What are the AASLD guidelines for the initial evaluation of hepatitis B surface antigen (HBsAg)-positive patients?

Updated: Aug 01, 2018
  • Author: Nikolaos T Pyrsopoulos, MD, PhD, MBA, FACP, AGAF; Chief Editor: BS Anand, MD  more...
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Answer

Select recommendations from the 2016 American Association for the Study of Liver Diseases (AASLD) guidelines for the treatment of chronic hepatitis B [37] as well as the 2018 AASLD guidance update on the prevention, diagnosis and treatment of chronic hepatitis B [47] are outlined below.

Screening for hepatitis B infection

The following recommendations are from the 2018 AASLD guidance update [47]:

  • Perform screening with both hepatitis B surface antigen (HBsAg) and antibody to HBsAg (anti-HBs).
  • Individuals who should undergo screening include all those born in countries that have an HBsAg seroprevalence of 2% or greater, US-born persons in areas with high HBV endemicity (≥8%), pregnant women, those who require immunosuppression, and specific at-risk populations.
  • Vaccinate screened individuals who are negative for anti-HBs
  • Although routine screening is not recommended for antibody to hepatitis B core antigen (anti-HBc) to assess for previous exposure, it is a valuable test in HIV patients; those about to receive hepatitis C or anticancer and other immunosuppressive treatment or renal dialysis; and in donated blood (or, organs, if feasible).

Recommendations for the initial evaluation of hepatitis B surface antigen (HBsAg)-positive patients

All patients

History and physical examination: Thoroughly evaluate for the following:

  • Alcohol, metabolic, and other risk factors for hepatitis B virus (HBV) infection
  • Patient's HBV vaccination status
  • Family history of HBV infection and hepatocellular carcinoma
  • The presence of symptoms/signs of cirrhosis

Routine laboratory studies

  • Complete blood cell (CBC) count, platelet count; international normalized ratio (INR)
  • Levels of aspartate transaminase (AST), alanine transaminase (ALT), total bilirubin, alkaline phosphatase (ALP), and albumin

Serologic/virologic studies

  • Hepatitis B e antigen (HBeAg)/anti-HBe
  • HBV DNA level
  • Anti-hepatitis A virus (anti-HAV) (to determine need for vaccination)

Imaging/staging studies

  • Abdominal ultrasonography
  • Vibration-controlled transient elastography (eg, FibroScan) or a serum fibrosis marker panel (APRI [AST-to-platelet ratio index], FIB-4 [platelet count, ALT, AST, age], or FibroTest [gamma-2 macroglobulin, gamma-2 globulin, gamma globulin, apolipoprotein A1, gamma-glutamyl transpeptidase (GGT), total bilirubin])

Select patients

Routine laboratory studies: In the setting of elevated liver function test results, obtain tests to exclude other causes of chronic liver disease. Obtain levels of alpha-fetoprotein (AFP) and GGT.

Serologic/virologic studies

  • HBV genotyping
  • Tests for coinfection with hepatitis C virus (HCV), hepatitis D (delta) virus (HDV), and/or human immunodeficiency virus (HIV) in at-risk individuals aged 13-64 years who have not undergone one-time screening

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