Laboratory Tests for Hepatitis Panel in Cirrhosis
A comprehensive hepatitis panel for patients with cirrhosis should include HBsAg, hepatitis B surface antibody, hepatitis B core antibody (HBcAb), HBcAb IgM (for suspected acute infection only), and HCV antibodies, with follow-on viral load testing for any positive results. 1
Core Hepatitis Panel Components
Hepatitis B Testing:
- Hepatitis B surface antigen (HBsAg) - Indicates current HBV infection
- Hepatitis B surface antibody (anti-HBs) - Indicates immunity from vaccination or resolved infection
- Hepatitis B core antibody (anti-HBc total) - Indicates previous or ongoing infection
- Hepatitis B core antibody IgM (anti-HBc IgM) - Only recommended in patients with suspected acute viral hepatitis 1
- HBV DNA viral load - For patients who test positive for HBsAg or isolated HBcAb IgG (since isolated HBcAb IgG may still indicate chronic HBV infection) 1
Hepatitis C Testing:
- Hepatitis C antibody (anti-HCV) - Screens for HCV exposure
- HCV RNA viral load - For patients who test positive for HCV antibodies 1
Additional Viral Hepatitis Testing:
- Hepatitis D antibody (anti-HDV) - For patients with HBV infection, especially those from countries where HDV is endemic or with history of injection drug use 1
- HIV antibody - For patients with risk factors 1
Extended Testing for Cirrhosis Patients
In addition to the core hepatitis panel, patients with cirrhosis should have:
Liver Function Assessment:
- Serum bilirubin (total and direct)
- Aspartate aminotransferase (AST)
- Alanine aminotransferase (ALT)
- Alkaline phosphatase (ALP)
- Gamma-glutamyl transferase (GGT)
- Prothrombin time (PT)/International Normalized Ratio (INR)
- Serum albumin 1
Complete Blood Count:
- Platelet count - Important surrogate marker for portal hypertension 1
- Complete blood count - To assess for cytopenias 1
Renal Function:
- Blood urea nitrogen
- Creatinine - Both an assessment of kidney function and established prognostic marker in liver disease 1
Autoimmune and Metabolic Testing
For comprehensive evaluation, especially if viral causes are negative:
- Autoantibody panel - Anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody 1
- Serum immunoglobulins - To assess for hypergammaglobulinemia 1
- Iron studies - Serum ferritin and transferrin saturation to rule out hemochromatosis 1
- Alpha-1-antitrypsin level - To rule out alpha-1-antitrypsin deficiency 1
- Ceruloplasmin - For patients under 40 years to rule out Wilson's disease 1
Monitoring Recommendations
For patients with confirmed hepatitis and cirrhosis:
- HBV patients: Regular monitoring of HBV DNA, ALT, AST, and liver function tests every 3-6 months 1
- HCV patients: After treatment, monitoring of liver function tests and assessment for complications of cirrhosis 1
- All cirrhosis patients: Regular surveillance for hepatocellular carcinoma with ultrasound ± AFP every 6 months 1
Common Pitfalls to Avoid
Failing to confirm viral replication - Always confirm viral load in patients who test positive for HBsAg, HBcAb IgG, or HCV antibodies 1
Missing occult HBV infection - Patients (especially those with HIV) can have high HBV DNA levels without HBsAg; test for both HBsAg and anti-HBc 1
Overlooking non-viral causes - Even in patients with known viral hepatitis, always consider concurrent autoimmune, alcoholic, or metabolic liver disease 1
Relying solely on transaminases - Normal ALT/AST does not rule out advanced disease; cirrhotic patients frequently have normal transaminases 2
Inadequate fibrosis assessment - Consider non-invasive fibrosis assessment with elastography or serum biomarkers (FIB-4, APRI) 1
By following this comprehensive approach to hepatitis testing in cirrhosis, clinicians can accurately diagnose the etiology, assess disease severity, guide treatment decisions, and monitor for complications.