Virology of HBV Infection

HBV is a small (3.2 kb), partially double-stranded, relaxed-

circular (rc) DNA virus which primarily infects liver cells
Up to 1011 to 1013 virions/day may be produced in an infected
person
Encoding 7 proteins: HBeAg (HBV e antigen), HBcAg (HBV core
antigen), HBV Pol/RT (polymerase,reverse transcriptase
activity), PreS1/PreS2/HBsAg (large, medium,and small surface
envelope glycoproteins), and HBx (HBV x antigen, regulator of
transcription required for the initiation of infection).

HBV-> Hepadnaviridae family cccDNA=covalently closed circular DNA.

Upon viral uptake into hepatocytes, the HBV

nucleocapsid is transported to the nucleus to release
the rcDNA genome. In the nucleoplasm, the rcDNA is
converted into a cccDNA, which is wrapped by
histones to form an episomal chromatinized
structure. It then serves as a transcription template
for all viral transcripts that are translated into the
different viral proteins 2
 HBV Life Cycle

Once inside the hepatocyte, the virus undergoes uncoating, and the HBV genome enters the
nucleus, followed by repair of the single stranded DNA strand and formation of the covalently
closed circular (ccc) DNA template. Viral transcripts are formed for the hepatitis B surface
antigen (HBsAg), DNA polymerase, X protein, and RNA pregenome; the pregenome and
polymerase are incorporated into the maturing nucleocapsid and removed after translation. The
surface protein enveloping process occurs in the endoplasmic reticulum. Some of the
nonenveloped nucleocapsid re-circulates back to the nucleus, and the cycle begins again. Excess
tubular and spherical forms of HBsAg are secreted in great abundance. 3
 Viral Life Cycle

HBsAg Hepatitis B Virus

HBV DNA
Hallmark of infection
Major tool for screening and Measure of viral load; indicates
diagnosis of CHB2 ongoing viral replication
(if present 6 months3) Correlates with infectivity and
risk of major liver disease

Anti-HBs
Antibody to HBsAg
Marker of immunity to HBV
Only detectable marker of
successful immunization HBeAg
Marker of risk of transmission
Anti-HBc of infection
Antibody to HBV core antigen
Marker of prior exposure
IgM anti-HBc is a marker of recent
infection4
anti-HBs=antibody to HBsAg; anti-HBc=antibody to hepatitis B core antigen; IgM=immunoglobulin M.

4
 Serologic Profiles of Progression from
Acute Infection to CHB

Progression from acute infection to chronic hepatitis B

Acute Chronic
(6 months) (years)
HBeAg anti-HBe
HBsAg

Total anti-HBc
Titer

IgM anti-HBc

0 4 8 12 16 20 24 28 32 36 52 Years

Weeks after exposure

Antigens and antibodies associated with HBV infection include HBsAg, anti-HBs,
anti-HBc, HBeAg, and anti-HBe
Serologic assays are available to test for these markers
5
Course of HBV Infection
HBsAg+ HBsAg
HBeAg+ 2 million have CHB Anti-HBe+ Anti-HBe+

HBV DNA

ALT

50,000
Immune Immune receive
Inactive
Tolerant Carrier
Reactive, HBeAg treatment
+ Reactivation Resolution

None/Minimal Moderate/severe None Active

Liver Disease Liver Disease Inflammation Inflammation Inactive

HBeAg +, HBeAg +, HBeAg -, HBeAg -,

Chronic Infection Chronic Hepatitis Chronic Infection Chronic Hepatitis HBsAg -

CHB follows a variable clinical course

not all patients will go through each phase (including remission) 6
 Phase 1: HBeAg-Positive Chronic Infection.
Prev: Immune Tolerant
HBsAg+ HBsAg
HBeAg
Anti-HBe

HBV DNA

ALT

Immune tolerant Immune reactive Inactive carrier Reactivation Resolution

Characteristic:
Presence of serum HBeAg
Very high levels of HBV DNA: >107 IU/ml (highly contagious)
Normal ALT
Liver: minimal or no liver necroinflammation or fibrosis
Hepatocarcinogenesis begin
More frequent and prolonged in subject infected perinatally and is associated with preserved
specific T cell function at least until young adulthood.

7
 Phase 2: HBeAg-Positive Chronic Hepatitis B.
Prev: Immune Reactive HBeAg +
HBsAg+ HBsAg
HBeAg
Anti-HBe

HBV DNA

ALT

Immune tolerant Immune reactive Inactive carrier Reactivation Resolution

Presence of serum HBeAg, High Level of HBV DNA (104-107 IU/ml) and elevated LFT (intermitten or
persistent)
Typically occurs during the 2nd and 3rd decades of life; may last for years, leading to progressive liver
damage
Presence of necroinflammation on liver biopsy and varying degrees of fibrosis are the result of
immune-mediated liver damage
It may occur after several years of the first phase and is more frequently and/or rapidly reached in subjects
infected during adulthood.
The outcome is variable. Most patients can achieve HBeAg seroconversion and HBV DNA suppression and
enter the HBeAg-negative infection phase. Other patients may fail to control HBV and progress to the
HBeAg-negative CHB phase for many years. 8
 Phase 3: HBeAg-Negative Chronic HBV Infection
Prev: Inactive Carrier State
HBsAg+ HBsAg
HBeAg
Anti-HBe

HBV DNA

ALT

Immune tolerant Immune reactive Inactive carrier Reactivation Resolution

Characteristic:
presence of serum antibodies to HBeAg (anti-HBe),
undetectable or low (<2,000 IU/ml) HBV DNA levels
normal ALT according to traditional cut-off values (ULN 40 IU/ml)
Some patients in this phase, may have HBV DNA levels >2,000 IU/ml (usually <20,000 IU/ml),
accompanied by persistently normal ALT and only minimal hepatic necroinflammatory activity and low
fibrosis.These patients have low risk of progression to cirrhosis or HCC if they remain in this phase, but
progression to CHB, usually in HBeAg-negative patients, may occur.
HBsAg loss and/or seroconversion may occur spontaneously in 13% of cases per year. Typically, such
patients may have low levels of serum HBsAg (<1,000 IU/ml)
9
 Phase 4: HBeAg-Negative Chronic Hepatitis B
Prev: HBeAg-Negative Chronic Hep B/Reactivation
HBsAg+ HBsAg
HBeAg
Anti-HBe

HBV DNA

ALT

Immune tolerant Immune reactive Inactive carrier Reactivation Resolution

Reactivation may occur spontaneously or due to immunosuppression

Characteristic:
Intermediate level of HBsAg
Lack of serum HBeAg usually with detectable anti-Hbe
Persistent or fluctuating moderate-high serum HBV DNA (often lower than in HBeAg-Positive
patients) (>2000 IU/mL)
Persistent or fluctuating ALT elevation
Liver: moderate/severe necroinflammation and fibrosis
This phase is associated with low rates of spontaneous disease remission. 10
 Phase 5: HBsAg-Negative Phase
Occult HBV Infection
HBsAg+ HBsAg
HBeAg
Anti-HBe

HBV DNA

ALT

Immune tolerant Immune reactive Inactive carrier Reactivation Resolution

Characteristic:
HBsAg negative
Positive antibodies to HBcAg (anti-HBc)
Anti HBs (+/-)
Normal ALT
Usually (not always) undetectable serum HBV DNA
HBsAg loss before the onset of cirrhosis is associated with a minimal risk of cirrhosis, decompensation
and HCC, and an improvement on survival. However, if cirrhosis has developed before HBsAg loss,
patients remain at risk of HCC. Immunosuppression may lead to HBV reactivation in these patients.
11
New Terminology in EASL 2017

12
HBV Progression to Cirrhosis and HCC
Chronic HBV Infection

8%-20%
2-5%
Cirrhosis

20% in 5 year
HCC
Decomp. Cirr Percentages are 5-year
cumulative incidence rates.1

Risk Of Developing HCC, related to the Host and HBV Properties Factor:

Host factors Host factors HBV Properties

Cirrhosis, Chronic co-infections with High HBV DNA and/or
Chronic hepatic Other hepatitis viruses or HIV HBsAg levels
necroinflammation
Older age Diabetes or metabolic syndrome HBV genotype C > B,
Male sex Active smoking specific mutations)
African origin Positive family history
Alcohol abuse

13
PAGE-B:
Predictability for
HCC

PAGE-B
good predictability for HCC during the
first 5 years of entecavir
or tenofovir therapy in Caucasian,
mostly European.

The PAGE-B score appears to predict

HCC development even in
untreated CHB patients

14
 Initial Assessment
Complete history
Physical examination
Liver Disease Activity (include severity and markers of HBV
infection) for tx and HCC surveillance:
1) HBeAg and anti-Hbe: determination phase of infection
2) HBV DNA: diagnosis, determination phase, decision to treat and subsequent
monitoring of patients
3) HBsAg quantication can be useful, particularly in HBeAg- chronic infection and in
patients to be treated with (IFN-)
4) HBV genotype is not necessary in the initial evaluation
5) Co-morbidities, alcoholic, autoimmune, metabolic liver disease with steatosis or
steatohepatitis and other causes of chronic liver: HDV, HCV, HIV
6) anti-HAV: should be performed, and patients with negative anti-HAV should be
advised to be vaccinated. 15
 Endpoints of Therapy (Recommendations)
The induction of long-term suppression of HBV DNA levels
represents the main endpoint of all current treatment strategies
(Evidence level I, grade 1)
The induction of HBeAg loss, with or without anti-Hbe
seroconversion, in HBeAg-positive CHB patients is a valuable
endpoint, as it often represents a partial immune control of the
chronic HBV infection (Evidence level II-1, grade 1).
A biochemical response defined as ALT normalisation should be
considered as an additional endpoint, which is achieved in most
patients with long-term suppression of HBV replication (Evidence
level II-1, grade 1).
HBsAg loss, with or without anti-HBs seroconversion, is an optimal
endpoint, as it indicates profound suppression of HBV replication
and viral protein expression (Evidence level II-1, grade 1).
16
Management of HBV Infection

17
 Indications for Treatment

Compensated/decom
Chronic Hepatitis: Cirrhosis
Any Detectable HBV DNA
HBeAg +/- Regardless ALT level

TREAT
HBV DNA>20,000 Chronic Infection:
ALT>2xULN HBeAg+/-
Regardless degree of fibrosis
Family History
Extrahepatic Manifest
Chronic Infection
HBeAg +
Age >30 yrs
Regardless severity of
histological lesions

18
Indications for Tx (cont)
Decision:
Serum HBV DNA levels
Serum ALT levels
Severity of liver disease
Patients without cirrhosis should be tx:
HBV DNA levels above 2,000 IU/ml
Serum ALT levels >ULN (40 IU/ml) and
Severity of liver disease, by liver biopsy: moderate
necroinflammation and/or moderate fibrosis
Patients with HBV DNA >20,000 IU/ml and ALT >2x ULN
can start treatment even without a liver biopsy. 19
 patients with chronic HBV infection either with
normal ALT and liver stiffness >9 kPa, or with
elevated ALT but below 5x ULN and liver
stiffness>12 kPa can be considered to have severe
fibrosis or cirrhosis.

20
Monitoring of Patients Currently not Treated

HBeAg+ HBeAg
Chronic Infection Chronic Infection
Age <30 yrs HBV DNA <2000
ALT every 3 months ALT every 6-12 months
HBV DNA 6-12 months HBV DNA every 2-3 years
Assmnt liver fibrosis 12 mo Assmnt liver fibrosis 2-3 years

MONITOR

HBeAg

Chronic Infection
HBV DNA 2,000
ALT every 3 months for first year
ALT every 6 months thereafter
HBV DNA and Assmnt liver fibrosis
every year for 3 years

21
Treatment Strategies

2 main treatment:
1. NA:
lamivudine (LAM), adefovir dipivoxil (ADV),
entecavir (ETV), telbivudine (TBV), tenofovir
disoproxil fumarate (TDF) and tenofovir
alafenamide (TAF)
low barrier against HBV resistance: (LAM, ADV, TBV)
high barrier to HBV resistance: (ETV, TDF, TAF)
2. IFN, currently pegylated(PegIFN)

22
Definitions of Response

Virological
Biochemical
Serological
Histological
 Virological Responses (NA Therapy)
Virological response undetectable (limit detection 10 IU/mL
Primary non-response less than one log10 decrease of serum HBV
DNA after 3 months of therapy
Partial virological response decrease in HBV DNA of more than 1
log10 IU/ml, but detectable after at least 12 months of tx
Virological breakthrough increase 1 log10 IU/ml from the lowest
value
biochemical breakthrough, increase ALT levels.
Sustained Off-therapy Virological Response HBV < 2000 for at least
12 mo after the end of tx
Virological Responses (PegIFN-a)

Virological Response, HBV <2000, evaluated at 6

months and at the end of therapy
Sustained off-therapy Virological Response, HBV<
2000 for at least 12 months after the end of
therapy.
Serological Response

HBeAg
HBeAg loss, (+) (-)
HBeAg Seroconversion,
anti HbE + in HBeAg +
Patients
HBsAg
HBsAg loss, (+) (-)
HBsAg Seroconversion,
development of anti
HbS
 Biochemical Response
(@3 months)
Normalisation ALT < 40
Minimal 1 years post
treatment
Histological Response (
necroinflammation)
Decrease 2 histologic
activity index or Ishaks
System
Without worsening in
fibrosis
 NAs for nave CHB Patients
The long-term administration of a
potent NA with high barrier to
resistance is the treatment of choice
regardless of the severity of liver
disease (Evidence level I, grade 1).
The preferred regimens are ETV, TDF
and TAF as monotherapies (Evidence
level I, grade 1).
LAM, ADV and TBV are not
recommended in the treatment of CHB
(Evidence level I, grade 1).

29
Monitoring of ETV, TDF, or TAF High renal risk:
1. Chirosis decompensate
2. eGFR < 60
3. Uncontrol DM
4. Uncontrol HT
5. Proteinuria
6. Nefrotoxic drug use
7. Active GN
8. Organ Transplant

HBV DNA
Every 3-4 months, first year
Every 6-12 months thereafter
LFT
Every 3-4 months, first year
Every 6 months thereafter
EGFR < 50, ETF and HBsAg
TDF need dosing At 12-mo intervals if HBV
adjusment undetectable
TAF dosage remains Anti HBS
at 25 mg until eGFR If HBsAg (-)
is<15 ml/min,
Long term Outcome During NA

NA Discontinuation
HBsAg Loss, with or without
seroconversion
Non-cirrhotic, HBeAg
seroconversion, undetectable
DNA, complete 12 months of
consolidation tx
Non-cirrhotic, HBeAg -,
longterm (3 years) virological
suppresion, (with close post-
NA monitoring)
 Management of NA Failure
Treatment Response
Primary nonresponse
Poor Compliance
Compliance, commonly seen in ADV
suboptimal antiviral potency (tx: rapidly switch
to TDF or ETV
Partial Virological Response
Poor Compliance
Compliance
(ADV, LAM, TBV )switch to more potent drug
(ETV, TAF, TDV) very high Viral load pre tx.
Treat w/ combination of ETV+TDF/TAF
Virological Breakthrough
mainly related to the development of HBV drug
resistance.

The combination of NAs with low barrier to

resistance, such as LAM or TBV with ADV,
should be avoided, this may lead to
inappropriate viral suppression and the
emergence of multidrug resistant strains
 Management of Antiviral Drug Resistance

The risk of Resistance: Manage resistance

1. high baseline HBV DNA levels
2. slow decline in HBV DNA
3. Previous suboptimal NA treatment.
Treat monoteraphy
Most effective antiviral
No cross-resistance
Multidrug resistance
genotypic resistance testing
Combination of TDF with ETV is safe option as a rescue
therapy.
 PegIFN Therapy
Efficacy
PegIFN can be considered as an initial treatment option for patients with mild to moderate
HBeAg positive or -negative CHB (Evidence level I, grade of recommendation 2).
The standard duration of PegIFN therapy is 48 weeks (Evidence level I, grade of
recommendation 1).
The extension of the duration of PegIFN therapy beyond week 48 may be benecial in
selected HBeAg-negative CHB patients (Evidence level II-1, grade of recommendation 2).

Monitoring of patients treated with PegIFN

All CHB patients treated with PegIFN should be followed with periodical assessments of
at least full blood count, ALT, TSH, serum HBV DNA and HBsAg levels (Evidence level I/II-
2, grade of recommendation 1).
HBeAg-positive CHB patients treated with PegIFN should be also followed with
periodical assessments of HBeAg and anti-HBe (Evidence level I, grade of
recommendation 1).
CHB patients with virological response after PegIFN therapy should remain under long-
term follow-up because of the risk of relapse (Evidence level II-2, grade of
recommendation 1).
PegIFN Therapy
Should be considered if:
mild to moderate CHB Monitoring
compensated cirrhosis but no Full BC (per mo)
portal hypertension ALT level (per mo)
TSH (per 3 mo)
Sustained Virologi Response : HBV DNA (per 3 mo)
HBV DNA < 2000 HbSAg (per 3 mo)
HbSAg loss
ALT Normal
Associated w/ remission liver
disease

35
 PegIFN Therapy
Predictors of PegIFN response and stopping rules
In HBeAg-positive CHB patients, HBsAg levels [20,000 IU/ml for genotype B and C,
or no decline of HBsAg levels for genotype A and D, at 12 weeks of PegIFN therapy
are associated with a very low probability of subsequent HBeAg seroconversion and
can be used as PegIFN stopping rules (Evidence level II-2, grade of
recommendation 2).
In HBeAg-positive CHB patients with genotype A-D, HBsAg levels [20,000 IU/ml at
24 weeks of PegIFN therapy are associated with a very low probability of
subsequent HBeAg seroconversion and can be used as PegIFN stopping rules
(Evidence level II-2, grade of recommendation 2).
In HBeAg-negative CHB patients with genotype D, a combination of no decrease in
HBsAg levels and \2 log IU/ml reduction in serum HBV DNA levels at 12 weeks of
PegIFN therapy predicts no response and should be used as PegIFN stopping
rules (Evidence level II-2, grade of recommendation 1).
PegIFN Therapy
Predictors During treatment
Low viral load 12 w, HbSAg <1500, seroconversi
High serum ALT (2-5 x ULN) 12 w, HbSAg > 20000, A-D, not
conversion
HBV genotypes and high
24 w, HbSAg > 20000, All, not
activity scores liver biopsy
conversion
HBV genotype A dan B HbEAg neg, HBV DNA 102, HbSAg
minimal, not conversion

Side effects: u-like syndrome, myalgia, headache, fatigue, weight loss, depression, hair
loss and local reactions at the site of injection.
Hepatitis ares may occur decompensation of liver disease PegIFN is
contraindicated in patients with decompensated cirrhosis.
PegIFN treatment is also associated with mild myelosuppression, but neutropenia
and thrombocytopenia are usually well managed with dose reduction and only rarely
result in clinically signicant infection or bleeding.
The combination of PegIFN with telbivudine is contraindicated due to a high risk of
neuropathy.
Week 12 and 24 Stopping Rules
for HBeAg(+&-)patients treated with PegIFNa

38
Long-term outcome after PegIFN
Patients with sustained responses after PegIFN therapy and high baseline
HCC risk should remain under surveillance for HCC even if they achieve
HBsAg loss (Evidence level III, grade of recommendation 1).
 Combination Therapy of VHB
NA plus NA
De novo combination therapy with two NAs with high barrier to resistance
(ETV, TDF, TAF) is not recommended (Evidence level I, grade 1).
In treatment-adherent patients with incomplete suppression of HBV
replication reaching a plateau during either ETV or TDF/TAF long-term
therapy, a switch to the other drug or combining both drugs may be
considered (Evidence level III, grade 2).

NA plus PegIFN
Patients with sustained responses after PegIFN therapy and high baseline
HCC risk should remain under surveillance for HCC even if they achieve
HBsAg loss (Evidence level III, grade 1).
 Treatment of patients with decompensated
cirrhosis
Patients with decompensated cirrhosis should be immediately treated with
a NA with high barrier to resistance, irrespective of the level of HBV
replication, and should be assessed for liver transplantation (Evidence
level II-1, grade of recommendation 1).
PegIFN is contraindicated in patients with decompensated cirrhosis
(Evidence level II-1, grade of recommendation 1).
Patients should be closely monitored for tolerability of the drugs and the
development of rare side effects like lactic acidosis or kidney dysfunction
(Evidence level II-2, grade of recommendation 1).
 Prevention of HBV recurrence after liver
transplantation
All patients on the transplant waiting list with HBV related liver disease
should be treated with NA (Evidence level II, grade of recommendation 1).
Combination of hepatitis B immunoglobulin (HBIG) and a potent NA is
recommended after liver transplantation for the prevention of HBV
recurrence (Evidence level II-1, grade of recommendation 1).
Patients with a low risk of recurrence can discontinue HBIG but need
continued monoprophylaxis with a potent NA (Evidence level II-1, grade of
recommendation 2).
HBsAg-negative patients receiving livers from donors with evidence of past
HBV infection (anti-HBc positive) are at risk of HBV recurrence and should
receive anti- viral prophylaxis with a NA (Evidence level II-2, grade of
recommendation 1).
Treatment in special patient groups:
HIV co-infected Patients

All HIV-positive patients with HBV co-infection

should start antiretroviral therapy (ART)
irrespective of CD4 cell count (Evidence level II-2,
grade 1).
HIV-HBV co-infected patients should be treated
with a TDF- or TAF-based ART regimen (Evidence
level I for TDF, II-1 for TAF, grade 1).
Drug toxicity (renal, bone density, liver) should be
closely monitored during ART.

43
Treatment in special patient groups:
HDV co-infected Patients
PegIFNa for at least 48 weeks is the current treatment of
choice in HDV-HBV co-infected patients with compensated
liver disease (Evidence level I, grade 1).
In HDV-HBV co-infected patients with ongoing HBV DNA
replication, NA therapy should be considered (Evidence level
II-2, grade 1).
PegIFNa treatment can be continued until week 48
irrespective of on-treatment response pattern if well
tolerated (Evidence level II-2, grade 2).
In patients with decompensated liver disease, PegIFNa
should not be used and these patients should be evaluated
for liver transplantation.
NA should be considerd in all patients with decompensated
disease if HBV DNA is detectable. 44
Treatment in special patient groups:
HCV co-infected Patients
Treatment of HCV with direct-acting antivirals (DAAs) may
cause reactivation of HBV. Patients fulfilling the standard
criteria for HBV treatment should receive NA treatment
(Evidence level II, grade 1).
HBsAg-positive patients undergoing DAA therapy should be
considered for concomitant NA prophylaxis until week 12
post DAA, and monitored closely (Evidence level II-2, grade
2).
HBsAg-negative, anti-HBc positive patients undergoing DAA
should be monitored and tested for HBV reactivation in case
of ALT elevation (Evidence level II, grade 1).
Accelerates liver disease progression and increase risk of
HCC
45
Treatment in special patient groups:
Acute Hepatitis B
More than 95% of adults with acute HBV hepatitis do not
require specific treatment, because they will fully recover
spontaneously (Evidence level II-2, grade 1).
Only patients with severe acute hepatitis B, characterised
by coagulopathy or protracted course, should be treated
with NA and considered for liver transplantation (Evidence
level II-2, grade 1).
INR >1.5
Persistent symptoms/marked jaundice for >4weeks
Or, sign of acute liver failure

46
Treatment in special patient groups:
Healthcare Workers
HBV infection alone should not disqualify infected persons
from the practice or study of surgery, dentistry, medicine, or
allied health fields (Evidence level III, grade 1).
Healthcare workers performing exposure prone procedures
with serum HBV DNA>200 IU/ml may be treated with NA to
reduce transmission risk (Evidence level II-2, grade 2).

47
Treatment in special patient groups:
Pregnancy
Screening for HBsAg in the first trimester of pregnancy is
strongly recommended (Evidence level 1, grade 1).
In a woman of childbearing age without advanced fibrosis
who plans a pregnancy in the near future, it may be prudent
to delay therapy until the child is born (Evidence level II-2,
grade 2).
Pregnant women with CHB and advanced fibrosis or
cirrhosis, therapy with TDF is recommended (Evidence level
II-2, grade 1).
In pregnant women already on NA therapy, TDF should be
continued while ETV or other NA should be switched to TDF
(Evidence level II-2, grade 1).

48
Treatment in special patient groups:
Pregnancy
In all pregnant women with high HBV DNA levels (>200,000
IU/ml) or HBsAg levels >4 log10 IU/ml, antiviral prophylaxis
with TDF should start at week 2428 of gestation and
continue for up to 12 weeks after delivery (Evidence level 1,
grade 1).
Breast feeding is not contraindicated in HBsAg-positive
untreated women or on TDF-based treatment or prophylaxis
(Evidence level III, grade 2).
PegIFN is contraindicated during pregnancy
The prevention of HBV perinatal transmission:combination
of HBIG and vaccination given within 12 h of birth

49
 Treatment in special patient groups:
Patients undergoing immunosuppressive therapy or chemotherapy
All candidates for chemotherapy and immunosuppressive therapy should
be tested for HBV markers prior to immunosuppression (Evidence level I,
grade 1).
All HBsAg-positive patients should receive ETV or TDF or TAF as treatment
or prophylaxis (Evidence level II-2, grade 1).
HBsAg-negative, anti-HBc positive subjects should receive anti-HBV
prophylaxis if they are at high risk of HBV reactivation (Evidence level II-2,
grade 1).

Dialysis and renal transplant patients

All dialysis and renal transplant recipients should be screened for HBV
markers (Evidence level II-2, grade 1).
HBsAg-positive dialysis patients who require treatment should receive ETV
or TAF (Evidence level II-2, grade 1).
All HBsAg-positive renal transplant recipients should receive ETV or TAF as
prophylaxis or treatment (Evidence level II-2, grade 1).
HBsAg-negative, anti-HBc positive subjects should be monitored for HBV
infection after renal transplantation (Evidence level III, grade 1).
Treatment in special patient groups:
Extrahepatic manifestations
Patients with replicative HBV infection and extrahepatic manifestations
should receive antiviral treatment with NA (Evidence level II-2, grade of
recommendation 1).
PegIFN should not be administered in patients with immune-related
extrahepatic manifestations (Evidence level III, grade of recommendation
1).

Manifestations: vasculitis, skin manifestations (purpura), polyarteritis nodosa,

arthralgias, peripheral neuropathy and glomerulonephritis.

Plasmapheresis, corticosteroids and potentially other immune-suppressive drugs

during the initial phase can be useful in addition to NA therapy in special
cases.
New biomarkers of HBV infection
Viral cccDNA is the key genomic form that is responsible for the
persistence of infection and was shown to persist in the liver of infected
patients even after long-term NA therapy and even after HBsAg loss and
seroconversion.
Hepatitis B core-related antigen (HBcrAg) is a composite biomarker
comprising several antigens expressed from the precore/core gene:
HBcAg, HBeAg, and prec22 precursor protein.
Circulating HBV RNA was rst described in 1996 in the serum of HBV
infected patients and later as a potential new marker for monitoring NA
therapy.
Future treatment options for HBV
Direct-acting antivirals include HBV entry inhibitors, drugs aiming at
cccDNA destruction or silencing, approaches targeting viral transcripts
by siRNA or anti-sense oligonucleotides, nucleocapsid assembly
modulators, approaches to decrease HBsAg release in serum. First
phase clinical trials are ongoing for several of these agents.
Several potential target mechanisms for immune modulation to
engender or restore HBV specic immune responses in conjunction with
profound inhibition of HBV replication and HBsAg production to attain
immunological control have been suggested. Several approaches are
currently being evaluated in clinical trials to restore innate immunity in
CHB patients Toll-like receptors 7 (TLR7) agonists
Future treatment options for HDV
At present, patients co-infected by HBV and HDV have
to be treated with PegIFN . The success rate of these
treatments is low.
Several candidates are being evaluated in clinical trials
mainly in combination with PegIFN and/or NA
including HBV/HDV entry inhibitors (Myrcludex-B),
drugs inhibiting the release of HBsAg (nucleic acid
polymers), and inhibitors of the prenylation of the large
HDV antigen.
Whenever possible, enrollment in these new clinical
trials should be considered, either as a rescue of PegIFN
failure or to improve treatment success rate in nave
patients.
 Indications for Treatment (Recommendations)
All patients with HBeAg-positive or -negative chronic hepatitis B, should be
treated (Evidence level I, grade 1).
Patients with compensated or decompensated cirrhosis need treatment, with
any detectable HBV DNA level and regardless of ALT levels (Evidence level I,
grade 1).
Patients with HBV DNA>20,000 IU/ml and ALT>2xULN should start treatment
regardless of the degree of fibrosis (Evidence level II-2, grade 1).
Patients with HBeAg-positive chronic HBV infection, may be treated if they are
older than 30 years regardless of the severity of liver histological lesions
(Evidence level III, grade 2).
Patients with HBeAg-positive or HBeAg-negative chronic HBV infection and
family history of HCC or cirrhosis and extrahepatic manifestations can be treated
even if typical treatment indications are not fulfilled (Evidence level III, grade 2).

56
Monitoring of Patients Currently not Treated
(Recommendations)

HBeAg-positive chronic infection, <30 years and do

not fulfill any of the above treatment indications
should be followed at least every 36 months
(Evidence level II-2, grade 1).
HBeAg-negative chronic infection, and HBV DNA
<2,000 IU/ml who do not fulfillany of the above
treatment indications should be followed every 6
12 months (Evidence level II-2, grade 1).
HBeAg-negative chronic infection and HBV DNA
2,000 IU/ml who do not fulfill any of the above
treatment indications should be followed every 3
months for the first year and every 6 months
thereafter (Evidence level III, grade 1). 57