Anti-viral therapy in hepatitis B virus reactivation with acute-on-chronic liver failure

Hepatitis B virus (HBV) reactivation with hepatic decompensation leading to acute on chronic liver failure is not uncommon. It is associated with high mortality of up to 30–70 %. Prognostic factors for mortality include high bilirubin level, more prolonged prothrombin time, low platelet count and presence of pre-existing cirrhosis. Several studies addressing the efficacy of different anti-viral therapies, namely lamivudine, entecavir and tenofovir, have been performed. Although the results were not highly consistent, it appeared that use of anti-viral agents was associated with decreasing chance of mortality, subsequent HBV reactivation, disease progression, and with excellent viral suppression. The beneficial effects were most prominently observed in patients with MELD score 20–30. However, even with anti-viral therapy, patients may still have irreversible liver decompensation requiring liver transplantation if other adverse parameters. including pre-existing cirrhosis, bilirubin >20 mg/dL (340 µmol/L), prothrombin time <40 %, platelet count <120 × 10⁹/L. were present. Mortality rate in patients with MELD score >30 was >92 % even with prompt anti-viral treatment. Liver transplantation should be considered urgently.