My daughter is 24 and has had chronic Hep B all her life. She is from Vietnam and I adopted her as a baby. She has been on anti-virals for about 2 years. First she was on Entecavir. Her viral load went down from over 8 Log IU/mL to 2.86 log, never reaching undetectable in that time. Her liver doc switched her to Vemlidy about 6 months ago to try and get her to undetectable. Her viral load went down after 3 months to 2.07 log. Her AST and ALT have been normal for some time until now.
2 weeks ago she got the new Covid vaccine and flu vaccine on the same day. She felt headachy and somewhat unwell for the first 3 days and then later in the week she was vomiting and unable to keep anything down for several day. She felt better after a week but has been tired ever since. She got new labs done this past week with the following results:
Alkaline Phosphatase 161 U/L
ALT 247 U/L
AST 79 U/L
Bilirubin .4 mg/dL
Hep B surface AB <3.5 mIU/mL
HBV DNA 2.06 log IU/ML
She has had some pain in her liver area (upper right abdomen) since yesterday. It’s not bothering her much right now. She doesn’t have any jaundice or dark-colored urine. Her doctor has ordered labs in another 2 weeks.
Our questions are:
Is there a possibility that she is experiencing an increase in liver levels because of an immune response to the Covid vaccine? Should we be worried about the apparent liver flare?
Do people sometimes take this long (more than 2 years) to get to undetectable when on anti-virals?
I cannot answer your first question. I can somewhat relate to the second question.
My viral load was around 8.57 log early 2020. The specialist recommended I start on entecivir(subsequently changed to tdf). There was a significant drop, but it seem to plateau/ hover around 3+ log during 2022 to 2023. By the beginning of 2024 it had dropped to 1.13 log. It’s been undetectable ever since.
I’m not sure what the common pattern is(if there is one). Whether there’s abit of resistance before reaching the undetectable level. Your daughter’s viral load has reduced a lot, but of course getting to the undetectable level is the objective.
This is just personal experience. The experts on here will have a better idea at an aggregate level and probably can answer your first question as well. Hope your daughter gets better!
@elderberryblu I’m not a doctor so I don’t know if the flu or Covid vaccine could lead to elevated liver values. However, I am personally of the opinion that young people generally do not need the flu and especially the Covid vaccine as they are not at any real risk of getting severely ill from those diseases and the risks of the vaccines (again, especially the Covid vaccine as it is still new) may well outweigh the benefits.
Therefore, such phenomenon would not be applicable in people who have been on potent nucleoside analogues and well suppressed HBV DNA.
As the liver is the biggest internal organ and also harbours immune cells and clears toxin and pathogens etc, any challenge to the body including infections or vaccines can potentially lead to a rise in liver enzyme which does not necessarily mean flare of underlying HBV. In the vast majority of cases, the elevation of liver enzyme will spontaneously go away in a few weeks without any long-term sequelae to the liver.
There was one study (Shin H. et al Immune Netw 2023) showed that covid vaccines can stimulate both innate and adaptive body immune responses in patients with chronic hepatitis B and resulting in a decrease in HBsAg levels but no reported adverse events about hepatitis flare ( elevation of ALT > 5 x upper limit of normal ).
HBV replication in your daughter was not fully suppressed to undetectable level while on Vemlidy. Therefore, the immune system stimulated by covid vaccine can eliminate the virus in hepatocytes resulting in liver inflammation and elevation of ALT level. However, HBV DNA in your daughter is quite low about 2 log 10 and not changing after covid vaccination, so it’s least likely to cause hepatitis flare.
Another possibility is vaccination induced liver injury after covid vaccination that can trigger interferon pathway resulting in immune mediated hepatitis and the median time to onset of liver injury was 15(range:3-65) days.(Efe C et al. Hepatology 2022 ) . You should consult with your doctor for further investigation and monitor ALT level for proper management.
Thanks everyone for sharing such comprehensive information. My daughter’s doctor thinks the elevated ALT was probably due to illness rather than the vaccines. Her ultrasound was good and she’ll get labs again soon.