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Chronic hepatitis B : an update

TL;DR: A group of experts in this field is assembled to present their expertise in such a level, where the practicing clinicians who deal with this disease in their daily practice can understand thereby implement this knowledge into their own practice.
Abstract: A recent Institute of Medicine report has concluded that 'there is a lack of knowledge and awareness about chronic viral hepatitis on the part of health-care and social-service providers, as well as among at-risk populations, members of the public, and policy-makers. Due to the insufficient understanding about the extent and seriousness of this public-health problem, inadequate public resources are being allocated to prevention, control, and surveillance programs'. It is with these concerns in mind that Dr. Tsai assembled a group of experts in this field to present their expertise in such a level, where the practicing clinicians who deal with this disease in their daily practice can understand thereby implement this knowledge into their own practice. Dr. Brian McMahon discusses the natural history of chronic hepatitis B with his vast knowledge and experience working with the high endemic population of Inuit in Alaska. Drs. Marc Ghany and Ed provide a very easy-to-understand description of HBV virology. Dr. Kyon-Mi Chang contributes an article on HBV immunology, which is the least understood area of this disease but has the most potential to improve our knowledge in the management of chronic hepatitis B. Dr. Anna Lok provides an authoritative review on the current issues and controversies of treatment of chronic hepatitis B. Dr. Stephen Locarnini, who has extensive experience in anti-viral resistance and its management, presents important issues in the usage of currently available anti-viral oral agents. Dr. Myron Tong discusses the current understanding of HBV carcinogenesis and updates HCC surveillance and treatment - the most dreadful outcome of this disease. Dr. Paul Martin discusses management of end- stage chronic hepatitis B - anti-viral therapy, montherapy vs combo therapy, choice of agent, when to start therapy and post-transplant patients including duration of HBIG therapy, HBcAb(+)only recipient) and Occult HBV infection. Dr. Tram Tran discusses the treatment in reproductive women, during pregnancy, and prevention of vertical transmission in third trimester with antiviral agents - an area with significant lack of good clinical evidence. Dr. Steve Han discusses management of patients with acute hepatitis B, co-infection with HDV/HCV/HIV, pre-immuno-suppressive therapy, and management of renal and heart transplant patients with HBV infection. Dr. Mei Huei Chang discusses Taiwanese success in implementing universal vaccination leading to a remarkable reduction in both prevalence of chronic hepatitis B and incidence of hepatocellular carcinoma. Finally Drs. Michelle Lai and Yun Fan Liaw provide a rundown of what we have accomplished and the hope for the future in our fight to control this disease.
Citations
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Journal ArticleDOI
TL;DR: This AASLD 2018 Hepatitis B Guidance provides a data-supported approach to screening, prevention, diagnosis, and clinical management of patients with hepatitis B.

2,399 citations


Cites background from "Chronic hepatitis B : an update"

  • ...Submitted for publication on January 11, 2018 Some persons may test positive for anti-HBc but not HBsAg; they may or may not also have anti-HBs, with the prevalence depending on local endemicity or the risk group (37, 38)....

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  • ...(iii) Anti-HBc may be the only marker of HBV infection during the window phase of acute hepatitis B; these persons should test positive for anti-HBc immunoglobulin M (37, 38)....

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Journal ArticleDOI
TL;DR: These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013.
Abstract: These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.

1,862 citations

Journal ArticleDOI
TL;DR: The final clinical practice guidelines and recommendations for the optimal management of chronic HBV infection are presented here, along with the relevant background information.
Abstract: Worldwide, some 240 million people have chronic hepatitis B virus (HBV), with the highest rates of infection in Africa and Asia. Our understanding of the natural history of HBV infection and the potential for therapy of the resultant disease is continuously improving. New data have become available since the previous APASL guidelines for management of HBV infection were published in 2012. The objective of this manuscript is to update the recommendations for the optimal management of chronic HBV infection. The 2015 guidelines were developed by a panel of Asian experts chosen by the APASL. The clinical practice guidelines are based on evidence from existing publications or, if evidence was unavailable, on the experts' personal experience and opinion after deliberations. Manuscripts and abstracts of important meetings published through January 2015 have been evaluated. This guideline covers the full spectrum of care of patients infected with hepatitis B, including new terminology, natural history, screening, vaccination, counseling, diagnosis, assessment of the stage of liver disease, the indications, timing, choice and duration of single or combination of antiviral drugs, screening for HCC, management in special situations like childhood, pregnancy, coinfections, renal impairment and pre- and post-liver transplant, and policy guidelines. However, areas of uncertainty still exist, and clinicians, patients, and public health authorities must therefore continue to make choices on the basis of the evolving evidence. The final clinical practice guidelines and recommendations are presented here, along with the relevant background information.

1,787 citations


Cites background from "Chronic hepatitis B : an update"

  • ...Identification of a HBV-infected person is helpful to [7, 105]: • detect and evaluate stage of the liver disease and extent of liver damage; • plan antiviral therapy which can delay or reverse the progression of liver disease; • permit ultrasound surveillance to detect HCC at a potentially treatable stage; • counsel to avoid excessive alcohol use; • take measures to reduce risk of transmission to others; • avoid unnecessary vaccination, as vaccination is not beneficial for persons already chronically infected and is unnecessary for persons already immune (either through prior vaccination or a previous resolved acute infection; • vaccinate unprotected individuals....

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  • ...the duration of anti-viral prophylaxis is 6–12 months after completion of chemotherapy [25, 105]....

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Journal ArticleDOI
TL;DR: Aasld Guidelines for Treatment of Chronic Hepatitis B Norah Terrault;Natalie Bzowej;Kyong-Mi Chang;Jessica Hwang;Maureen Jonas;Hassan Murad; Hepatology

1,596 citations


Cites background from "Chronic hepatitis B : an update"

  • ...Background The objective of HBV treatment is to prevent fibrosis progression and liver-related complications through achievement of sustained suppression of viremia.(2) In those with significant inflammation and/or fibrosis on histology and/or elevated ALT in association with elevated HBV DNA levels, the risk of liver-related complications is highest and the rationale for treatment can be made....

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  • ...Assessments are performed on continuous therapy (NAs)(27-30) and after therapy discontinuation (PegIFN).(2,31,32) The best predictor of sustained remission off-treatment is HBsAg loss, but this is infrequently achieved with current therapies....

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Journal ArticleDOI
TL;DR: Liver biopsy gives a snapshot and not an insight into the dynamic changes during the process of fibrogenesis, so immunohistochemical evaluation of cellular markers such as smooth muscle actin expression for hepatic stellate cell activation, cytokeratin 7 for labeling ductular proliferation or CD34 for visualization of sinusoidal endothelial capillarization can provide additional ‘‘functional’’ information.

1,441 citations


Cites background from "Chronic hepatitis B : an update"

  • ...Patients who have significant liver fibrosis and HBV DNA >2000 IU/ml should be considered for antiviral therapy even if their ALT levels are below two times ULN [251,252]....

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  • ...Among patients who have persistently elevated ALT >2 times ULN and HBV DNA >2000 IU/ml, all regional guidelines recommend commencement of antiviral therapy and liver fibrosis assessment may not be necessary....

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  • ...Among hepatitis B patients who have elevated ALT but not yet reached two times ULN, liver fibrosis assessment can assist the decision of antiviral therapy....

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  • ...Liver biopsy should only be considered in doubtful cases after TE (A1) • LS measurement should be interpreted with caution among patients with elevated ALT, and should not be used in patients with very high ALT levels (>10 x ULN) (A1) Use of non-invasive tests for staging liver disease in NAFLD NAFLD is a very common condition with reported prevalence of approximately 20% in different parts of the world [219,220]....

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  • ...Its main limitation is the impossibility of obtaining results in case of ascites or morbid obesity and its limited applicability in case of obesity and limited operator experience (A1) • TE should be performed by an experienced operator (>100 examinations) following a standardized protocol with the patient, fasting for at least 2 hours, in the supine position, right arm in full abduction, on the midaxillary line with the probe-tip placed in the 9th to 11th intercostal space with a minimum of 10 shots (A1) • Correct interpretation of TE results in clinical practice must consider the following parameters: - IQR/ median value ( 30%), - Serum aminotransferases levels (<5 x ULN), - BMI (use XL probe above 30 kg/m2 or if skin-tocapsule distance is >25 mm), - Absence of extra-hepatic cholestasis, - Absence of right heart failure, or other causes of congestive liver - Absence of ongoing excessive alcohol intake (A1) • Although alternative techniques, such as pSWE/ARFI or 2D-SWE seem to overcome limitations of TE, their quality criteria for correct interpretation are not yet well defined (A1) • At present correct interpretation of pSWE/ARFI results in clinical practice should systematically take into account the potentially confounding parameter: - fasting for at least 2 hours, transaminases levels ( 5 x ULN), absence of extra-hepatic cholestasis and absence or right heart failure (B1) • MR elastography is currently too costly and timeconsuming for routine clinical practice use and seems more suited for research purposes (A1) Endpoints for staging liver fibrosis In patients with viral hepatitis and HIV-HCV coinfection, the clinically relevant endpoints are: (1) detection of significant fibrosis (METAVIR, F P2 or Ishak, P3), which indicates that patients should receive antiviral treatment....

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