What is Hepatitis B Reactivation?
Hepatitis B reactivation (HBVr) is a sudden increase in HBV replication in a patient with chronic or resolved hepatitis B infection, leading to hepatic inflammation and in severe cases, acute liver failure or ACLF. Reactivation can be spontaneous or triggered by immunosuppressive therapy, chemotherapy, or biologics.
Dr. Chetan Kalal at Gleneagles Hospital Mumbai specialises in hepatitis B management including reactivation prophylaxis and treatment of severe reactivation with ACLF.
Who Is At Risk?
- HBsAg-positive patients starting chemotherapy, corticosteroids, TNF inhibitors, IL-6 inhibitors, or JAK inhibitors
- Anti-HBc-positive (HBsAg-negative) patients receiving rituximab or B-cell depleting therapies — high reactivation risk even without active HBV (occult HBV)
- Organ transplant recipients on long-term immunosuppression
- HIV-HBV co-infected patients starting antiretroviral therapy
Key principle: Screen ALL patients for HBsAg AND anti-HBc before any immunosuppressive therapy. This is mandatory per APASL, EASL, and AASLD guidelines.
Symptoms
- Jaundice, dark urine, pale stools
- Fatigue, nausea, right upper quadrant discomfort
- Elevated ALT/AST (often asymptomatic in early reactivation)
- Severe: ascites, encephalopathy, coagulopathy — signs of ACLF or acute liver failure
Prevention: Antiviral Prophylaxis
Tenofovir (TAF or TDF) or entecavir started 1–2 weeks before immunosuppression and continued 6–12 months after cessation dramatically reduces reactivation risk. Lamivudine is no longer recommended for prophylaxis due to high resistance rates.
Treatment
Immediate antiviral therapy (tenofovir or entecavir) is mandatory on confirmed reactivation. Reduce or stop immunosuppression where feasible. Severe reactivation with ACLF or acute liver failure requires ICU care and urgent liver transplant evaluation.
FAQs
Can I reactivate if HBsAg is negative?
Yes — anti-HBc-positive, HBsAg-negative patients (resolved HBV) can reactivate with rituximab or stem cell transplant. Anti-HBc testing is essential before major immunosuppression.
Best antiviral for prophylaxis?
Tenofovir alafenamide (TAF) or TDF preferred. High barrier to resistance and proven efficacy. Entecavir is an acceptable alternative. Lamivudine not recommended for prolonged prophylaxis.
Hepatitis B specialist in Mumbai?
Dr. Chetan Kalal at Gleneagles Hospital Mumbai manages complex hepatitis B cases including reactivation. Teleconsultation available for patients in UK, USA, UAE, and internationally.
Author: Dr. Chetan Kalal, Hepatologist, Gleneagles Hospital Mumbai. ORCID: 0000-0002-5284-7890. Hepatitis service page.
About the Author
Dr. Chetan Kalal — MBBS, MD (Internal Medicine), DM Hepatology (ILBS, New Delhi) — is the First DM Hepatologist of Maharashtra and Associate Director, Hepatology & Liver Transplant, at Gleneagles Hospital Mumbai. He has 26 peer-reviewed publications and serves on the APASL AARC Expert Panel. Fellow, National Academy of Medical Sciences (FNAMS). Learn more · Book appointment
