Hôpital Cochin, AP-HP, Unité d'hépatologie, Inserm U567, Institut Cochin, Université Paris-Descartes, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex, France
The severity of hepatitis B virus (HBV) liver diseases and the occurrence of cirrhosis and its complications are related to sustained viral replication which results in necro-inflammation and induce significant morbidity and mortality which are related to hepatocellular carcinoma, portal hypertension (variceal hemorragae, ascites) and liver failure (enkephalopathy, spontaneous bacterial peritonitis). The immune-mediated pathobiology explain the therapeutic approaches which combine antivirals reducing the liver expression of viral antigens on one hand and immune stimulating drugs to improve suboptimal specific lymphocytotoxicity and induce the clearance of infected hepatocytes on the other hand. The ain of therapy is to obtain a complete viral suppression (undetectability of serum HBV DNA) which reduce viral (resistance/viral breakthrough) and liver risks (cirrhosis complications). Anypatient with active and fibrosing hepatitis and detectable HBV DNA (or abnormal transaminases levels) should be treated with a potent antiviral drug with a high genetic barrier, namely in 2009 entecavir or tenofovir. Inactivation of necro-inflammation after one year of therapy in most patients allows a biopsy-proven stabilisation of fibrosis then a reversal. After several years of viral suppression, liver biopsy will confirm a significant reversal of fibrosis in most of patients and cirrhosis reversibility after five-year in around 40% of patients without co-morbidities. Thus, at any time of chronic HBV-related hepatitis, viral suppression due to Interferon or nucleos(t)ides analogues results in a clinical benefit which reflects inactivation of necro-inflammation: decrease in fibrosis progression, fibrosis reversal, decrease in cirrhosis complications, cirrhosis reversal. These benefits are evidenced by the decline in HBV-related morbidity and mortality highlighting the need to reinforce screening of chronic infection, evaluation of its liver impact and treatment of any significant liver disease.