Bridging for Better Outcome

Surabaya, 22 September 2012

 Announcements

• Coffee Break/Lunch is provided at Foyer area next

to Pelangi Room – 2nd Floor
• IDI accreditation No: 345/PKB/IDI-WJ/2012
Participant 5 SKP, Speaker 5 SKP, Moderator 2 SKP,
Committee 1 SKP
• Certificate will be printed at 3 pm onward. Kindly
bring your participant tag to Registration Desk for
certificate printing
• Musholla is located on Ground Floor
Advanced Knowledge to
Improve Hepatitis B
Management
Speaker
Dr. Aryati, dr, MS, SpPK (K)
Dr. Titong Sugihartono, SpPD, KGEH, FINASIM

Moderator
Dr. A.A Wiradewi Lestari, SpPK
 Agenda
Time Program Speakers
Moderator : Dr. A.A Wiradewi Lestari, SpPK
Advance in laboratory aspects of
10.00 – 10.45 biomarkers in Hepatitis B Management Dr. Aryati, dr, MS, SpPK (K)
Advance Knowledge in Hepatitis B Dr. Titong Sugihartono, SpPD,
10.45 – 11.30 Management KGEH, FINASIM
11.30 – 12.00 Discussion
12.00 – 13.00 Lunch
Dr. Aryati, dr, MS, SpPK (K)
Dr. Titong Sugihartono,
13.00 – 14.45 Case Studies SpPD, KGEH, FINASIM

14.45 – 15.00 Wrap up & discussion All

Curriculum Vitae
A.A.Wiradewi Lestari, dr., SpPK

• She graduated as Medical Doctor from Faculty of Medicine

University of Udayana in 2001, then finished her Clinical Pathology
specialization from Faculty of Medicine from Airlangga University
(2006)
• Following doctoral program at Udayana University (2008 – now)

• Her professional experience such as lecturer at Clinical Pathology

Udayana University (2001-2003) and Clinical Pathology Airlangga
University (2003-2006)

• She currently serves as lecturer at Clinical Pathology of Udayana

University (2003-now)

• She also actively participates in many workshops and publications

 Hepatitis B : Key facts and
epidemiologi data in Indonesia

A.A. Wiradewi Lestari

6
Key facts
• Hepatitis B : a viral infection, attacks the liver and can cause both
acute and chronic disease.

• A major global health problem

• Transmitted through contact with the blood or other body fluids of an

infected person.

• Two billion people worldwide have been infected with the virus, 240
million have chronic (long-term) liver infections, about 600 000
people die every year due to the consequences of hepatitis B.
» World Health organization, July 2012

7
• The hepatitis B virus : 50 to 100 times more
infectious than HIV.

• Hepatitis B vaccine has been available since

1982, 95% effective in preventing infection and
its chronic consequences, and is the first
vaccine against a major human cancer

8
• Hepatitis B virus, survive outside the body for at
least seven days (enters the body, who is not
protected by the vaccine).

• In developing countries, common modes of

transmission:
perinatal
unsafe injection practices
unsafe blood transfusions
unprotected sexual contact

9
• The incubation period : 90 days on
average, can vary from 30 to 180 days.

• The virus may be detected 30 to 60 days

after infection and persists for variable
periods of time

10
• Young children who become infected with the
hepatitis B virus : most likely to develop chronic
infections:
90% of infants infected during the first year
30–50% of children infected between one to four
years of age

11
In adults:
25% of adults who become chronically infected
during childhood, die from hepatitis B-related
liver cancer or cirrhosis;

90% of healthy adults who are infected with the

hepatitis B virus will recover and be completely
rid of the virus within six months.

12
CDC’s national strategy to eliminate
transmission of HBV infection

• Prevention of perinatal infection (routine screening of all

pregnant women for HBsAg and immunoprophylaxis of
infants born to HBsAg-positive mothers and infants born
to mothers with unknown HBsAg status
• Routine infant vaccination
• Vaccination of previously unvaccinated children and
adolescents through age 18 years
• Vaccination of previously unvaccinated adults at
increased risk for infection

13
Epidemiologi

• Hepatitis B : endemic in China and other parts of

Asia.
• 8–10% of the adult population is chronically
infected, most people become infected during
childhood
• Liver cancer caused by hepatitis B is among the
first three causes of death from cancer (men),
and a major cause of cancer in women.

14
<2% = low

2% – 7% = intermediate

≥8% = high 15
Indonesia High Prevalence of
Hepatitis B & C
Reported : around 30 million people suffer from the
diseases.
50 % (15.000.000) chronic liver disease

10 % menjadi liver fibrosis, liver cancer

1.500.000 people have a risk for liver cancer

13 out of 33 provinces in Indonesia are of high prevalence of hepatitis;

Central Sulawesi and East Nusa Tenggara being on top of the list.

16
Riskesdas Biomedis, 2007

• Σ Serum samples : 10.391,

HBsAg positive: 9,4%

HBsAg positive :
male: female = 9,7% : 9,3%
45-49 y o = 11,9%,
5-9 y o = 6,92%

17
 Markers involved in the diagnosis of chronic hepatitis B

The diagnosis of chronic hepatitis B (CHB) is made if HBsAg persists in the

serum for more than 6 months

Acute Hepatitis B Virus Infection with Recovery Progression to Chronic Hepatits B Virus Infection
Typical Serological Course Typical Serologic Course

Symptoms Acute (6 months) Chronic (years)

HBeAg Anti-HBe HBeAg Anti-HBe

Titer

0 4 8 12 16 20 24 28 32 36 52 100 0 4 8 12 16 20 24 2832 36 52 Years

Weeks after exposure Weeks after exposure
HBsAg Anti-HBs IgM anti-HBc Total anti-HBc HBsAg Total anti-HBc IgM anti-HBc

18
Phases of CHB infection

Immune Immune Immune Immune

Tolerant Reactive Control Escape
HBeAg+
HBeAg+
HBeAg–
HBV DNA
HBV-DNA

ALT
Beobachten
HBsAg
treatment? Treatment Treatment
HBeAg + Inactive-Carrier HBeAg –
chronic Hepatitis B Status chronic HBV

19
 Value of HBV DNA testing
HBV DNA viral load monitoring

Measuring HBV DNA levels is a

key test at all stages of HBV The consensus among practice
management strategy guidelines is to quantify HBV
DNA1–3
•Initial evaluation of CHB
•Decision to initiate therapy
•Monitoring the efficacy of
treatment
•Determining the outcome of
treatment

1Lok A.S.F., McMahon B. (2009). AASLD Practice Guidelines. http://www.aasld.org/practiceguidelines/Pages/default.aspx, accessed

October 27, 2011;
2European Association for the Study of the Liver. (2009). EASL Clinical Practice Guidelines. J Hepatol 50, 227–242;
3Liaw Y-F., et al. (2008). Hepatol Int 2, 263–283.

Bridging for Better Outcome 20

Personalized Healthcare :
a response guided therapy for the patient

Screening  Diagnosis  Response-guided therapy

Therapy Therapy
Prevention Diagnosis Therapy monitoring
initiation
and prognosis

• HBsAg II • HBV DNA

Anti-HBs • HBV DNA
• Anti-HBc Antiviral • HBsAg
(vaccine • HBeAg
• Anti-HBs drug quant
response) • ALT
• ALT

21
Terimakasih

22
Bridging for Better Outcome

Surabaya 22 September 2012

Curriculum Vitae
Dr Aryati, dr, MS, SpPK (K)

• Graduated as Medical Doctor from Faculty of Medicine Airlangga

University (1988), then finished her master of Immunology (1992)

• She finished Specialist of Clinical Pathology from Airlangga University

(2000) and Doctoral degree in 2006, continuing Consultant of
Infectious Disease (2007)

• Her professional experience such as

- Lecturer at Clinical Pathology Airlangga University (1992 - now)
- Head of Clin. Pathology Department and SMF of Sutomo Hospital
- Head of Development and Marketing Diagnostic Centre of Sutomo
Hospital, etc

• She is also active in local professional societies

 ADVANCE IN LABORATORY
ASPECTS OF BIOMARKERS IN
HEPATITIS B MANAGEMENT
22 September 2012
ARYATI
Clinical Pathology Department, School of Medicine,
Airlangga University, Surabaya

25
 Disease Progression
Chronic HCC
hepatitis
10-20%

Cirrhosis

Liver
15-40%
Failure
Death or
20% OLTx

Age 40 50 60 Years

EASL Consensus Guidelines. J Hepatol 2003

26
Lok et al, Hepatology 2004
26
 HBV Genotypes

27 27
 North Europe Mediterranean Africa India
& USA - A basin -D E&D A  Genotype G: increased
liver fibrosis1
 Genotype C: increased
risk of HCC2
Rare types: Far East  Genotype A: better
F – Latin
B&C
response to IFN
America  Genotype B: mild
G –France, hepatitis B, higher rate
USA
of seroconversion

H –Mexico,
Latin America

Worldwide HBV genotype distribution

(adapted Baghani S.)
 Whether routine genotyping is useful remains to be proved
1Lacombe K, AIDS 2006. 2Chan HL, J Clin Oncol2008.
28 28
 Mulyanto research, 2009

Indonesia 1989-2007 :
 66% of genotype B
 26% of genotype C
 7% of genotype D
 0,8% of genotype A

29 29
Performance of Elecsys HBsAg II assay
for the detection of HBV genotypes

Mühlbacher et al., Med. Microbiol Immunol. 2007; 197: 55-64 30

 HBV
Laboratory Aspects :
Serological markers

32 32
 Clinical Manifestations of
HBV Infection
• Only 30-50% of adult infections are
symptomatic
• Need diagnostic tests to distinguish
• Incubation period - 45 to 180 days
(average = 60-90 days)

33
 Hepatitis B Lab Markers
Marker
Hepatitis B surface antigen
M class immunoglobulin
antibody to hepatitis B core
antigen
Antibody to hepatitis B core
antigen
Antibody to Hepatitis B surface
antibody
Hepatitis B e antigen
Abbreviation Use
HBsAg Detection of acutely or chronically
infected persons; antigen used in hepatitis
B vaccine
IgM Anti-HBc Identification of acute or recent HBV
Anti-HBc, IgM infections (including those in HBsAg-
HBcAb, IgM negative persons during the “window”
phase of infection)
Anti-HBc Identification of persons with acute,
HBcAb resolved, or chronic HBV infection
(not present after vaccination)
Anti-HBs Identification of persons who have
HBsAb resolved infection with HBV;
determination of immunity after
immunization
HBeAg Identification of infected persons at
increased risk for transmitting HBV

Antibody to Hepatitis B e antigen Anti-HBe Identification of infected person with

HBeAb lower risk for transmitting HBV

34
Typical Serological Markers
for Acute Hepatitis B
Infection

35
 Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course

Symptoms
HBeAg anti-HBe
Total anti-HBc
Titer
IgM anti-HBc
HBV DNA

HBsAg anti-HBs

Window
Period

0 4 8 12 16 20 24 28 32 36 52 100
Weeks after Exposure
44
Typical Serological Markers
for Chronic Hepatitis B
Infection

45
 CHB Is A Dynamic Disease!

HBeAg
Treatment
Anti-HBe
Treatment
HBV DNA

ALT

Immune Immune Inactive HBeAg-

tolerant active carrier state negativeCHB

Normal or minimal Chronic Normal or Progressive Cirrhosis

hepatitis hepatitis inactive hepatitis fibrosis HCC
CHB is a dynamic disease and patients can transition backwards and forwards between stages

46 46
Adapted from Yim & Lok, Hepatology 2006; 43: S173
 Acute vs. Chronic HBV Infection
Acute
• HBsAg+ < 6 mos.
• IgM anti-HBc + positive
• Infection will resolve and
person will have lifelong
immunity
• HBsAb+ and HBcAb+
Chronic
• HBsAg + for at least 6
months
• Also known as a “carrier”
• Infection does not resolve
and the person remains
infectious
• HBsAb- and HBcAB+
47
 Interpretation of Serological Tests
Test Results Interpretation
HBsAg Negative Susceptible
anti-HBc Negative (Never infected or vaccinated)
anti-HBs Negative
HBsAg Negative Immune
anti-HBc Negative (Due to vaccine)
anti-HBs Positive
HBsAg Negative Immune
anti-HBc Positive (Resolved Infection)
anti-HBs Positive
HBsAg Positive Acutely Infected
anti-HBc Positive
IgM anti-HBc Positive
anti-HBs Negative
HBsAg Positive Chronically Infected
anti-HBc Positive
anti-HBs Negative
IgM anti-HBc Negative
HBsAg Negative Four Possible Interpretations
anti-HBc Positive
anti-HBs Negative

48
 Four Possible Interpretations

• May be recovering from acute HBV infection

• May be distantly immune and test not sensitive
enough to detect very low level of anti-HBs in serum
• May be susceptible with a false positive anti-HBc
• May be undetectable level of HBsAg present in the
serum and the person is actually a carrier

49
 Serological profile on Hepatitis B
infection

50 50
HBV Mutants
Professor Stephen Locarnini
Victorian Infectious Diseases Reference Laboratory,
North Melbourne, Victoria 3051,
AUSTRALIA

www.vidrl.org.au/publications/hep_updates.htm

51
HBV Genome

52
Clinically Significant HBV Mutants

• Basal core promoter and precore mutants

eg. A1762T, G1764A; G1896A (pcW28 stop)

• Envelope mutants
eg. Vaccine, HBIG and diagnostic escape (sG145R)

• Polymerase antiviral resistance mutants

eg. Lamivudine : rtM204I/V/S (+/- rtL180M)
Adefovir : rtN236T +1-rtA181T/V
Entecavir : rtL180M+rtM204V+rtS184G+
rtS202I+rtM250V
Telbivudine : rtM204I

53
Genome structure of HBV

Double stranded DNA with overlapping

reading frames

Mutations on Pol gene can be associated

with mutations on S gene

Mutations on Pol gene selected by

exposure to Nucleos(t)ides (3TC, FTC, ADV,
ETV, LdT)

 S gene mutations known to be

associated with decrease of HBs
antigenicity1 and vaccine escape2

1Torresi J, J clinc virol 2002. 2Kamili S, Hepatol 2009

Lee WM.N Engl J Med. 1997

54
 HBV markers :
Qualitative HBsAg

55 55
 Qualitative HBsAg

• Diagnosis of acute and chronic hepatitis B

infection
• Screening of blood and blood products
• Follow up of Hepatitis B infection
• Pregnancy screening

56
 HBsAg II (Roche)

ECLIA = Electrochemiluminescense Immunoassay

Cutoff index :
< 0.90 are nonreactive – considered negative for
HBsAg
≥ 0.90 to < 1.0 are borderline
≥ 1.0 are reactive
All reactive or borderline samples must be
redetermined in duplicate !!

57
 After redetermined :

If cutoff index :
• mean cutoff < 0.90 considered negative for HBsAg
• ≥ 0.90 considered repeatedly reactive

Repeatedly reactive samples must be investigated

using an independent neutralization test (HBsAg
Confirmatory Test)

58
 HBsAg Confirmatory Test

• Purpose : in vitro confirmation of the presence of

HBsAg in samples repeatedly reactive
• Based on the principle specific antibody
neutralization (polyclonal HBsAg specific
antibodies)
• Result : positive, indeterminate or non-reactive

59
60
61
 Hasil Pemeriksaan HBsAg
NAMA : TN. X TANGGAL : 22 September 2012
ALAMAT : JL. XY No. LAB : 120900XXX
UMUR : XX TH DOKTER : Dr. dr. Aryati, MS, Sp. PK (K)

TANGGAL PEMERIKSAAN : 22 September 2012

BAHAN PEMERIKSAAN : Serum
PEMERIKSAAN : HBsAg Kualitatif
METODE : ECLIA - ElectroChemiluniscent
HASIL PEMERIKSAAN

Nama Pemeriksaan Hasil Nilai Rujukan Satuan Keterangan

coi < 0.9 = Non Reactive
HBsAg Kualitatif 0.53 Non Reaktif coi 0.9< coi < 1.0 = Borderline
coi > 1.0 = Reactive

Surabaya, 22 September 2012

62 62
 HBV markers :
Quantitative HBsAg

63 63
 What makes HBsAg such an important
marker in CHB?
The clearance of HBsAg from serum is considered the ideal outcome of CHB – as
acknowledged by all major CHB management guidelines

EASL

HBsAg clearance is associated with a complete and definitive remission

of the activity of CHB and an improved long-term outcome

APASL

HBsAg clearance usually confers excellent prognosis

AASLD

Prognosis is improved in carriers who clear HBsAg

EASL. J Hepatol 2009; Liaw et al. Hepatol Int 2008; Lok & McMahon. Hepatology 2009

64
 HBsAg Quantification

• HBsAg level reflect the amount of covalently

closed circular DNA (cccDNA)
• Predictor of HBsAg clearance and sustained
virological response to antiviral treatment off
therapy

65
66
 HBsAg Quantification
(HBsAg quant - Roche)

• Fully automated chemiluminescent microparticle

immunoassay
• ECLIA = Electrochemiluminescent Immunoassay
• Pre-dilution of samples is mandatory according to
the test – automatically perform inside in the
instrument

67
 HBsAg quant Comparison
Roche Elecsys X

On-board (automated) Yes No

dilution
Manual dilution ~25% ~95%
Labor costs
Instrument base Elecsys X
E170, E2010, e601, e 602, e411
Broad global coverage
Precision 5.6% CV @ 6610 IU/mL 9.2% CV @ 182 IU/mL
Linear range 0.05–52,000 IU/mL 0.05–250 IU/mL
Onboard stability 8 weeks 30 days

Traceability Standardized against Standardized against

WHO 2nd International standard WHO 1st International standard

68 68
• The reduction of serum HBsAg levels
parallels the decline of intrahepatic
covalently closed circular DNA.

Gastroenterology 2004;126:1750-1758.
69 69
70 70
Taken from Dr. Irsan’s presentation from JLC 2012
 Quantitative HBsAg

Phases of Infection
Fung, 2010
71 71
Clinical goals of HBV treatment

Establish Inhibit Viral

Immune Control Replication

Quantitative Quantitative
HBsAg HBV-DNA

Optimize HBV Treatment and

Improve Patient Outcomes

72 72
Clinical value
HBsAg quantification and HBV DNA quantification
provide complementary information
HBV DNA HBsAg
Virology Dane particle (infectious) Dane particle (infectious)
Spherical and filamentous
bodies (non-infectious)
Natural history Reduced after HBeAg seroconversion but Very slow reduction over time
increases on immune escape regardless of HBV DNA levels
Implication Viral replication Immune response

73
 Hasil Pemeriksaan HBsAg
NAMA : TN. X TANGGAL : 22 September 2012
ALAMAT : JL. XY No. LAB : 120900XXX
UMUR : XX TH DOKTER : Dr. dr. Aryati, MS, Sp. PK (K)

TANGGAL PEMERIKSAAN : 22 September 2012

BAHAN PEMERIKSAAN : Serum
PEMERIKSAAN : HBsAg Kualitatif
METODE : ECLIA - ElectroChemiluniscent
HASIL PEMERIKSAAN

Nama Pemeriksaan Hasil Nilai Rujukan Satuan Keterangan

HBsAg Kuantitatif 145 < 0.05 IU/mL

Surabaya, 22 September 2012

74 74
 HBV markers :
HBV DNA

75 75
 Occult Hepatitis

76 76
 Laboratory Measurements

• HBV genotype: TRUGENE HBV genotyping kit.

• Serum HBV DNA : COBAS TaqMan,
Roche Molecular System , lower limit of detection,
29 IU/mL (range 29-1,10 x 108 IU/mL)
• Serum quantitave HBsAg: Roche HBsAg quant
(range, 0.05-52000 IU/mL)

77 77
 Laboratory Measurements

• LOD (Limit of Detection),

is the lowest quantity of substance that can be
distinguished from the absence of the substance (a
blank value)
Example : HBV DNA →LOD : 6 IU/mL

• LOQ (Limit of Quantification),

is the lowest amount of analyte in a sample that can be
quantitatively determined with a suitable precision and
accuracy
Example : HBV DNA→LOQ : 29 IU/mL

78
Result Interpretation

Titer result Interpretation

Target not detected Result is reported as ‘HBV DNA not detected’

<6.00E+00 IU/mL Result is <LoD; result is reported as ‘HBV DNA

detected, <6 HBV DNA IU/mL’

≥6.00E+00 IU/mL
and <2.90E+01 Result is <lower Limit of the Linear Range;
IU/mL result should be interpreted with caution

≥2.90E+01 IU/mL
and ≤1.10E+08 Result is reported as ‘XX IU/mL HBV DNA
IU/mL detected’

Result is reported as ‘>1.00E+08 HBV DNA

>1.00E+08 IU/mL
IU/mL’

80
 HASIL PEMERIKSAAN
HEPATITIS B VIRUS (HBV) DNA KUANTITATIF

NAMA : TN. X TANGGAL : 22 September 2012

ALAMAT : JL. XY No. LAB : 120900XXX
UMUR : XX TH DOKTER : Dr. dr. Aryati, MS, Sp. PK (K)

TANGGAL PEMERIKSAAN : 22 September 2012

BAHAN PEMERIKSAAN : Serum
PEMERIKSAAN : HBV DNA KUANTITATIF
METODE : Real Time PCR Kuantitatif dengan instrumen COBAS TAQMAN 48,
ROCHE DIAGNOSTIC yang telah distandarisasi terhadap Standar
Internasional WHO.
BATAS LINIER : 29 – 1,10 X 108 IU/mL
HASIL PEMERIKSAAN :

Kandungan DNA HBV :

DNA HBV tidak terdeteksi

Surabaya, 22 September 2012

81
 HASIL PEMERIKSAAN
HEPATITIS B VIRUS (HBV) DNA KUANTITATIF

NAMA : TN. X TANGGAL : 22 September 2012

ALAMAT : JL. XY No. LAB : 120900XXX
UMUR : XX TH DOKTER : Dr. dr. Aryati, MS, Sp. PK (K)

TANGGAL PEMERIKSAAN : 22 September 2012

BAHAN PEMERIKSAAN : Serum
PEMERIKSAAN : HBV DNA KUANTITATIF
METODE : Real Time PCR Kuantitatif dengan instrumen COBAS TAQMAN 48,
ROCHE DIAGNOSTIC yang telah distandarisasi terhadap Standar
Internasional WHO.
BATAS LINIER : 29 – 1,10 X 108 IU/mL
HASIL PEMERIKSAAN :

Kandungan DNA HBV :

Terdeteksi : < 29 IU/mL <170 copies/mL

Surabaya, 22 September 2012

82
 HASIL PEMERIKSAAN
HEPATITIS B VIRUS (HBV) DNA KUANTITATIF

NAMA : TN. X TANGGAL : 22 September 2012

ALAMAT : JL. XY No. LAB : 120900XXX
UMUR : XX TH DOKTER : Dr. dr. Aryati, MS, Sp. PK (K)

TANGGAL PEMERIKSAAN : 22 September 2012

BAHAN PEMERIKSAAN : Serum
PEMERIKSAAN : HBV DNA KUANTITATIF
METODE : Real Time PCR Kuantitatif dengan instrumen COBAS TAQMAN 48,
ROCHE DIAGNOSTIC yang telah distandarisasi terhadap Standar
Internasional WHO.
BATAS LINIER : 29 – 1,10 X 108 IU/mL
HASIL PEMERIKSAAN :

Kandungan DNA HBV :

Terdeteksi : 5,18 X 102 IU/mL 30,15 x 102 copies/mL

Surabaya, 22 September 2012

83
 CONCLUSIONS

88 88
 HBV biomarkers :
• Phase : acute or chronic
• Screening using Qualitative HBsAg (mutati -
on?, genotype ?,result borderline or true
reactive?)- becareful of index or S/N or COI
value
• Mutation on preS-S gene → HBsAg
• Mutation on preC-C gene → HBeAg
• CHB - biomarker? HBsAg kualitatif, HBeAg,
ALT, HBV DNA, HBsAg kuantitatif
• HBV DNA level
• HBsAg ≠ HBV DNA
89
90
dr_aryati@yahoo.com

91
Bridging for Better Outcome

Surabaya 22 September 2012

Curriculum Vitae
Dr Titong Sugihartono, SpPD, K-GEH

• He is a Staff of Division of Gastroenterology-Hepatology, SMF

Internal Medicine, Medical Faculty Airlangga University – Sutomo
Hospital

• His professional experience such as Head of Centre Public Health

in Rote (1989-1992), Head of Medical School SMF, Bangkalan
(2001-2005), Supervisor in Emergency Internist Installation, as
Lecturer Gastroenterology and Hepatology of Nurse Academy
Sutomo, etc.
• Graduated as Medical Doctor from Faculty of Medicine Airlangga
University (1988)

• He finished Specialist of Internal Medicine from Airlangga University

(2001) and continuing Consultant of Gastroentero-Hepatology
Advanced Knowledge in
Hepatitis B Management

TITONG SUGIHARTONO

Jeanne Latu Conference

Surabaya, 22 September 2012
HBV is a life long, dynamic disease

 Changes over time

 Risk of end stage liver disease and cancer increases with

ongoing inflammation and viremia in adults
 Fibrosis can be reversible
 Drugs can decrease fibrosis progression

 HBV can be controlled but not cured

 Reactivation can occur even in those who have lost

HBsAg
 Distribusi Hepatitis B Virus

HBsAg Prevalence
High ≥ 8%
Intermediate 2% to 7%
Low < 2%

Centers for Disease Control and Prevention. CDC Health Information for International Travel 2010.
Distribusi karier HB dan KHS

CDC Division of Viral Hepatitis – Statistics and Surveilance

 Virus Hepatitis B
• Berasal dari famili
hepadnaviridae
• Merupakan virus DNA dengan
3200 pasang basa
• Berbentuk sferis
• Mempunyai 2 lapis permukaan
dan kapsid yang melindungi
genom virus
 Struktur Genome VHB
• S (surface) – HBsAg, yang
akan menginduksi sistim imun
• C (core) – HBeAg & HBcAg,
menunjukkan status replikatif
VHB
• P (polymerase) – menyandi
protein DNA polimerase dan
enzim reverse transcriptase
• X : berfunngsi sebagai
transaktivator, berperan pada
karsinogenesis
Siklus replikasi VHB
 Mutasi VHB

Kesalahan transkripsi oleh

DNA polymerase

Mutasi VHB

Resistensi obat
?
Pada perjalanan alamiah infeksi kronik hepatitis B,
destruksi hepatosit terjadi pada fase:
a. Fase imunotolerans
b. Fase Imunoreaktif
c. Fase karier inaktif
Natural history of HBV
 Perjalanan Penyakit
• Respon imun minimal
Fase • Virus aktif bereplikasi
Imunotolerans • 2-4 minggu pada anal
• > 10 tahun pada dewasa

• Reskonstruksi imun
Fase • Proses inflamasi
Imunoreaktif • Destruksi hepatosit

• Sistim imun tubuh berhasil melawan VHB

Fase karier • Replikasi minimal
inaktif • Serokonversi HBeAg

• Gambaran inflmasi aktif

Fase • Derajat kerusakan hati
reaktivasi fluktuatif
 Fase Infeksi Hepatitis Kronis
Immune Immune Low Replicative Reactivation
Tolerance Clearance Phase Phase
HBeAg+ HBeAg-/anti-HBe+ (precore/core promoter variants)
< >< >
> 2000 IU/mL
HBV DNA < 2000 IU/mL
2x 108-
11
2 x 10 IU/mL 200,000 - 2 x 109 IU/mL

ALT

Normal/mild Moderate/severe CH Normal/mild CH Moderate/severe CH

CH
Cirrhosis Inactive cirrhosis Cirrhosis

HBeAg+ Inactive-carrier state HBeAg-

chronic hepatitis chronic hepatitis

Slide courtesy of A. S. F. Lok, MD.

 Varian Hepatitis B
• HBeAg Positif
• Lebih banyak pada laki-laki
• Dekade 3 – 4 kehidupan
• 65% mengalami serokonversi spontan
• FR serokonversi spontan: usia lanjut, ALT pra-terapi tinggi,
genotipe A dan B serta etnis selain Asia

• HBeAg Negatif
• Mutasi di core/ precore  guanine menjadi adenin  protein
HBeAg tidak diproduksi
• Ditandai oleh: replikasi VHB persisten setelah serokonversi,
HBV DNA fluktuatif
• Ditemukan pada usia lebih tua dengan HBV DNA yang lebih
rendah dibandingkan dengan HBeAg positif
Faktor Risiko Perjalanan Penyakit
• Umur saat terinfeksi
• Jenis kelamin laki-laki
• Koinfeksi dengan VHD, VHC dan HIV
• Genotipe C dan D
• Riwayat keluarga dengan KHS
• Konsumsi alkohol
• Viral load
• Derajat nekroinflmasi
• HBeAg positif
 Outcome of Hepatitis B Virus Infection
by Age at Infection
100 100

Symptomatic Infection (%)

80 80
Chronic Infection
Chronic Infection (%)

60 60

40 40

20 20

Symptomatic Infection
0 0
Birth 1-6 months 7-12 months 1-4 years Older Children
and Adults
Diagnosis Hepatitis B

Hepatitis B kronik asimptomatik, maka diperlukan

pemeriksaan laboratorium:
• Status infeksi VHB :
• Antigen dan antibodi
• Viral load

• Derajat kerusakan hepatosit

• Serum ALT
• Pemeriksaan histologis
?
Pemeriksaan penunjamg yang menandai replikasi
virus adalah:
a. HBsAg
b. HBeAg
c. HBV DNA
Diagnosis
A battery of serological tests are used for the diagnosis of acute and chronic
hepatitis B infection.
 HBsAg - used as a general marker of infection.

 HBsAb - used to document recovery and/or immunity to HBV infection.

 anti-HBc IgM - marker of acute infection.

 anti-HBcIgG - past or chronic infection.

 HBeAg - indicates active replication of virus and therefore infectiveness.

 Anti-Hbe - virus no longer replicating. However, the patient can still be

positive for HBsAg which is made by integrated HBV.
 HBV-DNA - indicates active replication of virus, more accurate than HBeAg
especially in cases of escape mutants. Used mainly for monitoring response
to therapy.
Patterns of Viral and Biochemical Markers in Patients
with Resolved versus Chronic Hepatitis B
A Acute self-limiting HBV infection
Antigen or Antibody Level

HBV DNA
HBeAg
Anti-HBs
HBsAg
Anti-HBc
Anti-HBe
ALT

0 5 10 15 20 48 2 4 6 8 >10

Weeks since exposure Years since exposure

B Chronic HBV infection

Antigen or Antibody Level

HBV DNA
HBeAg
Anti-HBs
HBsAg
Anti-HBc
Anti-HBe
ALT
0 5 10 15 20 48 2 4 6 8 >10

Weeks since exposure Years since exposure

Based on Ganem & Prince. N Engl J Med 2004

 Interpretation : Hepatitis Viral Markers

Phase HBsAg Anti-HBs HBeAg Anti-HBe Anti-HBc Anti-HBc HBV DNA

IgM IgG
Acute infection

Early acute HBV + - + - + + or - High

Convalescent Window - - - + + + or - Low

Acute HBV
Immune due to - + or - - + - + Absent
resolution of infection
Immune due to - + - - - - Negative
vaccination
Chronic Infection

HBeAg positive CHB + - + - - + High

HBeAg negative CHB + - - + - + Moderate

Inactive carrier + - - + - + Low

Absent
HBV DNA

 Cara yang paling akurat untuk mengukur jumlah virus

pada pasien CHB adalah dengan menghitung kopi dari
HBV DNA yang ada dalam darah
o Diekspresikan dalam kopi HBV DNA permililiter darah
o Peningkatan kadar HBV DNA menunjukkan bahwa virus sedang
aktif bereplikasi

 Jumlah total dari VHB dalam darah disebut “viral load”

Viral load dan progresi penyakit

 Tingginya viral load merupakan angka penting untuk

memprediksi progresifitas pasien menjadi:
o Sirosis dekompensata
o HCC

 Sebaliknya penurunan kadar HBV DNA menunjukkan

adanya perbaikan spontan atau respon terhadap
pengobatan
Viral load dan progresi penyakit
 Penurunan kadar HBV DNA berhubungan dengan
terjadiya serokonversi HBeAg dan perbaikan fungsi hati
setelah terapi
 Semakin tinggi dan semakin cepat penurunan kadar HBV
DNA setelah pengobatan juga menurunkan resiko
terjadinya resistensi
 Kemampuan untuk mempertahankan konsentrasi HBV
DNA dibawah kadar tertentu juga bisa untuk mengukur
respon terapi antivirus
?
Pemeriksaan HBV DNA dapat menunjukkan hal-hal
berikut, kecuali:
a. Risiko KHS
b. Waktu inisiasi antivirus pada ibu hamil
c. Derajat nekroinflmasi
 R.E.V.E.A.L: The Risk Evaluation of Viral Load
Elevation and Associated Liver Disease/Cancer
• REVEAL: prospective, multicenter, observational cohort study

1991–1992: 7 Taiwanese townships

Recruitment Individuals aged 30–65 years eligible
(n=89,293)

HCC-free individuals enrolled

(n=23,820)
Insufficient serum
for tests or HCV
seropositive
HCC ANALYSIS
HBsAg(+) with adequate baseline
HBV DNA sample
(n=3,851)
Diagnosed with
cirrhosis or died within
6 months of entry
June 2004: CIRRHOSIS ANALYSIS
43,993 PYs follow-up (n=3,582)

Chen CJ, et al. JAMA. 2006; 295:65-73.

Iloeje UH, et al. Gastroenterology. 2006; 130:678–86.
R.E.V.E.A.L: kadar viral load HBV tinggi berhubungan dengan
peningkatan kejadian kanker hati
Cumulative Incidence of HCC: All Subjects (n=3,653)
Relative Risk
(95% CI)
16
14.89% 10.7
Cumulative incidence of HCC, %

14 Baseline HBV DNA Level, copies/mL (5.7-20.1)

≥106
12 12.17% 8.9
105–<106 (4.6-17.5)
104–<105
10
300–<104
8 <300

4 3.57% 2.7
(1.3-5.6)
2 1.37%
1.0
1.30% (0.5-2.2)
0 1.0
(reference)
0 1 2 3 4 5 6 7 8 9 10 11 12 13

Year of follow-up
Chen CJ, et al. JAMA. 2006; 295:65–73.
 R.E.V.E.A.L: kadar viral load HBV tinggi berhubungan dengan
kejadian kanker hati – independen terhadap ALT

Cumulative Incidence of HCC:

HBeAg(-), normal ALT, no liver cirrhosis at entry (n=2,925)

14
Cumulative incidence of HCC, %

Baseline HBV DNA Level 13.50%

12 ≥106
105–<106
10 104–<105
300–<104
8 <300 7.96%

4
3.15%
2
0.89%
0 0.74%

0 1 2 3 4 5 6 7 8 9 10 11 12 13
Year of follow-up
Chen CJ, et al. JAMA. 2006; 295:65–73.
 R.E.V.E.A.L: Viral Load tinggi berhubungan
dengan peningkatan kejadian Sirosis
Cumulative Incidence of Liver Cirrhosis Relative Risk
All Subjects (n=3,582) (95% CI)
40
Baseline HBV DNA level, copies/ml 36.2% 9.8
≥106 (n=602) (6.7-14.4)
Cumulative incidence of liver

105–<106 (n=333)
30
104–<105 ( n=628)
300–<104 ( n=1,150)
cirrhosis (% subjects)

23.5% 5.9
<300 (n=869)
20 (3.9-9.0)

Log rank test of trend 2.5

p<0.001 (1.6-3.8)
10 9.8%
5.9%
1.4
4.5% (0.9-2.2)
1.0
0 (reference)

0 1 2 3 4 5 6 7 8 9 10 11 12 13
Years of follow-up
R.E.V.E.A.L: Viral load HBV tinggi merupakan
faktor risiko independen untuk sirosis

All participants (n=3,582) HBeAg(-), normal ALT (n=2,923)

18 #p <0.001 18 #p <0.001
16 16

14 14
#
Adjusted relative risk* of

12 12
#
10 10 #
#
cirrhosis (95% CI)

8 8
6.5 6.6
6 5.6 6 5.6
#
#
4 4
2.5 2.5
2 1.4 2 1.4

0 0
300–<104 104–105 105–106 >106 300–<104 104–105 105–106 >106
HBV DNA copies/mL HBV DNA copies/mL

*Cox proportional hazards regression analysis. Risk relative to HBV DNA <300 copies/mL.
Relative risk adjusted for age, gender, cigarette smoking, alcohol consumption.
?
Untuk menentukan perlu tidaknya terapi hepatitis B,
pemeriksaan yang perlu dilakukan pada seorang
pasien mencakup:
a. Status HBsAg dan ALT
b. HBV DNA, HBeAg, dan ALT
c. Biopsi hati
Indikasi Terapi
 Terapi infeksi HBV kronik perlu dipertimbangkan dengan baik
 Risiko resistensi tinggi, pada pemberian terapi yang tidak tepat pada
waktunya
 Beberapa regimen terapi perlu pemantauan efek sampingnya
 Indikator memulai terapi harus dinilai berdasarkan:
• HBV DNA
• Serum ALT
• Status HBeAg
• Gambaran histologis hati
 Fase Infeksi Hepatitis Kronis
Immune Immune Low Replicative Reactivation
Tolerance Clearance Phase Phase
HBeAg+ HBeAg-/anti-HBe+ (precore/core promoter variants)
< >< >
> 2000 IU/mL
HBV DNA < 2000 IU/mL
2x 108-
11
2 x 10 IU/mL 200,000 - 2 x 109 IU/mL

ALT TERAPI TERAPI

Normal/mild Moderate/severe CH Normal/mild CH Moderate/severe CH

CH
Cirrhosis Inactive cirrhosis Cirrhosis

HBeAg+ Inactive-carrier state HBeAg-

chronic hepatitis chronic hepatitis

Slide courtesy of A. S. F. Lok, MD.

Tujuan Terapi
 Tujuan jangka pendek
• Menurunkan kadar HBV DNA hingga tidak terdeteksi
dengan PCR (PCR negatively)
• Serokonversi HBeAg, yaitu hilangnya HBeAg dan
digantikan dengan munculnya Anti-Hbe
• Normalisasi ALT

 Tujuan jangka panjang

• Mencegah progresi penyakit menuju sirosis dan KHS
Therapeutic endpoints over time
Improved Improved
histology Anti-HBs+ survival

Anti-HBe+ Loss of
HBsAg
Loss of
HBeAg
Loss of
HBV DNA

TIME
 Indikasi Terapi
Konsensus PPHI 2012 & APASL 2012

 Pada pasien dengan HBeAg positif, terapi dapat dimulai pada

 HBV DNA diatas 2x104 IU/ml dengan SGPT 2-5x batas atas normal
yang menetap selama 3-6 bulan atau SGPT serum > 5x batas atas
normal, atau dengan gambaran histologis fibrosis derajat sedang
sampai berat
 Pada pasien dengan HBeAg negatif, terapi dapat dimulai pada :
 HBV DNA lebih dari 2x 103 IU/ml, dan kenaikan SGPT > 2x batas
atas normal yag menetap selama 3 – 6 bulan
 Pada pasien dengan sirosis kompensata, maka terapi akan dimulai
pada pasien dengan HBV DNA > 2x 103 IU/ml;
 Pada pasien sirosis dekompensata, terapi harus segera dimulai untuk
mencegah deteorisasi
Different tests provide different levels of information
on infection and response to therapy
Demonstrate sustained
Anti- response/indicate immunity
HBs
Quant Predict sustained
response
HBsAg
Identify initial
HBeAg,
HBVHBV DNA
DNA response

Initiate
HBV
HBV DNAALT
DNA, therapy
HBsAg, HBeAg, Diagnose
anti-HBe, anti-HBc IgM, HBV DNA

Modified from Pawlotsky et al. Gastroenterol 2008

 Pemantauan Respon Terapi
Pemeriksaan Waktu pemeriksaan

HBV DNA 3 – 6 bulan sekali sampai 12 selesai terapi

HBeAg/ Anti Hbe 3 – 6 bulan sekali sampai 12 selesai terapi

HBsAg/ Anti HBs Awal dan akhir terapi

ALT 3 – 6 bulan sekali sampai 12 selesai terapi

Biopsi Sesuai indikasi

USG dan AFP Setiap 6 bulan pada usia > 40

 Pemantauan Efek Samping
Terapi Pemeriksaan Waktu pemeriksaan

Interferon Darah lengkap 1 bulan sekali

Penapisan depresi dan Setiap kunjungan

gangguan psikiatri

Adefovir atau Pemeriksaan fungsi ginjal 1 – 3 bulan sekali

tenofovir

Telbivudin Penapisan adanya miopati Setiap kunjung

lewat anamnesa dan
pemeriksaan fisik
When to stop therapy
Recommendation 8
• For conventional IFN, the current recommended duration
of therapy is 4–6 months for HBeAg-positive patients (IA)
and at least a year for HBeAg-negative patients (IA).
• For Peg-IFN, the recommended duration is 12 months
(IA).
When to stop therapy
Recommendation 9 (For nucs)
• In HBeAg-positive patients, treatment can be stopped when HBeAg
seroconversion with undetectable HBV DNA has been maintained
for at least 12 months (IIA).
• In HBeAg-negative patients, it is not clear how long treatment
should be continued if HBsAg remains positive, but treatment
discontinuation can be considered if patients have been treated for
at least 2 years with undetectable HBV DNA documented on three
separate occasions 6 months apart (IIA).
• In compliant patients with primary treatment failure at month 3 or
suboptimal viral response at month 6, switch to a more potent drug
or add a drug without cross resistance if LAM, LdT, or ADV was
used (IIIA).
HBV Nucs: Nonresponse, Suboptimal Response,
and Virologic Breakthrough
1.0
Antiviral Drug
Change in HBV DNA

0
(log10 IU/mL)

Virologic
Primary nonresponse
-1.0 breakthrough

-2.0 Suboptimal response

-3.0
1 log
-4.0 Nadir

0 6 12 18
Months
Lok AS, et al. Hepatology. 2007;45:507-539.
 Announcements

• Coffee Break/Lunch is provided at Foyer area next

to Pelangi Room – 2nd Floor
• IDI accreditation No: 345/PKB/IDI-WJ/2012
Participant 5 SKP, Speaker 5 SKP, Moderator 2 SKP,
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