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elevated ALT, but biopsy is normal?
Jun 26, 2012

Dear Dr McGovern,

Thanks very much for your detailed answers on the forum. You have taught me what I must do to avoid the dire consequences of neglected HBV.

I might have a tough case for you today...

My doctor referred me to a liver biopsy after seeing that my ALT was elevated to 55 IU and 60 IU in two consecutive blood works ( 3 months apart ). Because I was an HBV carrier with negative e-antigen, he suspected that the damage was caused by the virus. At the same time the ALT tests were taken, my HBV DNA were around 5000 IU.

I am a 29 year old male of Asian descent. My mother was a carrier at the time of my birth. Unfortunately, postexposure prophylaxis for Hepatitis B was not available back then, as a result I became a life-time carrier.

My ALT readings in the past 10 years ranged from 30 IU to 37 IU. Tests were done yearly before age 25, and semi-annually thereafter. ( I didn't test for e-antigen until age 25. But the first time I took it, it showed that HBeAg negative and HBeAb positive) HBV-DNA was more volatile, jumping between 2000 IU to 7000 IU.

As you can see, my ALT and DNA have been very borderline. I could be an inactive carrier, but I could have active disease. My recent high ALT readings were the last straw. My doctor wanted to try interferon. I welcomed the idea, knowing that I was entering the most dangerous decade as an Asian male with HBV, the type of patient with the higheset chance to developing cirrhosis.

Biopsy result came back and showed Stage 0 (no fibrosis). My doctor expected that. But what surprised us was that histology showed no signficant inflammation (HAI or Knodell Score of 1).

What is going on here? Maybe biopsy has missed inflammtion because the inflammation doesn't occur everywhere in the liver, but rather at isolated spots?

What would be the best course of action to take? My ALT at the time of biopsy has spontaneously dropped to 42 IU, but it is still far from the normal level of 30 IU. I weigh 150 lbs, and biopsy does not show fatty liver.

My doctor is contemplating starting interferon. If HBV isn't the cause of my ALT, the only health price to pay is 48 weeks of potential side-effects (I don't mind sleeping through a drug-induced "mild flu" once every week). My immune system can anyway use some help to control the virus better, see that my DNA is above 2000 IU more often than not. If we go for Tenofovir, I might find myself in a disadvantage when a better drug appears in the future. On the upside, Tenofovir would almost certainly prevent HBV-related damage.

What would be the things to consider when making the choice?

Sincerely, Matt.

Response from Dr. McGovern

There is no rush to make a decision here. Your LFTs are minimally elevated and so is your virus level. Your biopsy fits in with these laboratory results so I don't doubt the biopsy.

However, you are correct that sometimes a biopsy can miss a finding. The key to having increased faith in the biopsy is whether it fits with your clinical judgment (which it does in my opinion) and whether the biopsy piece was a good size. Your doctor should be able to read the report and check on this.

For someone who is e antigen negative with a low level of virus, if your doctor and you decide to go on therapy, just about any drug will suppress you, including the weak agent Epivir. Your viral load is so low, a weak agent like that will even work.

However, treatment will be for a long time and there is also the chance of rebound after treatment, so don't rush in without careful consideration.

Continue to be monitored however (eg, LFTs, DNA)....And keep checking in for new recommendations from the guideline committees.



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