Hepatitis b and acute liver failure
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Hepatitis B and Acute Liver Failure. Jack Kuritzky, PGY-2 UNC Internal Medicine Morning Report 3/12/10. 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

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Hepatitis B and Acute Liver Failure

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Hepatitis b and acute liver failure

Hepatitis B andAcute Liver Failure

Jack Kuritzky, PGY-2

UNC Internal Medicine

Morning Report 3/12/10


Hep b natural history

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


Hep b acute phase

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


Acute liver failure

ACUTE LIVER FAILURE

Goldberg, E and Chopra, S. Acute liver failure: Definition; etiology; and prognostic indicators.

UpToDate, Sept. 2009.


Causes of acute liver failure

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


Hep b resolution of infection

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


Hep b chronic phase less than 5 of infected adults

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


Hep b treatment

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


Hep b vaccine

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)


Sources

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.


Questions

QUESTIONS?


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