0 log copies/mL. Note that patients who satisfy the above conditions but exhibit fibrosis are considered to have a high risk of hepatocarcinogenesis. Therefore, if fibrosis is suspected on the basis of imaging studies Obeticholic Acid chemical structure or platelet counts, a liver biopsy

should be conducted to assess the need for treatment. In the current Guidelines, the abovementioned off-treatment goals for chronic hepatitis are consistent with the definition of an HBeAg negative inactive carrier, namely an HBV DNA level of less than 4.0 log copies/mL. Accordingly, when the off-treatment goal is achieved the patient becomes an HBeAg negative inactive carrier and treatment is no longer required. Recommendation An HBeAg negative inactive carrier is defined as a patient who satisfies three key requirements in three or more blood tests taken over the course of a year or more: HBeAg negative, ALT ≤ 30 U/L, and HBV DNA < 4 log copies/mL. A liver biopsy provides valuable information for determining whether antiviral therapy is indicated. In cases where ALT levels are normal or show a gradual or intermittent Talazoparib increase, a liver biopsy is optionally considered, irrespective of whether the treatment indication thresholds given below are met. Treatment is indicated when findings of liver biopsy demonstrate moderate or greater liver fibrosis (Metavir 2 or more) or active hepatitis. A liver biopsy is particularly important in patients ≥40 years with high HBV DNA levels,[2, 36,

37] or platelet counts <150 000 /μl, or a family history of HCC,[38, 39] due to the increased risk of carcinogenesis. Since it is often

difficult Terminal deoxynucleotidyl transferase to distinguish whether fibrosis is advanced or not in HBeAg negative inactive carriers, a liver biopsy is required in order to ensure an accurate diagnosis. Conversely, a liver biopsy solely for the purpose of assessing treatment indication is not considered necessary for clinically demonstrable cases of cirrhosis or chronic hepatitis where the ALT levels is persistently greater than twice the upper limit of normal. Hepatic fibrosis can be evaluated via noninvasive alternatives to biopsy, such as serum fibrosis markers, imaging studies including CT and ultrasound, and liver stiffness measurement.[40-44] Confirmation of hepatic fibrosis using any of these techniques is considered a treatment indication. Note that the use of serum fibrosis markers alone is not sufficiently accurate for assessment of the degree of fibrosis. There are several useful serum fibrosis markers, including platelet count, serum γ globulin levels, and serum α macroglobulin levels, but none of these should be used as the sole marker.[45] Chronic hepatitis cases that qualify as neither asymptomatic carriers nor inactive carriers are indicated for antiviral therapy. As Table 8 shows, cases of chronic hepatitis with ALT of 31 U/l or more and HBV DNA levels of 4.0 log copies/mL or more should be indicated for treatment, irrespective of HBeAg status and age.