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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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HDV Testing: Comparison of Guidelines

Testing recommendations vary based on different guidelines, but in most cases, they recommend anti–hepatitis D antibody (anti-HDV) followed by confirmatory testing with HDV RNA.

AASLD guidelines recommend testing HBsAg-positive patients with HDV risk factors or those who have low or undetectable HBV DNA with an elevated ALT. Recommended testing includes an anti-HDV and, if positive, an HDV RNA.1

Guidelines by the European Association for the Study of the Liver are more permissive. They recommend HDV testing in all HBV-infected individuals, but they do not outline how to test, at least in the 2017 guideline iteration.5 Updated guidelines are expected soon.

The 2016 Asian Pacific Association for the Study of the Liver guidelines recommend a narrower group of HBV-infected patients be tested for HDV: those with chronic liver disease. For these patients, recommended testing includes using either an anti-HDV or hepatitis delta antigen, then confirming with a HDV RNA.10

Finally, the WHO guidelines do not include recommendations regarding whom to test for HDV but suggest use of anti-HDV followed by confirmatory testing with HDV RNA.11

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Algorithm for the Evaluation of HDV

Here is a simple algorithm for HDV testing in patients with a positive HBsAg. An anti-HDV antibody should be obtained and, if positive, an HDV RNA is warranted.12

After HDV is confirmed with HDV RNA, look for inflammation as implied by surrogate markers, liver enzymes with an ALT and AST, if not already done, and then stage the disease with noninvasive testing (eg, elastography, AST to platelet ratio index, Fibrosis-4, or proprietary serum fibrosis markers).

I would also recommend an ultrasound; elastography can be considered, as ultrasonography is important to not only stage the disease but also exclude liver cancer. To confirm the degree of liver scarring, a liver biopsy could be considered, as noninvasive tests do not always correlate perfectly.

For individuals who are anti-HDV negative, standard screening and management for HBV should be completed, which includes confirmation of the disease, screening for staging the disease, and screening for liver cancer in those at risk for developing hepatocellular carcinoma.1

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Following a positive test for anti-HDV antibodies in a person who is hepatitis B surface antigen (HBsAg) positive, what would be the next step to confirm HDV infection?
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