Bible Class: Hepatitis B Virus Infection

Transcription

1 Bible Class: Hepatitis B Virus Infection Nasser Semmo UVCM, Hepatology

2 What is the HBV prevalence? 2

3 Hepatitis B Worldwide approx. 350 Mio. chronically infected with HBV Approx. 40% of the world population: anti-hbc-antibodies positive Approx. 15 Mio. chronically HBV infected in Europe Switzerland 0,3% (24000) Worldwide annually, 0,6-1 Mio. people die from complications of chronic HBV-Infection (WHO, 2002) HBV responsible for 60% of all HCC cases worldwide 3

4 What are Hepatitis B Risk Factors? 4

5 Hepatitis B Risk Factors Blood contamination IV-Drug Abuse Injured mucus membranes Sexual Transmission Perinatal Transmission 5

6 What is the new nomenclature for HBV 6

7 New nomenclature for HBV 7

8 Natural course of HBV Infection? 8

9 Natural Course of Hepatitis B Infection 90% Resolution Acute Hepatitis B 10% Fulminant Hepatitis (0.5-1%) 70% Asymptomatic carriers 20 %/year Liver failure Chronic Hepatitis B 30 % Liver cirrhosis? 3-5%/year HCC Hepatic decompensation 9

10 Who to screen for HBV? 10

11 Hepatitis B Whom to screen? Elevated Liver enzymes and/or signs of hepatitis or chronic liver disease of unknown origin Liver cirrhosis/-fibrosis New diagnosis of HCC Pat. with migration background and from regions with high HBsAg prevalence (Africa, East Europe, Mediterranean) Family member or sexual partner from HBV infected patients DGVS-Leitlinie Hepatitis B 2007/ EASL

12 Hepatitis B Whom to screen? Medical staff Homosexuals a/o persons with frequent changing sexual partners Active o. previous i.v.-drug abuse Dialysis patients DGVS-Leitlinie Hepatitis B 2007/ EASL

13 Hepatitis B Whom to screen? HIV- a/o HCV-infected Pat. Recipients of organs before transplantation Blood- and Organ donors Patients before or during immunsuppressive therapy or Chemotherapy Pregnant women (HBsAg) DGVS-Leitlinie Hepatitis B 2007/ EASL

14 Hepatitis B How to screen? 14

15 Hepatitis B Screening How? HBsAg Anti-HBc Anti-HBs HBV DNA Chron. HBV /- Acute HBV + IgM Elimin. HBV (-) HBV Vaccine (-) HBeAg, Anti-HBe 15

16 Prevention of HBV Reactivation?? Algorithm?? 16

17 Risk of Hepatitis B Reactivation Associated With Immunosuppressive Therapies 15-30% 17

18 Prevention of HBV reactivation in immunosuppression HBsAg + HBsAg - Anti-HBc + HBsAg - Anti-HBc - Anti-HBs - High/moderate risk Low risk Vaccination Before start of immunosuppressive Tx Prophylactic antiviral Tx (NUCs) for up to months after end of immunosuppr. Tx Liver function + HBV DNA every 3 to 6 months Monitor HBV DNA/HBsAg Q1-3 months if DNA/HBsAg pos. NUCs Modified from EASL CPG

19 When to treat pregnant HBV pos. women? 19

20 Vertical transmission despite active and passive vaccination N=1068 children from HBeAg positive mothers 3% vertical Transmission with HBV DNA >10 6 cop/ml 5,5 % vertical Transmission with HBV DNA >10 7 cop/ml 9,6% vertical Transmission with HBV DNA >10 8 cop/ml à Antiviral Therapy in 2./3. Trimester with HBV-VL > IU/ml until 12 W postpartal Han et al., J Hepatology 2011, Petersen Hepatology

21 When to treat HBV? 21

22 HBV Treatment Indication 22

23 HBV Treatment Indication HBeAg-positive or -negative chronic hepatitis B: HBV DNA >2,000 IU/ ml, ALT>40IU/L and/or at least moderate liver necroinflammation or fibrosis compensated/decompensated cirrhosis, with any detectable HBV DNA level and regardless of ALT HBV DNA >20,000 IU/ml and ALT >2x40IU/L regardless of the degree of fibrosis HBeAg-positive chronic HBV infection: normal ALT and high HBV DNA levels, may be treated if they are older than 30 years regardless of the severity of liver histological lesions HBeAg-positive or HBeAg-negative chronic HBV infection and family history of HCC or cirrhosis and extrahepatic manifestations can be treated even if typical treatment indications are not fulfilled Indications for treatment may also take into account the patients age, health status, risk of HBV transmission, family history of HCC or cirrhosis and extrahepatic manifestations EASL CPG

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25 How to treat HBV? 25

26 PegIFN alpha vs. NUCs (high barrier resistance) 26

27 HBV- Treatment: HOW? High TA (>3-5 x) Low viral titer Short duration of infection GT A or B PEG-IFN 2a 180ug 48 weeks 27

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29 Is there a stopping rule for PegIFN? 29

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32 Can NUCs be stopped? 32

33 When to stop NUC therapy? Treatment End points HBeAg+ HBeAg- Seroconversion HBeAg-/anti-HBe+ No seroconversion End of therapy: At least after 12 months After seroconversion And HBV-DNA negative Long-term therapy Long-term therapy End of therapy: Anti-HBs-Seroconversion EASL HBV Guidelines

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38 THANK YOU 38