Hepatitis B and C - Approach and Management : Updates 2018

Hepatitis B and C - Approach and Management : Updates 2018

1. RECENT ADVANCES IN DAIGNOSIS AND MANAGEMENT OF HEPATITIS B AND CHRONIC HEPATITIS C CHAIR PERSON – Dr. KALINGA B E STUDENT – Dr. ARATHY S

2. HEPATITIS B

3. Hepatitis B is an infectious disease caused by the Hepatitis B virus (HBV ). It is a major public health problem, causing chronic hepatitis, cirrhosis of liver and hepatocellular carcinoma . Human carcinogen —cause of up to 80% of hepatocellular carcinomas.

4. HISTORY…

5. HBV GENOTYPES

6. HBsAg

7. Appears in the blood about 6 weeks after infection and has usually disappeared by 3 months after the clinical illness . Persistence for more than 6 months implies the development of a carrier state or progression to chronicity A diagnosis of HBV infection can usually be made by detection of HBsAg in serum

8. An inverse correlation exists between the serum concentration of HBsAg and the degree of liver cell damage . These suggest that, in hepatitis B, the degree of liver cell damage and the clinical course are related to variations in the patient’s immune response to HBV rather than to the amount of circulating HBsAg

9. HBcAg and HBeAg

10. HBeAg has a signal peptide that binds it to the smooth endoplasmic reticulum, the secretory apparatus of cell, leading to its secretion into circulation. This secreted nucleocapsid protein is thus a reliable qualitative marker of HBV replication and infectivity HBcAg , devoid of signal peptide is not secreted and incorporated into nucleocapsid .

11. HBxAg C apable of transactivating the transcription of both viral and cellular genes clinical association observed between the expression of HBxAg and antibodies to it in patients with severe chronic hepatitis and hepatocellular carcinoma The transactivating activity can enhance the transcription and replication of other viruses besides HBV such as HIV.

12. ACUTE INFECTION

13. CHRONIC INFECTION

14. PHASES OF CHRONIC HEPATITIS B

15. Phase Liver histology Immune Tolerant Minimal inflammation and fibrosis Immune Clearance Moderate to severe inflammation or fibrosis Inactive Disease Minimal necroinflammation but variable fibrosis HBeAg -negative Chronic HBV Moderate to severe inflammation or fibrosis

16. Evaluation of HBsAg + ve patients HISTORY Symptoms and signs of liver disease alcohol and metabolic risk factors Family history of HCC vaccination status

17. Laboratory tests complete blood count s.bilirubin , AST, ALT, ALP s.albumin , INR AFP, GGT

18. SEROLOGY/ VIROLOGY HBsAg quantitative assay - The quantitative electrochemiluminescence immunoassay determines the HBsAg levels expressed in IU/mL widely used to monitor chronic Hepatitis B (CHB) patients response to antiviral Therapy.

19. Antibodies to HBc In patients with hepatitis B surface antigenemia of unknown duration testing for IgM anti- HBc may be useful to distinguish between acute or recent infection (IgM anti- HBc -positive) and chronic HBV infection Specificity = 99.8% to 99.9%

20. HBeAg HBeAg correlates with ongoing viral synthesis and with infectivity Persistence for more than 10 weeks strongly suggests the development of chronicity

21. Anti HBe Prognostic for resolution of infection The appearance of Anti- Hbe is strong evidence that the patient will recover completely.

22. Anti HBs After immunization with hepatitis B vaccine, which consists of HBsAg alone, anti-HBs is the only serologic marker to appear Anti-HBs >12mIu – Protective

23. Molecular Advances in Diagnosis of HBV Infection Current HBV DNA assays make use of differing technologies and can generally divided into i ) signal amplification assays ii ) DNA amplification tests based on PCR HBV DNA detection based on PCR approach can detect as few as 10 2 – 10 3 Genome copies

24. HBV DNA the most sensitive index of viral replication. It is a good marker of the level of viraemia , can be correlated with serum transaminase levels

25. NEEDLE LIVER BIOPSY ascertain the degree of necroinflammation and fibrosis help guide the decision to treat . the amount of replicating virus in the serum does not correlate with the degree of histological activity

26. Non-Invasive Tests (NITs) APRI FIB-4 transient elastography ( FibroScan )

27. APRI

28. In a meta-analysis of 40 studies, investigators concluded that an APRI score greater than 1.0 had a sensitivity of 76% and specificity of 72% for predicting cirrhosis

29. FIB-4

30. FIB-4 score <1.45 had a negative predictive value of 90% for advanced fibrosis. FIB-4 >3.25 would have a 97% specificity and a positive predictive value of 65% for advanced fibrosis. these individuals could potentially have avoided liver biopsy.

31. Fibroscan measure liver stiffness based on ultrasound technology. Transient elastography performed with FibroScan has been the most widely evaluated. > 90% accuracy for early Fibrosis and Cirrhosis. Cost in India – Rs.4000 to 5000/- per scan.

32. Screening for HCC Patients who are HBsAg positive with chronic hepatitis or cirrhosis, especially if male and more than 45 years old, should be screened regularly so that hepato -cellular carcinoma may be diagnosed early when surgical resection may prove possible. Serum α-fetoprotein should be measured and ultrasound examination performed at 6-monthly intervals.

33. HBsAg seroclearance did not reduce therisk of HCC in patients with Hepatitis B Hepatitis B patients who have indications for surveillance pre seroclearance should continue getting surveillance post seroclearance . P pP Gounder , Bulkow , Snowball et al; Nested case control study: Hepatocellular carcinoma risk after Hepatitis B surface antigen seroclerance

34. TREATMENT

35. ACUTE HEPATITIS B Supportive management Recovery in 99% cases Severe acute Hepatitis B – antiviral therapy with nucleoside analogue duration – until 3 months after HBsAg seroconversion or 6months after HBeAg seroconversion

36. CHRONIC HEPATITIS B Interferons Nucleotide analogues Nucleoside analogues

37. INTERFERONS Interferon alpha was the first approved therapy for chronic Hepatitis B. Mechanisms – immunostimulatory intrinsic antiviral activity Dosage – 5million units daily or 10million units thrice a week

38. Contraindications - psychiatric disease neutropenia or thrombocytopenia coronary artery disease cardiac arrhythmia decompensated cirrhosis renal transplantation .

39. Complications – flu like symptoms marrow suppression emotional lability autoimmune reactions alopecia, rashes, diarrhoea numbness and tingling

40. PEGYLATED INTERFERONS Polyethylene glycol (PEG ) is added to make interferon last longer in the body Ease of administration Higher efficacy Better sustained response rate

41. NUCLEOSIDE/NUCLEOTIDE ANALOGUES INHIBIT VIRAL DNA POLYMERASE ENZYME

42. LAMIVUDINE Clinical and laboratory side effects of lamivudine are negligible Emergence of resistance Long-term monotherapy with lamivudine is associated with methionine to valine(M204V ) or methionine-to-isoleucine ( M2041) mutations, primarily at amino acid 204 in the tyrosine-methionine aspartate-aspartate ( YMDD ) motif of HBV DNA polymerase

43. lamivudine is no longer recommended as first-line therapy The drug is still used widely as first-line therapy in developing countries

44. ADEFOVIR DIPIVOXIL effective against both wild-type and lamivudine-resistant HBV. primary treatment failure (<1 log decline in the serum HBV DNA level at week 12) was observed in 30% of patients Adverse effect – nephrotoxicity Dose – 10mg/day

45. No longer recommended as a first line therapy Used widely as primary therapy or in combination with lamivudine in resistant cases.

46. TENOFOVIR More potent agent Dosage – 300mg/day Active against wild type HBV lamivudine resistant HBV slow or limited response to adefovir

47. The 5-year safety and resistance profile are very favourable Replaced adefovir both as first line therapy for chronic Hepatitis B and add on therapy for lamivudine resistant cases.

48. Tenofovir monotherapy was as effective as tenofovir emtricitabine combination and well tolerated in Lamivudine resistans chronic hepatitis B patients for upto 240 weeks Fung s, Kwan P, Fabri M et al; TDF versus TDF/FTC in Lamivudine resistant Hepatitis B : a 5yr randomised study. J.Hepatology 2016 Aug18.

49. ENTECAVIR The most potent of the HBV antivirals High potency and high barrier to resistance renders it a first line drug for patients with chronic Hepatits B Resistance to entecavir in lamivudine resistant chronic hepatitis B has been recorded to increase progressively to 43% at 4 years. Entecavir is not as attractive a choice as adefovir or tenofovir for patients with lamivudine resistant hepatitis B

50. EFFICACY OF ANTIVIRALS IN CHRONIC HEPATITIS B

51. GUIDELINES AASLD: American Association of Study of Liver Diseases EASL: European Association for the Study of Liver WHO: World Health Organization

52. TREATMENT RECOMMENDATIONS All adults, adolescents and children with CHB and clinical evidence of compensated or decompensated cirrhosis should be treated, regardless of ALT levels, HBeAg status or HBV DNA levels

53. Treatment is recommended for adults with CHB who do not have clinical evidence of cirrhosis but are aged more than 30 years have persistently abnormal ALT levels with evidence of high-level HBV replication (HBV DNA >20 000 IU/mL), regardless of HBeAg status

54. Antiviral therapy is not recommended and can be deferred in persons without clinical evidence of cirrhosis and with persistently normal ALT levels and low levels of HBV replication (HBV DNA <2000 IU/mL), regardless of HBeAg status or age

55. Continued monitoring is necessary persons without cirrhosis aged 30 years or less, with HBV DNA levels >20 000 IU/ mL but persistently normal ALT HBeAg -negative persons without cirrhosis aged 30 years or less, with HBV DNA levels that fluctuate between 2000 and 20 000 IU/mL, or who have intermittently abnormal ALT levels

56. TREATMENT OF HEPATITIS B IN INDIA Guidelines recommend selection of drugs with high potency and low risk of resistance Most guidelines advocate initial treatment with ETV, TDF or peg-IFN There is insufficient safety and efficacy data on antiviral agents in India

57. ETV has been associated with significantly higher rates of serological, viral and biochemical improvement with no resistance ADV was found to be less potent though the frequency of resistance mutations was low TDF and LdT were reported to reverse decompensation and improve hepatic functional status with significant reduction in HBV DNA levels

58. Though all approved agents are available in India, treatment with guideline recommended first-line agents is a challenge, the major hurdle being unaffordability due to high cost of therapy

59. DRUG COSTS [10 TABLETS] ENTACAVIR 0.5mg 750 – 1500 ENTACAVIR 1mg 1500-3500 TENOFOVIR 400 LAMIVUDINE 80 ADEFOVIR 245

60. ETV , LdT and TDF can be recommended in compliant patients who can afford good treatment LAM/ADV combination may be advised for non-affording patients with well compensated cirrhosis while LAM alone may be advised in those with grade II fibrosis.

61. When to stop treatment? Lifelong NA therapy : All persons with clinical evidence of Cirrhosis .

62. Discontinuation and careful long term follow up in : Persons without clinical evidence of cirrhosis Evidence of HBeAg loss and seroconversion to anti- HBe after completion of atleast 1 year of treatment. In association with persistently normal ALT levels and persistently undetectable HBV DNA levels

63. LIVER TRANSPLANTATION Liver transplantation is currently a successful therapy for end-stage chronic HBV-associated liver disease. The use of high dose HBIG ( Hepatitis B immunoglobulin ) peri -operatively and post-operatively, combined with treatment of heptitis B with entecavir or tenofovir are favored to prevent recurrent HBV infection post-transplantation.

64. Special Groups : HBV-HIV coinfection treating for both HBV and HIV is recommended . Lamivudine, Emtricitabine and Tenofovir are all nucleoside analogs with activity against both HIV and HBV Rate of HBV resistance to Lamivudine in HBV-HIV coinfection is almost 90% at 4 years, hence lamivudine should never be used as monotherapy

65. Entecavir has low-level activity against HIV and can result in selection of HIV resistance Tenofovir and the combination of tenofovir and emtricitabine in one pill are approved therapies for HIV and represent excellent choices for treating HBV infection in HBV-HIV co-infected patients

66. PREGNANCY Tenofovir is effective in reducing mother to child transmission Calvin Q Pan, Erhei Dai et al; Tenofovir to prevent Hepatitis B transmission in mothers with high viral load, N Engl J Med 2016 June 16,; 2324-2334

67. CHB on Cytotoxic Chemotherapy Preemptive treatment with anti- virals for 6 months for inactive Hepatitis B carriers prior to the initiation of chemotherapy has been shown to reduce the risk of such reactivation.

68. PREVENTION & IMMUNOPROPHYLAXIS Hepatitis B immunoglobulin (HBIG) : effective for passive immunization if given prophylactically or within hours of infection. It is indicated for sexual contacts of acute sufferers, babies born to HBsAg -positive mothers and victims of parenteral exposure (needle stick) to HBsAg -positive blood.

69. I n healthy individuals the recombinant vaccine is given in a dose of 20 μ g (2 ml) intramuscularly, repeated at 1 month with a booster at 6 months. For patients undergoing haemodialysis and for other immunosuppressed patients, higher vaccine dosages (40 μ g) or an increased number of doses are recommended(4 doses).

70. POST EXPOSURE PROPHYLAXIS 0.06ml/Kg HBIG plus first dose of Hepatitis B Vaccine and continue vaccine course.

71. HEPATITIS C

72. Family – Flaviviridae Genus – Hepacivirus A small ( 50 nm ) virus ss RNA virus RNA sequence analysis into at least six major genotypes (Clades) There are 100 subtypes.

73. HCV circulates in various forms in the serum of an infected host, including ( 1) virions that are bound to very-low-density and low-density lipoproteins and appear to represent the infectious fraction , ( 2) virions bound to immunoglobulins (3) free virions .

74. Chronic hepatitis develops in 50% to 90% of persons with acute HCV infection. In the minority of patients in whom acute HCV resolves, an early and multispecific T-cell response occurs. This response can be detected up to 20 years after resolution of infection and may contribute to protection in case of subsequent exposures to HCV.

75. ACUTE HEPATITIS C Acute hepatitis C is rarely seen in clinical practice nearly all cases are asymptomatic Even in symptomatic patients, however, most of the clinical symptoms are nonspecific fatigue , nausea, abdominal pain, loss of appetite, mild fever , itching, myalgia, Jaundice

76. The rate of viral persistence after acute infection ranges from 45% to more than 90%. Age and gender source of infection and size of inoculum immune status of the host patient’s race the rate of spontaneous clearance is higher in symptomatic patients in whom jaundice develops during acute infection than in those who remain asymptomatic

77. CHRONIC HEPATITIS C Chronic HCV infection has a variable course; in some patients disease progression to cirrhosis is slow, while in others, progression is more rapid

78. INVESTIGATIONS Indirect Assays EIAs detect antibodies against different HCV antigens The third-generation EIAs detect antibodies against HCV core, NS3, NS4, and NS5 antigens as early as 7 to 8 weeks after infection, with sensitivity and specificity rates of 99%

79. The presence of anti-HCV in high titer in serum (enzyme immunoassay [EIA] ratio> 9) indicates exposure to the virus does not differentiate among acute, chronic, and resolved infection . Serologic assays are used initially for diagnosis.

80. Direct Assays Virologic assays are required for confirming infection, monitoring response to treatment, and evaluating immunocompromised patients .

81. Quantitative assays Real time PCR Transcription meadiated amplification The advantages of these very sensitive tests include positivity within 1 to 3 weeks after acute infection and detection of low-level residual infection during antiviral therapy Disadvantage – lack of comparability among different assays

82. HCV core antigen assay - cheaper and faster alternative Fully automated immunoassays

83. HCV GENOTYPING The most accurate method is PCR methodology and direct sequencing of the NS5B or E1 region Reverse hybridization to genotype-specific probes restriction fragment length polymorphism analysis PCR amplification of the 5′ noncoding region of the HCV genome.

84. ASSESSMENT OF FIBROSIS

85. EASL Recommendations Anti-HCV antibodies are the first-line diagnostic test for HCV infection In the case of suspected acute hepatitis C or in immunocompromised patients, HCV RNA testing should be part of the initial evaluation

86. If anti-HCV antibodies are detected, HCV RNA should be determined by a sensitive molecular method Anti-HCV-positive, HCV RNA negative individuals should be retested for HCV RNA three months later to confirm true convalescence

87. TREATMENT DRUGS INTERFERONS PEGYLATED INTERFERONS DIRECTLY ACTING ANTIVIRAL AGENTS

88. Ribavirin Guanosine analogue Side effect – RBC breakdown birth defect in babies Taribavirin [ viramidine or ribamidine ] - ribavirin derivative less erythrocyte-trapping and better liver-targeting than ribavirin . phase III human trials

89. Directly acting agents

90. EASL Recommendations The goal of therapy is to cure HCV infection to prevent hepatic cirrhosis, decompensation of cirrhosis, HCC, severe extra-hepatic manifestations and death The endpoint of therapy is undetectable HCV RNA in a sensitive assay (≤15 IU/ml) 12 weeks (SVR12) and 24 weeks (SVR24) after the end of treatment

91. In patients with advanced fibrosis and cirrhosis, HCV eradication reduces the rate of decompensation and will reduce, albeit not abolish, the risk of HCC. In these patients surveillance for HCC should be continued In patients with decompensated cirrhosis, HCV eradication reduces the need for liver transplantation. Whether HCV eradication impacts mid- to long-term survival in these patients is unknown

92. Treatment is indicated All treatment-naive and treatment-experienced patients with compensated and decompensated liver disease

93. Treatment should be prioritized Patients with significant fibrosis (F3) or cirrhosis (F4), including decompensated cirrhosis Patients with HIV coinfection Patients with HBV coinfection Patients with an indication for liver transplantation

94. Patients with HCV recurrence after liver transplantation Patients with clinically significant extra-hepatic manifestations Patients with debilitating fatigue Individuals at risk of transmitting HCV (active injection drug users, men who have sex with men with high-risk sexual practices, women of child-bearing age who wish to get pregnant, haemodialysis patients, incarcerated individuals)

95. Treatment can be deferred Patients with no or mild disease (F0-F1) and none of the above-mentioned extrahepatic manifestations

96. Treatment is not recommended Patients with limited life expectancy due to non-liver related comorbidities

97. HCV genotype 1 a combination of weekly PegIFN -α, daily weightbased ribavirin (1000 or 1200 mg in patients <75 kg or ≥ 75 kg, respectively), and daily sofosbuvir (400 mg) 12 weeks

98. combination of weekly PegIFN -α, daily weightbased ribavirin (1000 or 1200 mg in patients <75 kg or ≥ 75 kg, respectively), and daily simeprevir (150 mg ) for 12 weeks to be followed bg PegIFN and ribavirin for 12weeks

99. IFN free regimens Sofosbuvir (400 mg) and ledipasvir ( 90 mg ) sofosbuvir ( 400 mg ) and simeprevir (150 mg ) sofosbuvir ( 400 mg ) and daclatasvir (60 mg)

100. Duration - 12 weeks Patients with cirrhosis - with daily weight-based ribavirin If ribavirin contraindicated - combination for 24 weeks

101. the fixed-dose combination of ombitasvir (12.5 mg), paritaprevir ( 75 mg ) and ritonavir (50 mg) in one single tablet ( two tablets once daily with food), and dasabuvir (250 mg ) ( one tablet twice daily )

102. 1a with cirrhosis – 24weeks with ribavirin 1a without cirrhosis – 12weeks with ribavirin 1b without cirrhosis – 12weeks without ribavirin 1b with cirrhosis – 12weeks with ribavirin

103. HCV genotype 2 daily weight-based ribavirin (1000 or 1200 mg in patients <75 kg or ≥75 kg, respectively), and daily sofosbuvir (400 mg) for 12 weeks Cirrhosis or treatment experienced – 16-20 weeks

104. Cirrhotic and/or treatment-experienced patients weekly PegIFN - α, daily weight-based ribavirin (1000 or 1200 mg in patients <75 kg or ≥75 kg, respectively ), and daily sofosbuvir (400 mg) 12 weeks an IFN-free combination of daily sofosbuvir (400 mg) and daily daclatasvir (60 mg) for 12 weeks

105. HCV genotype 3 weekly PegIFN - α, weightbased ribavirin (1000 or 1200 mg in patients <75 kg or ≥ 75 kg, respectively), and sofosbuvir (400 mg) daily 12 Weeks weight-based ribavirin (1000 or 1200 mg in patients <75 kg or ≥75 kg, respectively) sofosbuvir (400 mg ) daily for 24 weeks sofosbuvir (400 mg) and daclatasvir (60 mg) daily for 12weeks

106. HCV genotype 4 a combination of weekly PegIFN -α, daily weightbased ribavirin (1000 or 1200 mg in patients <75 kg or ≥ 75 kg, respectively), and daily sofosbuvir (400 mg) 12 weeks

107. combination of weekly PegIFN -α, daily weightbased ribavirin (1000 or 1200 mg in patients <75 kg or ≥ 75 kg, respectively), and daily simeprevir (150 mg ) for 12 weeks to be followed bg PegIFN and ribavirin for 12weeks

108. HCV genotype 5 or 6 a combination of weekly PegIFN -α, daily weightbased ribavirin (1000 or 1200 mg in patients <75 kg or ≥ 75 kg, respectively), and daily sofosbuvir (400 mg) 12 weeks

109. IFN free regimens for HCV genotype 4/5/6 Sofosbuvir (400 mg) and ledipasvir ( 90 mg ) sofosbuvir ( 400 mg ) and simeprevir (150 mg ) sofosbuvir ( 400 mg ) and daclatasvir (60 mg)

110. Duration - 12 weeks Patients with cirrhosis - with daily weight-based ribavirin If ribavirin contraindicated - combination for 24 weeks

111. Monitoring therapy PegIFN - α and ribavirin – Haematological parameters Sofusbuvir – Renal function tests Simprevir – rashes and indirect bilirubin

112. A real-time PCR-based assay with a lower limit of detection of ≤15 IU/ml should be used to monitor HCV RNA levels during and after therapy PegIFN - α, ribavirin and sofosbuvir - at baseline and at weeks 4, 12 (end of treatment), and 12 or 24 weeks after the end of therapy PegIFN -α, ribavirin and simeprevir - at baseline, week 4, week 12, week 24 and 12 or 24 weeks after the end of therapy IFN-free regimen - at baseline, week 2 (assessment of adherence), week 4, end of treatment and 12 or 24 weeks after the end of therapy

113. Success of the treatment is assessed by SVR – defined as absence of detectable HCV RNA in the serum six months following end of treatment Relapsers: are defined as patients who achieved undetectable HCV RNA at the end of treatment and subsequently relapsed and did not achieve SVR

114. With the triple combination of PegIFN -α, ribavirin and simeprevir , treatment should be stopped if HCV RNA level is ≥25 IU/ml at treatment week 4, week 12 or week 24 An immediate switch to another IFN-containing DAA containing or to an IFN-free regimen without a protease inhibitor should be considered

115. HBV HCV COINFECTION Patients should be treated with the same regimens, following the same rules as HCV monoinfected patients If HBV replicates at significant levels before, during or after HCV clearance, concurrent HBV nucleoside/ nucleotide analogue therapy is indicated

116. POST TRANSPLANT INFECTION All patients with post-transplant recurrence of HCV infection should be considered for therapy an IFN-free regimen, for 12 or 24 weeks with ribavirin

117. In hemodialysis patients Haemodialysis patients should be considered for antiviral therapy an IFN-free, if possible ribavirin-free regimen, for 12 weeks in patients without cirrhosis, for 24 weeks in patients with cirrhosis Sofosbuvir should not be administered to patients with an eGFR <30 ml/min/1.73 m2 or with end-stage renal disease

118. HCV HIV COINFECTION Regardless of genotype Weekly PEG IFN plus daily ribavirin Duration - 48 weeks

119. TRANSPLANTATION IN CIRRHOSIS

120. Hepatitis C in India According to current estimates more than 6 million people are affected with Hepatitis C in India The predominant genotypes of HCV in India are genotype 3, followed by genotype 1 and genotypes 4 Until recently PEG IFN and ribavirin was the only treatment available in India which costs around Rs.6000 per week

121. Generic versions of sofosbuvir , ledipasvir and daclatasvir have now become available in India, reducing the cost of therapy Combination therapy with ledipasvir and sofosbuvir or daclatasvir and sofosbuvir with or without ribavirin is much more affordable than the earlier treatment with PEG- IFNbased therapy

122. Harvoni , the fixed-dose combination of ledipasvir-sofosbuvir of 90mg and 400mg, respectively - Rs.25,000 for a bottle of 28 tablets . Sofusbuvir tablets – Rs 17000 for a bottle of 28 tablets Daclatasavir – Rs.3500 for 28 tablets Epclusa – sofusbuvir and velpatasavir

123. WHO organizes World Hepatitis day on 28 July every year to increase awareness and understanding of viral Hepatitis

124. REFERENCES Harrison’s Principles of Internal Medicine 19 th Edition Sleisinger and Fordtran’s Gastrointestinal and liver diseases 10 th edition Diseases of liver and biliary system Sheila Sherlock 11 th edition Pawlotsky et al, EASL Recommendations on Treatment of Hepatitis C 2015, Journal of Hepatology 2015 vol. 63 j 199–236 WHO global guideline for Hepatitis B 2015

125. THANK YOU..