What blood work is necessary for patients with chronic hepatitis?

Blood Work for Chronic Hepatitis

All patients with chronic hepatitis require regular monitoring of liver function tests (ALT/AST), HBV DNA or HCV RNA levels, complete blood count, and serologic markers (HBeAg/anti-HBe for hepatitis B), with frequency determined by disease activity and treatment status. 1

Initial Evaluation Panel

When chronic hepatitis is first identified, the following blood work is essential:

• Complete blood count to assess for cytopenias suggesting advanced disease 1
• Comprehensive liver panel including ALT, AST, bilirubin, albumin, and alkaline phosphatase 1
• Viral markers: For hepatitis B, test HBsAg, HBeAg, anti-HBe, and HBV DNA by real-time PCR; for hepatitis C, test HCV RNA 1
• Coinfection screening: HIV, hepatitis C (if HBV), hepatitis B (if HCV), hepatitis D (if HBV), and hepatitis A antibody 1
• Baseline alpha-fetoprotein (AFP) for hepatocellular carcinoma surveillance in at-risk patients 1
• Immunoglobulin levels may be elevated in autoimmune hepatitis 2

Monitoring Schedule for Untreated Patients

Patients with Normal ALT Levels

• ALT and HBV DNA every 3-6 months 1
• HBeAg/anti-HBe every 6-12 months 1
• This applies to immune-tolerant or inactive carrier phases where treatment is not yet indicated 1

Patients with Elevated ALT Levels

• Liver function tests every 1-3 months 1
• HBV DNA by real-time PCR every 2-6 months 1
• HBeAg/anti-HBe every 2-6 months 1
• More frequent monitoring is critical as up to 40% may experience exacerbations before spontaneous HBeAg clearance 1

Patients with Compensated Cirrhosis

• Liver function tests every 2-6 months 1
• HBV DNA and HBeAg status every 2-6 months 1
• These patients require closer surveillance regardless of viral activity 1

Patients with Decompensated Cirrhosis

• Liver function tests every 1-3 months 1
• Immediate antiviral therapy if any HBV DNA is detectable, regardless of level 1

Monitoring During Antiviral Treatment

For Nucleos(t)ide Analogue (NA) Therapy

• Liver function tests and HBV DNA every 1-6 months initially, then every 3-6 months after virological response 1
• HBeAg/anti-HBe every 3-6 months 1
• HBV DNA every 1-3 months for the first months to confirm virological response, then every 3-6 months 1
• Creatine kinase (CK) monitoring for patients on telbivudine or clevudine due to myositis risk 1
• Even after achieving undetectable HBV DNA, continue monitoring every 3-6 months as detectable DNA (even if <2,000 IU/mL) increases HCC risk 1

For Peginterferon Alfa Therapy

• CBC and ALT monthly 1
• HBV DNA after 1-3 months to assess primary response 1
• HBeAg/anti-HBe at 6 and 12 months during treatment, and 6 months post-treatment 1
• Quantitative HBsAg (qHBsAg) pre-treatment, at 12 and 24 weeks, and at end of treatment to predict response 1

Important Caveats

The magnitude of liver enzyme elevation does not correlate with disease severity or prognosis. 1 Patients with hepatitis C or NAFLD may have normal or minimally elevated ALT yet still progress to cirrhosis, while acute hepatitis A can cause ALT >1,000 U/L with complete recovery 1. The current upper limit of normal for ALT may be too high; hepatitis B treatment guidelines use ALT >30 U/L for males and >19 U/L for females as significant 1.

Do not assume normalized liver tests mean disease resolution. Patients with chronic hepatitis C and NAFLD can have normal ALT despite ongoing fibrosis progression 1. Repeating tests to see if they normalize is only justified when an acute insult is identified 1.

HBV DNA quantification assays vary significantly. Detection limits range from 50 copies/mL (molecular beacons) to 700,000 copies/mL (branched DNA), with different genotype sensitivities 1. For initial evaluation, assays with detection limits of 10^5 to 10^6 copies/mL are adequate 1.