Mr. G. is a 57-year-old man who came to the outpatient clinic for laboratory check up. Mr. G. mentioned that three years ago he travelled to his home country and had a hip replacement surgery. He needed blood transfusion after the surgery which resulted in an infection. He was treated at the local hospital at that time. However, he did not have any follow-up examination since then. At the clinic, Mr. G. states: “I have been feeling ill and weak for a month. My feet are swollen, my skin is dry and itchy, and I have no appetite at all.”

On examination:

• Height: 173 cm, Weight: 86.8 Kg, BMI: 29
• BP: 118/65 mmHg, Heart Rate: 94/min, Respiratory Rate: 16/min, Temperature: 37.0°C
• Mild jaundice, spider nevi on the chest, gynecomastia, palmar erythema, and 2+ pitting edema of the feet.

Based on the history and physical examination, what infection do you suspect Mr. G. had that is related to his current symptoms?

Mr. G's laboratory investigation showed: Blood analysis:

• • CBC:
    • RBCs: 3.7 x 10¹²/ L, Hemoglobin: 125 g/L, Hematocrit: 0.37,
    • MCV: 89 fL, MCH: 25 pg, RDW: 12.6%, Reticulocytes: 2.6 x 10⁹/ L, ESR: 14 mm/hour,
    • WBC: 5.9 x 10⁹/l, (Neutrophils: 2.7 x 10⁹/L, Lymphocytes: 4.0 x 10⁹/L, Basophils: 0.05. x 10⁹/L, Eosinophils: 0.22 x 10⁹/L, Monocytes: 0.3 x 10⁹/L),
    • Platelet counts: 97 x 10⁹/L
  • Na: 132 mmol/L, K: 3.5 mmol/L,
  • Glucose: 3.9 mmol/L, BUN: 8.0 mmol/L, creatinine: 115.2 umol/L, uric acid: 364 mmol/L
  • Triglycerides: 2.0 mmol/L, Cholesterol total: 3.9 mmol/L, LDL: 2.1 mmol/L, HDL: 0.8 mmol/L,
  • Total bilirubin: 52 umol/L, conjugated bilirubin: 31 umol/L, unconjugated bilirubin: 21 umol/L,
  • AST: 64 U/L, ALT: 86 U/L, ALP: 190 IU/L, GGT: 52 IU/L, 5'-NT: 18 IU/L, albumin: 28 g/L, globulins: 60 g/L, LDH: 232 U/L
  • INR: 2.5, Prothrombin time: 28 Sec
  • Iron: 22 umol/L, Ferritin: 111 pmol/L, Copper: 19 umol/L
  • Alpha fetoprotein: 19 mg/L
  • B₁: 10.8 umol/L
  • ANA, AMA, ALKM, ASM: negative

Viral serology:

Diagnostic marker	Result
HBsAg	positive
Anti-HBs	negative
Anti-HBc IgG	positive
HBV DNA	positive
HBeAg	positive
HAV IgG	negative
HCV Ab	negative
HDV Ag and Anti-HDV	negative

Urine analysis: color: dark yellow, pH: 6.7, specific gravity: 1025, osmolarity: 832 mOsm/L; glucose, nitrates, ketones: negative, bilirubin: +, bile salts: negative, urobilinogen: trace, WBCs and RBCs: 2 and 6/HPF, squamous epithelial cells: negative, casts, bacteria, yeast: negative, crystals: urate. How do you interpret the virus serology result considering the clinical history?

Select the laboratory findings that specifically indicate chronic (advanced) liver damage? (select all that apply)