HBV immunosuppressed patients Flashcards
Patients who are undergoing immunotherapy/ chemotherapy are screened for active HBV infection.
Check HBsAg and anti-HBc
Which patients should receive treatment/ prophylaxis?
HBsAg pos
HBsAg neg + anti-HBc pos
HBsAg pos - should start ETV/TAF/TDF regardless if does not fit other criteria
HBsAg neg + anti-HBc pos -
- check for HBV DNA - if viraemic start ETV/TAF/TDF
HBsAg neg + anti-HBc pos -
- check for HBV DNA - if undetectable, consider ETV/TAF/TDF if at high risk of reactivation
Risk of reactivation depends on drugs patient will receive
e.g prednisolone would not need prophylaxis, but chemotherapy will
anti-HBc positive patient undergoing chemotherapy
How long to continue HBV prophylaxis for?
12 months following cessation of immunosuppressive
18 months following cessation of rituximab
anti-HBc positive patient undergoing chemotherapy
Is on anti-viral prophylaxis
What monitoring is required?
LFTs and HBV DNA monitoring every 3 months
LFTs and HBV DNA monitoring continues, every 3 months, for up to 1 year following cessation
anti-HBc positive patient undergoing chemotherapy
What are drug options for prophylaxis?
Lamivudine - often first choice, as less side effects. Can be used for short periods without risk of resistance
ETV/ TAF/ TDF are options
HBsAg neg + anti-HBc pos
Patient is starting low risk immunosuppresion (<10%)
What prophylaxis should be given?
Does not need prophylaxis
Needs pre-emptive therapy
Monitor HBsAg/ HBV DNA/ ALT - if rise then quickly start treatment
HBsAg neg + anti-HBc pos
Patient is starting high immunosuppresion (<10%)
What prophylaxis should be given?
LAM/ ENT/ TAF/ TDF
continue for 12 months following cessation of immunosuppression
continue for 18 months following cessation of rituximab
HBsAg neg + anti-HBc pos
They are on low risk immunosuppression, so you are monitoring HBsAg and HBV DNA appearance
Which is likely to appear first, and what is the significance of these?
HBV DNA likely to appear first
If appears, 50% chance of hepatitis flare
HBsAg appearance is almost certainly going to cause a hepatitis flare
Dialysis patient with chronic HBV infection, but not hepatitis.
Should be monitored for reactivation
What are drug options in this population?
Entecavir preferred
TDF/TAF can be used if renally doses
Dialysis patient, antiHBc positive
You are monitoring for reactivation
What is important to consider when monitoring bloods?
ALT levels are falsely low in dialysis patients as it is cleared during dialysis
Renal transplant patient
Does this patient require monitoring or prophylaxis?
HBsAg pos - start prophylaxis
HBsAg neg + anti-HBc pos - monitor for risk of reactivation
Reactivation can occur spontaneously, but risk increases in patients on immunosuppressive therapies
How do we define reactivation?
Detectable HBV DNA
HBsAg positive
In patient who was previously HBV DNA neg, and HBsAg neg
What part of HBV genome provides template for reactivation?
The key molecular agent driving HBV reactivation is covalently closed circular DNA (cccDNA).
During an acute HBV infection, HBV viral particles enter hepatocytes by receptor-mediated endocytosis.
The partially double-stranded HBV genome is imported to the nucleus, where both viral and host machinery complete a full-length cccDNA molecule, or mini-chromosome.
This mini-chromosome persists as the reservoir for both new viral particles and more cccDNA
Although acute HBV infection in adults generally resolves without development of CHB, persistent cccDNA still poses a risk for reactivation.
Patient known anti-HBc positive, about to receive an immunosuppressive treatment
What action would you take if HBsAg pos?
Start antiviral treatment - current reactivation already
Patient known anti-HBc positive, about to receive an immunosuppressive treatment
What action would you take if HBsAg neg?
Moderate risk immunosuppressive
Moderate risk immunosuppressive - monitor ALT, HBsAg, HBV DNA every 1-3 months
Patient known anti-HBc positive, about to receive an immunosuppressive treatment
What action would you take if HBsAg neg?
High risk immunosuppressive
High risk immunosuppressive - start antiviral prophylaxis
