What are the recommended yearly tests for individuals with chronic Hepatitis B (HBV) infection?

Yearly Monitoring Tests for Chronic Hepatitis B Infection

All patients with chronic Hepatitis B infection require lifelong monitoring with ALT testing every 6-12 months at minimum, along with annual hepatocellular carcinoma (HCC) surveillance using ultrasound (with or without AFP) in high-risk patients. 1

Core Annual Monitoring Requirements

Liver Function Monitoring

• ALT testing every 6-12 months for patients in the inactive carrier state (HBeAg-negative, normal ALT, HBV DNA <2,000 IU/ml) after initial verification with quarterly testing during the first year 1
• More frequent ALT monitoring (every 3-6 months) for HBeAg-positive patients with persistently normal ALT 1
• Complete hepatic panel including AST, alkaline phosphatase, bilirubin, albumin, and prothrombin time/INR should accompany ALT testing to assess synthetic liver function 1, 2

Viral Replication Markers

• HBeAg status checked every 6-12 months in HBeAg-positive patients to detect seroconversion 1
• HBV DNA levels should be tested when ALT becomes elevated or at least annually to assess disease activity and treatment need 1
• Anti-HBe testing in conjunction with HBeAg to determine phase of infection 1, 3

Hepatocellular Carcinoma Surveillance

Annual ultrasound screening is mandatory for high-risk patients, defined as: 1

• Asian men over age 40 years
• Asian women over age 50 years
• All patients with cirrhosis
• Patients with family history of HCC
• Africans over age 20 years
• Any HBV carrier over age 40 with persistent/intermittent ALT elevation or HBV DNA >2,000 IU/ml

AFP (alpha-fetoprotein) testing every 6-12 months should be added to ultrasound surveillance, or used alone when ultrasound is unavailable 1, 4

Monitoring Frequency Based on Disease Phase

Inactive Carriers (Low Risk)

• First year: ALT every 3 months to verify truly inactive state 1
• After first year: ALT every 6-12 months if persistently normal 1
• Annual HCC surveillance if patient meets high-risk criteria above 1

Active Disease or Elevated ALT

• ALT every 3-6 months with more frequent testing when values become elevated 1
• HBV DNA and HBeAg testing more frequently when ALT rises 1
• Consider liver biopsy if age >40 with borderline ALT elevations (1-2× ULN) to assess need for treatment 1

Additional Baseline and Periodic Testing

Coinfection Screening

• Anti-HCV, anti-HDV (in high-risk populations), and anti-HIV should be checked at baseline and periodically in at-risk patients 1
• Anti-HAV testing with vaccination if non-immune 1

Complete Blood Count and Platelets

• Monitor annually to assess for cytopenias suggesting portal hypertension or cirrhosis 1, 2

Critical Monitoring Pitfalls to Avoid

Do not rely on single ALT measurements - patients with chronic HBV can have widely fluctuating ALT and HBV DNA levels, requiring serial monitoring over time rather than single values 1

Do not delay HCC surveillance in high-risk patients - 25% of persons infected as infants/children and 15% infected as adults will die from cirrhosis or liver cancer, making surveillance critical 1

Do not forget to monitor synthetic function - albumin, bilirubin, and INR are essential to detect progression to cirrhosis and hepatic decompensation, which changes management urgency 1, 2

Escalate monitoring frequency immediately if ALT rises above 2× ULN (recheck within 2-5 days) or if any hepatic symptoms develop 5