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Rapid increase in ALT and AST (I am in panic, please help)
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Rapid increase in ALT and AST (I am in panic, please help)

Dear Friends,

I am on Entecavir treatment for 5 months.

5 months ago
ALT: 86
HBV DNA: 557 000 000

2 months ago
ALT: 90
HBV DNA: 55 000

This Week
ALT 347
HBV DNA: not resulted yet.

As you see my ALT increased rapidly in the last 2 months. My doctor says It may be because of (1) mutation or (2) sport+eating protein. They want me to wait HBV DNA result.

Dear Stef and other friends. Please share your comments. I am in panic.

Regards.
Tags: alt, AST, entecavir
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Avatar_m_tn
resistance to etv so fast is extremely unlikly, hbvdna is also too low to be the virus to induce the flare

it is hbeag seroconversion and lowering of hbsag, only if you find hbvdna increase over  many logs it can be considered a bad sign...many of us would like to have your little flare (not that much of a flare)
27 Comments Post a Comment
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Avatar_m_tn
To understand what s going on start monitoring your hbsag in iu/ml. Any doctors suggestion without this test result will have no sense. Usually alt flare is a good sign as but as long as hbvdna und and hbsag decreasing.
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Avatar_m_tn
It can be either host or virus induced ALT flare, so you need to understand which one you have.
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Avatar_m_tn
Thank you for your reply.

I am waiting for HBV DNA result. HBSAG in quantity test is not common in here. But the hospital will find a way to do the test.

'Usually ALT flare is good sign' what do you mean? Why good?

Should I take it positive according to my above results?
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Avatar_m_tn
'It can be either host or virus induced ALT flare, so you need to understand which one you have.'

Is HBV DNA test enough to understand?
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Avatar_m_tn
Hi safi, I'll help as I also had even worst flares during the years (ALT up to 900).

Increase of ALT means your immune systme is stronlgy fightinh hbv to get rid of that.

I'm sure DNA is further loweriing sice you are taking ETV.

This flare could lead to EAG serovnversion... are you still EAG+ve?
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Avatar_m_tn
Thanks a lot dear.

My treatment was going well and my motivation was getting higher until today.

For HBEAG, I only have base number (5 months ago) and 3rd month number (2 months ago). The new result will come with HBV DNA.

ALT
Before: 86 (5 months ago before treatment)
After: 90 (2 months ago - after 3 months treatment)
Now: 347 (Today - 5 months after treatment)


HBEAG
Before: 912 (5 months ago before start treatment)
After: 7.4  (2 months ago - after 3 months treatment)
Now: Not resulted yet

HBV-DNA
Before: 557 000 000 (5 months ago before treatment)
After: 55 000 (2 months ago - after 3 months treatment)
Now: Not resulted yet
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Avatar_m_tn
I am 29 years old and a fit body. I eat healthy foods.
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Avatar_m_tn
Stef and others, where are you?

I need your comments. My pshycology is terrible.
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Avatar_m_tn
I don't think panicking is useful here.

Is it possible that the lab result got a wrong reading on your blood test?

If you are healthy and eating healthy, have good bmi ratio, have no bad symptom, then I think it's OK to have a flare like that. You have any support group like your parents and siblings/friends??

Maybe another blood test in 1 weeks time to see 'maybe' a typo or mistake on the lab.

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Avatar_m_tn
resistance to etv so fast is extremely unlikly, hbvdna is also too low to be the virus to induce the flare

it is hbeag seroconversion and lowering of hbsag, only if you find hbvdna increase over  many logs it can be considered a bad sign...many of us would like to have your little flare (not that much of a flare)
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Avatar_m_tn
Dear mustthinkpositive and stef2011

It is good to see you.

I have two doctors, one is a famous professor of virology in my country, the other one is assoc. professor of virology. Both of them are from different hospitals. Believe in me that, they are not knowledgeable as much as stef2011. The assoc professor is not even be aware  of fibroscan and quantity test of hbsag.

Anyway. What I should understand from the ALT flare;

1. It is very low percentage of resistance in 5 months

2. My HBV DNA is too low to flare ALT

3. If my HBV DNA keeps the decrease, my ALT flare is good, right?


So, if my HBV DNA increase, what can the bad sign be?

Thanks a lot
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Avatar_m_tn
What is your current situation?
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Avatar_m_tn
the standard would be to have:
hbsag quant iu/ml
hbeag quant pei units or s/co
hbvdna iu/ml

if alt goes up and hbsag/hbvdna goes down, you are clearing

if alt goes up, hbsag and hbvdna goes up, the virus is reinfecting many cells and immuen system is trying to manage the situation but fails because both hbsag and hbvdna goes up

using hbvdna only is not extremely precise to tell but it should be more than enough on entecavir or antivirals in general (hbsag plus hbvdna is more useful on peg)
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Avatar_m_tn
Very clear description. Thank you stef
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Avatar_m_tn
Here is an article to give you a clue of your ALT flare level:

Hepatology. 2001 Nov;34(5):1021-6.
Serum alanine aminotransferase flares during interferon treatment of chronic hepatitis B: is sustained clearance of HBV DNA dependent on levels of pretreatment viremia?
Nair S1, Perrillo RP.
Author information
Abstract
During interferon treatment of chronic hepatitis B, an alanine aminotransferase (ALT) flare may herald a sustained loss of viral replication, but the relationship between virologic response, the extent of a flare, and pretreatment hepatitis B virus (HBV) DNA level has not been defined. We retrospectively examined the impact of an ALT flare on sustained virologic response in 121 interferon-treated patients and 42 untreated controls with either low-level ( or =100 pg/mL) viremia. The degree of ALT flare was classified as mild (increase in ALT of 86-171 IU/L above baseline), moderate (increase of 172 to 343 IU/L above baseline), and severe (increase of > or =344 IU/L above baseline). Undetectable serum HBV DNA and hepatitis B e antigen (HBeAg) loss were significantly more likely at the end of follow-up in patients having a flare (P =.0001 and.001, respectively). In the high viremia group, a proportionate increase in virologic response was observed as the degree of flare increased. By multivariate analysis, high baseline HBV DNA, high pretreatment ALT, and both moderate and severe ALT flare were independently predictive of a virologic response with severe flare being the most powerful predictor for a sustained loss of serum HBV DNA (odds ratio, 5.3; P =.004). Severe flare was predictive of a virologic response in the high but not low viremia group. We conclude that a virologic response in patients with high-level viremia is dependent on the degree of ALT flare. Induction of a robust flare may enhance virologic response when high-level viremia is detected.
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Avatar_m_tn
Thank you Andrey19.

What I understand from the article above is that my viral load and e antigen are decreasing strongly and that is why my ALT flared, right?

Sorry for my poor English :(
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Avatar_m_tn
So, this is a good news for me, right?
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Avatar_m_tn
Hello Stef, andrey19, grmr, mustthinpositive, and other friends.

You know my last story (if you do not know, see above..)

I got the test results today.

HBV DNA came down from 55000 (it was 557 million 5 months ago) to 26000.

And my HBEAG is seroconverted. My ANTI-HBE is negative (1.57).

ALT is increased 90 to 347 in the last 2 months.

So, could you share your comments for the latest situation?
Shoul I be happy or be sad with the results?

Thnx.

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Avatar_m_tn
you are seroconverting hbeag and soon will have hbeab positive

the flare is low so it will probably take long for hbeab to become positive, the good thing is that hbsag goes very low usually, it would be good to have it tested too

just for you to compare, my natural hbeag seroconversion happened at about 18yo with 6 months of alt over 1500....to bad at that time there was only experimental use of peg and no hbsag quantitative even in research hospitals, add ing pegintf at that time (if my hbsag was low) would have cleared hbv for sure
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Avatar_m_tn
by the way it made no liver damage and liver was very little enlarged
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Avatar_m_tn
Dear Stef,

I thank you a lot for your valuable contribution.

I have a four questions for you and others;

1. "the good thing is that hbsag goes very low usually, it would be good to have it tested too" what do you exactly mean? I do not understand.

2. My ALT increased from 90 to 347. my immune system is activated to fight with HBEAG and produce ANTI-HBE. There are very effective natural supplements to lower down the ALT, such as; parsley cure and lavender cure. I tried lavender cure before my treatment (5 months ago). On the other hand, there are also very effective immune booster natural supplements (may increase ALT), such as; kephir. Should I try to lower my ALT with something lavender cure, or should I try to help my immune system (which may cause ALT increase) with something kephir?? Please answer this by considering my biopsy is F3 and fibroscan is 6.6

3. My HBV-DNA is still positive (26000) and my ANTI-HBE is negative. Is it a bad sign? Does it mean any drug resistance?

4. Is it possible that the seroconverting period makes me cirrhosis?
  
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Avatar_m_tn
Note that lavender cure decreased my ALT 197 to 90 5 months ago before treatment.
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Avatar_m_tn
1
test hbsag quantity otherwise you dont know what you are doing


2
you must not lower alt, you must increase it to clear hbv.do not take any antinflammatory or supplements with this action because they will weaken your immune response now

3
hbvdna is meanless, its lowering just means etv is working to lower it, no other meaning

4
no to make cirrrhosis you need 40-50years of high oxidative stress in the liver.alt can be 3000-5000 for 3-6months and make no fibrosis, it is not high alt to make fibrosis but the broken balance ebtween damage and repair thought to be due to oxidative stress
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Avatar_m_tn
thank you Stef.

My doctor told me that we should re-test HBVDNA after one month to see it increase or decrease. He added that if HBV DNA increases, we will change treatment. What do you think that if he get a bad signal?
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Avatar_m_tn
if hbvdna increases you need to combo entecavir plus tenofovir, that would be a good choice tdf has 16% hbsag clearance on hbeag pos, while entecavir only 5%
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Avatar_m_tn
Today I did qHBSAG test. This is the first time of it. What is the scala from bedt to worst?
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Avatar_m_tn

hbsag 1000iu/ml immune control and highest chances to clear hbsag by peginterferon, lowest hcc risk

on hbeag neg:
values higher than that have too much suppression on immune system so peginterferon works on small percentages of patients.pegintf can be tried on hbsag<7500iu/ml
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