NICE clinical guideline 165: Hepatitis B (chronic): Diagnosis and management of chronic hepatitis B in children, young people and adults

2013

Recommendations [...]
- Assessment of liver disease in secondary specialist care - Adults with chronic hepatitis B
o Ensure all healthcare professionals who refer adults for non-invasive tests for liver disease are trained to interpret the results and aware of co-factors that influence liver elasticity (for example, fatty liver caused by obesity or alcohol misuse). [...]
o Offer transient elastography as the initial test for liver disease in adults newly referred for assessment.
o Offer antiviral treatment without a liver biopsy to adults with a transient elastography score greater than or equal to 11 kPa, in line with recommendation 1.5.6.
o Consider liver biopsy to confirm the level of fibrosis in adults with a transient elastography score between 6 and 10 kPa. Offer antiviral treatment in line with recommendations 1.5.3 to 1.5.7.
o Offer liver biopsy to adults with a transient elastography score less than 6 kPa if they are younger than 30 years and have HBV DNA greater than 2000 IU/ml and abnormal ALT (greater than or equal to 30 IU/ml for males and greater than or equal to 19 IU/ml for females) on 2 consecutive tests conducted 3 months apart. Offer antiviral treatment in line with recommendations 1.5.3 to 1.5.7.
o Do not offer liver biopsy to adults with a transient elastography score less than 6 kPa who have normal ALT (less than 30 IU/ml in males and less than 19 IU/ ml in females) and HBV DNA less than 2000 IU/ml as they are unlikely to have advanced liver disease or need antiviral treatment (see recommendations 1.5.3 to 1.5.7).
o Offer an annual reassessment of liver disease using transient elastography to adults who are not taking antiviral treatment.
- Antiviral treatment - Adults with chronic hepatitis B [...]
o Offer antiviral treatment to adults younger than 30 years who have HBV DNA greater than 2000 IU/ml and abnormal ALT (greater than or equal to 30 IU/ml in males and greater than or equal to 19 IU/ml in females) on 2 consecutive tests conducted 3 months apart if there is evidence of necroinflammation or fibrosis on liver biopsy or a transient elastography score greater than 6 kPa. [...]
[4]: Adults with a transient elastography score greater than or equal to 11 kPa are very likely to have cirrhosis and confirmation by liver biopsy is not needed.
[5] The degree of fibrosis cannot be accurately predicted in adults with a transient elastography score between 6 to 10 kPa. Some people may choose to have a liver biopsy in these circumstances to confirm the extent of liver disease.
[6] Adults with a transient elastography score less than 6 kPa are unlikely to have significant fibrosis.