Fibroscan Above 11 kpa

Hi,

I am 47 year old male from Canada with CHB . I was on medication (Tenofovir) from 2020 to 2023. Treatment was stopped after 3 years as no viral load was detected in 2 years in a row (3 DNA tests).

But 6 months after stopping the medication, viral load came back again (~ 29,000 IU/ml). My last 4 lab results are normal for ALT, AST, PLT count etc. 2 Ultrasounds detected mild fatty liver, but no signs of Cirrhosis.

However, my Fibroscan done recently came at 11.3 kpa and CAP score 295. I have mild pain in my upper right abdomen (intermittent, but feels like pain in liver). I believe as my ALT, AST are normal my FIB-4 and APRI scores are well below the guidelines.

However, my Fibroscan results worries me (already F3). My BMI is below 25.

  1. Is there anyway I can lower my viral load using diet etc?
  2. How treatment plan is decided when ALT, AST are normal but Fibroscan score is F3?

Please advise.

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Hi smarty 2000
Welcome to hepbcommunity forum. I hope you are doing well.
From your questions and concerns ,
the 1st question I think that the current approved way to suppress HBV viral load is to restart treatment with NUCs and follow up for monitoring and evaluation . At present, dietary supplements are not used to treat patients with CHB.
Your 2nd question , according to the information provided, you have BMI of less than 25 which is normal but an ultrasound examination shows mild fatty liver and no cirrhosis , this mean that you have NAFLD but in the lean group. Your Fibroscan results show CAP score at 295 ( > 280 ) which mean S3 stage (severe fatty liver) and liver stiffness measurement at 11.3 kPa or F3 staging(cirrhosis )by Metavir score . From evidence based study compared between Fibroscan and traditional ultrasound in detecting fatty liver and fibrosis , the results showed that Fibroscan is more sensitive and specific than ultrasound.( Magabuag-Oliva.A.M. et al J of ASEAN Fed of Endocrine Society, 2014) . Normal liver enzymes (AST/ALT) results don’t mean there is no cirrhosis. So I think that you have CHB and NAFLD comorbidity which may have interactive effects on progression of your liver. However, cirrhosis can be reversible if we get rid of etiologies due to plasticity of liver that can healing the scars as time passes . You should consult with your doctor about management of NAFLD with lifestyle modifications and CHB therapy for your healthy liver.
I hope this may help you understand and plan for decision making with your doctor.

chul_chan
Chulapong Chanta MD. Pediatrics

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Welcome @smarty2000

Firstly, The reason your viral load went down is because of the medication, but you need to stay on the medication for your viral load to remain low. It’s not like you get a cold and take medication and stop medication, it is for life. To stop the virus from silently attacking your liver and doing damage. There is no food or lifestyle changes that will stop the virus or lower the virus load it is only medication. Please see your doctor, the sooner the better
Secondly, with the FLD you can make lifestyle changes to try and get rid of it.
It’s a slow process, but worth it because your body will feel so much better, exercise and healthy eating and managing stress levels.

Thanks for joining us and sharing your story. I have lived experience of over forty years of HBV. Other professionals will join our conversation soon
@ThomasTu @Bansah1

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Just wondering you stopped medication because your HBsAB was reactivate/positive and HBsAG was negative/non-reactive in addition to undetectable viral load? How about your HBcAB, HBeAG/HBeAB? I believe once you are taken of medication you need to be monitored regularly to determine you naturally achieved serocoversion .

Hi @smarty2000, F3 fibrosis and viral load >2000 are indications to (re)start treatment, which (as others have mentioned) the most direct way of reducing viral load and inflammation. It is worthwhile following up with your provider to discuss this.

Thomas
Thomas

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Thank you all for replying to my post. Presently,

Anyway, @TomPsu I am not sure about HBsAB was reactivate/positive and HBsAG was negative/non-reactive. I was told if Viral Load becomes undetectable, treatment will continue for 2 more years after its undetectable and then would be stopped if Viral Load continues to be undetectable. And hence it was stopped.

What worries me is light intermittent pain in my upper right abdomen and Fibroscan @ F3. Is pain because of viral load or Fatty Liver? Is there anyway to know this?

Dear @smarty2000,

Dr. Chanta’s comments here are quite important.

However, TDF should not have been stopped in your case unless HBsAg was not detectable for at least 6 months in a row. HBV DNA titers (regardless of what they are) during NUC therapy play no role in the decision to stop antiviral therapy.

If the recent result in increased liver stiffness actually reflects a new change in your liver condition (we cant be sure about this) driven by a spike in HBV DNA, most likely ALT would not be normal. However, your pain symptoms are problematic and an HBV DNA test should be done as soon as possible to rule out acute reactivation. This could be increasing the insult to your liver. Many times chronic HBV infection is accompanied by fatty liver but one does not necessarily cause the other. There is no way to control HBV DNA levels by diet.

@availlant

@ availlant. Thank you for the reply. I was asked to do HBV DNA test 6 months after I stop taking medications.

In June 2024 HBV DNA Viral Load and liver function test was done. Viral Load was found to be just above the threshold (I was told threshold is 20,000 and my viral load was ~29,000) & AST, ALT were normal.

Subsequently, when I met the specialist doctor in Sept 2024, I was asked to repeat liver function tests for 3 months in a row ( 2 are already done) and Fibroscan.

Subsequently Fibroscan was done in Sept 2024 (11.3kPa, CAP=295).

So far 4 blood tests done in past 6 months (April, June, Sept, Oct) gave Normal ALT & AST levels. I was told if liver enzymes comes out abnormal then treatment needs to be restarted.

Do you think HBV DNA test needs to be repeated again despite it was done in June/July of 2024?

However, what is course of action if ALT,AST are normal and Fibroscan is at F3, and Viral Load is above threshold ? as per above reply from Dr. Chul_Chan “Normal liver enzymes (AST/ALT) results don’t mean liver is ALL healthy”

As per AGA (American Gastro Assoc.) guidelines Fibroscan takes the precedence (See Q#5, and Q#7).
https://www.gastrojournal.org/article/S0016-5085(17)30326-8/pdf

Dear @smarty2000,

As I previously mentioned, F3 fibrosis and viral load >2000 are indications to (re)start treatment by EASL guidelines. This is regardless of ALT and AST levels.

Thomas