Normal AST and ALT, high viral load, antiviral treatment


What I do not understand, even if AST and ALT are normal but viral load is high, some say you must go on antiviral medication.
Doesn’t normal AST and ALT mean no damage on the liver, so why go on treatment ?
Can viral load go low after a while meaning the immune system learns how to suppress the virus again after a while ?
Does this has influence ? The older you get the weaker your immune system gets even if you have a healthy lifestyle, so that’s why the virus load rises when getting older ?


Ill give my thoughts but just as a fellow carrier.

I think it becomes a problem because at some point your immune system might recognize the virus and try to kill the infected liver cells and this is when the damage would occur. So the thought is that you bring down the virus before your immune system has a chance to fight the virus.

ok, when the immune system start attacking then take the antiviral medicine ? Would be too late maybe ? because antiviral medicine suppresses replication, so the immune system will try to kill the already existing viruses which causes damage on the liver ?

I found this info online, The hepatitis B virus (HBV) has a complex life cycle. The virus enters the host liver cell and is transported into the nucleus of the liver cell., This criters are hidding in the liver cell it seems.

Fortunately, the liver can function even when up to 80% of it is diseased or removed. This is because it has the amazing ability to regenerate - or create - itself from healthy liver cells that still exist.

Life Cycle of the Hepatitis B Virus

The hepatitis B virus (HBV) has a complex life cycle. The virus enters the host liver cell and is transported into the nucleus of the liver cell. Once inside the nucleus, the viral DNA is transformed into a covalently closed circular DNA (cccDNA), which serves as a template for viral replication (creation of new hepatitis B virus). New HBV virus is packaged and leaves the liver cell, with the stable viral cccDNA remaining in the nucleus where it can integrate into the DNA of the host liver cell, as well as continue to create new hepatitis B virus. Although the life cycle is not completely understood, parts of this replicative process are error prone, which accounts for different genotypes or “genetic codes” of the hepatitis B virus.

As for the liver, the human body’s detoxifier, its cells’ lives are quite short - an adult human liver cell has a turnover time of 300 to 500 days .

That’s why I’ve never understood why liver cancer is so lethal when you can remove up to 80% of it and it will regenerate. Or when the liver cells regenerate, do they regenerate with the virus inside.

It’s scary stuff. Sadly I m guessing there are no solid answers. Dr just follow guidelines and patients follow the guild lines and just hope things don’t get worse.

I read somewhere that there are 5 stages of chronic hepatitis b. Out of the 5, 3 stages have recommendations of treatment. I m sure if I knew about it when I was younger, I probably be on treatment. But since I found out during inactive immune stage, I am not. But guessing we all get to stage 5, which recommends treatment.

But you can get HCC in all stages. 15-40% will suffer/die from liver related death. But it’s better to look at 60-85% won’t die due to HCC or cirrhosis or liver decompensation.

Very good questions.

There is a current move to treat anyone over 30 with high viral loads, even if their ALT levels are normal. Partly because we now know some immune activity is happening in these patients even though their ALT is not raised. Also we now know that integration of the virus into the cell’s DNA is happening early on too and it is linked with liver cancer.

Finally, there is data showing that people with hep B are more likely to experience high levels of liver inflammation after age 30, which can be controlled by antiviral treatment. Here it’s seen more of a prevention of liver damage that may occur in the near future. Liver damage makes liver cancer more likely. This is basically what @Albasil808 was saying.

That is an alternate strategy, to wait until your ALTs are high before treating. But the drawback is that many people may not get regularly tested or the tests may fall into a period between ALTs going up (and you would miss it in the blood tests).

That’s true, but the other parts of the liver need to be healthy. You can’t cut out 80% of a cirrhotic liver and still be able to survive because it is already under stress. Also, the liver is a very vascularised organ (it has a lot of blood vessels) so liver cancer can spread easily and that’s where it’s deadly.

Hope that makes things a bit clearer,

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@ThomasTu , let’s assume the immunesystem is still in a phase of not recognizing infected liver cells so it is not attacking them, so this means low ALT and AST. The higher the viral load, the more liver cells get infected I assume. So when the immune system starts recognizing the infected liver cells and start attacking them, taking antivirals then at this time will not protect the already infected livercells from being attacked by the immunesystem because the liver cells are already infected. So that’s why it is best to start antiviral treatment, to keep viral load as low as possible, to prevent more livercells from being infected, so that when the immunesystem start recognizing and attacking the livercells, the damage on the liver will be as minimun as possible ? Just some thoughts, idk if it is correct.

I like the debate@Thomas,@hep b1 @Neptune.But it’s too academic for folks like us. Let’s take our daily dose and all shall be well. Probably a permanent cure might find us still around.

Yes, this is correct!

That might be the case for some people, Kinoti. But I think the more people living with hep B can understand what is going on, then the better they can talk to their doctors about the best decision based on their life-styles and concerns.



@ThomasTu , 10 year ago when I was 30 something, my alt and asat was high and I was feeling a bit sick, fever, tired and muscle pain, my hbeag was positive, we did not have viral load measurement then, than after a few months, my alt and ast normalized, hbeag turned negative. Now fast forward , I am 44 year, alt and ast normal, but high viral load, what stage is this ? immune tolerant phase ?


One question. Were your HbeAg converted to negative with or without medication?

without medication hbeag+ to hbeag-

This sounds like the starting of a reactivation after an HBeAg-negative inactive phase to me.


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