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Understanding Hepatitis B and Acute Liver Failure: Clinical Insights and Management

This report provides an overview of Hepatitis B and its association with acute liver failure. Transmission modes, incubation periods, symptoms, and phases of infection are outlined, emphasizing the acute and chronic phases. The document discusses the complications of acute liver failure, particularly the rapid progression of encephalopathy. Key treatment options for acute and chronic Hepatitis B are highlighted, including antiviral therapies, supportive care, and vaccination recommendations. The prognosis and resolution of infection are also addressed based on recent studies and clinical guidelines.

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Understanding Hepatitis B and Acute Liver Failure: Clinical Insights and Management

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  1. Hepatitis B andAcute Liver Failure Jack Kuritzky, PGY-2 UNC Internal Medicine Morning Report 3/12/10

  2. HEP B - NATURAL HISTORY • Mode of Infection • Perinatal most common worldwide • In US, most commonly transmitted by sexual contact or IVDU • Incubation period 1-4 months • Symptoms • Anorexia • Constitutional symptoms • Jaundice • Nausea • RUQ disomfort

  3. HEP B – ACUTE PHASE • Subclinical or anicteric hepatitis (70%) • Icteric hepatitis (30%) • Fulminant Hepatitis (0.1% - 0.5%) • Acute Liver Failure: Rapid development of severe acute liver failure with impaired synthetic function and encephalopathy in a patient who previously had a normal liver or well compensated liver disease • Development of encephalopathy within 8 weeks of symptoms in a pt w/o liver disease • Development of encephalopathy within 2 weeks of jaundice

  4. ACUTE LIVER FAILURE Goldberg, E and Chopra, S. Acute liver failure: Definition; etiology; and prognostic indicators. UpToDate, Sept. 2009.

  5. CAUSES OF ACUTE LIVER FAILURE • Data from 17 US sites, 308 consecutive patients with acute liver failure (Ostapowicz G, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med 2002 Dec 17;137(12):947-54.) • Acetaminophen overdose (39 percent) • Indeterminate (17 percent) • Drug reactions (13 percent) • Viral hepatitis A or B (12 percent) • survival at 3 weeks was 67%. • 29% had liver transplantation and 43% survived without transplantation

  6. HEP B – RESOLUTION OF INFECTION • Previous infection without further virologic, biochemical, or histologic evidence of disease • Symptoms typically improve in 1-3 months • >95% of cases resolve in adults • >90% progress in neonatal hepatitis and 20-50% progress in patients 1-5 yrs old

  7. HEP B – CHRONIC PHASELess than 5% of infected adults • Asymptomatic carrier state • HBsAg+ but no chronic, active inflammatory damage • Chronic hepatitis • Chronic "necroinflammatory infection", subdivided with HBeAg positive and HBeAg negative • HBeAg is a marker of viral replication and infectivity • 12-20% progress cirrhosis • Cirrhosis • 6-15% of compensated cirrhosis progress to HCC • Hepatocellular carcinoma

  8. HEP B - TREATMENT • SUPPORTIVE • Antiviral options: lamivudine, adefovir, entecavir, telivudine, and tenofivir  • Who to treat--Acute HepB: • Trial of 71 patients with lamivudine for acute HepB (Kumar, et al. A randomized controlled trial of lamivudine to treat acute hepatitis B. Hepatology. 2007 Jan;45(1):97-101.) • No difference in clinical or biochemical outcomes • No difference in patients with severe disease, though numbers limited • Fulminant HepB, immunocompromised, prolonged course (>4 weeks), pre-existing liver disease, coinfection with HepC/D • Who to treat--Chronic HepB • Compensated cirrhosis w/HBV DNA >2,000 IU/mL • Decompensated cirrhosis w/detectable viral load

  9. HEP B - VACCINE • Series of 3 injections at time 0, 1 month, and 6 months • Indicated for health-care workers, dialysis patients, patients w/chronic liver disease, patients with high-risk sexual practices, and IV drug users • Good response is determined by an anti-HepB surface Ag titer of  >10 mIU/mL • Available US vaccines are 95% effective in healthy adults • Post vaccination testing only recommended for health-care workers, dialysis patients, and other selected patient populations • Non-responders should complete a second 3-dose regimen (successful in 50-70% of patients)

  10. SOURCES • Goldberg, E and Chopra, S. Acute liver failure: Definition; etiology; and prognostic indicators. UpToDate, Sept 2009. • Kumar, et al. A randomized controlled trial of lamivudine to treat acute hepatitis B. Hepatology. 2007 Jan;45(1):97-101 • Lok, A. Clinical manifestations and natural history of hepatitis B virus infection. UpToDate, Sept 2009. • Ostapowicz G, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med 2002 Dec 17;137(12):947-54.

  11. QUESTIONS?

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