— Christine M. Kukka, Project Manager, HBV Advocate
Many adults with chronic hepatitis B eventually
develop HBeAg-negative infection as they age, and unfortunately this
phase of infection is difficult to monitor and treat.
Over time, HBV in older people
are able to replicate without generating HBeAg because of mutations in
the HBV's core promoter or precore region. A person with HBeAg-negative
hepatitis B often has:
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Low or moderate viral load
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Undetectable HBeAg and detectable "e" antibodies
-
Normal or slightly elevated alanine aminotransferase (ALT) levels. ALT levels increase above normal when liver damage occurs.
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Varying levels of fibrosis and liver damage, which makes it challenging for doctors to know when to order a liver biopsy.
Current guidelines suggest
HBeAg-negative patients with viral loads higher than 20,000 IU/mL or
signs of liver damage (elevated ALT levels) should be treated. But when
viral loads are teetering just under 20,000 IU/mL and ALT levels are
in the upper reaches of normal, it's difficult for doctors to gauge
which patient needs treatment or more frequent monitoring.
A study from Iran, published in the February 2014 issue of Hepatitis Monthly,
followed viral loads and ALT levels in 243 HBeAg-negative patients for
one year to see if viral load could be used to identify which patients
had an "active" infection that required treatment.
They found that patients with
viral loads ranging between 2,000 and 20,000 IU/mL and persistently
normal ALT levels could truly be considered "inactive" carriers who do
not need treatment.
However, they stressed that
doctors could miss liver damage in these patients if they relied on
only one HBV DNA test, "...so appropriate follow-up (using) HBV DNA and
ALT levels is recommended to differentiate inactive carriers and
patients with (active) HBeAg-negative chronic hepatitis B."(1)
An unrelated study published in the January 2014 issue of the Journal of Clinical Virology
tracked hepatitis B surface antigen (HBsAg) levels in patients with
varying stages of hepatitis B infection to see if this antigen level
could be used as an indicator of staging a hepatitis B infection or when
treatment was needed.
Of interest was whether there
was a difference in HBsAg levels in the HBeAg-negative patients who had
active liver disease or needed treatment.
They found HBsAg levels when
combined with ALT levels shed little light on which HBeAg-negative
patients needed treatment. "HBsAg is not a suitable marker for
evaluating hepatitis activity and distinguishing between cases of
HBeAg-negative chronic hepatitis B and inactive (hepatitis B)," they
wrote. (2)
HBV Journal Review
Marcxh 1, 2014, Vol 11, no 3 Labels: Monitoring HBeAG-negative patients
