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Director, Medical Data Analytics Centre (MDAC)
Deputy Director, Center for Liver Health
Assistant Dean (Learning Experience), Faculty of Medicine
The Chinese University of Hong Kong
Division of Gastroenterology and Hepatology
Department of Medicine and Therapeutics
Prince of Wales Hospital
Grace LH Wong, MD: consultant: AbbVie, Gilead Sciences, Janssen.
Chronic hepatitis B (CHB) remains endemic in many parts of the world. Globally, it affects up to 296 million people. A small yet significant number of these patients are coinfected with hepatitis delta virus (HDV), either as a simultaneous hepatitis B virus (HBV) coinfection or HDV superinfection occurring in the setting of CHB. It is important to diagnose and treat patients with HDV as soon as possible, but identifying these patients can be challenging.
Chronic HDV infection is underdiagnosed in many parts of the world, as anti-HDV may not be routinely checked in all patients with CHB. Furthermore, the HDV RNA assay is not readily available in some locales, and when it is available, the turnaround time can be up to several months.
Fortunately, some popular and user-friendly apps and online tools may aid in increasing diagnosis of HDV and would be helpful to prompt identification of such HBV/HDV coinfected patients. Clinical Care Options’ updated Hep B Consult tool includes HDV screening questions and HDV treatment recommendations to raise the awareness among healthcare professionals to consider HDV screening (and subsequent treatment if indicated) in their patients with CHB. HDV screening should be considered for all patients with CHB living in regions where HDV is prevalent, in patients with CHB with more severe or rapidly progressive liver disease, and for patients with CHB with certain risk factors (eg, injection drug use).
Identifying Persons With HDV—Using an App
Identifying persons with HDV in HBV-endemic regions is particularly relevant today, as bulevirtide, the first entry inhibitor that can inactivate HBV and HDV receptors and compete with HBV for the sodium-taurocholate cotransporting polypeptide, has been approved in many countries as the antiviral therapy for chronic HBV/HDV infection. Early diagnosis of HDV triggered by the questions in the Hep B Consult tool, together with other appropriate assessments, would aid healthcare professionals in deciding whether their patients are candidates for antiviral treatment. Untreated patients should be monitored closely to see if they become candidates for treatment in the future.
A specific population of patients who can benefit from HDV screening is those with CHB indicated for liver transplantation. It is important that HDV infection be identified before patients undergo liver transplantation, and patients who screen positive for HDV should undergo treatment. In regions where bulevirtide is not yet available, HDV may be treated with interferon or pegylated interferon, although efficacy is typically disappointing; interferon-based therapy requires ≥1 year of treatment, and sustained clearance of HDV infection is rare. There is a need for highly effective, well-tolerated treatment for HDV.
After liver transplantation and in the presence of immunosuppression, it is possible to observe HDV expression in the absence of recurrent HBV infection in a unique situation where HDV infection does not appear to be reliant on HBV infection. Hepatitis B immune globulin infusions, which have been very effective in preventing HBV reinfection of liver allografts, also can prevent HDV infection of the new graft.
However, you can’t prevent what you don’t look for, so we hope our updated version of the Hep B Consult tool will increase awareness of HDV infection in persons with CHB and assist you in identifying which of your patients with CHB should be screened for HDV.
Do you routinely screen for HDV in your patients with CHB? How often are you encountering HDV in your patients with CHB? Have you used the Hep B Consult tool? Join the discussion by leaving a comment.