Is liver biopsy still needed in children with chronic viral hepatitis?

Table 1 Indications for the liver biopsy in children with chronic hepatitis B according to the phase of the infection[21,22,29]

Phase of HBV infection	Immune-tolerant	Immune-active (-clearance)	Immune-inactive	Reactivation/HBeAg-negative chronic hepatitis
HBsAg	Detectable	Detectable	Detectable	Detectable
HBeAg	Detectable	Detectable	Undetectable (anti-HBe positive)	Undetectable (anti-HBe positive)
HBV DNA (IU/mL)/(copies/mL)	> 20000/> 105	> 20000/> 105	< 2000/< 104 or undetectable	> 2000/> 104
ALT	Normal	Persistently elevated	Normal	Normal or elevated
Histopathology: necroinflammation and fibrosis	Minimal or absent	Can develop	Liver inflammation absent or minimal, fibrosis regresses over time	Active liver inflammation +/- fibrosis
Liver biopsy	Generally not indicated	Indicated	Generally not indicated	Indicated, especially if ALT elevated
Antiviral therapy	Generally ineffective, risk of drug resistance; continued monitoring recommended	Should be considered	Continued monitoring recommended	Should be considered if moderate or severe inflammation or fibrosis detected

ALT: Alanine aminotransferase; HBV: Hepatitis B virus; HBsAg: Hepatitis B surface antigen; HBeAg: Hepatitis B e antigen.