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home - Liver - Hepatitis B - Hepatitis B Special Situations Written by Dr Sebastian Zeki

Understands the serological interpretation categorisation and
investigation of patients with chronic hepatitis B and/or C with
particular emphasis on the need for treatment and surveillance

Recognises the particular populations at risk
Aware of national and international agreed guidelines on viral
hepatitis management and use of interferon and antiviral drugs

Aware of hepatitis B reactivation in the context of immunosuppression
Uses appropriate diagnostic modalities including serology
genotyping viral load measurements liver biopsy and related

Monitors anti-viral and immunomodulatory therapies with appropriate

Communicates effectively with patients and relatives in the context of
viral liver disease and underlying social and psychological risk factors

Marshals multi-disciplinary support networks and in particular
recognise the crucial role of nurse practitioners in disease



Identifies patients with acute hepatitis B and can a rtain the
severity of their illness

Defines the different phases of chronic hepatitis B infection with a
clear understanding of serological results

Appreciates risks of transmission to close contacts
Has awareness of indications for therapy in both HBeAg positive and
negative hepatitis and the potential influence of genotype on choice of

Identifies patients where prophylaxis is required to prevent
reactivation and vertical transmission

Can determine an appropriate surveillance programme for those
patients with varices and/or hepatocellular carcinoma

Identifies patients who are appropriate candidates for liver transplant

Demonstrates ability to take a relevant history perform examination
and organise appropriate investigations

Able to advise risks of viral transmission
Interprets results of blood tests for hepatitis B antigen and antibody
Appreciates when liver biopsy is appropriate
Be able to select the most appropriate treatment and how to monitor
patient response

Able to select appropriate imaging techniques for evaluation of
abnormal results
Appreciates the cultural differences in the ethnic populations infected
and the influence this may have on screening

Provides advice and education to families and shows appreciation of
the potential difficulties that may arise

Understands the importance of cooperation with virologists and staff
in other clinical laboratories

Hepatitis B Special Situations

Who to treat: Written by Dr Sebastian Zeki Reactivation:Described esp. with long term steroids and infliximab therapy.If HbAsg +ve consider prohylaxisIf HBsAg positive patients + hepatitis flare then treat. Continue treatment for 6m after chemoIf have a high baseline HBV DNA, treat to therapeutic endpoint.If serology suggest-ing recovery from HBV infection then monitor Chemotx Initiate antivirals ASAP regardless of HBV DNA and e antigen status if scheduled for chemotherapy.Can use any of the oral anti-HBV drugs, but avoid Interferon (bone marrow suppression or exacerbation of hepatitis) +ve If risk factors for Hep B, test HIV10% of HIV patients have Hep B.There are higher reactivation rates in HIV- associated with low CD4 counts.Spontaneous clearance of HBeAg is lower in HIV.It is unclear as to whether coinfection speeds progression but mortality is increased esp post HAART as AIDS mortality is decreased.HBV flares are increased after HAART is initiated due to immune reactivation. a. Coinfection can worsen progression to cirrhosis and HCC development.b. Coninfection present in 15% HepBc.Acute coinfection with both can shorten HbSAg and lower peak ALT compared to monoinfection with HBV but equally can increase the risk of severe hepatitis and fulminant hepatic failure.d. HCV is the predominant cause of cirrhosis and should be treated with interferon + ribavirin but can result in HBV replication increase after HCV clearance Hepatitis DIt is always coinfected as Hep B is needed for Hep D virus coating.Coinfection is more severe than Hep B alone. Hepatitis C Hepatitis B Coinfection and HepB Hepatitis B virus reactivation associated with immunosuppression. As per the non-HIV populationIf HAART candidate: Truvada® (tenofovir and emtricit-abine) + NNRTI or a PIOn on HAART and good HIV response but Hep B lamivudine resistance, i) Replace lamivudine with Truvada ORii) Add adefovir to lamivudineIf not HAART candidate, i) Pegylated interferon or adefovir (dont cause HIV resistance) ORii) Early treatment with HAART with 2 dual active agents with HIV and Hep B activity (eg, tenofovir with emtricit-abine or lamivudine plus an additional antiretroviral agent).Optimal duration of therapy is unknown.Patients who are not candidates for HAART —Treat indefinitely unless good CD4 and e seroconversion in which case treatment continues for 12 months after seroconversion

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