Guideline sources The following summarized guidelines for the evaluation and management of hepatitis B virus infection are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/CDC/NIH/HIVMA 2023), the Center for Disease Control (CDC 2022), the American Association for the Study of Liver Diseases (AASLD 2021; 2018; 2014), the World Health Organization (WHO 2020; 2015), the American Society of Clinical Oncology (ASCO 2020), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2020), the U.S. Preventive Services Task Force (USPSTF 2020; 2019), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2020; 2017), the European Association for the Study of the Liver (EASL 2017), the American College of Physicians (ACP/CDC 2017), the Italian Association for the Study of the Liver (AISF 2016), the American College of Gastroenterology (ACG 2016), and the American Gastroenterological Association (AGA 2015). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 CalculatorChild Pugh score for mortality in CalculatorRisk estimation for hepatocellula https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 1/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway Guidelines 1. Screening and diagnosis Indications for screening, persons at risk: As per IDSA/HIVMA/CDC/NIH 2023 guidelines, screen for HBV infection (with HBsAg, total HBcAb, and HBsAb) in patients with human immunodeficiency virus infection. A As per USPSTF 2020 guidelines, screen for HBV infection in adolescents and adults at increased risk for infection. B As per CDC/ACP 2017 guidelines, screen for HBV infection (with HBsAg, HBcAb, and HBsAb) in high-risk persons, including: persons born in countries with 2% HBV prevalence MSM injection drug users incarcerated persons patients with elevated ALT levels ( 19 IU/L in females and 30 IU/L in males) patients requiring immunosuppressive therapy patients with end-stage renal disease (including receiving hemodialysis) blood and tissue donors pregnant females infants born to HBV-infected mothers household and sexual contacts of HBV-infected patients patients with HCV infection patients with human immunodeficiency virus infection. B As per AGA 2015 guidelines: Screen for HBV (with HBsAg and HBcAb, followed by a sensitive HBV DNA test if positive) in moderate-to-high-risk patients on immunosuppressive medical therapy. B Avoid screening for HBV infection routinely in low-risk patients on immunosuppressive medical therapy. D Indications for screening, pregnancy: As per AASLD 2021 guidelines, screen all pregnant females for HBsAg. E As per WHO 2020 guidelines, screen all pregnant for HBsAg at least once and as early as possible in the pregnancy. B As per USPSTF 2019 guidelines, screen for HBV infection in pregnant females at their first prenatal visit. A https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 2/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway As per EASL 2017 guidelines, screen for HBsAg in the first trimester of pregnancy. A As per SOGC 2017 guidelines, screen pregnant females for HBV infection with HBsAg in early pregnancy. A Show 2 more As per AISF 2016 guidelines, screen all pregnant females for HBsAg A and, if positive, test for HBeAg/HBeAb and HBV-DNA. B Indications for screening (before anticancer therapy): test for HBV with 3 tests (HBsAg, HBcAb total immunoglobulin or IgG, and HBsAb) before or at the beginning of treatment in all patients with cancer anticipating systemic anticancer therapy while not delaying initiation of treatment. A 2. Diagnostic investigations Pretreatment evaluation: assess baseline renal function and baseline risk for renal dysfunction in all patients before initiating tenofovir or entecavir therapy. E 3. Medical management Management of acute HBV hepatitis: Do not initiate specific treatment in most (> 95%) adult patients with acute HBV because they will fully recover spontaneously. D Initiate nucleoside/nucleotide analogs only in patients with severe acute hepatitis B, characterized by coagulopathy or protracted course, and assess for liver transplantation. B Indications for antiviral therapy: As per AASLD 2018 guidelines, initiate antiviral therapy to decrease the risk of liver-related complications in adult patients with immune-active chronic hepatitis B (HBeAg-negative or - positive). B Show 2 more As per EASL 2017 guidelines, initiate treatment in all patients with HBeAg-positive or -negative chronic hepatitis B defined by HBV DNA > 2,000 IU/mL, ALT > ULN, and/or at least moderate liver necroinflammation or fibrosis. A Show 4 more As per WHO 2015 guidelines, initiate treatment in all patients with chronic hepatitis B and clinical evidence of compensated or decompensated cirrhosis (or cirrhosis based on APRI score > 2 in adults) regardless of ALT levels, HBeAg status, or HBV DNA levels. B Show 4 more Goals of antiviral therapy: set induction of long-term suppression of HBV DNA levels as the main endpoint of all current treatment strategies. A Show 3 more Choice of antiviral regimens: https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 3/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway As per AASLD 2018 guidelines, initiate pegylated interferon, entecavir, or tenofovir as preferred initial therapy in adult patients with immune-active chronic hepatitis B. B As per EASL 2017 guidelines, initiate long-term potent nucleoside/nucleotide analogs with a high barrier to resistance as the treatment of choice regardless of the severity of the liver disease. A Initiate nucleoside/nucleotide analogs with a high barrier to resistance in patients with decompensated cirrhosis irrespective of the level of HBV replication, and assess for liver transplantation. B Show 9 more As per WHO 2015 guidelines, initiate nucleoside/nucleotide analogs with a high barrier to drug resistance (tenofovir or entecavir), if antiviral therapy is indicated, in all adult patients. B Show 2 more Maintenance therapy: As per AASLD 2018 guidelines, consider discontinuing nucleoside/nucleotide analog therapy after a period of treatment consolidation in hepatitis B e-antigen-positive adult patients without cirrhosis but with chronic hepatitis B seroconverted to HBeAb on therapy. C Show 6 more As per EASL 2017 guidelines, discontinue nucleoside/nucleotide analogs after confirmed HBsAg loss, with or without HBsAb seroconversion. B Show 7 more As per WHO 2015 guidelines, continue treatment with nucleoside/nucleotide analogs for lifelong in all patients with cirrhosis based on clinical evidence (or APRI score > 2 in adults). Do not discontinue antiviral therapy because of the risk of reactivation which can cause severe acute- on-chronic liver injury. B Show 2 more Management of treatment failure: As per EASL 2017 guidelines, check compliance to nucleoside/nucleotide analog therapy in all cases of treatment failure. B Show 2 more As per WHO 2015 guidelines, switch to tenofovir if the patient is not responding to lamivudine, entecavir, adefovir, or telbivudine. B Management of relapse: re-initiate treatment in patients with consistent signs of reactivation (HBsAg or HBeAg becoming positive, ALT level increase, or HBV DNA becoming detectable again). B 4. Surgical interventions Liver transplantation, pre-transplant antiviral therapy: As per EASL 2017 guidelines, initiate nucleoside/nucleotide analogs in all patients with HBV- related liver disease on the transplant waiting list. B https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 4/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway As per AASLD 2014 guidelines, initiate antiviral therapy in patients with HBV liver disease to suppress HBV replication before liver transplantation. B Liver transplantation (post-transplant antiviral prophylaxis): initiate a combination of hepatitis B IgAnd a potent nucleoside/nucleotide analog after liver transplantation for the prevention of HBV recurrence. B Show 2 more 5. Specific circumstances Pregnant patients, indications for screening: As per AASLD 2021 guidelines, screen all pregnant females for HBsAg. E As per WHO 2020 guidelines, screen all pregnant for HBsAg at least once and as early as possible in the pregnancy. B As per USPSTF 2019 guidelines, screen for HBV infection in pregnant females at their first prenatal visit. A As per EASL 2017 guidelines, screen for HBsAg in the first trimester of pregnancy. A As per SOGC 2017 guidelines, screen pregnant females for HBV infection with HBsAg in early pregnancy. A Show 2 more As per AISF 2016 guidelines, screen all pregnant females for HBsAg A and, if positive, test for HBeAg/HBeAb and HBV-DNA. B Pregnant patients (immunization of the mother): offer recombinant hepatitis B vaccine series in unvaccinated HBsAg-negative patients at high risk for acquiring hepatitis B infection. Recognize that pregnancy is not a contraindication for immunization against hepatitis B. B Pregnant patients (indications for testing): obtain testing for common etiologies of acute liver injury including viral hepatitis (HAV, HBV, HBV, and HSV) in pregnant patients presenting with acute hepatitis. B Pregnant patients, laboratory testing: As per AASLD 2021 guidelines, assess HBV DNA level in the second trimester in HBsAg- positive pregnant patients. E As per SOGC 2017 guidelines, obtain testing for HBeAg, HBV DNA level, and ALT during pregnancy for the purposes of maternal health and perinatal HBV transmission risk stratification in HBsAg-positive pregnant patients. A Pregnant patients (liver imaging): obtain liver ultrasound during pregnancy for the purposes of maternal health and perinatal HBV transmission risk stratification in HBsAg-positive pregnant patients. B Pregnant patients, antiviral therapy: As per AASLD 2021 guidelines: https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 5/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway Initiate antiviral therapy (preferably tenofovir disoproxil fumarate) at 28-32 weeks of gestation to reduce the risk of mother-to-child transmission when maternal HBV DNA is > 200,000 IU/mL. Consider discontinuing antiviral therapy at delivery or up to 3 months postpartum. E Monitor ALT and HBV DNA levels for 6 months postpartum or after cessation of antiviral therapy. E As per SOGC 2020 guidelines, consider initiating antiviral therapy with tenofovir to decrease the vertical transmission risk in patients with chronic hepatitis B infection and a significant viral load (> 200,000 IU/mL or > 10 copies/mL). B As per WHO 2020 guidelines, initiate tenofovir prophylaxis (starting at 28 weeks of gestation until at least birth) to prevent mother-to-child transmission of HBV in HBsAg-positive pregnant patients with HBV DNA levels 200,000 IU/mL. Consider obtaining HBeAg testing as an alternative to HBV DNA testing, if antenatal HBV DNA testing is not available, to determine eligibility for tenofovir prophylaxis. B As per AASLD 2018 guidelines, consider initiating antiviral therapy to reduce the risk of perinatal transmission of HBV in HBsAg-positive pregnant patients with HBV DNA levels > 200,000 IU/mL. C Do not initiate antiviral therapy in patients with HBV DNA levels 200,000 IU/mL. B As per EASL 2017 guidelines, consider delaying therapy until the child is born in patients of childbearing age without advanced fibrosis planning a pregnancy in the near future. C Show 3 more As per SOGC 2017 guidelines, consider initiating antiviral therapy (starting at 28-32 weeks of gestation and continuing until delivery), in collaboration with an adult infectious disease/gastroenterology or hepatology specialist, for the prevention of perinatal transmission in patients with hepatitis B DNA viral loads level > 200,000 IU/mL (> 10 copies/mL). C As per ACG 2016 guidelines, initiate antiviral therapy with tenofovir or telbivudine in the third trimester of pregnancy in patients with chronic hepatitis B with a high viral load ( 200,000 IU/mL) to reduce perinatal transmission of HBV. B As per AISF 2016 guidelines: Consider initiating early antiviral therapy in patients with advanced liver fibrosis (F3-4). Initiate tenofovir as the preferred drug due to its high genetic barrier, safety, and potency. Continue treatment after delivery. B Initiate nucleoside/nucleotide analogs to minimize the risk of vertical transmission in pregnant patients with serum HBV DNA levels 10 IU/mL. B Initiate tenofovir or telbivudine as the drugs of choice started no later than 32 weeks of gestation. B Consider initiating lamivudine as an alternative option. B . Discontinue treatment 0-4 weeks after delivery. Insufficient evidence regarding the safety of continuing treatment during breastfeeding. B Pregnant patients, counseling: As per AASLD 2021 guidelines, counsel HBsAg-positive pregnant patients on the increased risk of mother-to-child-transmission with invasive pregnancy procedures, such as amniocentesis. E As per SOGC 2017 guidelines, counsel HBsAg-positive pregnant patients on the prevention of HBV transmission to sexual partners and household contacts. B https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 6/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway Show 2 more Pregnant patients, fetal evaluation: As per SOGC 2020 guidelines, obtain noninvasive methods of fetal aneuploidy risk assessment (maternal serum placental analytes with or without nuchal translucency, detailed ultrasound, and maternal serum cell-free placental DNA as first- or second-tier screening test) in patients with chronic hepatitis B infection. B Show 3 more As per SOGC 2017 guidelines, obtain noninvasive screening for aneuploidy before invasive testing in HBsAg-positive patients. B Pregnant patients, delivery: As per SOGC 2017 guidelines: Do not perform a C-section for the sole purpose of reducing the risk of perinatal transmission of HBV. D Avoid performing intrapartum invasive procedures (such as fetal ECG and scalp lactate), if possible, to avoid increasing the infant's risk of percutaneous HBV exposure. D As per ACG 2016 guidelines, do not perform elective C-section in HBV-positive pregnant patients to prevent fetal infection. D Pregnant patients, immunization of the infant: As per SOGC 2017 guidelines: Administer hepatitis B vaccination in all infants. Administer hepatitis B immunoglobulin within the first 12 hours of life in all infants born to HBsAg-positive mothers. A Encourage families to complete the infant immunization series for HBV according to local infant vaccination schedule and obtain serological confirmation of protection after completion of the series, no sooner than 9-12 months of age. A As per ACG 2016 guidelines, administer active-passive immunoprophylaxis with hepatitis B IgAnd the HBV vaccination series in all infants born to HBV-infected mothers to prevent perinatal transmission. B As per AISF 2016 guidelines, administer vaccination to prevent HBV transmission. Administer hepatitis B immunoglobulin in infants born to HBsAg-positive mothers to prevent HBV vertical transmission. A As per AISF 2016 guidelines, administer standard prophylaxis with hepatitis B vaccination and anti-HBsAg immunoglobulins in all infants born to HBsAg-positive mothers within 12 hours after delivery. A Pregnant patients, breastfeeding: As per AASLD 2021 guidelines, recognize that breastfeeding is not contraindicated, even in patients continuing antiviral therapy. E As per EASL 2017 guidelines, recognize that breastfeeding is not contraindicated in HBsAg- positive untreated patients or in patients on tenofovir disoproxil fumarate-based treatment or prophylaxis. B https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 7/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway As per SOGC 2017 guidelines, encourage breastfeeding in mothers with chronic hepatitis B infection wishing to breastfeed as it does not pose an additional risk of HBV infection, even without neonatal vaccination. B As per ACG 2016 guidelines, advise breastfeeding as recommended for infant health in patients with chronic hepatitis B. B Pediatric patients (screening): screen for HBV infection in adolescents at increased risk for infection. B Pediatric patients, antiviral therapy: As per AASLD 2018 guidelines, do not initiate antiviral therapy in HBeAg-positive pediatric (aged 2-18 years) patients with persistently normal ALT regardless of HBV DNA level. D As per EASL 2017 guidelines: Recognize that the course of the disease is generally mild in pediatric patients and most of them do not meet standard treatment indications. Consider offering treatment with caution. B Consider initiating entecavir, tenofovir disoproxil fumarate, tenofovir alafenamide, or pegylated interferon alfa in pediatric and adolescent patients meeting treatment criteria. C As per WHO 2015 guidelines, initiate treatment in all pediatric and adolescent patients with chronic hepatitis B and clinical evidence of compensated or decompensated cirrhosis (or cirrhosis based on APRI score > 2 in adults) regardless of ALT levels, HBeAg status, or HBV DNA levels. B Show 3 more Pediatric patients (monitoring): obtain careful monitoring of growth in pediatric patients on long- term tenofovir or entecavir therapy. B Pediatric patients (patients with HIV co-infection): Initiate antiretroviral therapy in all pediatric patients with HBV/human immunodeficiency virus co- infection irrespective of CD4 cell count. E Initiate tenofovir disoproxil fumarate or tenofovir alafenamide-based antiretroviral regimens in pediatric patients with HBV/human immunodeficiency virus co-infection. E Pediatric patients, patients on immunosuppressive therapy: As per NASPGHAN/ESPGHAN 2020 guidelines, test for HBV (with HBsAg, HBsAb, and HBcAb) in all pediatric patients at risk of HBV reactivation. E Show 6 more As per EASL 2017 guidelines, test for HBV markers before immunosuppression in all candidates for chemotherapy and immunosuppressive therapy. A Show 2 more Pediatric patients (liver transplant recipients): initiate antiviral therapy as soon as possible before liver transplantation with the aim of achieving an undetectable HBV DNA level at the time of transplantation in HBsAg-positive liver transplant recipients with detectable serum HBV DNA. E Show 4 more https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 8/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway Pediatric patients (non-liver transplant recipients): initiate lifelong antiviral therapy with entecavir, tenofovir disoproxil fumarate, or tenofovir alafenamide in HBsAg-positive non-liver solid transplant recipients. E Show 3 more Pediatric patients (hematologic stem cell transplant recipients): consider stratifying the risk of HBV reactivation in pediatric and adolescent patients into the following broad groups: high risk (> 10%), moderate risk (1-10%), and low risk (< 1%). Classify patients undergoing bone marrow or hematologic stem cell or solid organ transplantation as at high risk of HBV reactivation. E Show 2 more Patients with renal impairment: As per AASLD 2018 guidelines, insufficient evidence to recommend in preference between entecavir or tenofovir regarding potential long-term risks of renal and bone complications. I As per EASL 2017 guidelines, screen for HBV markers in all dialysis and renal transplant recipients. B Show 3 more Patients with malignancy: test for HBV with 3 tests (HBsAg, HBcAb total immunoglobulin or IgG, and HBsAb) before or at the beginning of treatment in all patients with cancer anticipating systemic anticancer therapy while not delaying initiation of treatment. A Show 5 more Patients with HDV co-infection: initiate pegylated interferon alfa for at least 48 weeks as the treatment of choice in patients with HBV/hepatitis D virus co-infection and compensated liver disease. A Show 2 more Patients with HCV co-infection: recognize that treatment of HCV infection with direct-acting antivirals may cause reactivation of HBV. Initiate nucleoside/nucleoside analog therapy in patients fulfilling the standard criteria for HBV treatment. B Show 2 more Patients with HIV co-infection: As per EASL 2017 guidelines: Initiate antiretroviral therapy in all patients with HBV/human immunodeficiency virus co- infection irrespective of CD4 cell count. B Initiate a tenofovir disoproxil fumarate- A or tenofovir alafenamide-based regimen in patients with HBV/human immunodeficiency virus co-infection. B As per WHO 2015 guidelines, initiate antiretroviral therapy in HBV/human immunodeficiency virus-coinfected patients with evidence of severe chronic liver disease regardless of CD4 cell count, and with a CD4 cell count 500 cells/mm regardless of the stage of liver disease. B Show 2 more Patients on immunosuppressive therapy: screen for HBV (with HBsAg and HBcAb, followed by a sensitive HBV DNA test if positive) in moderate-to-high-risk patients on immunosuppressive medical therapy. B https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 9/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway Show 8 more Patients with extrahepatic manifestations: Initiate nucleoside/nucleotide analog therapy in patients with replicative HBV infection and extrahepatic manifestations. B Do not use pegylated interferon alfa in patients with immune-related extrahepatic manifestations. D 6. Preventative measures Immunizations, infants: As per WHO 2020 guidelines, administer the first dose of the hepatitis B vaccine in all infants as soon as possible after birth, preferably within 24 hours, followed by 2-3 doses to complete the primary series. E As per ACG 2016 guidelines, administer active-passive immunoprophylaxis with hepatitis B IgAnd the HBV vaccination series in all infants born to HBV-infected mothers to prevent perinatal transmission. B As per AISF 2016 guidelines, administer standard prophylaxis with hepatitis B vaccination and anti-HBsAg immunoglobulins within 12 hours after delivery in all infants born to HBsAg-positive mothers. A Immunizations, adults: As per CDC 2022 guidelines: Offer vaccination against HBV in adults aged 19-59 years and adults aged 60 years with the following risk factors for hepatitis B: Situation Guidance Sex partners of persons testing positive for HBsAg Persons at risk for infection by sexual exposure Sexually active persons not in a long-term, mutually monogamous relationship (such as persons with > 1 sex partner during the previous 6 months) Persons seeking evaluation or treatment for a STI MSM Persons with current or recent injection drug use Persons at risk for infection by percutaneous or mucosal exposure to blood Household contacts of persons testing positive for HBsAg Residents and staff members of facilities for persons with developmental disabilities https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 10/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway Healthcare and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids Patients on maintenance dialysis, including in-center or home hemodialysis and peritoneal dialysis, and predialysis patients Patients with diabetes at the discretion of the treating clinician International travelers to countries with high or intermediate levels of endemic HBV infection (HBsAg prevalence of 2%) Other Patients with HCV infection Patients with chronic liver disease (including, but not limited to, patients with cirrhosis, fatty liver disease, alcoholic liver disease, AIH, and an ALT or AST level > 2 the ULN) Patients with human immunodeficiency virus infection Incarcerated persons. E Consider offering vaccination against HBV in adults aged 60 years without known risk factors for hepatitis B. E As per CDC/ACP 2017 guidelines, offer vaccination against HBV in all unvaccinated adults (including pregnant females) at risk for infection, including: history of sexual, percutaneous, or mucosal exposure healthcare and public safety workers at risk for blood exposure adult patients with chronic liver disease, end-stage renal disease (including receiving hemodialysis), or human immunodeficiency virus infection travelers to HBV-endemic regions adults seeking protection from HBV infection. B 7. Follow-up and surveillance Monitoring of untreated patients: As per EASL 2017 guidelines, follow-up < 30 years old patients with HBeAg-positive chronic HBV infection not meeting criteria for treatment initiation at least every 3-6 months. B Show 2 more https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 11/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway As per WHO 2015 guidelines, obtain continued monitoring in all patients with chronic hepatitis B not meeting the criteria for treatment initiation to determine if antiviral therapy may be indicated in the future to prevent progressive liver disease, including: 30 years old patients with HBV DNA levels > 20,000 IU/mL, persistently normal ALT levels, and without cirrhosis HBeAgn-negative 30 years old patients with HBV DNA levels fluctuating between 2,000- 20,000 IU/mL or intermittently abnormal ALT levels and without cirrhosis 30 years old patients with persistently normal ALT levels and without cirrhosis, regardless of HBeAg-negative status, if HBV DNA testing is not available. E Show 2 more Monitoring of treatment response: As per AASLD 2018 guidelines, monitor ALT levels at least every 6 months in adult patients with immune-tolerant chronic hepatitis B to monitor for potential transition to immune-active or immune-inactive chronic hepatitis B. B As per EASL 2017 guidelines, obtain periodic assessments of ALT and serum HBV DNA in all patients treated with nucleoside/nucleotide analogs. A Show 3 more As per WHO 2015 guidelines: Monitor the following at least annually: ALT level (and AST for APRI), HBsAg, HBeAg, and HBV DNA levels (where HBV DNA testing is available) noninvasive tests (APRI score or FibroScan) to assess for the presence of cirrhosis in patients without cirrhosis at baseline adherence to treatment regularly and at each visit. B Obtain more frequent monitoring (at least every 3 months for the first year) in the following circumstances: patients with more advanced disease (compensated or decompensated cirrhosis) patients with human immunodeficiency virus co-infection during the first year of treatment to assess treatment response and adherence where treatment adherence is a concern after discontinuation of treatment. B Monitoring of treatment adverse effects: As per EASL 2017 guidelines, obtain renal function monitoring at least with estimated GFR and serum phosphate levels in patients at risk of renal disease treated with any nucleoside/nucleotide analogs and in all patients treated with tenofovir disoproxil fumarate regardless of renal risks. B Show 3 more As per WHO 2015 guidelines, monitor renal function annually in patients on long-term tenofovir or entecavir therapy. B https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 12/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway Surveillance for hepatocellular carcinoma: As per EASL 2017 guidelines, obtain HCC surveillance in all patients with cirrhosis and in patients with moderate or high HCC risk scores at the onset of nucleoside/nucleotide analog therapy. B Show 2 more As per WHO 2015 guidelines: Obtain routine surveillance for HCC with abdominal ultrasound and AFP testing every 6 months in patients with cirrhosis regardless of age or other risk factors and in patients with a family history of HCC. B Obtain routine surveillance for HCC with abdominal ultrasound and AFP testing every 6 months in > 40 years old patients (a lower age may apply according to the regional incidence of HCC) with HBV DNA level > 2,000 IU/mL (where HBV DNA testing is available) in the absence of clinical evidence of cirrhosis (or based on APRI score 2). B 8. Quality improvement Healthcare workers: Do not disqualify persons from the practice or study of surgery, dentistry, medicine, or allied health fields based on HBV infection alone. D Consider initiating nucleoside/nucleotide analogs to reduce transmission risk in healthcare workers performing exposure-prone procedures with serum HBV DNA > 200 IU/mL. C References 1. Eliana Castillo, Kellie Murphy, Julie van Schalkwyk. No. 342 Hepatitis B and Pregnancy. J Obstet Gynaecol Can. 2017 Mar;39 3 181 190. Open 2. No authors listed. Guidelines for the Prevention, Care and Treatment of Persons with Chronic Hepatitis B Infection. Geneva: World Health Organization; 2015. Open 3. Norah A Terrault, Anna S F Lok, Brian J McMahon et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B AASLD 2018 hepatitis B guidance. Hepatology. 2018 Apr;67 4 1560 1599. Open 4. European Association for the Study of the Liver. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. J Hepatol. 2017 Aug;67 2 370 398. Open 5. Italian Association for the Study of the Liver AISF , Italian Association for the Study of the Liver AISF. AISF position paper on liver disease and pregnancy. Dig Liver Dis. 2016 Feb;48 2 120 37. Open 6. No authors listed. Prevention of Mother-to-Child Transmission of Hepatitis B Virus: Guidelines on Antiviral Prophylaxis in Pregnancy. Geneva: World Health Organization; 2020. Open 7. Tram T Tran, Joseph Ahn, Nancy S Reau. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol. 2016 Feb;111 2 176 94; quiz 196. Open 8. Reddy KR, Beavers KL, Hammond SP et al. American Gastroenterological Association Institute guideline on the prevention and treatment of hepatitis B virus reactivation during immunosuppressive drug therapy. https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 13/14 6/24/23, 12:41 PM Hepatitis B virus infection Pathway Gastroenterology. 2015 Jan;148 1 215 9. Open 9. Monika Sarkar, Carla W Brady, Jaquelyn Fleckenstein et al. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Jan;73 1 318 365. Open 10. Jessica P Hwang, Jordan J Feld, Sarah P Hammond et al. Hepatitis B Virus Screening and Management for Patients With Cancer Prior to Therapy: ASCO Provisional Clinical Opinion Update. J Clin Oncol. 2020 Nov 1;38 31 3698 3715. Open 11. Giuseppe Indolfi, Mona Abdel-Hady, Sanjay Bansal et al. Management of Hepatitis B Virus Infection and Prevention of Hepatitis B Virus Reactivation in Children With Acquired Immunodeficiencies or Undergoing Immune Suppressive, Cytotoxic, or Biological Modifier Therapies. J Pediatr Gastroenterol Nutr. 2020 Apr;70 4 527 538. Open 12. Paul Martin, Andrea DiMartini, Sandy Feng et al. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology. 2014 Mar;59 3 1144 65. Open 13. Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Department of Health and Human Services. 2023. Open 14. US Preventive Services Task Force, Alex H Krist, Karina W Davidson et al. Screening for Hepatitis B Virus Infection in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2020 Dec 15;324 23 2415 2422. Open 15. R Douglas Wilson. Guideline No. 409 Intrauterine Fetal Diagnostic Testing in Women with Chronic Viral Infections. J Obstet Gynaecol Can. 2020 Dec;42 12 1555 1562.e1. Open 16. US Preventive Services Task Force, Douglas K Owens, Karina W Davidson et al. Screening for Hepatitis B Virus Infection in Pregnant Women: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. 2019 Jul 23;322 4 349 354. Open 17. Drake LA, Dinehart SM, Farmer ER et al. Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2017 Dec 5;167 11 794 804. Open 18. Mark K Weng, Mona Doshani, Mohammed A Khan et al. Universal Hepatitis B Vaccination in Adults Aged 19 59 Years: Updated Recommendations of the Advisory Committee on Immunization Practices United States, 2022. MMWR Morb Mortal Wkly Rep. 2022 Apr 1;71 13 477 483. Open 19. Terrault NA, Bzowej NH, Chang KM et al. AASLD guidelines for treatment of chronic hepatitis B. Hepatology. 2016 Jan;63 1 261 83. Open https://web.pathway.md/diseases/rectTxvoSS1Qsiskg 14/14