Table 2.

Summary of Current International Guidelines and Clinical Recommendations Regarding Immune Tolerant Patients

Organization/Guidelines	Recommendations regarding immune tolerant patients
European Association for the Study of the Liver	Most patients under 30 years of age with persistently normal ALT levels, a high HBV DNA level (usually >107 IU/mL), no suspicion of liver disease, and no family history of HCC or cirrhosis do not require immediate liver biopsy or therapy. Follow-up is mandatory.
American Association for the Study of Liver Diseases	HBeAg-positive patients with persistently normal ALT levels should have their ALT levels tested at 3–6 month intervals. ALT and HBV DNA levels should be tested more often when ALT levels become elevated. HBeAg status should be checked every 6–12 months.
Asian Pacific Association for the Study of the Liver	Patients with viral replication but persistently normal or minimally elevated ALT levels should not be treated, except patients with advanced fibrosis or cirrhosis. Immune tolerant patients need adequate follow-up and HCC surveillance every 3–6 months.
National Institutes of Health Consensus	Therapy is not recommended for patients who are in the immune tolerant phase, which includes the presence of HBsAg, high HBV DNA levels, normal ALT levels, and liver histology showing mild or minimal inflammation and fibrosis.
US Algorithm	Younger patients are often immune tolerant. A biopsy should be considered, particularly if a patient is older than 35–40 years of age. Patients should be treated if there is evidence of histologic disease on liver biopsy. In the absence of biopsy, patients should be observed for elevation in ALT levels.

ALT

alanine aminotransferase

HBsAg

hepatitis B surface antigen

HBV

hepatitis B virus

HCC

hepatocellular carcinoma