From the Guidelines
The management approach for a patient with HB surface antigen negative, HB surface antibody positive, HB core total antibody positive, HB e antigen negative, HB DNA undetectable, and HB e antibody negative indicates resolved hepatitis B infection with natural immunity, and no specific treatment is required. This serological profile suggests that the patient has cleared the virus and developed protective antibodies, indicating a past HBV infection that has resolved spontaneously 1. The presence of surface antibody (anti-HBs) indicates immunity, while the core antibody (anti-HBc) confirms previous exposure to the virus. The undetectable HBV DNA confirms absence of viral replication.
However, in situations of severe immunosuppression, such as chemotherapy, organ transplantation, or HIV infection, viral reactivation is possible, so HBV DNA monitoring may be warranted in these circumstances 1. Some clinicians recommend prophylactic antiviral therapy (entecavir 0.5mg daily or tenofovir 300mg daily) during profound immunosuppression. Routine liver function tests are reasonable at baseline, but extensive follow-up is generally unnecessary in the absence of other liver diseases or immunosuppression.
Key points to consider in the management of this patient include:
- The patient's immune status and potential for immunosuppression
- The risk of HBV reactivation, particularly in patients with negative anti-HBs or those undergoing anti-CD20 therapy or stem-cell transplantation
- The importance of monitoring HBV DNA and liver function tests in patients with a history of HBV infection who are undergoing immunosuppressive therapy
- The potential benefits and risks of prophylactic antiviral therapy in patients with a history of HBV infection who are undergoing immunosuppressive therapy. It is essential to note that the risk of HBV reactivation is higher in patients with negative anti-HBs than in those who are anti-HBs–positive, supporting anti-HBs testing in these patients 1.
From the Research
Management Approach
The patient's serological profile, with HB surface antigen negative, HB surface antibody positive, HB core total antibody positive, HB e antigen negative, HB DNA undetectable, and HB e antibody negative, suggests a past infection with hepatitis B virus (HBV) and immunity due to either past infection or vaccination 2, 3.
- The presence of HB core total antibody indicates a past exposure to HBV.
- The absence of HB e antigen and the presence of HB e antibody negative suggest that the virus is not actively replicating.
- The undetectable HBV DNA further supports the notion that the virus is not actively replicating.
Treatment and Monitoring
Given this serological profile, the patient is not considered to have chronic HBV infection and therefore does not require antiviral therapy for HBV 3, 4. However, it is essential to monitor liver function tests and HBV DNA levels periodically to detect any potential reactivation of HBV, especially if the patient is to receive immunosuppressive therapy or has other underlying liver diseases 2, 5.
- Monitoring for HBV reactivation is crucial, especially in patients with isolated anti-HBc pattern, as HBV reactivation can occur in the setting of HCV therapy or immunosuppression 2.
- The choice of antiviral therapy, if needed, would depend on various factors, including the patient's liver disease status, renal function, and potential for drug resistance 4, 6.
Comparison of Antiviral Therapies
Studies have compared the efficacy and safety of different antiviral therapies for HBV, including entecavir and tenofovir alafenamide 4, 6.
- Entecavir has been shown to be effective in treating chronic HBV infection, with a high genetic barrier to resistance 4.
- Tenofovir alafenamide has been compared to entecavir in patients with HBV-related acute-on-chronic liver failure, with similar efficacy and safety profiles, but with potential advantages in preserving renal function and reducing liver transplantation rates in certain patient populations 6.