Fibrosis staging in patients with chronic HBV on therapy
Clinical Challenge
Do you recommend additional work-up for fibrosis staging at this time?
Expert Opinions
Richard Andrews, MD, MPH
Addiction Medicine Physician
Former Chair, National Task Force on Hepatitis B
Honorarium: Medscape Global
I think fibrosis staging is reasonable given that at 46 y/o she is still HBeAg positive and anti-HBe negative. This increases her risk of progressing to advanced liver disease and HCC, according to this article from Hepatology: Yi-Cheng Chen, Chia-Ming Chu, Yun-Fan Liaw, Age-specific prognosis following spontaneous hepatitis B e antigen seroconversion in chronic hepatitis B, First published: 25 January 2010, https://doi.org/10.1002/hep.23348
Her viral load decline is in line with what many patients on tenofovir experience. Even at the TWO year mark 12% of TDF patients were still not yet suppressed < 20 IU/mL (see Wang T et al, Hepatitis B virus (HBV) viral load, liver and renal function in adults treated with tenofovir disoproxil fumarate (TDF) vs. untreated: a retrospective longitudinal UK cohort study. BMC Infect Dis. 2021 Jun 26;21(1):610. doi: 10.1186/s12879-021-06226-0.)
Her ALT is normal range, as are her platelets, although some hepatologists say they like to see it higher than 169 in CHB patients. This could reflect some fibrosis that is not reflected on the FIB-4.
Fibroscan is helpful if available, but I would offer liver MRI imaging before liver biopsy.
Co-Chair, National Taskforce on Hepatitis B
Director of Immigrant Health
North East Medical Services, San Francisco, CA
Non-invasive liver fibrosis assessment is recommended for all patients with chronic hepatitis B to risk-stratify individuals for hepatocellular carcinoma (HCC) and liver cirrhosis and help inform treatment decisions.
A FIB-4 score should be performed at minimum, however if FibroScan (vibration controlled transient elastography) or other forms of elastography are available and not cost-prohibitive for the patient, I would recommend it. Elastography not only evaluates liver stiffness but also provides a steatosis score and stage which can be helpful for addressing comorbid steatotic liver disease.
I would not recommend liver biopsy for this patient since there are many non-invasive options to stage her liver fibrosis. Aside from elastography already mentioned, there are also serum markers such as FibroSure and FibroTest that can provide a fibrosis score and stage (F0 to 4)
If she is found to have advanced fibrosis (F3) or cirrhosis (F4) on FibroScan, I would make sure that she receives a liver ultrasound every 6 months with AFP to monitor for HCC.
For patients who are found to have a moderate fibrosis (F2) or higher (F3-4), I recommend an annual fibrosis assessment (ideally with the same modality used previously) to monitor for improvement on treatment, or worsening (if not on treatment). For patients with no to minimal fibrosis F0-1, I do not typically recommend reassessment unless it would affect a treatment initiation decision.