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<sup>4</sup> Cirrhosis defined by clinical features or noninvasive test.<br><br>
<b>Clinical features</b> of compensated or decompensated cirrhosis include:<br>
• Portal HTN (ascites, variceal hemorrhage, and hepatic encephalopathy)<br>
• Coagulopathy<br>
• Liver insufficiency (jaundice)<br>
• Other (hepatomegaly, splenomegaly, pruritus, fatigue, arthralgia, palmar erythema, edema)
<br><br>
<b>Noninvasive test</b> options:<br>
• APRI (AST-to-platelet ratio), score >2 consistent w/ cirrhosis: preferred in resource-limited settings <a href=http://www.hepatitisc.uw.edu/page/clinical-calculators/apri>| View online APRI Calculator</a><br>
• Transient elastography (eg, FibroScan) or FibroTest: may be preferred if available and cost not a concern
<br><br>
<sup>5</sup> Pre-tx eval: baseline renal function w/ Cr and eGFR; liver dz severity, viral replication, HIV, HCV, HDV, NAFLD, alcoholic liver dz, Fe overload, HCC. Counsel pt on tx, committing to long-term tx, follow-up, adherence, measures to ↓transmission, ↓use of tobacco/EtOH, and costs. HBV genotyping and resistance testing not required to guide tx when using NAs w/ high resistance barrier.
<br><br>
<sup>6</sup> Avoid agents w/ low resistance barrier (lamivudine, adefovir, telbivudine) [S/M].
<br><br>
<sup>7</sup> If eGFR <50 mL/min, ↓tenofovir disoproxil dose or use entecavir.
<br><br>
<sup>8</sup> Eval baseline renal dysfxn risk: proteinuria, glycosuria, uncontrolled DM, active glomerulonephritis, solid organ transplant, concomitant nephrotoxic drugs.
<br><br>
<sup>9</sup> Tenofovir disoproxil preferred in pregnancy. IFN-based tx is contraindicated in pregnancy.
<br><br>
<sup>10</sup> Entecavir preferred in children 2-11 yo. Use oral solution in children <30 kg.
<br><br>
<sup>11</sup> During tx, adjust dose or interrupt tx if CrCl <50 ml/min.
<br><br>
<sup>12</sup> ART should be initiated in all HBV/HIV-co-infected pts w/ evidence of severe chronic liver dz, regardless of CD4 count and in pts w/ CD4 ≤500 cells/mm<sup>3</sup> regardless of liver dz stage [S/L].
<b>Clinical features</b> of compensated or decompensated cirrhosis include:<br>
• Portal HTN (ascites, variceal hemorrhage, and hepatic encephalopathy)<br>
• Coagulopathy<br>
• Liver insufficiency (jaundice)<br>
• Other (hepatomegaly, splenomegaly, pruritus, fatigue, arthralgia, palmar erythema, edema)
<br><br>
<b>Noninvasive test</b> options:<br>
• APRI (AST-to-platelet ratio), score >2 consistent w/ cirrhosis: preferred in resource-limited settings <a href=http://www.hepatitisc.uw.edu/page/clinical-calculators/apri>| View online APRI Calculator</a><br>
• Transient elastography (eg, FibroScan) or FibroTest: may be preferred if available and cost not a concern
<br><br>
<sup>5</sup> Pre-tx eval: baseline renal function w/ Cr and eGFR; liver dz severity, viral replication, HIV, HCV, HDV, NAFLD, alcoholic liver dz, Fe overload, HCC. Counsel pt on tx, committing to long-term tx, follow-up, adherence, measures to ↓transmission, ↓use of tobacco/EtOH, and costs. HBV genotyping and resistance testing not required to guide tx when using NAs w/ high resistance barrier.
<br><br>
<sup>6</sup> Avoid agents w/ low resistance barrier (lamivudine, adefovir, telbivudine) [S/M].
<br><br>
<sup>7</sup> If eGFR <50 mL/min, ↓tenofovir disoproxil dose or use entecavir.
<br><br>
<sup>8</sup> Eval baseline renal dysfxn risk: proteinuria, glycosuria, uncontrolled DM, active glomerulonephritis, solid organ transplant, concomitant nephrotoxic drugs.
<br><br>
<sup>9</sup> Tenofovir disoproxil preferred in pregnancy. IFN-based tx is contraindicated in pregnancy.
<br><br>
<sup>10</sup> Entecavir preferred in children 2-11 yo. Use oral solution in children <30 kg.
<br><br>
<sup>11</sup> During tx, adjust dose or interrupt tx if CrCl <50 ml/min.
<br><br>
<sup>12</sup> ART should be initiated in all HBV/HIV-co-infected pts w/ evidence of severe chronic liver dz, regardless of CD4 count and in pts w/ CD4 ≤500 cells/mm<sup>3</sup> regardless of liver dz stage [S/L].
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