute hepatitis B
have subclinical or anicteric hepatitis, while 30 % develop
icteric hepatitis. The course of acute hepatitis B is divided
into the incubation period, and preicteric, icteric and convalescence phases. From the incubation period to the onset
of symptoms or jaundice, it averages 75 days (range
40140 days). The onset of hepatitis B is typically insidious, with nonspecific symptoms of malaise, poor appetite,
nausea and pain in the right upper quadrant. With the onset
of the icteric phase, symptoms of fatigue and anorexia
typically worsen. Jaundice can last from a few days to
several months, the average being 23 weeks. Itching and
pale stools may occur. The convalescent phase of hepatitis
B begins with the resolution of jaundice. Fatigue is generally the last symptom to abate and may persist for many
months into convalescence.
The physical signs of typical acute hepatitis B are not
prominent. Variable degrees of jaundice are present. The
only other common physical finding in acute hepatitis B is
a mild and slightly tender hepatomegaly. Mild enlargement
of the spleen or lymph nodes occur uncommonly.
Pathogenesis
It is clear that replication and persistence of HBV is not
cytopathic per se. Studies in acutely HBV-infected chimpanzees and woodchucks showed that no host response to
viral replication occurred during the incubation phase, as
HBV infection does not stimulate the innate immune system, which recognizes pathogen-associated molecular
patterns. In contrast, later in the infection period, most of
the effector molecules associated with the adaptive cellular
immune response are induced, followed by HBV antibodies. HBV elimination starts several weeks before onset of
the disease with T-cell-dependent noncytolytic mechanisms, but later cytolytic immune responses follow and
generate the symptoms of acute hepatitis [553].
High disease activity usually leads to clinical and
serological resolution. However, even after serological

123

resolution, small amounts of cccDNA persist in the liver

for years, decades and possibly for life. T cell immunity
suppresses viral replication originating from these cccDNA
copies to very low levels [554]. Anti-HBc appears with the
onset of the disease as the first anti-HBV antibody, then
anti-HBe, anti-pre-S, and finally, anti-SHBs. These antibodies probably contribute neither to virus elimination
from the liver nor to the pathogenesis of hepatitis. However, anti-HBs formed during convalescence and later may
enhance opsonization of HBsAg and block de novo
infection of hepatocytes by released HBV. In contrast to
the other HBV antibodies, anti-HBc induction is partially T
cell independent. This explains the presence of anti-HBc
even in those patients who do not build up an efficient
immune response. Serological resolution is defined by the
disappearance of HBsAg, which may take months after
onset.
In subjects who have been previously vaccinated, there
is earlier engagement of innate and adaptive immunity at
much lower viral loads, leading to blunted viral load
increase and rapid clearance of virus, thus preventing
development of clinically significant acute and chronic
HBV infection [555].
Diagnosis
The differential diagnosis of HBsAg-positive acute hepatitis includes reactivation (flare or exacerbation) of hepatitis in chronic HBV-infected patients.
Laboratory testing during the acute phase of acute
hepatitis B reveals elevations in the concentration of alanine and aspartate aminotransferase levels (ALT and AST);
values up to 10002000 IU/l are typically seen during the
acute phase, with ALT being higher than AST. The serum
alkaline phosphatase and lactic dehydrogenase are usually
only mildly elevated (less than threefold). The bilirubin is
variably increased, in both direct and indirect fractions.
The serum bilirubin concentration may be normal in
patients with anicteric hepatitis. Serum albumin rarely falls
except with protracted severe disease. The prothrombin
time can increase and is the most reliable marker of
severity of injury. In patients who recover, normalization
of serum aminotransferases usually occurs within
14 months. Persistent elevation of serum ALT for more
than 6 months may indicate progression to chronic hepatitis. Various auto-antibodies can appear during the course
of acute hepatitis B, most typically to smooth muscle.
The diagnosis of acute hepatitis B is based upon the
detection of HBsAg and IgM anti-HBc. During the initial
phase of infection, markers of HBV replication, HBeAg
and HBV DNA, are also present. Recovery is accompanied
by the disappearance of HBV DNA, HBeAg to anti-HBe
seroconversion, and subsequently HBsAg to anti-HBs

Hepatol Int

seroconversion. During resolving acute hepatitis B, antiHBe appears after anti-HBc, but before anti-HBs. It usually
disappears earlier than anti-HBs.
Rarely, patients present during the window period when
HBsAg has become negative but anti-HBs is not yet positive. In this setting, which is more common in patients
with fulminant hepatitis B in whom virus clearance tends to
be more rapid, IgM anti-HBc is the sole marker of acute
HBV infection.
In acute infections, HBsAg concentrations rise logarithmically for weeksmonths from undetectable to typical
final concentrations of 10,000100,000 ng/ml with
24 days of doubling time [556]. If the acute HBV infection is resolved, HBsAg decreases with an initial half-life
of 8 days until it has been completely removed from serum
after weeksmonths. In about 25 % of acute resolving
hepatitis B cases, the elimination of HBsAg proceeds much
faster, with the consequence that samples taken in the late
acute phase may be HBsAg negative [557]. A decrease in
HBsAg concentration by more than 50 % within the first
4 weeks indicates resolving acute infection in [95 % of
cases [558]. Hence, quantitative analysis of highly concentrated HBsAg is an excellent prognostic marker, indicating progression to chronicity if the values remain
stable or increase.
Anti-HBc immunoglobulin (Ig)M (anti-HBc IgM) may
be useful in two situations: (1) to distinguish an acute
hepatitis caused by HBV from a hepatitis of different etiology in a chronic HBV-infected patient; and (2) to identify
an acute hepatitis in some hepatitis B patients, particularly
those with fulminant hepatitis B or HDV coinfection,
where HBsAg may have been eliminated very rapidly.
Predominant TH1 immune response in AVH-B favors cellmediating viral clearance, while TH2-mediated immune
response in chronic HBV infection favors antibody production. HBV antigens elicit immune-mediated liver injury
in a dose-dependent manner; therefore, low viral antigen
load and subsequent resolution of infection in AVH-B as
compared to persistent viral antigenemia in chronic HBV
infection leads to significantly increased production of
HBV specific antibodies (mainly Anti HBe/Anti HBc) in
chronic HBV infection or its exacerbation in comparison to
AVH-B [559]. Tests should be quantitative because antiHBc IgM is also positive in CHB and during convalescence. Levels[600 PaulEhrlich units/ml or IgM anti-HBc
([1:1000) suggest an acute HBV infection with high
inflammatory activity. In all other situations, concentrations are lower or undetectable [23, 319]. In a study on
patients with a protracted clinical course of [2 months
with elevated liver enzymes and positive HBV DNA, it was
found that peak bilirubin level, peak AST levels and least
platelet count within the first 8 weeks had the highest
predictive power for differentiating patients with CHB with

acute flare from acute hepatitis B. Bilirubin, AST and

platelet count (BAP) score was calculated, and a score of
[2 strongly suggested an acute flare of CHB [560].
The meaning of the term anti-HBs is somewhat
ambiguous. Some understand it to mean antibodies only
against the small HBsAg protein (SHBs), others the entire
antibody spectrum against all three surface proteins
including pre-S1 and pre-S2. During acute infection, antipre-S antibodies appear before anti-SHBs, and they often
coexist with HBsAg.
Outcome of acute hepatitis B
Fulminant hepatitis B is an atypical course for acute hepatitis B infection, occurring in \1 % of icteric cases.
Typically, in fulminant disease, HBV DNA and HBeAg
become undetectable as hepatic failure supervenes.
The rate of progression from acute to chronic hepatitis B
is determined primarily by the age at infection. The rate is
approximately 90 % for a perinatally acquired infection,
2050 % for infections between the age of 1 and 5 years
and \5 % for an adult-acquired infection [561]. Genotype
A was an independent risk factor for progression to chronic
infection following AVH-B in Japan [562]. In Japanese
patients, high levels of HBsAg at 12 weeks and HBV DNA
at 8 weeks were useful for discriminating between the
patients who lost HBsAg within 12 months and those who
did not. Only those who fail to clear HBV within
12 months from the onset may develop chronic infection
[563].
Treatment
Treatment for acute HBV is mainly supportive. In addition,
appropriate measures should be taken to prevent infection
in exposed contacts.
Patients who have a coagulopathy, are deeply jaundiced,
are encephalopathic or cannot tolerate oral intake should
generally be hospitalized.
Whether patients should be treated with nucleos(t)ide
therapy is unsettled since few studies have addressed the
benefits of antiviral therapy during acute infection. One
prospective case series treated 15 patients with severe AHB
(INR [1.6, serum bilirubin levels [10 mg/dl or hepatic
encephalopathy) with 100 mg of lamivudine, achieving a
response rate of 86 % [564]. The first randomized clinical
trial included a total of 71 patients with AHB (31 randomized to lamivudine for 3 months and 40 to placebo)
and showed no biochemical or clinical benefit to lamivudine; the lack of response to therapy was also observed in
the subset of patients with severe AHB. There was also no
difference in HBsAg loss after 12 months (94 vs. 97 % in
the groups that received lamivudine and placebo,

123

Hepatol Int

respectively) [565]. However, another RCT that included

80 AVH-B patients showed statistically significant differences in mortality (7.5 % lamivudine vs. 25 % placebo)
and incidence of acute liver failure (20 vs. 42.5 %). The
study also showed that the sooner the treatment is initiated,
the better the results obtained, and a rapid decline of HBV
DNA load was a good predictor for the treatment outcome
[566]. In a few other studies, patients with severe acute or
fulminant hepatitis B were treated with lamivudine,
demonstrating the safety and efficacy of this antiviral drug,
with a capacity for improving the prognosis of these
patients [567569]. Antivirals other than lamivudine have
been investigated so far, in small case reports or series of
acute severe hepatitis B, with some promising preliminary
results with the use of entecavir [570, 571], tenofovir [572,
573], and telbivudine [574].
Thus, antiviral therapy is not indicated in the vast
majority of patients with acute hepatitis B, but may be
indicated in certain subgroups of patients as follows:
(a) patients with fulminant acute hepatitis B; (b) severe
AVH-B: individuals who fulfill any two of the following
criteria: (1) hepatic encephalopathy; (2) serum bilirubin
[10.0 mg/dl; and (3) international normalized ratio
(INR) [1.6, especially if it is increasing; and (c) a protracted course [such as persistent symptoms or marked
jaundice (bilirubin [10 mg/dl) for more than 4 weeks after
presentation].
These indications outline the limitations in differentiating AVH-B from reactivation of chronic HBV infection.
An argument can be made for treating all of the above
groups of patients using an NA, given its safety and the fact
that many of these patients may ultimately need liver
transplantation and reduction of HBV DNA levels would
reduce the risk of recurrent hepatitis B after transplant.
Interferon should be avoided because of the increased
risk of hepatic necro-inflammation. Telbivudine, lamivudine, adefovir, entecavir or tenofovir are acceptable options
when given as monotherapy, as the duration of treatment
should be short. Treatment can be stopped after confirmation that the patient has cleared HBsAg.
3:14

Recommendations (acute viral hepatitis B)

3:14:1

123

Establishing a diagnosis of acute HBV is

important, as majority of adult patients
presenting as acute hepatitis B have reactivation of CHB. A definite history of
exposure, positive HBeAg and IgM
antiHBc with low HBV DNA levels and
liver biopsy in doubtful cases can help to
establish the diagnosis of acute HBV
infection and exclude the diagnosis of
HBV reactivation (B1).

3:14:2

3:14:3
3:14:4

3:14:5

3:14:6

3:14:7
3:14:8

More than 9599 % of adults with acute

HBV infection will recover spontaneously
and seroconvert to anti-HBs without antiviral therapy (A1).
Patients with fulminant hepatitis B must be
evaluated for liver transplantation (A1).
Treatment is only indicated for patients
with fulminant hepatitis B or for those with
severe or protracted acute hepatitis B (C2).
Tenofovir, entecavir, telbivudine, lamivudine or adefovir are acceptable options
when given as monotherapy, as the duration
of treatment should be short (C2).
The duration of treatment is not established. However, treatment should be continued until HBsAg clearance is confirmed,
or indefinitely in those who undergo liver
transplantation (C2).
Interferon is contraindicated (A1).
When the distinction between true severe
acute hepatitis B and spontaneous reactivation of chronic HBV infection is difficult,
NA treatment should be administered (A1).

3.15 Antiviral prophylaxis

before immunosuppressive therapy
or chemotherapy
Chemotherapy-induced HBV reactivation and hepatitis
flare is a common complication in HBsAg(?) cancer
patients, with the incidence ranging from 20 to 70 % in
previous reports [575]. Increased incidence of HBV reactivation was associated with cancer types (lymphoma,
breast cancer, HCC), viral factors (high baseline HBV
DNA, HBeAg positivity), and types of anti-cancer therapy
(steroid, anthracyclines). All candidates for chemotherapy
and immunosuppressive therapy should be screened forHBsAg and anti-HBc prior to initiation of treatment.
Vaccination of HBV seronegative patients should be considered. Higher vaccine doses may be required to achieve
anti-HBs response in immunocompromised patients.
The efficacy of prophylactic anti-viral therapy in preventing HBV reactivation in HBsAg(?) patients was firmly
established by two randomized trials in lymphoma patients
and meta-analysis involving clinical trials and cohort
studies of various cancer types [576578]. Lamivudine was
used in all of these studies and was shown to reduce the
risk of HBV reactivation [risk ratio (RR) 0.13, 95 % CI
0.070.24], reactivation-related mortality (RR 0.30, 95 %
CI 0.10.94), and to reduce the delay/premature termination of chemotherapy (RR 0.41, 95 % CI 0.270.63) [579].
The optimal duration of lamivudine prophylaxis was not

Hepatol Int

explored in these studies, and current recommendation for

the duration of anti-viral prophylaxis is 612 months after
completion of chemotherapy [25, 105]. It is not known
whether more potent anti-viral agents, such as entecavir
and tenofovir, can further improve the prophylactic efficacy in reducing the risk of HBV reactivation or reactivation-related mortality. However, these agents should be
considered if prolonged anti-viral therapy is indicated,
because of their lower rate of treatment-induced HBV
resistance.
HBV reactivation has also been reported in HBsAg(?)
cancer patients who received other molecular target therapies. In the case of mTOR (mammalian target of rapamycin) inhibitor, everolimus is approved for the treatment
of neuroendocrine tumor and renal cell carcinoma (as
single-agent), and breast cancer (in combination with
hormonal therapy) [580, 581]. This may be due to the
effects of everolimus (and other mTOR inhibitors) on
immune suppression or on HBV synthesis [582].
Immunosuppressive therapy is required for patients who
undergo solid organ transplantation, and long-term antiviral therapy is recommended for HBsAg(?) organ transplant recipients [583]. Immunosuppressive therapy,
including steroid, cytotoxics, and biological agents (e.g.,
tumor necrosis factor-a-blocking agents), is also commonly used in patients with inflammatory bowel disease
and rheumatic diseases. Although prospective studies in
these patient populations are lacking, the incidence and
severity of HBV reactivation has generally correlated with
the extent of immune suppression, and fatal HBV reactivation has been reported [584586]. Therefore, despite the
lack of randomized clinical trials, prophylactic anti-viral
therapy is recommended for HBsAg(?) patients who
received immunosuppressive agents for auto-immune and
rheumatic diseases. However, the duration may be longterm, and its cost-effectiveness is not yet established.
Chemotherapy-induced HBV reactivation in patients
with resolved HBV infection (i.e., patients who are negative for HBsAg but positive for anti-surface (anti-HBs) or
anti-core (anti-HBc) antibodies) is also mostly reported in
lymphoma patients who received rituximab-containing
regimens [587592]. The cumulative risk of hepatitis-related mortality in these early, retrospective series, in which
no preventive strategies were adopted, was about 1 %. Two
prospective studies exploring different preventive strategies were recently reported. Hsu et al. reported prospective
follow-up of HBV DNA and entecavir therapy upon HBV
DNA reactivation in lymphoma patients who received
rituximab-based chemotherapy [593, 594]. The incidence
of HBV DNA reactivation was 1040 %, depending on the
sensitivity of the HBV DNA test and the diagnostic criteria
for HBV reactivation. Huang et al. [595] compared prophylactic entecavir treatment and therapeutic (started when

HBV DNA reactivation was confirmed) entecavir treatment

in lymphoma patients who received rituximab-CHOP
chemotherapy, and confirmed that prophylactic entecavir
treatment significantly reduced the risk of HBV reactivation. In these studies, the incidence of HBV-related hepatitis flare in patients with HBV DNA reactivation was
\50 %, and no HBV-related liver decompensation or
death was noted. No risk factors for HBV reactivation were
identified, though baseline anti-HBs titer was proposed.
Physicians should be aware of the potential life-threatening
consequence of HBV reactivation in this patient population. However, the optimal preventive strategy remains
undetermined. RCT has clearly demonstrated the efficacy
of prophylactic anti-HBV in high-risk lymphoma patients
with resolved HBV infections. Further studies to identify
host and viral risk factors for HBV reactivation and costeffectiveness of different preventive strategies are clearly
needed.
Incidence and severity of HBV reactivation in patients
with resolved HBV infection who received other
immunosuppressive agents are not well defined [596].
HBsAg-negative patients with positive anti-HBc antibodies
should be tested for HBV DNA. HBsAg-negative, antiHBc positive patients with detectable serum HBV DNA
should be treated similarly to HBsAg positive patients.
HBsAg-negative, anti-HBc positive patients with undetectable serum HBV DNA, and who receive chemotherapy
and/or immunosuppression regardless of anti-HBs status,
should be followed carefully by means of ALT and HBV
DNA testing, and be treated with NA therapy upon confirmation of HBV reactivation before ALT elevation [25].
The frequency of monitoring can range from 1 to 3 months,
depending on the type of immunosuppressive therapy and
comorbidities. Some experts recommend prophylaxis in all
HBsAg-negative, anti-HBc positive patients who receive
rituximab and/or combined regimens for hematological
malignancies, if they are anti-HBs negative and/or if close
monitoring of HBV DNA is not guaranteed [597599].
NA prophylaxis is also recommended for anti-HBc
positive patients receiving bone marrow or stem cell
transplantation [599, 600]. The optimal duration of prophylaxis for these indications is not known.
3:15

Recommendations: antiviral prophylaxis before

immunosuppressive therapy or chemotherapy
3:15:1

3:15:2

All candidates for chemotherapy and

immunosuppressive therapy should be
screened for HBsAg and anti-HBc prior to
initiation of treatment (A1).
Prophylactic anti-viral therapy should be
given to HBsAg(?) cancer patients who
receive cytotoxic or immunosuppressive
therapy, both during therapy (regardless of

123

Hepatol Int

3:15:3

3:15:4

3:15:5

HBV DNA levels) and for 12 months after

cessation of therapy to reduce the incidence
and severity of HBV reactivation (A1).
Physicians should be aware of the risk of
HBV reactivation in lymphoma patients
with resolved HBV infection [HBsAg(-)
and anti-HBc(?) who receive rituximabcontaining chemotherapy]. Further studies
are needed to compare the efficacy and
cost-effectiveness of different preventive
strategies (prophylactic antiviral therapy vs.
regular HBV DNA monitoring) (B1).
HBsAg-negative patients with positive antiHBc antibodies should be tested for HBV
DNA. HBsAg-negative, anti-HBc positive
patients with detectable serum HBV DNA
should be treated similarly to HBsAgpositive patients (C1).
HBsAg-negative, anti-HBc positive patients
with undetectable serum HBV DNA and
who receive chemotherapy and/or immunosuppression regardless of anti-HBs status
should be followed carefully by means of
ALT and HBV DNA testing, and be treated
with NA therapy upon confirmation of HBV
reactivation before ALT elevation (C1).

3.16 Public health issues for HBV: prevention

and management
Needles and other sharp instruments
It has been well established that HBV can be spread by
contaminated needles, including intravenous drug use,
accupuncture, tattoos, ear piercing and needle prick injuries
in hospital situation. This can be prevented by raising
awareness and by public education. In more developed
countries, disposable needles are used for accupuncture and
ear piercing. The use of disposable needles/instruments is
more difficult to implement. The importance of implementing safe sharps practices in the hospital setting cannot
be over emphasized. Other than the use of disposable
needles and sharps boxes, education and surveillance
concerning the disposal of sharps, the banning of recapping
needles, the transfer of blood from syringes into containers,
and needle disassembly should be enforced.
Transfusion services
There has been widespread implementation of screening
for HBsAg (and anti-HCV as well as anti-HIV) in the
transfusion services in most countries in Asia. However,

123

with the use of potent immunosuppressors, especially antiCD20s such as rituximab and ofatumumab, it becomes
increasingly important for transfusion services to screen for
occult hepatitis B, since such recipients may develop severe/fulminant hepatitis B. This would require the use of a
nucleic acid test (NAT) to quantify small amount of HBV
DNA [601]. The great expense for such testing is a
potential limitation, but NAT has become mandatory in
more developed countries.
Prevention of maternal to child transmission
of the hepatitis B virus: vaccination and antiviral treatment
The risk of maternal to child transmission of HBV had
been well documented, mostly from studies from Taiwan,
prior to the development of the hepatitis B vaccine in 1981
[602]. Up to 63 % of infants born of HBsAg-positive
mothers became HBsAg-positive during the first 6 months
of life. Six percent of fathers and 67 % of siblings were
also HBsAg-positive. Infants born of HBeAg-positive
mothers have a higher chronic HBV positivity rate compared to those born of HBeAg-negative mothers, proving
that transmission is related to high viral load. However, up
to 2530 % of infants born of HBeAg-negative mothers
also become chronic HBsAg positive, showing that
HBeAg-negative mothers can also have high viral load. It
has subsequently also been shown by sequence analysis of
HBV mutations that post-natal transmission can occur from
HBsAg-positive fathers and even aunts [603]. With the
availability of both hepatitis B immune globulin (HBIG)
and hepatitis B vaccine (at first plasma-derived, later
recombinant), there was marked reduction in the infant
infection rate [125]. In one of the most carefully planned
studies, the infant chronic HBV positivity state was
reduced from 73.2 % in the control group to 21.0 % in the
vaccine alone group, 6.8 % in the group receiving vaccine
plus one dose of HBIG and 2.9 % in the group receiving
vaccine plus multiple doses of HBIG (p B 0.0001 for all
groups) [604]. With increased knowledge of, and better
assays for, HBV DNA, it has recently been shown in a
retrospective study of 869 HBsAg-positive mothers and
their infants who had received HBIG with three does of
hepatitis B vaccine, that 27 infants (3.1 %) were HBsAgpositive at age 712 months [605]. Multivariate analysis
showed that maternal HBV DNA levels and
detectable HBV DNA in the cord blood were independent
risk factors for immunoprophylaxis failure. All failures
occurred in infants born of HBeAg-positive mothers with
pre-delivery HBV DNA C6 log10 copies/ml. Other smaller
studies also confirm that high maternal viral load (in the
study of Wiseman et al. HBV DNA of [8 log10 copies/ml)
is associated with failure of prophylaxis [126, 606]. Since it
is possible that mothers with HBV DNA levels between 6

Hepatol Int

and 8 log10 copies/ml can still induce immuonprophylaxis

failure in their infants, it is advisable to treat mothers with
antiviral therapy when their HBV DNA levels are C6 log10
copies/ml. There have been long-term follow-up studies of
vaccinated infants, one of which follow the vaccine
recipients for 22 years [606]. Booster doses are probably
not necessary for immune competent subjects, because of
good anamnestic responses even after the anti-HBs titers
have fallen to very low levels (\10 mIU/ml).
Increasing the awareness of the public and medical
personnel
Education of public and health care professionals will help
in identification of persons at risk for viral hepatitis, and
ensure appropriate counseling, diagnosis, medical management, and treatment [607]. Appropriate training for
medical personnel is important.
Shift in focus from tertiary care to community and primary
care settings
The management of CHB requires a shift in focus from
tertiary care to community and primary care settings. This
could also include an exploration of alternative arrangements for care, including possible roles for nurse practitioners or hepatitis coordinators besides primary care
doctors. Primary care services, particularly those working
in high prevalence areas, and community organizations
providing support and advice to priority populations will
need to play an increasingly important role in hepatitis B
screening, testing and monitoring. Better understanding of
hepatitis B and C and its management is also required for
some primary care practitioners and non-hepatology specialists such as those involved in antenatal care, where in
some cases, maternal treatment can significantly reduce the
risk of transmission of HBV to the baby. A 6-year study
from China reported that the training of general practitioners (GPs) of village clinics in Hebei province improved
their practice, for instance, the sterilization of needles,
syringes and transfusion sets. The chronic HBV positivity
rate of 2-year-old children (mothers are HBsAg negative)
dropped from 11.6 to 2.1 %, which indicates that the
training of GPs decreases the transinfection rate of HBV
[608].
3:16

Recommendations: public health issues for HBVprevention and management

3:16:1

3:16:2

The general public should be educated

concerning care in using needles and other
sharp instruments (A1).
Hospitals should strongly enforce the implementation of safe sharps practices (A1).

3:16:3
3:16:4
3:16:5
3:16:6
3:16:7

Transfusion services should be encouraged

to use NAT as screening tests (B1).
Universal hepatitis B vaccination of newborns should be enforced (A1).
Increasing the awareness of the public and
medical personnel should be a priority (A1).
Appropriate training for medical personnel
at various levels is important (A1).
A shift in focus from tertiary care to
community and primary care settings is
needed (A1).

3.17 Occult HBV infection

Definition and patient category
Occult hepatitis B (OBI) infection is defined by
detectable HBV DNA in serum and/or liver in patients who
are tested negative for serum HBsAg by the most sensitive
commercial assays [609]. There are three groups of subjects in whom HBV DNA is detectable with concomitant
undetectable serum HBsAg.
For the first group, subjects are in the window phase of
HBV infection, exposed recently. Depending on the
immune status at the time of contacting HBV, the subjects
may have acute hepatitis B with resolution of the disease or
become chronically infected with hepatitis B. They are
therefore regarded as subjects with past infection and
subjects with chronic HBV infection, respectively, in
subsequent follow-ups. In the former group, subjects would
have positive or negative anti-HBs and anti-HBc in subsequent follow-ups. It is, however, important to note that
studies have shown that HBV DNA may still be
detectable in some of these subjects even after years of socalled acute HBV infection [610, 611]. These subjects may
also be having OBI. More longitudinal studies are required
to delineate the outcome of acute HBV infection in this
regard.
For the second group, patients are considered as having
primary OBI. These patients have been identified only by
persistently detectable HBV DNA without prior documentation of HBsAg positivity before the presentation.
For the third group, patients have known chronic HBV
infection with previous documentation of HBsAg positivity
for at least 6 months and are undergoing subsequent
HBsAg seroclearance, i.e., entering into the last phase of
chronic HBV infection. Around 5060 % of these patients
are positive for anti-HBs [612].
OBI can also be serologically classified into sero-positive (anti-HBs and/or anti-HBc positive) or sero-negative
(both anti-HBs and anti-HBc negative). It is estimated that
upto a total of 20 % of OBI patients are negative for all

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Hepatol Int

serological markers of HBV infection [613]. These serologically negative OBI patients may likely be infected with
minute amounts of HBV which are insufficient to mount
intense and specific immune responses.

HBV disease activity [628] and also the chance of loss of

HBsAg seroclearance [629].

Prevalence of OBI

OBI is of particularly interest in three main clinical areas.

First, whether HBV is transmissible from OBI patients.
Second, what are the clinical manifestations of OBI,
including liver function, histological features, and longterm complications, e.g., liver cirrhosis and HCC? Finally,
what is the risk of reactivation of HBV from OBI patients
who have undergone immunosuppressive therapy?
There are several studies addressing the issue of transmissibility of HBV through the blood products from OBI
subjects. It has been shown that while HBV transmission is
possible, the risk is relatively low (13 %) [630]. Factors
affecting the chance of infection of recipients include the
anti-HBs status in the donors and the recipients, the blood/
product volume received by the recipients, and the immune
status of the recipients [631]. There has been a practice of
anti-viral prophylaxis being given to recipients receiving
bone marrow or solid organ donations from OBI subjects.
Many centers advocate the use of nucleos(t)ide analogs for
recipients who received bone marrow/organs from donors
who are anti-HBc positive with or without detectable HBV
DNA.
There are many studies examining the possible pathogenic role of OBI. According to several studies, nearly all
OBI patients will have normal liver biochemistry and
minimal or no necroinflammation and fibrosis in liver
histology [632, 633]. However, OBI may still be associated
with the development of liver cirrhosis and HCC. OBI as
the etiology for development of cirrhosis and HCC is well
reported in the setting of coinfection with chronic hepatitis
C infection [634]. The estimated frequency of OBI in
patients with cryptogenic liver cirrhosis ranges from 4.8 to
40 % [635, 636].
4580 % of patients with apparently unidentifiable
cause of HCC have had HBV detected in the liver, suggesting that OBI is associated with increased risk of HCC
[637, 638]. A longitudinal follow-up study conducted in
Japan confirmed OBI increased the risk of HCC [639]. A
recent meta-analysis recruiting 16 studies revealed that
OBI increased the risk of development of HCC, with an
adjusted odds ratio of 2.9 from five prospective studies
[634]. This was confirmed by another meta-analysis that
included 14 studies showing increased risk of HCC in OBI
subjects with an OR of 8.9 [640]. Possible mechanisms for
OBI leading to these complications include (1) persistent
low-grade inflammation leading to or continuing with
existing cirrhosis [641]; (2) persistent oncogenic role of the
HBV genome with its possible integration into the human
genome as well as with its free episome [642]; and (3) low

There is a wide range of estimation of the prevalence of

OBI reported in different countries. It ranges from \1 to
18 % [614618]. These data are grossly underestimated,
and this is related to the fact that most of the OBI patients
have extremely low HBV DNA levels in the serum (and
liver tissues are generally not easily assessible). Although
the viremia level (HBV DNA) is generally quoted as lower
than 200 IU/ml [613], at least more than 90 % of OBI
patients will have HBV DNA levels of \20 IU/ml in the
serum [616]. These low levels of HBV DNA as well as
their fluctuations make the detection of this condition difficult even when using existing standardized and sensitive
HBV DNA assays.
Pathogenesis of OBI
Mechanisms leading to OBI remain obscure. Proposed
mechanisms include mutations of viral genomes, especially over the surface gene (e.g., G145R), such that they
escape detection by commercial HBsAg assays [619].
However, studies have shown that there is an absence of
relevant mutations in the genomic HBsAg coding region
[620, 621]. Another better accepted postulation is that in
OBI patients, the HBV is replicating at an extremely low
rate [622]. This can either be due to intrinsically low viral
replicative activities or extrinsic factors; namely, an
immense immune suppressive effect on the HBV. Several
studies have found that there are significantly more
genomic mutations and rearrangement in splice donor
sites of the pre-S1, pre-S2, and S genes and their regulatory regions [623, 624]. Other studies reported greater
nucleoside and amino acid diversities in OBI compared to
those of overt chronic HBV infection [621, 623]. Additive
effects from these mutations may restrain the virus
replication capacity. Post-transcriptional mechanism
involving the Pre-S2/S RNA splicing has also been proposed to explain the marked decrease in pre-S2/S transcript and HBsAg [625]. On the other hand, reactivation
of HBV from OBI during and after immunosuppressive
therapy (including anti-CD20) indirectly suggests that the
OBI state is kept by immune-mediated suppression of
virus replication [626]. In fact, it has been shown that
human genomic constitutions, in particular, the HLA DP
region as illustrated by studies using single nucleotide
polymorphisms (SNP) affecting the immune responses,
are associated with the chance of HBV chronicity [627],

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Clinical scenarios of OBI

Hepatol Int

levels of HBV transcriptional activities with viral protein

synthesis (e.g., X protein and truncated preSS protein)
with transforming properties [643].
HBV reactivation in OBI subjects undergoing
immunosuppressive therapy has recently gained increasing
attention because of the potential fatal hepatic decompensation if the condition is not treated promptly (see 3.15
Antiviral prophylaxis before immunosuppressive therapy
or chemotherapy section).
Concerning the antiviral treatment, it is recommended
that whenever HBV DNA is detectable in the serum of
HBsAg-negative and anti-HBc/anti-HBs-positive patients
at baseline, antiviral treatment should be given as in the
case of HBsAg-positive patients. Patients who are negative
for HBV DNA at baseline should have HBV DNA and
liver function checked at regular intervals of 13 months
unil at least 12 months after the last cycle of immunosuppressive therapy. The frequency of monitoring depends
on which agents are being used (for example patients on
rituximab should be checked more frequently). HBV DNA
levels are more sensitive indices of reactivation than liver
function since they become detectable before ALT levels
start to increase. For those with undetectable HBV DNA at
baseline, once HBV DNA is detectable on follow-up,
patients should be treated with nucleos(t)ide analogues. It
has also been suggested that patients should be treat preemptively if they are anti-HBs negative or if close followup cannot be assured [597, 598].
To date, there are insufficient data to recommend whether routine antiviral prophylaxis right at the initiation of
immunosuppressive therapy or postponement of antiviral
agents until HBV DNA becomes undetectable is more
appropriate. In addition, there is no good data on the frequency of monitoring of HBV DNA and HBsAg during
and after immunosuppressive therapy. According to a
recent study adopting 4 weekly HBV DNA monitoring in
HBsAg-negative, anti-HBc positive patients receiving
rituximab and prompt entecavir treatment once the HBV
DNA is detectable, all of the patients achieved excellent
control [594].
3:17

3:17:3

3:17:4

3:17:5

HBV DNA measurement in serum and liver

(if available) by highly sensitive assays
should be performed in patients with
cirrhosis and/or HCC in which no causes
are identifiable (B1).
Chronic hepatitis B patients with HBsAg
seroclearance still require continuous follow-up for the development of cirrhosisrelated complications and HCC (A1).
HBsAg negative, anti-HBc positive subjects
with or without positive anti-HBs should be
closely monitored by HBV DNA during and
at least 12 months after immunosuppressive
therapy. Monitoring should be more frequent
in patients receiving potent B cell depletion
agents, e.g., anti-CD20. Antiviral treatment
should be started once the HBV DNA is
detectable (B1).

4 Newer therapies and future perspectives

4.1 Newer therapies and immunomodulatory
therapies
The limited efficacy of the currently available antiviral
treatments requires the development of new therapeutic
tools for the treatment of CHB. Promising therapies have
recently been developed that directly target HBV-infected
hepatocytes by inducing cccDNA degradation or by
inhibiting HBV entry or the expression of viral proteins.
HBV-infected hepatocytes may also be targeted by
immunotherapeutic approaches designed to either boost the
HBV-specific T cell component of the immune response or
to directly stimulate the intrahepatic innate response [644].
The efficacy and feasibility of these approaches will,
however, need to be carefully evaluated in humans.
Antiviral therapies targeting hepatitis B virus-infected
hepatocytes

Recommendations: occult HBV infection

3:17:1

3:17:2

Occult hepatitis B infection is not an

uncommon disease entity. Suspicion should
be raised in all HBsAg-negative subjects
with or without positive anti-HBs or antiHBc (C1).
Sensitive nucleic acid tests should be used
to screen all blood donations from HBsAgnegative subjects. Transfusion products
should be discarded if HBV DNA is
detectable in these products (A1).

The life cycle of the virus begins with its attachment to the
appropriate hepatocyte receptor, which is now recognized
to be a bile salt transporter known as sodium taurocholate
co-transporting polypeptide (NTCP) [645]. The region
between amino acids 2147 of the Pre-S1 present in LHBsAg in virus binds to the hepatocyte membrane.
Cyclosporine (known to inhibit NTCP) analogues without
its immunosuppressive properties and oxysterols [646] may
thus constitute possible drugs for development against
HBV for the future. Myrcludex-B, a synthetic lipopeptide
ligand derived from the pre-S1 domain of L-HBsAg blocks

123

Hepatol Int

de novo HBV infection both in vitro and in vivo, as

demonstrated after pretreatment of human chimeric uPA/
SCID mice [647]. Six weeks of Myrcludex administration,
initiated either 3 days or 3 weeks post infection in the same
animal model, efficiently blocked cell-to-cell virus spread
and cccDNA amplification [648]. Although the above
drugs appear to block HBV at the point of entry and
therefore prevent the infection of new hepatocytes, their
use as monotherapy regimens is unlikely to prove very
effective unless there is an obvious effect on already
infected hepatocytes harboring transcriptionally active
cccDNA. Therefore, future regimens may include such
drugs only in combination with others.
Following attachment, the processes of endocytosis,
uncoating and delivery of the resulting naked nucleocapsids to the nuclear pores are initiated. Ezetimibe was tested
using the HepaRG cell model and was shown to inhibit the
establishment of intrahepatic cccDNA and expression of
viral replication markers when the cells were infected with
HBV. These findings indicate that the drug acts at early
stages in the life cycle of the virus by modulating hepatic
cholesterol uptake and interfering with lipid transport,
pathways that may represent new targets for antiviral
therapy in the case of HBV infection [649].
Nucleocapsid disassembly occurs at the nuclear pore,
followed by translocation to the nucleoplasm of the
released HBV-DNA. Within the nucleus, the rcDNA is
converted into a double-stranded cccDNA molecule. This
involves a number of stages. In this form, cccDNA is quite
stable and behaves as a minichromosome, being the template for viral transcript synthesis by host RNA polymerase
II. Most HBV-specific antiviral agents have thus far been
unable to prevent the replenishment of the cccDNA pool
from maturing HBV-DNA containing nucleocapsids,
which are recycled to the nucleus from the cytoplasm, or to
effect efficient clearance of cccDNA-containing hepatocytes. In the last few years, new strategies aimed at
improving cccDNA clearance have been developed. These
include lymphotoxin-b receptor (LT-b R) activation of
HBV-infected cells [650], and cccDNA-specific transcription activator-like effector nucleases (TALENs) [651]. An
alternative approach is to modulate the expression of viral
proteins, such as HBsAg and HBeAg, which are believed to
play a role in induction of T cell exhaustion. This could
potentially be achieved by using RNA interference-based
therapeutics that target expression of specific viral RNAs
[652].
Viral messenger RNAs are translated in the cytoplasm to
yield viral proteins. Once synthesized, the polymerase
engages, an event that leads to recruitment of core protein
dimers triggering encapsidation of the complex into the
nucleocapsid. Three inhibitors that act at this stage in the

123

life cycle of the virus are Bay 41-4109 [653], GLS4 [654]
and NVR-1221 [655].
Following encapsidation of the polymerase and pgRNA
complex, the subsequent steps in virus nucleic acid replication take place within the nucleocapsid and involve
RNAse H. A potential drug targeting RNase H is b-thujaplicinol, which inhibited the enzyme from genotypes D
and H in biochemical assays with IC50 values of 5.9 0.7
and 2.3 1.7 lM, respectively. It also blocked replication
of HBV genotypes A and D in culture by inhibiting RNase
H activity with an estimated EC50 of 5 lM and a CC50 of
10.1 1.7 lM. Thus, if chemical derivatives of b-thujaplicinol with improved efficacy and reduced toxicity can
be identified, such compounds could be used in future
regimens of combined therapy with nucleos(t)ide analogues [656].
Maturing nucleocapsids in the final stages of morphogenesis bud through the endoplasmic reticulum membrane.
Peptidomimetic compounds that would prevent HBsAgnucleocapsid interaction and glucosidase inhibitors preventing glycosylation of HBsAg are potential drugs at this
stage of the viral life cycle [657].
Immunotherapeutic approaches: restoration of adaptive
immunity
During CHB infection, HBV-specific T cells are deleted
or functionally exhausted, most likely due to the repeated
exposure of these cells to large quantities of HBsAg and
HBeAg. Exhausted virus specific T cells express inhibitory molecules, such as PD-1 (programmed cell death
protein 1), CTLA-4 (cytotoxic T-lymphocyte-associated
protein 4), SLAM (signalling lymphocyte activation
molecule), and TIM-3 (T-cell immunoglobulin domain
and mucin domain 3), and acquire a progressive and
step-wise loss of their effector functions [658]. Blocking
inhibitory receptors has been shown to partially recover
the exhausted T cells of CHB patients in vitro [659], but
the in vivo efficacy of this approach is still uncharacterized. Therapeutic vaccination aimed at eliciting the
patients immune system represents another attractive
therapy for HBV. Potential approaches include HBV
therapeutic vaccines targeting different HBV proteins
[660, 661], vaccine based on immunogenic complexes
composed of HBsAg and antihuman HBsAg antibodies
[662], or TLR-mediated or anti CD40-mediated stimulation of intrahepatic monocytes or dendritic cells [663,
664]. Improving HBV-specific T cell immunity by
engineering HBV-specific T cells through the transfer of
HBV-specific T cell receptors (TCR) or HBV-specific
chimeric antigen receptors (CARs) represents another
novel approach [665, 666].

Hepatol Int

Immunotherapeutic approaches: direct stimulation

of innate intrahepatic immunity
Therapeutic strategies aimed at increasing innate immunity
exploit the antiviral efficacy of distinct cytokines (tumour
necrosis factor-a, IFN-a, IFN-c and interleukin-1b), mimic
the activation of innate immunity during the early phase of
acute HBV infection and induce a correct maturation of the
adaptive immunity [667]. Strategies include boosting
intrahepatic IFN- a levels by TCR-like antibodies conjugated with IFN- a that specifically target HBV-infected
hepatocytes [668], use of TLR7 agonists to induce IFN- a
production in pDCs (plasmacytoid dendritic cells) [669],
stimulating NK and NKT cells by IL-12 and IL-18 [670,
671], and use of TLR8 agonists [672].
However, these new therapeutic approaches have mainly
been tested in animal models and await lrarge-scale human
studies. A cure for chronic HBV infection requires agents
that can target different stages in the life cycle of the virus.
However, this requirement must deal effectively with the
cccDNA pool by either inhibiting the cccDNA complex
formation or destroying infected hepatocytes. The latter is
only achievable through immune-mediated mechanisms, a
fact that strongly suggests a combination therapy approach
for the future [657].
4.2 Unresolved issues and unmet needs
The challenges in the management of hepatitis B are still
very daunting, and despite significant advances, cure from
HBV infection is a far cry. We need to improve our
understanding of the natural history of chronic HBV
infection, including the role of serum HBsAg levels in the
evaluation of the natural history.
The role of noninvasive methods for the evaluation of
the severity of liver disease and for the follow-up of treated
and untreated patients needs to be established.
The future of hepatitis B treatment will involve personalized decisions regarding when to initiate treatment
based on prognostic models/risk calculators that include
host genetic and viral markers that predict cirrhosis and
HCC.
There is need to assess the impact of long-term treatment in chronic Hepatitis B with normal ALT.
Identify markers that predict successful NA
discontinuation.
Assess the safety and efficacy of the combination of
Peg-IFN with a potent NA (entecavir or tenofovir) to
increase anti-HBe and anti-HBs seroconversion rates.
The future of hepatitis B treatment will also involve
personalized decisions regarding choice of treatment based
on pharmacogenetics and predicted responses.

There is the need for novel therapiesantiviral agents

with new targets in the HBV replication cycle combined
with immunotherapies that can restore the host immune
response to HBV.
The persistence of cccDNA in HBV-infected cells
remains one of the main obstacles to complete eradication
of the virus during chronic infection. In that respect, a
better understanding of the biochemical steps of cccDNA
biosynthesis and epigenetic control of cccDNA is needed.
The characterization of the complex interaction between
viral and host cellular proteins and/or genomes represent
other research challenges that may pave way to identification of new treatment targets.
Further confirmatory studies need to be done on the use
of potent NAs from the time of listing to provide a completely HBIG-free oral prophylaxis regimen and thus further improve the outcomes, tolerability and cost
effectiveness of liver transplantation for CHB.
Compliance with ethical standards
Conflict of interest S. K. Sarin, M. Kumar, G. K. Lau, Z. Abbas, H.
L. Y. Chan, C. J. Chen, D. S. Chen, H. L. Chen, P. J. Chen, R.
N. Chien, A. K. Dokmeci, Ed Gane, J. L. Hou, W. Jafri, J. Jia, J.
H. Kim, C. L. Lai, H. C. Lee, S. G. Lim, C. J. Liu, S. Locarnini, M. Al
Mahtab, R. Mohamed, M. Omata, J. Park, T. Piratvisuth, B.
C. Sharma, J. Sollano, F. S. Wang, L. Wei, M. F. Yuen, S. S. Zheng,
J. H. Kao declare that they have no conflict of interest.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://crea
tivecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
made.

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