What labs should be ordered for a patient with chronic hepatitis?

Laboratory Testing for Chronic Hepatitis

For patients with chronic hepatitis, a comprehensive laboratory panel should include HBsAg, anti-HBc, anti-HBs, HBeAg, anti-HBe, HBV DNA quantification, liver function tests, complete blood count, and abdominal ultrasound as the initial evaluation. 1

Initial Diagnostic Panel

Viral Markers

• Hepatitis B testing:

  • HBsAg (hepatitis B surface antigen)
  • Anti-HBc (hepatitis B core antibody)
  • Anti-HBs (hepatitis B surface antibody)
  • HBeAg (hepatitis B e antigen) and anti-HBe
  • HBV DNA quantification 2, 1

• Hepatitis C testing:

  • Anti-HCV (antibody testing)
  • HCV RNA testing (if anti-HCV positive)
  • HCV genotyping (if HCV RNA positive) 1

Liver Function Tests

• Alanine aminotransferase (ALT)
• Aspartate aminotransferase (AST)
• Alkaline phosphatase
• Gamma-glutamyl transferase (GGT)
• Total and direct bilirubin
• Albumin
• Prothrombin time/INR 2, 1

Additional Laboratory Tests

• Complete blood count (CBC)
• Renal function tests (BUN, creatinine)
• Alpha-fetoprotein (for HCC surveillance)
• Autoantibodies (if autoimmune hepatitis suspected):
  • Antinuclear antibody (ANA)
  • Smooth muscle antibody (SMA)
  • Liver-kidney microsomal antibody (anti-LKM-1) 1

Monitoring Schedule

For HBeAg-Positive Patients:

• With normal ALT: Monitor ALT every 3-6 months
• With elevated ALT: More frequent monitoring
• Check HBeAg status every 6-12 months
• HBV DNA testing when ALT becomes elevated 2

For HBeAg-Negative Patients:

• With normal ALT and HBV DNA <2,000 IU/ml: Test ALT every 3 months during first year, then every 6-12 months
• With elevated ALT: More frequent monitoring of ALT and HBV DNA 2

Imaging and Liver Biopsy

• Abdominal ultrasound: Recommended for all patients with chronic hepatitis for baseline assessment and HCC surveillance 1

• Liver biopsy should be considered in:

  • Patients with unclear diagnosis after initial workup
  • HBeAg-positive patients with HBV DNA >20,000 IU/ml after 3-6 months of elevated ALT (1-2× ULN)
  • Patients >40 years old with HBV DNA >20,000 IU/ml
  • Assessment of disease severity and fibrosis stage 2, 1

• Non-invasive fibrosis assessment:

  • Transient elastography (FibroScan)
  • Serum biomarkers of liver fibrosis 1

Special Considerations

• Patients with chronic hepatitis should be tested for immunity to hepatitis A and vaccinated if not immune 2

• For patients with elevated ALT but normal HBV markers, consider:

  • Testing for other viral hepatitis (A, D, E)
  • Autoimmune hepatitis markers
  • Metabolic causes (NAFLD, alcohol, medications) 1

• HBV genotype testing may be useful for treatment decisions in certain cases 1

Monitoring Pitfalls to Avoid

• Don't rely on a single HBV DNA measurement for treatment decisions; serial monitoring is more important than arbitrary cutoff values 2

• ALT levels may fluctuate widely in chronic hepatitis; persistent or intermittent elevation requires closer monitoring 2

• Traditional upper limits of normal for ALT may be too high; consider lower thresholds (30 U/L for men, 19 U/L for women) especially for patients >40 years old 2

• False negative HCV RNA results can occur; repeat testing may be necessary in high-risk patients with negative initial results 1

By following this systematic approach to laboratory testing and monitoring, clinicians can effectively diagnose, stage, and manage patients with chronic hepatitis to prevent disease progression and improve outcomes.