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Foundational Overview of HDV

CE / CME

Hepatitis Delta in Focus: A Foundational Overview of HDV

Pharmacists: 0.75 contact hour (0.075 CEUs)

Nurses: 0.75 Nursing contact hour

Physicians: Maximum of 0.75 AMA PRA Category 1 Credit™

Released: December 09, 2022

Expiration: December 08, 2023

CME/CE Information

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This patient should be screened for viral hepatitis because her liver function test results are elevated. 

Unlike universal screening for hepatitis C virus, HBV screening remains risk based. The slide shows the different risk categories in which screening is recommended by CDC and American Association for the Study of Liver Diseases (AASLD) guidelines.1,2 However, some experts, including myself, believe that deciding whom to screen for HBV should not be this and instead simply recommend screening everyone regardless of risk.

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Algorithm for the Evaluation of HBV

Testing for HBV can be overwhelming for healthcare professionals; it is not as straightforward as testing for other viral hepatitis like hepatitis C.

This algorithm can be helpful in evaluating patients for HBV infection, starting with their HBsAg result.2

HBV screening studies typically include HBsAg, hepatitis B surface antibody (anti-HBs), and hepatitis B core antibody (anti-HBc).

As demonstrated on the left side of the algorithm, if patients’ HBsAg is positive, additional testing is needed. One needs to determine if the virus is active with an HBV DNA and liver enzymes (eg, alanine aminotransferase ALT, aspartate aminotransferase AST), which are surrogate markers for liver inflammation. Following, disease staging is recommended to determine what ongoing monitoring and HBV treatment is indicated.

The anti-HBc can be helpful to differentiate between acute vs chronic infection. An anti-HBc can also be helpful in immunosuppressed persons who may be considering chemotherapy or rituximab or patients who are considering organ donation because they are at higher risk of HBV reactivation.

On the right side of the algorithm, one can see that if patients’ HBsAg is negative,HBV vaccination is likely warranted, if not already completed. Use of an anti-HBs and anti-HBc can help determine if the patients are HBV immune, and if they are not, an HBV vaccine series in accordance with the Advisory Committee on Immunization Practices schedule is recommended.3

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Patient Case: What’s Next?

Let us return to our patient case.

In the office, FibroScan results are concerning for cirrhosis and additional hepatitis B serology (hepatitis B e antigen HBeAg, hepatitis B e antibody HBeAb) and HBV DNA are ordered, the results of which show HBeAg negative, HBeAb positive, and HBV DNA undetectable.

In a young female with increased liver enzymes, a positive HBsAg, and evidence of significant fibrosis, does HBV explain the patient’s presentation? Even when her HBV DNA is undetectable? What are we missing?

HDV Testing

According to the AASLD guidelines, testing for HDV is recommended in individuals who are HBsAg positive and have risk factors for HDV infection and/or have increased liver test numbers not explained by some other reason.1

According to Terrault and Ghany,4 “given the challenges of using risk-based screening, universal screening of all HBsAg-positive persons may be a reasonable alternative.” This approach has been adopted by the European guidelines but should be considered in other areas, including the United States.5

Our patient was HBsAg positive and born in a region (Mongolia) with reported high HDV endemically. Despite having an undetectable HBV DNA, we still have a strong concern that this might be HBV coinfection or superinfection with HDV.

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