Laboratory Tests for Evaluation of Hepatitis B

Initial Serologic Testing

The American Association for the Study of Liver Diseases recommends HBsAg as the primary marker for active HBV infection, with positivity for >6 months defining chronic infection 1, 4, 5
The American Association for the Study of Liver Diseases indicates that anti-HBc total indicates current or previous HBV infection 2, 5
The Centers for Disease Control and Prevention suggests that anti-HBc IgM indicates acute infection when positive, and may be detected at low levels in chronic infection 2, 5
The American Association for the Study of Liver Diseases states that anti-HBs indicates recovery from infection or successful vaccination 2, 3
The American Association for the Study of Liver Diseases recommends HBeAg as a marker of high viral replication 1, 3
The American Association for the Study of Liver Diseases indicates that anti-HBe usually indicates lower viral replication when HBeAg becomes negative 3, 6

The American Association for the Study of Liver Diseases recommends HBV DNA quantification as essential for assessing viral replication, disease activity, and treatment decisions 1, 4
The American Association for the Study of Liver Diseases states that HBeAg-positive chronic hepatitis B typically has HBV DNA ≥20,000 IU/mL 3, 6
The American Association for the Study of Liver Diseases indicates that HBeAg-negative chronic hepatitis B typically has HBV DNA ≥2,000 IU/mL 3, 6
The American Association for the Study of Liver Diseases recommends that an inactive carrier state is defined by HBV DNA <2,000 IU/mL 3, 6

The American Association for the Study of Liver Diseases recommends ALT/AST to assess liver inflammation 1, 3
The American Association for the Study of Liver Diseases suggests that alkaline phosphatase and gamma-glutamyl transpeptidase are additional markers of liver injury 3, 6
The American Association for the Study of Liver Diseases states that bilirubin evaluates liver function 3
The American Association for the Study of Liver Diseases recommends albumin to assess synthetic liver function 1, 3
The American Association for the Study of Liver Diseases indicates that prothrombin time/INR evaluates coagulation and liver synthetic function 3, 6

The Centers for Disease Control and Prevention recommends testing for anti-HCV to rule out HCV coinfection 1, 3
The Centers for Disease Control and Prevention suggests testing for anti-HDV in patients with a history of injection drug use or from endemic areas 7, 3
The Centers for Disease Control and Prevention recommends testing for anti-HIV in high-risk groups 7, 3
The Centers for Disease Control and Prevention states that testing for anti-HAV IgG determines immunity status to hepatitis A, and vaccination is recommended if negative 2, 7

The American Association for the Study of Liver Diseases recommends baseline screening for hepatocellular carcinoma with alpha-fetoprotein 1, 3
The American Association for the Study of Liver Diseases suggests ultrasound for baseline evaluation in high-risk patients 1, 7
The American Association for the Study of Liver Diseases recommends liver biopsy or non-invasive fibrosis assessment to evaluate inflammation and fibrosis when indicated 1, 4, 3

The American Association for the Study of Liver Diseases states that acute HBV infection is characterized by HBsAg positive, IgM anti-HBc positive 2, 5
The American Association for the Study of Liver Diseases indicates that chronic HBV infection is characterized by HBsAg positive for >6 months, total anti-HBc positive, IgM anti-HBc negative 2, 3
The American Association for the Study of Liver Diseases recommends that past HBV infection with immunity is characterized by HBsAg negative, anti-HBs positive, total anti-HBc positive 2, 5
The American Association for the Study of Liver Diseases states that vaccine-induced immunity is characterized by HBsAg negative, anti-HBs positive, total anti-HBc negative 2, 5

The American Association for the Study of Liver Diseases recommends monitoring ALT every 3-6 months, HBV DNA every 6-12 months, and HBeAg/anti-HBe status annually for untreated patients with chronic HBV 1, 7
The American Association for the Study of Liver Diseases suggests monitoring ALT, HBV DNA, and other markers at regular intervals to assess response in patients on treatment 1, 7
The American Association for the Study of Liver Diseases recommends more frequent monitoring and surveillance for HCC with ultrasound every 6 months for cirrhotic patients 1, 7

The American Association for the Study of Liver Diseases warns of the failure to recognize the "window period" when both HBsAg and anti-HBs may be negative (IgM anti-HBc is positive during this period) 2, 5
The American Association for the Study of Liver Diseases cautions against misinterpreting isolated anti-HBc positivity (requires follow-up testing) 2, 3
The American Association for the Study of Liver Diseases notes that HBeAg-negative chronic hepatitis B can have lower HBV DNA levels but still cause progressive liver disease 1, 3
The Centers for Disease Control and Prevention emphasizes the importance of recognizing the need for coinfection testing, particularly in high-risk populations 7, 3