Management of Decompensated Hepatitis B Causing Ascites
Patients with decompensated hepatitis B causing ascites should be promptly treated with oral antiviral therapy using nucleos(t)ide analogues with high genetic barriers to resistance, specifically entecavir or tenofovir, regardless of HBV DNA levels, and liver transplantation should be considered. 1
Initial Management Approach
- Prompt antiviral therapy is recommended if HBV DNA is detectable by PCR test regardless of ALT/AST levels 1
- Patients with decompensated cirrhosis should be treated in specialized liver units due to the complexity of management and potential need for liver transplantation 1
- Antiviral treatment is indicated irrespective of HBV DNA level to prevent reactivation 1
- Peginterferon-α is contraindicated in decompensated cirrhosis due to the risk of serious complications, such as hepatic failure 1
Antiviral Medication Selection
- Oral nucleos(t)ide analogues (NAs) with high genetic barriers to resistance are the treatment of choice 1
- Monotherapy with either tenofovir or entecavir is preferred as first-line treatment 1
- For entecavir, the recommended dose in decompensated cirrhosis is 1 mg daily (higher than the 0.5 mg dose used for compensated liver disease) 1
- Lamivudine should not be used due to high resistance rates 1
- Newer agents such as tenofovir alafenamide (tenofovir AF) and besifovir are also recommended by some guidelines and may have improved safety profiles regarding renal and bone toxicity 1
Monitoring During Treatment
- Liver function should be tested every 1-3 months 1
- Serum HBV DNA should be measured by real-time PCR plus HBeAg status should be checked every 2-6 months 1
- Close monitoring of clinical and laboratory parameters is essential, especially in patients with advanced decompensated cirrhosis (MELD score >20) due to risk of lactic acidosis 1, 2
- Monitor for hepatitis flares which may occur during treatment and require urgent management 1
- Renal function should be closely monitored, particularly in patients receiving tenofovir, with dose adjustments necessary for patients with creatinine clearance <50 ml/min 1, 2
Expected Outcomes and Prognosis
- Clinical improvement often requires 3-6 months of antiviral therapy 1
- Patients may show slow clinical improvement over a period of 3-6 months under NA therapy, potentially avoiding the need for transplantation 1
- Prolonged and adequate suppression of HBV DNA can stabilize patients and prevent progression of decompensated liver disease 1, 3
- Some patients with advanced hepatic disease with high Child-Pugh or MELD scores may have progressed beyond the point of no return and may still require liver transplantation despite antiviral therapy 1
Liver Transplantation Considerations
- Liver transplantation should be considered for patients with decompensated HBV cirrhosis 1
- Pre-transplant therapy with potent NAs with high barriers to resistance is recommended to achieve the lowest possible HBV DNA level before transplantation 1, 4
- Treatment with NAs inducing HBV DNA undetectability at transplantation will decrease the risk of HBV recurrence in the graft 1
- Post-transplantation, a combination of hepatitis B immunoglobulin (HBIg) and NA therapy is the standard of care for prophylaxis against HBV recurrence 5, 4
Special Considerations and Potential Complications
- Lactic acidosis has been reported in some NA-treated patients with advanced decompensated cirrhosis (particularly with entecavir in patients with MELD score >20) 1, 6
- The HCC risk remains high in these patients even under effective NA therapy, necessitating long-term HCC surveillance 1
- Tenofovir has been associated with potential nephrotoxicity and decreased bone mineral density, requiring monitoring 2
- Entecavir has been associated with a 9% incidence of on-treatment hepatic flares in decompensated cirrhosis patients 6