Chronic hepatitis B virus in young adults: the need for new approaches to management

Abstract

One in four patients infected with hepatitis B virus (HBV) at birth or in early childhood will develop cirrhosis or hepatocellular carcinoma. Historically, guidelines have overlooked treatment in young people, as the immune tolerant disease phase is considered synonymous with chronic infection in the young. Current treatment aims to suppress HBV replication through long-term nucleos(t)ide therapy with little emphasis on virus eradication. To achieve HBsAg loss, it is accepted that effective immune control of virus is required, mimicking that seen in those who resolve acute HBV infection. We have recently challenged the accuracy of a generic immune tolerant state in young people, thus raising a potential role for earlier treatment. Here we report on our immunological analysis of HBV in young people and the role of a dedicated clinic; we make the case for earlier intervention to achieve effective immune control leading to better outcomes.

Keywords::

• exhaustion
• HBV-specific T cells
• hepatitis B virus
• immune tolerance
• nucleos(t)ide analogue
• pegylated-interferon
• young adult

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Chronic hepatitis B (CHB) virus infects approximately 400 million people worldwide and accounts for more than 600,000 deaths annually.

• CHB is thought to run a benign course in young patients; however, there is growing debate around the accuracy of this concept.

• Patients thought to be immune tolerant demonstrate an immune response which is more robust than that seen in their adult counterparts, thus meriting more stringent assessment and follow-up.

• More structured transition from pediatric to adult care and greater focus on CHB in young adults is likely to provide significant patient benefit.

• We provide a dedicated young adult viral hepatitis clinic in East London, an area recognized for its high prevalence of CHB.

• This unique clinic provides continuity of care with the same team and enhances the doctor–patient relationship; where feasible, remote follow-up by e-mail/skype is being evaluated.

• Challenging the concept of immune tolerance raises questions about current treatment decisions and may pave the way for earlier treatment in young patients with the potential for better treatment outcomes.

• Recent National Institute for Health and Care Excellence guidelines recommend the use of pegylated-interferon-alpha as a first-line therapy for CHB, using a response-guided approach. This may allow for an early switch strategy to NUC therapy with the potential for finite treatments.

Notes