TREATING HBV IN UNIQUE

POPULATIONS
A case study
 HISTORY
• Mrs. Soran Devi, a 47 year old female, who presentd to ILBS OPD with c/o
polyarthralgia, intermittent pedal edema,anorexia and dyspepsia was found on
evaluation (outside) to be HbsAg positive.
• On examination she was found to have pallor, with no palpable abdominal
organomegaly. LFTs done prior to presenting in OPD showed AST/ALT - 101/75. Her
BMI was 23.3 with waist circumference of 86 cm
• On further testing Fibroscan showed CAP of 331 (IQR -23) and LSM of 10.9 (IQR –
2.2). HBsAg(Q) – 2.5 x 10^2, HBV DNA(Q) – 75, HBeAg negative, Anti Hbe positive,
AFP – 4.8 with an impaired fasting blood glucose of 110 mg/dL. USG Abdomen
showed a 15.8 cm liver with Grade II fatty changes. Her Hb was 10 (microcytic
hypochromic RBCs) with transferrin saturation of 15.6 % for which she was started
on Oral Fe tablets. She was also advised a Gynecological consult i/v/o h/o
menorrhagia. I/v/o high LSM and ALT levels she was advised a liver biopsy which
she underwent on 17/4/17
 Family History
• Her mother was expired at time of presentation due to Acute MI, her father had expired after
being diagnosed with HCC secondary to HBV infection. Her brother was HBsAg positive (non-
cirrhotic) and husband and children were HBsAg negative. They were counseled to undergo
vaccination for HBV.
• Liver biopsy is as shown in the next slide
• She had started Metformin (from outside consultation) and was counseled low CHO diet
along with resistance training exercises to improve muscle mass

HCC

Patient

X3
 Follow up
• Her Fibroscan on follow up after 1 year showed LSM of 7.3 with CAP of 293.
AST/ALT were 24/19, HbA1c was 6 %, Lipid Profile and Thyroid function tests were
WNL. HBV DNA was 2.8 x 10^2, HBsAg (Q) – 1.74 x 10^2
• Despite 6 months of oral Fe therapy her Hb was 8.1, for which further evaluation is
being done.
• I/v/o Family h/o HCC, features of NASH (NAS CRN score 5) on biopsy with F3, and
HBsAg positivity, patient was started on Metformin 850 mg OD and Tenofovir
Alfenamide 25 mg OD
• The above case shows the importance of a clinical assessment of starting antivirals
in patients in whom there is strong risk of developing HCC with multifactorial
causes.
• The following slides show the basics of pathogenesis of HCC.
Journal of Vascular and Interventional Radiology 2017 28, 949-955DOI: (10.1016/j.jvir.2017.03.002)
Immunomodulators associated with
HCC
HCC tumor Microenvironment
Multistep hepatocarcinogenesis
Mutational and epimutational pathway representation in HCC

Gastroenterology 2015;149:1226–1239
Mechanisms of
malignant
transformation
in HCC

Gastroenterology 2015;149:1226–1239