Hepatitis B reactivation: diagnosis and management

ABSTRACT

Introduction

Hepatitis B virus (HBV) reactivation can be induced by treatments that attenuate the immunological control over HBV, leading to increased morbidity and mortality. The risk of HBV reactivation is determined by host immunity, viral factors, and the type and dose of treatments. Nevertheless, the risk of HBV reactivation for a growing number of novel therapies remains uncertain and needs to be carefully examined. Identification of patients at risk and administration of prophylactic antiviral agents are critical to prevent HBV reactivation. Early diagnosis and initiation of antiviral treatment are the keys to avoid devastating outcomes.

Area covered

We summarized the latest evidence and recommendations for risk stratification, early diagnosis, prophylaxis, and management of HBV reactivation.

Expert opinion

Universal screening, adequate prophylaxis, and close monitoring are essential for the prevention of HBV reactivation. Risk stratification of patients at risk with appropriate antiviral prophylaxis can prevent HBV reactivation effectively. Several emerging biomarkers have been proved to help determine the risk precisely. Early detection and timely administration of antiviral agents are crucial for management. Further studies on the precision of risk stratification as well as the optimal duration of prophylaxis and treatment are needed to establish an individualized strategy.

KEYWORDS:

• HBV reactivation
• HBV prophylaxis
• predictors
• risk stratification
• nucleos(t)ide analogues

Article highlights

• The risk of HBV reactivation persists both in patients with chronic and resolved infection because the covalently closed circular DNA (cccDNA) of HBV exists in the hepatocytes permanently.

• The diagnosis of HBV reactivation is made according to reverse seroconversion of HBsAg, or a significant rise in serum HBV DNA.

• The risk of HBV reactivation is determined by host immunity and viral factors as well as type and duration of causative therapies. Those who are anticipated to receive the drugs with risk should be screened routinely.

• Antiviral prophylaxis is recommended for patients at high risk (>10%) and may be considered for those at moderate risk (1 – 10%) for HBV reactivation. Those with low risk (<1%) should be monitored closely with blood tests every 1 to 3 months.

• For patients not receiving antiviral prophylaxis, early diagnosis of HBV reactivation and timely use of antiviral agents are the key for a better prognosis. The preferred ones for antiviral prophylaxis and treatment are ETV, TDF and TAF.

• Future studies will focus on individualized preventive strategies composed of precise risk stratification, the optimal timing of initiation and duration of antiviral therapy.

Declaration of interest

The authors have no other 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.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was funded by National Taiwan University Hospital (grant number 108-S254) and the Ministry of Science and Technology, Executive Yuan, Taiwan (grant number 107-2314-B-002-036-MY3).