My hbv lab and liver elastography results

[MMal_jr]

Hello everyone, I’m new here and glad I found this valuable community, because I have been really stressed lately about my results. Please forgive my long writing. I’m 31 years old, height 6’3, weight 70kgs and dark skinned. I’m from S.Sudan, where HBV is currently endemic. I unfortunately lived in a concentrated refugee camps in 2019, I have never tested HBV or Mom either, I have no known viral infections before then. Both my parents don’t have HBV. Suddenly mid 2019, I began to fall sick frequently and went for HBV, HCV and HIV tests, it turned out that HBsAg is reactive. Rest of the test came out okay, no other co-infections. I was told there was nothing to worry about. My partner at the time test negative too. By early 2021, I went for tests again and subsequent viral loads - HBV DNA in a reputable hospital in Khartoum, Sudan. The test came out reactive again with HBV DNA undetectable and was told to do regular tests on yearly basis. On May 2022, I went to India, Bangalore at Apollo Hospital, one of the most reputable hospitals in India. Still reactive tests shown with undetectable viral loads again. Doctor said I should do yearly AST/ALT tests. I have been doing regular liver function tests ever since, always turned out normal, especially AST/ALT. On August 2023 to August 2024, I began doing rigorous fasting to lose weight, some time 24 - 36 hours regular fasting. I lost nearly 20kgs, from 89kgs to current 70 kgs. Around Feb 2024, I began feels some inflammation on my right side of the abdomen. I went for liver function test and ultrasound and everything turned out fine. On May 31st, I went for liver functions test again and AST/ALT were still normal. I’m currently in US and did a comprehensive test this time, will share all the tests below, including US Liver Elastography.

Now major concern is that the test came out that I have F2-F3 or mild to moderate fibrosis with viral load of 12 IU/mL. I mean it’s the first time they found my HBV DNA detectable and still very low but with significant liver damage, how all of a sudden? My other test shows I have no NASH, Fatty liver disease or high cholesterol. No co-infections. I don’t have any other illness or symptoms, perfectly looks healthy. AST shows small elevation and the rest of the tests are normal. I have Vitamin Level at 25 Ng/ml. My vitamin D have been low because of dark skin but currently not very bad. I’m not taking any supplements of any kind, no sugar intake for a year now.

The confusion is that my doctor in Africa said I should start medication when I shared the results with her, she’s a qualified gastroenterologist with specialty in hepatology. My American doctor, who’s actually a nurse because I haven’t met the real Gastroenterologist at the hospital yet, said he’s advised I should not take meds and just do regular checks every 3-6 months. He said he consulted with head gastroenterologist and was advised those are the standards in US since my viral loads is low.

Here is what I think; I think I don’t trust anything now including the fibrosis or liver function test and think I should seek a third opinion and repeat tests at another hospital. I don’t know I’m just very confused right now . I’m thinking I should do supplements and herbs to restore my liver function since viral loads seem to be not the major cause. I’m considering taking tinctures mix of milk thistle, dandelion and Schisandra Berries, extracted in organic grain alcohol, purified water and vegetable glycerine. Not sure either . Maybe start Vit D supplements. And maybe after two months if no changes and second repeated tests, I should start meds. Tenofovir Alaferamide was recommended.

I came here because I learned about doctor @ThomasTu. I would very much appreciate his opinion on this and the way forward. And would appreciate anyone else who’s expert in this subject or have gone through similar experience as me. Thank you so much everybody and hope to get your quick feedback. Be bless.

[chul_chan]

Hi @ MMal_jr
Welcome to hepbcommunity forum.
According to your concern about liver elastography, the results reviewed LSM level of 9.71 kPa which is consistent with F3 according to Metavir scoring system. However,we should carefully interpret due to the test maybe overestimate the actual results. We need to look at or exclude other factors that may affect the results such as IQR , elevated AST/ALT>120 IU/ml,liver congestion etc. Currently, there are many guidelines for starting HBV treatments which may be complexity and difficulty to understand by general physicians even specialists may have different opinions and it is not surprising. In my opinion, we should use evidence based medicine (EBM) which consists of the best available evidence, consensus guidelines with expert opinions and the patient’s preference values.
Finally after wait and see for chronic HBV , the solution is to treat or not to treat , however, there are growing evidences based to start early treatment and has cost effectiveness in health economic issues as we consider that chronic HBV is an infectious disease more than liver disease.
Your HBV DNA = 12 IU/ml which is quite low but your ALT and AST are slightly elevated compare to international standards (ULN 30 IU/ml in male and 19 IU/ml in female ) . The question is why you have elevation of ALT/AST and F3 fibrotic staging
but low HBV viral load ? So , we should find out the causes of this conflict results. The possibilities are other viral coinfection (HCV, HIV, HDV) , MASLD , drug induced liver injury or autoimmune diseases etc . The results of your laboratory findings as you showed are mostly adequate for decision making in chronic HBV management but I think that you should investigate about HDV if available laboratory test due to the fact that HDV super infection may interfere with HBV replication like HCV and make progressive liver damage. You should consult with your doctor for make decision making about your laboratory results. I hope this may help you to understand your disease condition.
chul_chan
Chulapong Chanta MD. Pediatrics.

[Stargazer6138]

Great answer.

I had a question about HDV in general. Is it possible for HDV to somehow make the HBV tests a false negative? Since HDV consumes HBsAg, is it possible for both HBsAg and HBV DNA to be negative in a HDV positive person since the HDV is dominating?

[MMal_jr]

Thank you so much for your reply and insightful inputs. Yes like I mentioned, I do not have any co-infections. No HCV, HIV or HDV. I don’t have any known autoimmune disease either. I don’t know what to do and investigate anymore. It’s somewhat clear HBV viral loads may not be the major cause, I’m suspicious of my recents fasting routine. I’m thinking it could be the culprit. My general thinking is, if the HBV is not the main cause, then can I not take antivirals now and maybe start taking herbs that supports the liver regeneration and main functions. I have a spouse and child. Me and wife have been having unprotected intercourse without her being vaccinated due financial constraints but she and child do not have any infections. Wife is now on her final HBV vaccine shot and baby was vaccinated at birth last year.

[ThomasTu]

@MMal_jr

I’m thinking I should do supplements and herbs to restore my liver function since viral loads seem to be not the major cause. I’m considering taking tinctures mix of milk thistle, dandelion and Schisandra Berries, extracted in organic grain alcohol, purified water and vegetable glycerine. Not sure either .

Dear @MMal_jr,
Thanks for sharing your story with us and sorry about the confusion that you are experiencing. It must be very difficult.
As @chul_chan has mentioned, there are a lot of different hep B guidelines that fuel this confusion. We’re actually trying to develop an online tool for everyone to use to try to explain lab results in everyday terms (we’re still seeking funding for this), that hopefully will help.

In general, this phase (very low HBV DNA, HBeAg negative and normal ALTs) is relatively stable and is associated with lower disease progression than high HBV DNA levels.

Regarding your consideration for tinctures and supplements, as I have mentioned in other threads, these have not been shown to give any clinical benefit in any way. In fact, some of these may damage your liver even more - in particular, if they contain toxins such as ethanol/alcohol.

@Stargazer6138

I had a question about HDV in general. Is it possible for HDV to somehow make the HBV tests a false negative? Since HDV consumes HBsAg, is it possible for both HBsAg and HBV DNA to be negative in a HDV positive person since the HDV is dominating?

Dear @Stargazer6138,
In HDV co-infection, only the HBV DNA levels are lowered. There is generally very little impact on HBsAg levels (as HDV uses HBsAg to spread, so it doesn’t “want” to lower it).

Hope this helps,
Thomas

[MMal_jr]

Dear @ThomasTu, I’m truly grateful for your insightful comment. Thank you.

What do you think should be the way forward for me? Anymore investigations needed? Should I start medication regardless? Because my worries is that if I start taking meds that might be lifelong, on low viral load, doesn’t seem convincing. About the slow progression part, I’m not sure because I have been regularly monitoring the liver health functions on regular basis and no single issue. If it’s then slow progress that caused the fibrosis, what are the available guidelines in my case?

Kindly comment on the followings that I mentioned previously:

1. My rigorous fasting routine (currently stopped)
2. Low Vit D - 25 Ng/mL
3. What’s the fibrosis progression rate in months or years. Especially with my condition

Thank you
Blessing

[ThomasTu]

@MMal_jr

What do you think should be the way forward for me? Anymore investigations needed? Should I start medication regardless? Because my worries is that if I start taking meds that might be lifelong, on low viral load, doesn’t seem convincing. About the slow progression part, I’m not sure because I have been regularly monitoring the liver health functions on regular basis and no single issue. If it’s then slow progress that caused the fibrosis, what are the available guidelines in my case?

Kindly comment on the followings that I mentioned previously:

1. My rigorous fasting routine (currently stopped)
2. Low Vit D - 25 Ng/mL
3. What’s the fibrosis progression rate in months or years. Especially with my condition

Dear @MMal_jr,

In cases such as these, it comes down to the patient and what they value.

As you mention, your viral load is very low and so any additional reduction by antiviral therapy may not do very much. This is reflected by the major society guidelines.

Regarding your other questions: progression rate of fibrosis is low in people with your lab values, people can go decades with no detectable progression. However, this can change (e.g., viral load increases and causes liver inflammation), so it is important to get regular monitoring to determine your status.

Fasting should not affect Hep B at all.

Low vitamin D levels can be addressed with supplements or walking outside and getting out in the sun more often. If they remain low, it is worthwhile discussing other options with your health professional.

Thomas

[MMal_jr]

Thank you so much @ThomasTu. I will just be monitoring every 3 months and start taking Vitamin D3, maybe around 5000 IU per day.
Will take below brand. Anyone trust this brand here with all those other supplements added?

[Althaea]

I’m not familiar with this brand, so I can’t really give my opinion on it. However, I thought I’d share this link that explains the co-factors of Vitamin D in case you’re interested: https://vitamindwiki.com/Vitamin+D+Cofactors+in+a+nutshell

Personally, I use CanPrev Liquid D3 drops, which are suspended in MCT oil. I prefer not to use the D3 + K2 combo since the K2 dosage is lower than what I’d like.