HBV DNA raising

Dear all,

Can you please share with me if someone have experience fluctuation of the viral load. My viral load is moving up and down within a year. I have detected the first raise 8 months ago. It was 13 000 IU/ml, then after 3-4 months- 7200, and now 10 200 IU/ml. ALAT/ ASAT- -always normal- around 17-18U/I.

So I was hoping to decrease under 2000 like I have kept for 26 years. Hbe -negative, Fibroscan is ok, around 5.4 kPA.

I have noticed that this have happened since I have decided to decrease the sugar and the consumption of oil.

I have started to eat more veggie and healthy. I do not want to make connection between the food and the viral load. just mention it.

I am aware what the guidelines recommend: Monitor HBV DNA and ALT every 6 months

I know that the viral load is fluctuation, but it was the same before, but keeping it under 2000. What could be the reason to provocate? What should be my expectations? I have heard that lever start suffer when the load raise to 500,000 or more.

If someone has experience this, I would be grateful to share.

Thanks

Lili

Dear @Lili,

I would not say your levels are changing that much. Almost everyday in my lab, I run the sort of test that is used to measure Hep B DNA in the blood. If you do the same assay on the same sample 3 times, you are going to get a variation between them anyway; this is different by up to 50%. For a sample that really is 1000, I could get a reading of 500 to 1500.

There are also other factors that might change the reading of your levels that have nothing to do with your liver. For example, if you drink lots of water before one test, but are dehydrated for another test, then you will see a difference even if the amount of virus in your liver is the same.

In the clinical practice, they are more interested in changes that happen up to 10-fold. A jump from 1000 to 1000000 would be significant, but the changes here aren’t.

I hope this helps,
Thomas

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Fluctuations of serum HBV DNA levels within half a log are normal in untreated HBV patients

Prof. Pietro Lampertico, MD, PhD

Full Professor of Gastroenterology

Head of Gastroenterology and Hepatology Division

Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico

University of Milan

Via Francesco Sforza 35

20122- Milan

Italy

Phone +390255035432

Fax +390250320410

Email pietro.lampertico@unimi.it

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Thank you Dr Tu and Professor Lampertico for the very helpful information. We do see fairly often concerns from members when their hbv viral load results vary without changes in other measurements. So what will be a reasonable step to take - test again, stick to the same lab, or interpret the trend rather than actual numbers? Do the same fluctuation (± 1/2 log) applies to the measurement of serum HBsAg ?

Stephen in Sydney

Hi Thomas,
Thank you for calming me with your feedback.
I know that my hepatologist is not going to offer me any medication yet due to my normal ALAT/ASAT.
But during my 26 years of carrying out the virus I have never catch a values bigger than 2000. Maybe this is the thresholds that is important to see if the disease is going to move up or stay calm. I know that this can go both ways up or down.
So what is interesting to me if this value really can go down again? Did you see such cases between your samples?
I am trying to get some relations between my results and my general condition. Definitely I can relate this condition to some changes in my autoimmune disease which is under control now.
Do you think the stress is playing also key role for the fluctuation of the viral load? Also good sleep?
Is there any supplements that my bring this level again down- like silymarin or turmeric.

I know the opinion of the Hep B foundation about supplements. But my questions are more practical rather than scientific base?

And one more Q- what is the value of the HBV DNA that ALAT can start increasing?

Thank you so much for your time and feedbacl

Lili

Hi Lili, I know that several members have offered you valuable professional advices, but I would like to add what I think is best for your situation. Please note that I am not a medical doctor and my opinion should not be construed as medical advice. You will need to convince your doctor if you want any treatment, as continued monitoring during treatment is essential. There are a few details that would affect the decision about whether to initiate treatment or not: 1. your age. Not sure what you meant by 26 yrs of Hep B. Are you 26 yrs old? Since you are eAg negative, I assume you are older than 26. 2. Your HBV genotype? You should worry more if it’s genotype C or D. If you don’t know it, ask your doctor to test for it, and add HDV to the test. 3. Your family history of HCC. 4. Are you under steroid or any immunosuppressant for autoimmune disease? What autoimmune disease? — please be aware that rise in viral load usually precedes hepatitis flare. Although rise in your viral load could simply due to “normal” fluctuations or changes in your stress/immune conditions, close monitoring of hepatitis flare is necessary. There are situations that the rise in hepatitis flare could be extremely fast and may go up to very high levels within a few weeks. My bottom line is to seriously consider starting treatment early by convincing your doctor to give you prescription for ETV or TAF. Rises in viral load to 20,000 is known to be associated with a significant increase in HCC risk in REVEAL studies. Also, if you search YouTube for a recent webinar by APASL, you will see that many doctors advocate for early treatment and have demonstrated benefits, including Dr. Lim from Korea, Dr. Kao from Taiwan, Dr. Dietrich from New York, and many others. Let me know if you have other questions and you are welcome to message me privately. Best wishes, Jacki

Dear @Stephenw, I think what doctors generally do is look more at the trends and I would expect that to be the same for HBsAg levels, yes.

Dear Jacki,

thank you for your response to my Qs. I am 53 years old. I have get the Hep B while I was student during dentist visit. I underwent acute phase too. My Autoimmune disease is Thyroiditis of Hashimoto. I am taking Euthyrox since 12 years. I do not know my genotype. I think it is the same what is characteristic for the Central Europe. I do not have history of HCC. I am not under steroid or any immunosuppressant for autoimmune disease. I believe that my age is the threshold that my immune system is getting weaker and cannot suppress the viral good enough as used to be.
Anyway, I take your advise for the treatment seriously even though I am a bit concerned. Let’s see what the doctor is going to comment next week.
Thank you very much for your comprehensive explanation.
Best
Lili

Hi @Lili, these HBV DNA levels go up and down in every patient. It’s up to your hepatologist to interpret the trends of the numbers appropriately.

Yes, stress and the autoimmune diseases can alter things. As long as your hepatologist is updated on what is happening as well, that is good.

Regarding supplements, I have seen no evidence that HBV DNA levels can successfully decrease them to any important degree. You’re much better off trying to get good sleep, eat well, exercise, and keep healthy so your body is in a better state to fight. Most of the time, it knows what to do best.

In the end, having a high virus load is not directly related to liver disease, it is more complicated than that. I can have very high virus load, but no liver disease; I can have very low virus load with a lot of liver disease. Simply lowering your virus in some way doesn’t necessarily lower your risk of liver disease. This is why we have to trust and discuss with specialist to interpret the tests appropriately.

TT

thank you so much prof. Lampertico,

Best regards,

Lili

Hi Thomas,

thank you. I know that there is not a direct correlation between viral load and liver disease to some extent. Please let me know if the Fibroscan test have the same reliable information as the biopsy.
By the end of the day you need to trust some measurements to have objective view for your own situation.
The questions I am asking is because during those years I have visited 2-3 hepatologic and their opinion is differ to each other. It is difficult to 100% trust someone here.
KR

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Hi Jacki,
How I can message you privately?
Can I get link to the REVEAL study. I am interesting to read.

Thank you

Hi Lili, My email is jacki@thica.com.tw , you can also follow me on Twitter or FB, or by Line or WeChat. For REVEAL studies, the principal investigator Dr. Chien-Jen Chen just gave us a presentation in Mandarin not long ago, along with Dr. Luyu Hwang and others. I assume you know Chinese, if so here is a link to the event in our YouTube channel: https://youtu.be/hjyQbbAfboY

Dr. Chen’s presentation starts at around 37 minutes. The other two sessions are valuable to watch as well.

Best,
Jacki

I believe your genotype could be estimated on your race. It seems like measuring is different between countries, not sure though. E negative, treatment is recommended at levels above 2000 in the USA, but was also told immediately treatment is recommended but not necessary. Whatever that means.

It’s definitely a tough call.

According to US Guidelines if viral level is above 2000 , and ALAT/ASAT are normal, you need to monitor your transaminases every 3 months. I am wondering if the doctors put you in medication strait away unless you are in the stage of cirrhosis. Am I wrong?

Indication to start antiHBV treatment in HBeAg negative patients requires the diagnosis of hbeag negative chronic hepatitis

I do not understand, sorry. Can you please explain more? Thanks

Hi Lili,

I believe it is correct that if you are cirrhotic you will be put on antivirals straight away, yes.

And that if you are in HBeAg-negative, then you need to have high ALTs to be recommended to be on treatment.

TT