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Z Gastroenterol 2011; 49(7): 871-930
DOI: 10.1055/s-0031-1273462
Leitlinie

© Georg Thieme Verlag KG Stuttgart · New York

Aktualisierung der S 3-Leitlinie zur Prophylaxe, Diagnostik und Therapie der Hepatitis-B-Virusinfektion

AWMF-Register-Nr.: 021 / 011Prophylaxis, Diagnosis and Therapy of Hepatitis B Virus Infection – The German GuidelineM. Cornberg1 , U. Protzer2 , J. Petersen3 , H. Wedemeyer4 , T. Berg5 , W. Jilg6 , A. Erhardt7 , S. Wirth8 , C. Sarrazin9 , M. M. Dollinger10 , P. Schirmacher11 , K. Dathe12 , I. B. Kopp13 , S. Zeuzem14 , W. H. Gerlich15 , M. P. Manns16
  • 1Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover
  • 2Institut für Virologie, Technische Universität München
  • 3IFI Institut für Interdisziplinäre Medizin, Asklepios-Klinik St. Georg
  • 4Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover
  • 5Klinik und Poliklinik für Gastroenterolgie und Rheumatologie, Sektion Hepatologie, Universitätsklinikum Leipzig
  • 6Institut für Medizinische Mikrobiologie und Hygiene, Universität Regensburg
  • 7Klinik für Gastroenterologie, Hepatologie und Infektologie, Heinrich-Heine-Universität Düsseldorf
  • 8Zentrum für Kinder- und Jugendmedizin, Universität Witten-Herdecke
  • 9Medizinische Klinik I, Johann Wolfgang Goethe-Universität
  • 10Klinik und Poliklinik für Innere Medizin I, Martin-Luther-Universität Halle-Wittenberg
  • 11Pathologisches Institut, Universitätsklinikum Heidelberg
  • 12Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten
  • 13AWMF-Institut für Medizinisches Wissensmanagement, c/o Philipps-Universität
  • 14Medizinische Klinik I, Johann Wolfgang Goethe-Universität
  • 15Institut für Med. Virologie
  • 16Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover
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Publication History

Publication Date:
11 July 2011 (online)

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Inhaltsverzeichnis Vorwort und Methodik 872 Einleitung 876 1 Definition der Hepatitis B und Hepatitis Delta und Empfehlungen zur Diagnostik 877 Indikation zur Durchführung einer Hepatitis-B-Virus-Diagnostik 878 1.1 Bei welchen Personen soll eine Diagnostik erfolgen? 878 1.2 Wie ist das weitere Vorgehen nach initialer HBV-Diagnostik? 878 1.3 Wie wird eine Infektion mit dem HBV diagnostiziert? Welche serologischen Parameter sollten initial, welche im Verlauf bestimmt werden? 879 1.4 Wann ist eine Hepatitis-Delta-Virus-Diagnostik indiziert? Wie wird eine Hepatitis Delta diagnostiziert? 880 1.5 Welche weitere Diagnostik ist bei Erstdiagnose einer HBV-Infektion erforderlich? 881 1.6 Bei welchen Patienten ist eine Leberbiopsie indiziert? 881 1.7 Wie sollte das Follow-up einer Hepatitis B bei fehlender Therapie-Indikation aussehen? 882 1.8 Wie sollte das Therapie-Monitoring bei chronischer Hepatitis B aussehen? 882 2 Indikationsstellung zur Therapie der Hepatitis B 883 2.1 Kann die klinische Heilungsrate durch eine antivirale Therapie erhöht werden? Kann durch eine antivirale Therapie die Krankheitsdauer verkürzt und die Schwere der Erkrankung reduziert werden? 883 2.2 Welche Patienten sollten therapiert werden? 883 2.3 Sollen HBV-Patienten mit Alkohol- und Drogenkonsum antiviral behandelt werden? 884 3 Therapie der Hepatitis B 885 3.1 Was sind die Ziele der Therapie der chronischen Hepatitis B? 885 3.2 Welche grundsätzlichen Fragen sind bei der Therapieplanung der Hepatitis B zu berücksichtigen? 886 3.3 Bei welchen Patienten soll eine Behandlung mit Interferon alpha erwogen werden? 886 3.4 Wie sind Therapieansprechen und Resistenz definiert? 889 3.5 Wie ist das Vorgehen bei nicht ausreichendem Therapieansprechen oder Resistenzentwicklung? 890 3.6 Was ist bei Langzeittherapie mit Nukleosid- oder Nukleotid-Analoga zu beachten? 890 3.7 Wie lange soll eine antivirale Therapie der Hepatitis B mit Nukleosid- oder Nukleotid-Analoga fortgeführt werden? 893 3.8 Wie sollten HBV-Patienten mit Leberzirrhose antiviral behandelt werden? 893 3.9 Wie sollen Patienten mit extrahepatischen Manifestationen behandelt werden? 894 3.10 Wie sollen Patienten mit eingeschränkter Nierenfunktion und Dialysepatienten behandelt werden? 894 3.11 Welche Behandlungsempfehlungen werden für schwangere HBsAg-positive Patientinnen gegeben? 894 3.12 Wie kann eine Hepatitis-B-Reaktivierung unter Immunsuppression verhindert werden? 895 4 Infektionen mit Hepatitis-B-Viren im Zusammenhang mit Organtransplantationen (Management prä- und post-Tx) 897 4.1 Wie ist das Management von Patienten mit HBV-Infektion vor LTx? 897 4.2 Was versteht man unter einer HBV-Reinfektion? 897 4.3 Wie ist das Management von Patienten mit HBV-Infektion nach LTx? Wie erfolgt die Reinfektionsprophylaxe? 898 4.4 Wie ist das therapeutische Vorgehen bei nachgewiesener HBV-Reinfektion? 899 4.5 Wie ist das Management von HBV-infizierten Patienten mit kombinierter Organtransplantation (z. B. Leber plus Niere)? 899 4.6 Wie ist das Management von Patienten, die für eine Transplantation anderer Organe (nicht LTx) evaluiert werden? 900 4.7 Wie ist das Management von Patienten mit positiver HBV-Serologie nach Transplantation anderer Organe (nicht LTx)? Wann, wie und bei wem wird eine Prophylaxe durchgeführt? 900 4.8 Wie ist das Management von Patienten vor und nach KMT/SZT? Wann, wie und bei wem wird eine antivirale Therapie bzw. Prophylaxe durchgeführt? 900 4.9 Wie ist das Management von Patienten mit De-novo-HBV-Infektion nach Organtransplantation? 901 4.10 Wie ist das Management von Patienten, die ein Anti-HBc-positives Organ erhalten? 901 4.11 Wer sollte vor einer Organtransplantation gegen HBV geimpft werden? 902 5 Immunprophylaxe der Hepatitis B 902 5.1 Wer soll gegen Hepatitis B geimpft werden? 903 5.2 Wann sollte die Impfung gegen Hepatitis B durchgeführt werden? 903 5.3 Ist es vor einer Hepatitis-B-Impfung notwendig zu testen, ob bereits Kontakt mit dem Hepatitis-B-Virus stattgefunden hat? 904 5.4 Ist es nach einer Hepatitis-B-Impfung notwendig zu testen, ob die Impfung erfolgreich war? 904 5.5 Ist nach erfolgreicher Impfung gegen Hepatitis B eine Auffrischimpfung notwendig? 905 5.6 Wie ist bei Nichtansprechen auf die Hepatitis-B-Impfung (Anti-HBs nach drei Impfungen < 10IU/l) zu verfahren? 905 5.7 Wie ist bei Personen zu verfahren, deren Anti-HBs-Konzentration 4 – 8 Wochen nach Grundimmunisierung 10 – 99 IU/l beträgt (gesunde Lowresponder)? 905 5.8 Was ist bei der Impfung von Immunsupprimierten generell zu beachten? 906 5.9 Wie ist die Postexpositionsprophylaxe bei Neugeborenen durchzuführen? 906 5.10 Wie ist bei nicht gegen Hepatitis-B-Immunen im Falle eines Kontakts mit HBV-haltigem Material zu verfahren? 907 5.11 Gibt es Kontraindikationen gegen eine Hepatitis-B-Impfung? 907 6 HBV-Koinfektionen 907 6.1 Bei welchen Patienten mit HDV-Infektion soll eine Therapie durchgeführt werden? Wie soll die antivirale Therapie durchgeführt werden? 907 6.2 Bei welchen Patienten mit HBV/HCV-Koinfektion soll eine Therapie durchgeführt werden? Wie soll die antivirale Therapie durchgeführt werden? 908 6.3 Sollen Patienten mit HBV/HIV-Koinfektion regelmäßig untersucht werden? Bei welchen Patienten mit HBV/HIV-Koinfektion soll eine Therapie durchgeführt werden? 909 6.4 Wie soll die antivirale Therapie bei Patienten mit HBV/HIV-Koinfektion durchgeführt werden? Welche Besonderheiten in der Therapie sind aufgrund der HIV-Koinfektion zu berücksichtigen? 910 6.5 Wie soll die antivirale Therapie bei Patienten mit HBV/HIV-Koinfektion überwacht werden? 910 6.6 Bei welchen Patienten mit Dreifach- und Vierfach-Infektionen soll eine Therapie durchgeführt werden? Wie soll die antivirale Therapie durchgeführt werden? Welche Besonderheiten in der Therapie müssen aufgrund der HIV-Koinfektion berücksichtigt werden? 912 7 Hepatitis B im Kindes- und Jugendalter 912 7.1 Wie wird die Diagnose gestellt? 913 7.2 Welche Therapiemöglichkeiten und -ziele bestehen bei einer Hepatitis B im Kindesalter? 914 7.3 Welche Therapiemöglichkeiten und -ziele bestehen bei einer chronischen Hepatitis B im Kindes- und Jugendalter? 914 7.4 Mit welchen Medikamenten bestehen im Kindes- und Jugendalter Therapieerfahrung? 914 7.5 Welche prophylaktischen Maßnahmen sind sinnvoll? 915 7.6 Können Neugeborene HBsAg-positiver Mütter nach postpartaler aktiver und passiver Immunisierung gestillt werden? 916 Literatur 917

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17 1 Minderheitenveto: Einige Virologen forderten darüber hinaus gehend, dass in jedem Fall vor Beendigung der Therapie eine negative HBV-DNA vorliegen soll (entspricht Empfehlungsgrad A).

Prof. Dr. med. Michael P. Manns

Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover

Carl-Neuberg-Str. 1

30623 Hannover

Phone:  ++ 49/5 11/5 32 33 05

Fax:  ++ 49/5 11/5 32 48 96

Email: manns.michael@mh-hannover.de