Hepatitis B laboratory tests

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

Diagnosis of hepatitis is made by biochemical assessment of liver function. Initial laboratory evaluation usually reveals: total and direct bilirubin, ALT, AST, alkaline phosphatase, prothrombin time, total protein,albumin, globulin, complete blood count, and coagulation studies.

Laboratory Findings

Diagnosis of hepatitis is made by biochemical assessment of liver function. Initial laboratory evaluation should include:

• Total and direct bilirubin
• ALT
• AST
• Alkaline phosphatase
• Prothrombin time
• Total protein
• Albumin
• Globulin
• Complete blood count
• Coagulation studies

Diagnosis is confirmed by demonstration in sera of specific antigens and/or antibodies. Three clinical useful antigen-antibody systems have been identified for hepatitis B:

• Hepatitis B surface antigen (HBsAg) and antibody to HBsAg (anti-HBs)
• Antibody (anti-HBc IgM and anti-HBc IgG) to hepatitis B core antigen (HBcAg)
• Hepatitis B e antigen (HBeAg) and antibody to HBeAg (anti-HBe)

Serological markers may vary throughout the course of the disease:

Hepatitis B diagnosis Adapted from World Health Organization

• Pre-S1 and pre-S2 antigens are present early in the incubation period. They are never detected in the absence of HBsAg.

• Hepatitis B virions, HBV DNA, DNA polymerase, and HBeAg are then also detected.

• The presence of HBeAg is associated with relatively high infectivity and severity of disease.

• Anti-HBc is the first antibody to appear. Demonstration of anti-HBc in serum indicates HBV infection, current or past.

• IgM anti-HBc is present in high titre during acute infection and usually disappears within 6 months, although it can persist in some cases of chronic hepatitis. This test may therefore reliably diagnose acute HBV infection.
• IgG anti-HBc generally remains detectable for a lifetime.

• Anti-HBe appears after anti-HBc and its presence correlates to a decreased infectivity. Anti-HBe replaces HBeAg in the resolution of the disease.

• Anti-HBs replaces HBsAg as the acute HBV infection is resolving. Anti-HBs generally persists for a lifetime in over 80% of patients and indicates immunity. Acute hepatitis patients who maintain a constant serum HBsAg concentration, or whose serum HBeAg persists 8 to 10 weeks after symptoms have resolved, are likely to become carriers and at risk of developing chronic liver disease.

Serological Markers

Hepatitis B viral antigens and antibodies detectable in the blood following acute infection.

Hepatitis B viral antigens and antibodies detectable in the blood of a chronically infected person

Diagnostic Studies

The following studies are used to examine pathological specimens for the presence of HBV-associated antigens or particles. They provide information about the relationship between HBV DNA replication and HBV gene expression:

• Immunofluorescence studies
• In situ hybridization
• Immunohistochemistry
• Thin-section electron microscopy

PCR

More recently, PCR tests have been developed to detect and measure the amount of viral nucleic acid in clinical specimens. These tests are called viral loads and are used to assess a person's infection status and to monitor treatment.

Recommendations for Monitoring Patients with Chronic HBV Infection: AASLD Practice Guidelines 2009

Class I

"1. HBeAg-positive and HBeAg-negative patients who meet criteria for chronic hepatitis B should be evaluated for treatment."

Class III

"2. HBeAg-positive patients: HBeAg-positive patients with persistently normal ALT should be tested for ALT at 3-6 month intervals. ALT along with HBV DNA should be tested more often when ALT levels become elevated. HBeAg status should be checked every 6-12 months. Patients who remain HBeAg positive with HBV DNA levels >20,000 IU/mL after a 3-6 month period of elevated ALT levels between 1-2 ULN, or who remain HBeAg positive with HBV DNA levels >20,000 IU/mL and are >40 years old, should be considered for liver biopsy, and treatment should be considered if biopsy shows moderate/severe inflammation or significant fibrosis. Patients who remain HBeAg positive with HBV DNA levels >20,000 IU/mL after a 3-6 month period of elevated ALT levels >2 ULN should be considered for treatment."

Class III

"3. HBeAg-negative patients: HBeAg-negative patients with normal ALT and HBV DNA <2,000 IU/mL should be tested for ALT every 3 months during the first year to verify that they are truly in the "inactive carrier state" and then every 6-12 months. Tests for HBV DNA and more frequent monitoring should be performed if ALT or AST increases above the normal limit."