Hepatitis B, Chronic

Hepatitis B is a common reason for chronic hepatitis Patients may have asymptomatic or nonspecific symptoms such as fatigue and malaise. Without treatment, often cirrhosis developed; the risk of hepatocellular carcinoma is increased. Antiviral drugs can help, but a liver transplant may be necessary.

See also causes of hepatitis, overview of chronic hepatitis, and acute hepatitis B.)

Hepatitis B is a common reason for chronic hepatitis Patients may have asymptomatic or nonspecific symptoms such as fatigue and malaise. Without treatment, often cirrhosis developed; the risk of hepatocellular carcinoma is increased. Antiviral drugs can help, but a liver transplant may be necessary. See also causes of hepatitis, overview of chronic hepatitis, and acute hepatitis B) Hepatitis, which is longer than 6 months, is usually defined as chronic hepatitis, although this time is arbitrary. Acute hepatitis B of patients chronically for a total of about 5 to 10%. However, the younger the age when an acute infection occurs, the higher the risk that a chronic infection develops: For infants: 90% for children aged 1 to 4 years old: 25 to 50% of adults: About 5% the Centers for Disease Control and Prevention (CDC) estimate that 700.00 to 1.4 million people in the United States and about 240 million people have chronic hepatitis B infection worldwide. Without treatment, chronic hepatitis B can pass spontaneously regress (very rare), progress rapidly or slowly over decades in cirrhosis. The healing often begins with a temporary active episode of illness and is accompanied by seroconversion from HBeAg to anti-HBe. A co-infection with hepatitis D virus causes the most severe form of chronic HBV infection. Without treatment, cirrhosis develops in up to 70% of patients. Chronic HBV infection increases the risk of liver cancer. Symptoms and signs The symptoms vary depending on the degree of the underlying liver damage. Many patients, especially children, are asymptomatic. On the other hand, often appear malaise, loss of appetite and fatigue, sometimes also low-grade fever and discomfort in the right upper abdomen. Jaundice is not usually. Often the first results signs of chronic liver disease or portal hypertension are (z. B. splenomegaly, spider nevi, palmar erythema) complications of cirrhosis (. Eg portal hypertension, ascites, encephalopathy) Some patients with chronic hepatitis develop Cholestasezeichen (z. B. jaundice, itching, pale stools, steatorrhea). Extrahepatic manifestations may include nodosa and glomerular disease polyarteriitis. Diagnosis Serological tests liver biopsy, the diagnosis of chronic hepatitis B is suspected in patients with suspicious symptoms and signs, coincidentally noticed transaminase elevations or earlier diagnosed acute hepatitis. Diagnosis is by finding a positive hepatitis B surface antigen (HBsAg) and IgG anti-HBc and negative IgM antibodies to HBcAg confirmed (anti-HBc see table: hepatitis B serology *) and by measuring the hepatitis B virus DNA (quantitative HBV-DNA). Hepatitis B serology markers * Acute HBV infection Chronic HBV infection previous HBV infection † HBsAg + + – Anti-HBs – – + ‡ Anti-HBc IgM + – – IgG anti-HBc – + ± ± ± HBeAg – Anti-HBe – ± ± HBV DNA + + – * antibodies against Hepatitis D virus (anti-HDV) levels should be measured when serological tests have confirmed HBV and the infection is severe. † Patients had HBV infection and have recovered. ‡ Anti-HBs also be regarded as the sole serological markers for HBV vaccination. Anti-HBc = antibody against hepatitis B core, anti-HBe antibodies against HBeAg =, Anti-HBs Antibodies to HBsAg =; HBeAg = hepatitis B e antigen; HBsAg = hepatitis B surface antigen; HBV = hepatitis B virus. In chronic hepatitis B usually hepatitis B e antigen (HBeAg) and anti-HBe is tested to determine the prognosis of the disease and establish an antiviral treatment. If the serologically diagnosed HBV infection is severe, antibodies of the hepatitis D virus (HDV-nti) should be determined. Quantitative HBV DNA tests before and during treatment used to assess the reaction. A biopsy is typically performed to assess the degree of liver damage and rule out other causes of liver disease. A liver biopsy is most in the cases helpful, in which there are no clear guidelines for treatment (see also:. American Association for Study of Liver Disease practice guideline Diagnosis and Management of Autoimmune Hepatitis) Other function tests Liver function tests be determined if that was not has happened before. These include serum transaminases (ALT and AST), alkaline phosphatase and bilirubin. Other tests should be performed to assess the severity of the disease; they include serum albumin, platelet count and PT / INR. Patients should be tested for HIV and hepatitis C infection, since the transmission of these infections is similar. A high rheumatoid factor and low complement levels are suggestive of cryoglobulinemia. If symptoms or signs occur a cryoglobulinemia in the course of chronic hepatitis provisions of Kryoglobulins and rheumatoid factor should be performed werden.Screening complications in patients with chronic HBV infection should every 6 months for the presence of hepatocellular carcinoma by sonography and determination of the alpha-fetoprotein be controlled in the serum, although the cost-effect of this approach is discussed. (See also the Cochrane summary under Alpha-fetoprotein and / or liver ultrasonography for liver cancer screening in patients with chronic hepatitis B.) therapy Antiviral drugs Sometimes liver transplantation (See also the American Association for Study of Liver Disease Practice Guidelines for the Treatment of Chronic hepatitis B.) antiviral therapy is indicated in patients with: Increased transaminase clinical or biopsy evidence of progressive disease Both findings above the goal is to eliminate the HBV-DNA (1). The treatment may occasionally cause loss of hepatitis B e antigen (HBeAg) or anything seltener- the loss of hepatitis B surface antigen (HBsAg). The majority of patients that need to be treated for chronic hepatitis B must be treated indefinitely; Thus, the treatment can be very expensive. The premature termination of treatment may lead to relapses, which can be severe. The therapy can be stopped if any of the following events occurs: HBeAg transformed into antibody to HBeAg (anti-HBe) around. Tests for HBsAg are negative. Resistance to drugs are also a problem. Seven antiviral drugs – entecavir, adefovir, lamivudine, interferon alfa (INF-alpha), pegylated INF-alpha (peginterferon-alpha), telbivudine and tenofovir are available (see Table: Comparison of the drugs commonly used in chronic hepatitis B). Comparison of the drugs commonly used in chronic hepatitis B effect (% of patients) INF-alpha, PEG-IFN-alpha, lamivudine, adefovir Entecavir Telbivudine Tenofovir serum HBV DNA undetectable 37% 30-42% 44% 21% 61% 60% 76 % Seroconversion from HBeAg to anti-HBe occurs normalized 18% 29-36% 16-21% 12% 21-22% 22% 21% 23% 34-52% 41-75 ALT% 48% 68-81% 77% 68% histological improvement occurs NA 38% 49-56% 53% 72% 65% 74% undetectable HBsAg (at 1 year) 8% 3% <1% 0% 2-3% 0% 3% resistance development None None After 1 Year: ~ 14-32% by 5 years: ~ 60-70% After 1 year: 0% After 5 years: 29% After 1 year: 0% After 6 years: 1, 2% After 1 Year: 5% After 2 years, 25% after the age of 6: 0% anti-HBe = antibody to HBeAg; HBeAg = hepatitis B e antigen; HBsAg = hepatitis B surface antigen; HBV = hepatitis B virus; INF-alpha = alpha interferon; PEG-IFN-alpha = pegylated INF-alpha. Adapted from Lok ASF, McMahon BJ: Chronic hepatitis B, last update 2009. American Association for Study of Liver Diseases (AASLD) practice guidelines update. Hepatology 50: 661-699, 2009 Terrault NA, Bzowej NH, Chang KM, et al: AASLD guidelines for treatment of chronic hepatitis B. Hepatology 63: 261-283, 2016. First-line drugs are usually an oral antiviral medication as entecavir (a nucleoside analogue) or tenofovir (a Nukleotidanalogom) Oral antiviral drugs have few side effects and can be given to patients with decompensated liver disease. The combination therapy has not been shown to be superior to monotherapy, but there are studies that examine their comparable benefits. If HBsAg is not detectable and occur HBeAg seroconversion in patients with HBeAg-positive chronic HBV infection, these patients can stop taking antiviral drugs. Patients with HBeAg-negative chronic HBV infection almost always need to take antiviral medication indefinitely to maintain viral suppression; they already have antibodies to HBeAg and thus the only specific criterion for the termination of HBV therapy is the loss of HBsAg. Entecavir has a high antiviral potency, resistance development is unusual. This remedy is considered as HBV treatment of choice. Entecavir is effective against adefovir-resistant strains. The dosage is 0.5 mg p.o. once a day. But patients who have previously taken a nucleoside analogue should, 1 mg po take once a day. Dose reduction is required in patients with renal insufficiency. Serious adverse effects are rare, but a harmless intake during pregnancy has not been established. Tenofovir has (an older nucleotide analog) in treating replaced adefovir as an agent of first choice. Tenofovir is the most potent oral antiviral drug for hepatitis B. resistances are rarities. It has little adverse effects. The dosage is 245 mg p.o. once a day; the frequency of dosing may need to be reduced if the creatinine clearance is reduced. For adefovir dose is 10 mg p.o. once a day. Interferon alfa (IFN-?) may be used, but will no longer be considered the first choice. The dose is 5 million IU s.c. once daily or 10 million IU s.c. 3 times a week for 16 to 24 weeks in patients with HBeAg-positive chronic HBV infection and about 12 to 24 months in patients with HBeAg-negative chronic HBV infection. In approximately 40% of patients, this regimen results in the elimination of HBV DNA and causes seroconversion to anti-HBe. A successful response to treatment is usually preceded by a transient increase in transaminases. The drug has to be injected and is often poorly tolerated. The first one or two injections are accompanied by flu-like side effects. Later in fatigue, malaise, depression, bone marrow suppression and rare bacterial infections and autoimmune diseases may occur. Among the counterpoint Indikatione of INF-alpha include the following: advanced cirrhosis: In patients with cirrhosis IFN-alpha may precipitate decompensation of cirrhosis. Kidney failure immunosuppression Solid organ transplant cytopenia A few patients have treatment because of intolerable side effects must be discontinued. The treatment must be carried out carefully. Patients with active drug abuse or pronounced psychiatric disorders should not be treated. Pegylated IFN-alpha can be used instead of IFN-alpha. The dosage is usually 180 micrograms by injection once a week for 48 weeks. The side effects are similar to those of IFN-alpha, but are not as strong as a rule. Lamivudine (a nucleoside analogue) is no longer regarded as HBV drug of first choice, because of the risk of development of resistance is higher and the effectiveness is lower compared to the newer antiviral drugs. The dosage is 100 mg p.o. once a day. There are few side effects. Telbivudine is a newer nucleoside analog that has greater efficacy and potency than lamivudine, but also a high degree of resistance. It is therefore not considered a drug of first choice. The dose is 600 mg p.o. once a day. End-stage liver disease caused by HBV liver transplantation should be considered. In patients with HBV infection, the long-term use of oral antiviral drugs of choice and the peritransplantationelle use of hepatitis B immune globulin (HBIG) have improved the results after liver transplantation. The survival rate is equal to or better than the survival rate after transplantation of other indications, and recurrence of hepatitis B are minimized. Treatment Note 1. Terrault NA, Bzowej NH, Chang KM, et al: AASLD guidelines for treatment of chronic hepatitis B. Hepatology 63: 261-283, 2016. Key Points Acute Hepatitis B becomes chronic in about 5 to 10% of patients; the risk is at a young age (90% for infants, 25 to 50% for children aged 1 to 5 years and about 5% for adults) the highest. The CDC estimates that about 240 million people have chronic hepatitis B infection worldwide. The symptoms vary depending on the degree of the underlying liver damage. Antiviral drugs can improve liver function test results and liver histology and delay the progression to cirrhosis, but may need to be taken indefinitely; Drug resistance is a concern. A liver transplant may be necessary with decompensated cirrhosis due to hepatitis B in patients. For more information alpha-fetoprotein and / or liver ultrasonography for a study on liver cancer in patients with chronic hepatitis B American Association for the Study of Liver Disease Practice Guidelines

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