What are the essential components of monitoring in hepatitis B (HBV)?

Essential Components of Monitoring in Hepatitis B (HBV)

Regular monitoring of serological markers, viral load, and liver function is essential for all patients with chronic hepatitis B to assess disease progression, determine treatment eligibility, and prevent complications such as cirrhosis and hepatocellular carcinoma. 1

Monitoring Components for Untreated Patients

Basic Monitoring Schedule

• For patients not indicated for treatment, monitor serum ALT and HBV DNA levels every 3-6 months and HBeAg/anti-HBe every 6-12 months to assess if treatment criteria have developed 1
• More frequent monitoring (ALT and HBV DNA every 1-3 months, HBeAg/anti-HBe every 2-6 months) is recommended for patients in the "grey area" where treatment indication is uncertain 1
• Quantitative HBsAg (qHBsAg) testing helps differentiate immune-active phase from immune-tolerant or immune-inactive phases 1

Disease Phase Assessment

• Monitor for transition between phases: immune-tolerant, immune-active, immune-inactive, and HBeAg-negative chronic hepatitis B 1
• Non-invasive fibrosis assessment (elastography or blood tests) or liver biopsy should be considered for patients who remain in the "grey area" despite close monitoring 1
• Complete blood count and liver panel should be performed regularly to assess liver disease severity 1, 2

Initial Evaluation Components

• Family history of liver disease and HCC 1
• Tests to rule out coinfections: anti-HCV, anti-HDV (in high-risk individuals), and anti-HIV 1, 2
• Serologic tests for hepatitis A immunity (IgG anti-HAV); vaccination recommended if negative 1, 2
• Baseline alpha-fetoprotein and ultrasound for HCC screening in high-risk patients 1, 2

Monitoring Patients on Antiviral Therapy

During Nucleos(t)ide Analogue (NA) Treatment

• Liver function tests and serum HBV DNA measurement at 1-6 month intervals 1
• HBeAg/anti-HBe testing at 3-6 month intervals 1
• Even after virological response, continue monitoring serum HBV DNA every 3-6 months 1
• Monitor for medication side effects specific to each drug 1, 3
• For patients on tenofovir, monitor renal function (eGFR and serum phosphate levels) 1

During Peginterferon Therapy

• Complete blood count and liver function tests monthly 1
• Serum HBV DNA at intervals of 1-3 months 1
• HBeAg/anti-HBe at 6 months and one year during treatment and 6 months after treatment 1
• HBsAg quantification pre-treatment, after 12 and 24 weeks of treatment, and at the end of treatment 1

Special Monitoring Considerations

Patients with Cirrhosis

• More intensive monitoring is required for patients with cirrhosis 1
• In decompensated cirrhosis, initiate NAs if any detectable HBV DNA, regardless of ALT level 1
• Interferon is contraindicated in patients with decompensated cirrhosis due to risk of liver failure 1
• Ultrasound screening for HCC every 6 months 1, 2

After Treatment Discontinuation

• Hepatic function should be monitored closely with both clinical and laboratory follow-up for at least several months in patients who discontinue anti-hepatitis B therapy 3
• Monitor for severe acute exacerbations of hepatitis B after discontinuation of treatment 3

Common Pitfalls in Monitoring

• Failure to recognize HBV reactivation in patients receiving immunosuppressive therapy 1
• Inadequate monitoring frequency in patients with fluctuating ALT levels 1
• Misinterpreting isolated anti-HBc positivity (requires follow-up testing) 2
• Overlooking HBeAg-negative chronic hepatitis B, which can have lower HBV DNA levels but still cause progressive liver disease 2
• Discontinuing HCC surveillance in patients with advanced fibrosis even if liver stiffness improves on treatment 4

Interpretation of Monitoring Results

• Persistent HBV replication during antiviral treatment is a major risk for hepatitis progression and viral mutation 1
• Undetectable HBV DNA is associated with lower risk of HCC compared to detectable HBV DNA (persistently or intermittently) 1
• Normalization of ALT, undetectable HBV DNA, HBeAg loss/seroconversion, and HBsAg loss/seroconversion are used as treatment endpoints 1
• Rising AST/ALT ratio, especially when AST exceeds ALT, may indicate increasing fibrosis 1