Treatment of Acute Hepatitis B with Impaired Synthetic Liver Function (Prothrombin Time ≤50% / INR ≥1.5)
Acute hepatitis B in adults whose hepatic synthetic capacity is compromised — indicated by a prothrombin time at or below 50% of normal (corresponding to an INR of 1.5 or higher) — requires an urgent, structured management approach that goes beyond standard supportive care.
Clinical scenario
This protocol covers adults presenting with acute hepatitis B in whom impaired hepatic synthesis is documented: prothrombin time ≤50% (INR ≥1.5). This laboratory finding signals a significant risk of progression to fulminant liver failure, and the management strategy reflects that urgency. Involvement of a liver transplant centre is a required component of care in this setting.
Treatment approach
Prompt oral nucleos(t)ide analogue (NA) antiviral therapy is indicated without delay. Treatment continues until a defined virological endpoint is confirmed. Alongside antiviral therapy, prompt engagement with a liver transplant centre is an essential and concurrent step — not deferred until clinical deterioration.
Treatment goal
The primary target is confirmed loss of hepatitis B surface antigen (HBsAg). Antiviral therapy is maintained until this endpoint is reached.
References
DOI: 10.1016/j.jhep.2025.03.018
Patients with acute hepatitis B and impaired synthetic liver function should be treated with NAs and should be managed in cooperation with a transplant centre (LoE 2, strong recommendation, strong consensus).
In cases of impaired hepatic synthesis (e.g. prothrombin time ≤50% corresponds to an INR ≥1.5), immediate NA therapy is indicated to prevent fulminant liver failure.
Antiviral therapy should be continued until confirmed HBsAg loss.
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