1
Diagnostyka
serologiczna zakażeń
wywołanych przez
wirusy pierwotnie
hepatotropowe
Maciej Jabłkowski
Katedra i Kilinika Chorób
Zakaźnych Uniwersytetu
Medycznego
w Łodzi
Polskie Towarzystwo Diagnostyki
Laboratoryjnej
Łódź 14.12.2006r.
1
Diagnostyka
serologiczna zakażeń
wywołanych przez
wirusy pierwotnie
hepatotropowe
Maciej Jabłkowski
Katedra i Kilinika Chorób
Zakaźnych Uniwersytetu
Medycznego
w Łodzi
Polskie Towarzystwo Diagnostyki
Laboratoryjnej
Łódź 14.12.2006r.
A
A
“
“
I
I
n
n
fectious”
fectious”
“
“
Serum”
Serum”
Viral
Viral
hepatitis
hepatitis
Enterically
Enterically
transmitted
transmitted
Parenterally
Parenterally
transmitted
transmitted
other
other
?
?
E
E
“
“
NANB”
NANB”
B
B
D
D
C
C
VIRAL HEPATITIS
HISTORICAL PERSPECTIVE
Treatment Landscape
Serology
HBV DNA
(PCR)
HBV DNA
(hybridization)
• Progress has been made in laboratory assessment
tools
Hepatitis B Virus
Phases of HBV Infection:
1981
Yim JY, Lok AS-F. Hepatology. 2006;43:S173-S181.
Symptoms
HBeAg
anti-HBe
Total anti-HBc
IgM anti-HBc
anti-HBs
HBsAg
0
4
8 12 16 20 24 28 32 36
52
100
Acute Hepatitis B Virus Infection with
Recovery
Typical Serologic
Course
Weeks after
Exposure
Titr
e
IgM anti-
HBc
Total anti-HBc
HBsAg
Acute
(6 months)
HBeAg
Chronic
(Years)
anti-HBe
0 4 8 1
2
1
6
2
0
2
4
2
8
3
2
3
6
5
2
Year
s
Weeks after Exposure
Titr
e
Progression to Chronic Hepatitis B
Virus Infection
Typical Serologic
Course
Screening Tests
• HBsAg
– If positive, indicates infection
• Anti-HBc
– If positive, indicates HBV
exposure
• Anti-HBs
– If positive, indicates immunity
Further Testing
for HBsAg+ Patients
• HCV antibody in at-risk individuals
• HIV antibody or RNA quantification in
at-risk individuals
• Consider screening for hepatitis
delta virus (HDV)
if adult-acquired HBV
–
Anti-HDV
–
Delta antigen
–
Delta RNA if any HDV testing is available
2nd-Phase Testing
in HBsAg+ Patients
• Anti-HBc
– IgG: if positive, indicates HBV exposure
– IgM: if positive, indicates acute HBV
• HBeAg
– If positive, indicates active HBV replication
– If negative
• If HBV DNA negative, suggests HBV replication is
suppressed
• If HBV DNA positive, most likely has precore mutation
• Anti-HBe
• HBV DNA quantification
– Quantitative level correlates with level of HBV
replication
2nd-Phase Testing
in HBsAg+ Patients
• HBeAg
– Positive, indicates active HBV replication
– Negative
• If HBV DNA negative, suggests HBV replication is
suppressed
• If HBV DNA positive, most likely has precore mutation
• Anti-HBe
• HBV DNA quantification
– Quantitative level correlates with level of HBV replication
• Anti-HDV
– Detects coinfection with delta agent
Phases of HBV Infection:
2005
Yim JY, Lok AS-F. Hepatology. 2006;43:S173-S181.
HBV Serologic and
Molecular Tests in Serum
Category
Test
Significance
Viral antigens
HBsAg*
Acute or chronic
infection; infectivity
HBeAg
Acute or chronic
infection; infectivity
Viral antibodies
Anti-HBc*
Anti-HBe
Anti-HBs*
Marker of infection
Low infectivity
Marker of immunity
Molecular tests
HBV DNA
Acute or chronic
infection; infectivity
*Test recommended for initial screening
*Test recommended for initial screening
Phases of Chronic HBV
Infection
*Precore mutant
†
Expert opinions vary as to this value
1IU = ~5 copies/mL
Lai CL, et al. Lancet. 2003:362:2089. Lok AS, et al. Gastroenterology. 2001;120:1828.
Immune Inactive HBeAg
HBeAg
Tolerant
HBsAg Positive
Negative
Phase
Carrier
CHB
CHB*
HBsAg
+
+
+
+
HBeAg
+
–
+
–
Anti-HBe
–
+
–
+
ALT
Normal
Normal
HBV DNA
>10
5
>10
4
<10
5
>10
4†
copies/mL
copies/mL copies/mL
copies/mL
Histology Normal/Mild
Inactive
Active
Active
Treatment Algorithm
Patients With Compensated
Disease
•No treatment
•Monitor every 6–12 months
•Monitor every
3–12 months
(immune
tolerant)
•Consider
biopsy, if age
>35–40, and
treat if
significant
disease
Keeffe EB et al. Clin Gastroenterol Hepatol. 2006.
•Treat
•Adefovir,
entecavir, and
PEG-IFN are
first-line options
HBeAg-positive
ALT
Elevated
ALT
Normal
HBV DNA
≥10
5
c/mL
HBV DNA
<10
5
c/mL
Treatment Algorithm
Patients With Compensated
Disease
Keeffe EB et al. Clin Gastroenterol Hepatol. 2006.
•No treatment
•Monitor every 6–12 months
•Monitor ALT, or
•Consider biopsy,
since ALT often
fluctuates, and
treat if
significant
disease
•Long-term
treatment
required
•Treat
•Adefovir,
entecavir, and
PEG-IFN are first-
line options
•Long-term
treatment
required (oral
agents
)
HBeAg-negative
ALT
Elevated
ALT
Normal
HBV DNA
≥10
4
c/mL
HBV DNA
<10
4
c/mL
•May choose to treat or observe
•If treat: adefovir or entecavir, or
combination Rx
•May be a role for combination therapy
•Treat with adefovir or entecavir
•May be a role for combination therapy
•Significant clinical consequences
associated with lamivudine resistance in
this population
Keeffe EB et al. Clin Gastroenterol Hepatol. 2006.
Treatment Algorithm
Patients With Compensated
Cirrhosis
HBV DNA
(PCR)
HBV DNA
<10
4
c/mL
HBV DNA
≥10
4
c/mL
Observe
Wait list for
transplant
Treat
Wait list for
transplant
HBV DNA
Detectable by PCR?
No
Ye
s
Treatment Algorithm
Decompensated Cirrhosis
Keeffe EB, et al. Clin Gastroenterol Hepatol. 2006;4:936.
Zapadalność na 100 tys. mieszkańców WZW
typu B
w województwie łódzkim przed i po
wprowadzeniu szczepień ochronnych
0,00
10,00
20,00
30,00
40,00
50,00
60,00
70,00
80,00
90,00
19
79
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
Lata
Z
ap
ad
al
no
ść
okres przed
wprowadzeniem
szczepień
ochronnych
intensyfikacja szczepień
stopniowe
wprowadzanie
szczepien
Hepatitis D (Delta) Virus
Hepatitis D (Delta) Virus
HBsAg
RNA
antigen
HBV - HDV Coinfection
HBV - HDV Coinfection
Typical Serologic Course
Typical Serologic Course
Time after Exposure
Time after Exposure
T
it
e
r
T
it
e
r
anti-
HBs
Symptom
s
ALT
Elevated
Total anti-
HDV
IgM anti-
HDV
HDV RNA
HBsAg
HBV - HDV Superinfection
HBV - HDV Superinfection
Typical Serologic Course
Typical Serologic Course
Time after
Exposure
Time after
Exposure
T
it
e
r
T
it
e
r
Jaundic
e
Symptoms
ALT
Total anti-HDV
IgM anti-HDV
HDV RNA
HBsAg
Hepatitis C
Serologic Pattern of Acute HCV
Infection with Progression to
Chronic Infection
Symptoms
+/-
Time after Exposure
T
it
e
r
anti-
HCV
ALT
Norma
l
0
1
2
3
4
5
6
1
2
3
4
Years
Month
s
HCV RNA
Serologic Pattern of Acute HCV
Infection
with Recovery
Symptoms
+/-
Time after Exposure
T
it
e
r
anti-
HCV
ALT
Norma
l
0
1
2
3
4
5
6
1
2
3
4
Years
Month
s
HCV RNA
Hepatitis A
Virus
Fecal
HAV
Symptom
s
0
1
2
3
4
5
6
1
2
2
4
Hepatitis A
Infection
Total anti-
HAV
Titr
e
ALT
IgM anti-HAV
Months after
exposure
Typical Serological
Course
Epidemiological shift in
Epidemiological shift in
seroprevalence of
seroprevalence of
anti-HAV
anti-HAV
Age (years)
Age (years)
S
e
ro
p
re
v
a
le
n
c
e
S
e
ro
p
re
v
a
le
n
c
e
o
f
a
n
ti
-H
A
V
(
%
)
o
f
a
n
ti
-H
A
V
(
%
)
Improvement
Improvement
in hygiene
in hygiene
0
0
20
20
40
40
60
60
80
80
100
100
10 20 30 40
10 20 30 40
50
50
Van Damme P et al. 1994.
Hepatitis A in Poland
Hepatitis A in Poland
Cianciara J. Vaccine 2000;18:S68–S70.
Cianciara J. Vaccine 2000;18:S68–S70.
Shift
Shift
Hepatitis E Virus
Hepatitis E Virus
Hepatitis E Virus Infection
Hepatitis E Virus Infection
Typical Serologic Course
Typical Serologic Course
Weeks after Exposure
Weeks after Exposure
T
it
e
r
T
it
e
r
Symptom
s
ALT
IgG anti-HEV
IgM anti-HEV
Virus in stool
0
1
2
3
4
5
6
7
8
9 1
0
1
1
1
2
1
3
