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Severe hepatitis B flare and liver failure: current assessment and management.

Λεπτομέρειες βιβλιογραφικής εγγραφής
Τίτλος: Severe hepatitis B flare and liver failure: current assessment and management.
Συγγραφείς: Lim SG; Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore. mdclimsg@nus.edu.sg.; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. mdclimsg@nus.edu.sg., Buti M; Liver Unit, Hospital General Universitari Valle Hebron, Barcelona, Spain., Feld JJ; Toronto Center for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, ON, Canada., Fung J; Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR., Gehring AJ; Toronto Center for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, ON, Canada., Reddy KR; Department of Medicine, University of Pennsylvania, Philadelphia (K.R.R.), PA, USA.
Πηγή: Clinical and molecular hepatology [Clin Mol Hepatol] 2026 Jul; Vol. 32 (3), pp. 1117-1134. Date of Electronic Publication: 2026 Mar 18.
Τύπος έκδοσης: Journal Article; Review
Γλώσσα: English
Στοιχεία περιοδικού: Publisher: Korean Association for the Study of the Liver Country of Publication: Korea (South) NLM ID: 101586730 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 2287-285X (Electronic) Linking ISSN: 22872728 NLM ISO Abbreviation: Clin Mol Hepatol Subsets: MEDLINE
Imprint Name(s): Original Publication: Seoul, Korea : Korean Association for the Study of the Liver
Ιατρικοί όροι (MeSH): Hepatitis B, Chronic*/complications , Hepatitis B, Chronic*/drug therapy , Hepatitis B, Chronic*/diagnosis , Liver Failure*/diagnosis, Antiviral Agents/therapeutic use ; Acute-On-Chronic Liver Failure/diagnosis ; Acute-On-Chronic Liver Failure/etiology ; Alanine Transaminase/blood ; Hepatitis B virus/genetics ; DNA, Viral/blood ; Humans ; Liver Transplantation ; Prognosis ; Viral Load
Περίληψη: Hepatitis B flare is a common complication of chronic hepatitis B and is defined as an increase in HBV viral load associated with abnormal alanine aminotransferases (ALT), the consensus being an ALT level ≥5 times the upper limit of normal. The immunopathogenesis is related to induction of inflammatory cells and cytokines by the rise in HBV DNA. There are multiple causes of flares, and they carry the risk of progression to hepatic decompensation and acute-on-chronic liver failure (ACLF) with associated mortality, potentially requiring liver transplantation. Initial assessment should exclude other causes of liver dysfunction and determine severity and prognosis. General prognostic models of ACLF are useful but the COSSH-ACLF II score is specific to HBV. Early initiation of nucleos(t)ide analogues is crucial, even in severe HBV flares; it can reduce mortality by 73.6%. Once jaundice and coagulopathy occur, salvage by antivirals is challenging, and liver transplantation should be considered. However, many patients may not be suitable candidates for transplant or donor livers may not be available, as is common in Asia. Recently, there has been increasing evidence of the benefits of adjunctive therapies such as corticosteroids and plasma exchange, but there are associated risks and these approaches should be considered rescue therapies in severe HBV flares or ACLF. Liver transplant is the ultimate intervention when these other strategies fail. In summary, HBV flares are clinically serious events that can lead to hepatic decompensation, ACLF, and the need for a donor liver; however, strategies for rescue should be considered before liver transplantation.
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Grant Information: NMRC/TCR/014-NUHS/2015 National Medical Research Council; NMRC/CIRG/1351/2013 National Medical Research Council; NMRC/CSASI/0016/2017 National Medical Research Council; NMRC/CIRG/1479/2017 National Medical Research Council; NMRC/OFLCG-19May-0038 National Medical Research Council
Contributed Indexing: Keywords: Acute-on-chronic liver failure; Alanine transaminase; Hepatitis B, chronic; Hepatitis B, chronic/therapy; Plasma exchange
Substance Nomenclature: 0 (Antiviral Agents)
EC 2.6.1.2 (Alanine Transaminase)
0 (DNA, Viral)
Entry Date(s): Date Created: 20260318 Date Completed: 20260731 Latest Revision: 20260813
Update Code: 20260813
PubMed Central ID: PMC13430368
DOI: 10.3350/cmh.2026.0177
PMID: 41846518
Βάση Δεδομένων: MEDLINE
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  Data: Severe hepatitis B flare and liver failure: current assessment and management.
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  Data: <searchLink fieldCode="AU" term="%22Lim+SG%22">Lim SG</searchLink>; Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore. mdclimsg@nus.edu.sg.; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. mdclimsg@nus.edu.sg.<br /><searchLink fieldCode="AU" term="%22Buti+M%22">Buti M</searchLink>; Liver Unit, Hospital General Universitari Valle Hebron, Barcelona, Spain.<br /><searchLink fieldCode="AU" term="%22Feld+JJ%22">Feld JJ</searchLink>; Toronto Center for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.<br /><searchLink fieldCode="AU" term="%22Fung+J%22">Fung J</searchLink>; Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR.<br /><searchLink fieldCode="AU" term="%22Gehring+AJ%22">Gehring AJ</searchLink>; Toronto Center for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.<br /><searchLink fieldCode="AU" term="%22Reddy+KR%22">Reddy KR</searchLink>; Department of Medicine, University of Pennsylvania, Philadelphia (K.R.R.), PA, USA.
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  Data: <searchLink fieldCode="JN" term="%22101586730%22">Clinical and molecular hepatology</searchLink> [Clin Mol Hepatol] 2026 Jul; Vol. 32 (3), pp. 1117-1134. <i>Date of Electronic Publication: </i>2026 Mar 18.
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  Data: <i>Publisher: </i><searchLink fieldCode="PB" term="%22Korean+Association+for+the+Study+of+the+Liver%22">Korean Association for the Study of the Liver </searchLink><i>Country of Publication: </i>Korea (South) <i>NLM ID: </i>101586730 <i>Publication Model: </i>Print-Electronic <i>Cited Medium: </i>Internet <i>ISSN: </i>2287-285X (Electronic) <i>Linking ISSN: </i><searchLink fieldCode="IS" term="%2222872728%22">22872728 </searchLink><i>NLM ISO Abbreviation: </i>Clin Mol Hepatol <i>Subsets: </i>MEDLINE
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  Data: <i>Original Publication</i>: Seoul, Korea : Korean Association for the Study of the Liver
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  Data: <searchLink fieldCode="MM" term="%22Hepatitis+B%2C+Chronic%22">Hepatitis B, Chronic*</searchLink>/<searchLink fieldCode="MM" term="%22Hepatitis+B%2C+Chronic+complications%22">complications</searchLink> <br /><searchLink fieldCode="MM" term="%22Hepatitis+B%2C+Chronic%22">Hepatitis B, Chronic*</searchLink>/<searchLink fieldCode="MM" term="%22Hepatitis+B%2C+Chronic+drug+therapy%22">drug therapy</searchLink> <br /><searchLink fieldCode="MM" term="%22Hepatitis+B%2C+Chronic%22">Hepatitis B, Chronic*</searchLink>/<searchLink fieldCode="MM" term="%22Hepatitis+B%2C+Chronic+diagnosis%22">diagnosis</searchLink> <br /><searchLink fieldCode="MM" term="%22Liver+Failure%22">Liver Failure*</searchLink>/<searchLink fieldCode="MM" term="%22Liver+Failure+diagnosis%22">diagnosis</searchLink><br /><searchLink fieldCode="MH" term="%22Antiviral+Agents%22">Antiviral Agents</searchLink>/<searchLink fieldCode="MH" term="%22Antiviral+Agents+therapeutic+use%22">therapeutic use</searchLink> ; <searchLink fieldCode="MH" term="%22Acute-On-Chronic+Liver+Failure%22">Acute-On-Chronic Liver Failure</searchLink>/<searchLink fieldCode="MH" term="%22Acute-On-Chronic+Liver+Failure+diagnosis%22">diagnosis</searchLink> ; <searchLink fieldCode="MH" term="%22Acute-On-Chronic+Liver+Failure%22">Acute-On-Chronic Liver Failure</searchLink>/<searchLink fieldCode="MH" term="%22Acute-On-Chronic+Liver+Failure+etiology%22">etiology</searchLink> ; <searchLink fieldCode="MH" term="%22Alanine+Transaminase%22">Alanine Transaminase</searchLink>/<searchLink fieldCode="MH" term="%22Alanine+Transaminase+blood%22">blood</searchLink> ; <searchLink fieldCode="MH" term="%22Hepatitis+B+virus%22">Hepatitis B virus</searchLink>/<searchLink fieldCode="MH" term="%22Hepatitis+B+virus+genetics%22">genetics</searchLink> ; <searchLink fieldCode="MH" term="%22DNA%2C+Viral%22">DNA, Viral</searchLink>/<searchLink fieldCode="MH" term="%22DNA%2C+Viral+blood%22">blood</searchLink> ; <searchLink fieldCode="MH" term="%22Humans%22">Humans</searchLink> ; <searchLink fieldCode="MH" term="%22Liver+Transplantation%22">Liver Transplantation</searchLink> ; <searchLink fieldCode="MH" term="%22Prognosis%22">Prognosis</searchLink> ; <searchLink fieldCode="MH" term="%22Viral+Load%22">Viral Load</searchLink>
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Hepatitis B flare is a common complication of chronic hepatitis B and is defined as an increase in HBV viral load associated with abnormal alanine aminotransferases (ALT), the consensus being an ALT level ≥5 times the upper limit of normal. The immunopathogenesis is related to induction of inflammatory cells and cytokines by the rise in HBV DNA. There are multiple causes of flares, and they carry the risk of progression to hepatic decompensation and acute-on-chronic liver failure (ACLF) with associated mortality, potentially requiring liver transplantation. Initial assessment should exclude other causes of liver dysfunction and determine severity and prognosis. General prognostic models of ACLF are useful but the COSSH-ACLF II score is specific to HBV. Early initiation of nucleos(t)ide analogues is crucial, even in severe HBV flares; it can reduce mortality by 73.6%. Once jaundice and coagulopathy occur, salvage by antivirals is challenging, and liver transplantation should be considered. However, many patients may not be suitable candidates for transplant or donor livers may not be available, as is common in Asia. Recently, there has been increasing evidence of the benefits of adjunctive therapies such as corticosteroids and plasma exchange, but there are associated risks and these approaches should be considered rescue therapies in severe HBV flares or ACLF. Liver transplant is the ultimate intervention when these other strategies fail. In summary, HBV flares are clinically serious events that can lead to hepatic decompensation, ACLF, and the need for a donor liver; however, strategies for rescue should be considered before liver transplantation.
– Name: Ref
  Label: References
  Group: RefInfo
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(PMID: <searchLink fieldCode="PM" term="%2235163476%22">35163476)</searchLink><br />Hepatology. 2011 Jan;53(1):73-85. (PMID: <searchLink fieldCode="PM" term="%2221254163%22">21254163)</searchLink><br />Hepatology. 2023 Aug 1;78(2):592-606. (PMID: <searchLink fieldCode="PM" term="%2236896974%22">36896974)</searchLink><br />Medicine (Baltimore). 2020 Jun 19;99(25):e20604. (PMID: <searchLink fieldCode="PM" term="%2232569189%22">32569189)</searchLink><br />World J Gastroenterol. 2016 Jan 7;22(1):126-44. (PMID: <searchLink fieldCode="PM" term="%2226755865%22">26755865)</searchLink><br />J Viral Hepat. 2020 Feb;27(2):96-109. (PMID: <searchLink fieldCode="PM" term="%2231828894%22">31828894)</searchLink><br />J Exp Med. 2007 Mar 19;204(3):667-80. (PMID: <searchLink fieldCode="PM" term="%2217353365%22">17353365)</searchLink><br />Hepatology. 2009 Dec;50(6):2001-6. 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– Name: GrantInfo
  Label: Grant Information
  Group: Grant
  Data: NMRC/TCR/014-NUHS/2015 National Medical Research Council; NMRC/CIRG/1351/2013 National Medical Research Council; NMRC/CSASI/0016/2017 National Medical Research Council; NMRC/CIRG/1479/2017 National Medical Research Council; NMRC/OFLCG-19May-0038 National Medical Research Council
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  Data: <i>Keywords: </i>Acute-on-chronic liver failure; Alanine transaminase; Hepatitis B, chronic; Hepatitis B, chronic/therapy; Plasma exchange
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  Data: 0 (Antiviral Agents)<br />EC 2.6.1.2 (Alanine Transaminase)<br />0 (DNA, Viral)
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  Data: <i>Date Created: </i>20260318 <i>Date Completed: </i>20260731 <i>Latest Revision: </i>20260813
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  Data: 10.3350/cmh.2026.0177
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        Value: 10.3350/cmh.2026.0177
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        Text: English
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      – SubjectFull: Antiviral Agents therapeutic use
        Type: general
      – SubjectFull: Acute-On-Chronic Liver Failure diagnosis
        Type: general
      – SubjectFull: Acute-On-Chronic Liver Failure etiology
        Type: general
      – SubjectFull: Alanine Transaminase blood
        Type: general
      – SubjectFull: Hepatitis B virus genetics
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      – SubjectFull: DNA, Viral blood
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      – SubjectFull: Humans
        Type: general
      – SubjectFull: Liver Transplantation
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      – SubjectFull: Viral Load
        Type: general
      – SubjectFull: Hepatitis B, Chronic complications
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      – SubjectFull: Hepatitis B, Chronic drug therapy
        Type: general
      – SubjectFull: Hepatitis B, Chronic diagnosis
        Type: general
      – SubjectFull: Liver Failure diagnosis
        Type: general
    Titles:
      – TitleFull: Severe hepatitis B flare and liver failure: current assessment and management.
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              M: 07
              Text: 2026 Jul
              Type: published
              Y: 2026
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            – TitleFull: Clinical and molecular hepatology
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