Acute exacerbations of chronic hepatitis B virus (HBV) infection can lead to hepatic decompensation. It is important to identify factors that predict the development of hepatic decompensation during exacerbation so that antiviral therapy can be initiated immediately.

Acute exacerbation, defined by an abrupt increase in alanine aminotransferase (ALT) levels to more than 5-fold the upper limit of normal, occurred in 110 hepatitis B e antigen (HBeAg)-seropositive patients (138 episodes). The patients were monitored every 1 to 2 weeks for serum levels of ALT, bilirubin, albumin, and prothrombin. Patients who were seropositive for the antibody against HBeAg or evidence of cirrhosis were excluded. Sex, age, HBV genotype, ALT level, HBV viral load, and the causes (spontaneous or relapse from antiviral treatment) of exacerbation were included in multivariate logistic regression analyses. The receiver operating characteristic curve was used to identify the optimal cut-off value of serum HBV DNA level to identify patients at risk for decompensation.

Seven of the 138 episodes of acute exacerbation (5.1%) resulted in hepatic decompensation; serum HBV DNA level was the only significant risk factor (P = .003). The area under the receiver operating characteristic curve was 88.6% (P < .001). A serum HBV DNA cut-off value of 1.55 × 10⁹ copies/mL predicted decompensation with a sensitivity value of 85.7%, a specificity value of 85.5%, a negative prediction value of 99.1%, and positive prediction value of 24.0%.

During acute exacerbation of HBeAg-positive chronic hepatitis B, a serum HBV DNA cut-off value of 1.55 × 10⁹ copies/mL can be used to identify patients in need of immediate antiviral therapy.