Year : 2005 | Volume
: 2 | Issue : 1 | Page : 9--10
Hepatitis B viral infection: Emerging challenges
Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
Y K Chawla
Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012
|How to cite this article:|
Chawla Y K. Hepatitis B viral infection: Emerging challenges.Hep B Annual 2005;2:9-10
|How to cite this URL:|
Chawla Y K. Hepatitis B viral infection: Emerging challenges. Hep B Annual [serial online] 2005 [cited 2021 Oct 16 ];2:9-10
Available from: https://www.hepatitisbannual.org/text.asp?2005/2/1/9/29371
Hepatitis B is a common problem worldwide, especially in the developing world. Therapy of hepatitis B infection is far from ideal, since the antivirals available produce a response only in 30-40% of cases. Moreover, none of the drugs have been shown to produce cure of the disease. Curing a patient of hepatitis B would not only decrease the incidence of HBV related cirrhosis but also hepatocellular carcinoma. Many issues, apart from ideal drug therapy, need to be addressed and resolved.
The natural history of patients with inactive HBsAg carrier who are HBeAg positive but have normal transaminases needs to be studied in a large group of patients. What are the levels of HBV DNA in these 'e' antigen positive HBsAg inactive carriers and at what level of HBV DNA copies should these patients be treated? How often should they have liver function tests and HBeAg determination are questions that can be answered best by a multicenter study since the number of these patients would be small in any tertiary care centre.
The ideal goal of achieving a therapeutic response is not very clear in hepatitis B. Whether it is the 'e' antigen seroconversion or loss of HBV DNA in the serum or liver tissue or whether the aim should be clearance of HBsAg from an individual with chronic hepatitis B is what needs to be studied. Should all patients who have seroconverted or have shown an end of treatment response have a liver biopsy to study the quantity of cccDNA in the hepatocytes. It is also important to determine whether more prolonged therapy needs to be given to achieve a total complete response. Unfortunately, at present we do not have antivirals that help in eliminating the cccDNA from the hepatocytes totally. Besides, we also need to know - the seroconversion of 'e' antigen to anti HBe, while on therapy, correlates with what levels of HBV DNA? Does the concentration or optical density of HBeAg or HBsAg, have any correlation with HBV DNA levels? If a correlation does exist, then the cost of determining HBV DNA load can be eliminated, making treatment of HBV easy for the hepatologists and the patients.
While the patients of 'e' negative chronic hepatitis B are monitored while on therapy by repeated liver functions and HBV DNA, the arbitrary level of 10 4sub or 10 5sub copies/ml of HBV DNA needs to be better factualized. If one is able to achieve a level of 10 3sub , 10 2sub or 10 copies/ml, what would be the relapse rate in these groups of patients? The effect on the long-term complications of hepatitis B would also be worth knowing.
Although the indication for antiviral therapy for acute viral hepatitis B is limited, we need to have documentary proof of its use in complicated HBV related acute viral hepatitis especially sub acute failure, acute viral hepatitis with prolonged cholestasis, and acute viral hepatitis in immunosuppressed individuals including renal failure/transplanted patients and patients with malignancy who are likely to be given chemotherapeutic agents. The genomic sequence of HBV in patients with acute viral hepatitis, fulminant hepatic failure, and chronic hepatitis as a viral factor for producing these varied presentations along with the immune host factors like gene polymorphisms also need to be studied. Studies have shown the persistence of HBV genome in the hepatocytes and occasionally the serum many years after resolution of acute viral hepatitis B. What needs to be done for this group of patients also needs to be looked into.
The HBV genotype and its relationship with the type of liver disease and long-term consequences have not been adequately studied. How HBV genotype affects the treatment response is also far from clear. Definitely further studies are needed to shed more light on these issues. Adjuvant therapy for hepatitis B after a patient of HCC has been resected or has undergone radiofrequency ablation or TACE also needs to be studied and so also the effect this would have on recurrence of HCC. The treatment of non-responders has also not been adequately studied. These should be studied with different combinations of drugs with different mechanism of action. Another very important aspect, which has not yet been studied is the co-association of alcohol and non-alcoholic steatohepatitis with HBV infection both of which are common globally. Knowledge of the natural history and response to therapy in this group would be of help in their management too.