2.1 Chronic hepatitis

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When transaminases remain elevated for more than 6 months, chronic hepatitis is present.

Chronic hepatitis B presents with chronically elevated transaminases and the presence of hepatitis B DNA. Worldwide, there are an estimated 315 million carriers. Hepatitis B is a highly contagious virus. This poses a great risk to cohabitants. It is a sexually transmitted disease, it is also transmitted from mother to child (vertical transmission) and it is also transmitted via needle stick injuries. The diagnosis is made based on the presence of hepatitis B surface antigen. Based on hepatitis B DNA and transaminase, different forms can be distinguished. One form can progress to another.

1) HBe antigen positive

2) HBe antigen negative

Chronic hepatitis B (hepatitis B antigen positive and negative forms) leads to cirrhosis after 10 years in 30% of infected patients. Carriers with high viral replication have no risk of developing cirrhosis, but from middle age onwards have an increased risk of developing hepatocellular carcinoma. Carriers with low viral replication have a very favorable prognosis. These patients are infectious. Flare-ups of the disease can occur with cytostatics and corticosteroids.

Patients with chronic active (meaning: disturbed transaminases) hepatitis B (hepatitis B antigen positive and negative form) are best treated with polymerase inhibitors (anti-viral effect). A therapy that best lasts until the hepatitis B surface antigen has become negative. However, this can take years.

Chronic hepatitis C presents with chronically elevated transaminases and the presence of hepatitis C RNA.

High risk groups include: intravenous/nasal drug users and homosexual HIV patients. The diagnosis is made by detecting hepatitis C antibodies. If these are positive, an additional hepatitis C RNA determination is indicated. If the RNA is negative, it concerns past hepatitis C. If the RNA is positive, which is accompanied by an increase in transaminases over time, it concerns chronic active hepatitis. 

Chronic HCV may be associated with extrahepatic manifestations. These include B-cell lymphomas, porphyria cutanea tarda, and vasculitis (mixed cryoglobulinemia associated with skin and renal lesions). Chronic active hepatitis C leads to cirrhosis in approximately 20% of patients after approximately 20 years, with a subsequent progression to hepatocellular carcinoma (HCC) of 2% per year. Chronic hepatitis C can be successfully treated with direct active antiviral medication; usually a combination of protease inhibitors, NS5A inhibitors and polymerase inhibitors. It is important to check whether the dose of the associated medication does not need to be adjusted (drug-drug interactions, polypharmacy).

Presents with chronically elevated transaminases and presence of anti-smooth muscle antibodies. It may also manifest as impending liver failure.

It is a rare condition, occurring in approximately 25 to 30 patients per million. It mainly affects women (75%). It can occur at any age. The diagnosis is made by means of chronically abnormal transaminases, increased gammaglobulins, more than 20 to 30g/l with specific increase in IgG, but can also present as acute liver failure. There are different types, of which type 1 is the most common. This is characterized by the presence of anti-smooth muscle antibodies. To confirm the diagnosis, a liver biopsy is needed that shows an aggressive form of hepatitis. A favorable response to steroids is a prerequisite for correct diagnosis.

The disease can be characterized by periods of normal transaminases with flares. About 30% of patients have cirrhosis at the time of diagnosis. These patients have a poorer long-term prognosis. There is an effective treatment with steroids. The treatment is usually lifelong; the therapy should be given for at least three years. If this first-line therapy fails, a second-line therapy can be used, including cyclosporine or tacrolimus.

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