Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance

High HBsAg clearance rate and viral dynamics in HBeAg-positive, ALT-normal children and adolescents with chronic HBV infection: results from the prospective sprout project

Hepatitis B e antigen (HBeAg)-positive chronic hepatitis B virus (HBV) infection in children and adolescents with normal alanine aminotransferase (ALT) levels constitutes a substantial population in China, yet the optimal timing for antiviral therapy remains unclear. This prospective, real-world study, conducted as the primary centre of the Sprout Project, evaluated the hepatitis B surface antigen (HBsAg) loss rate and viral-immune dynamics of pegylated interferon α (PEG-IFN-α) treatment in 85 chronic HBV patients aged 3-18 years over a 24-month period. A total of 27 HBeAg-positive, ALT-normal patients were selected for analysis. Patients were treated with a combination of PEG-IFN-α and entecavir. After 24 months, the overall HBsAg loss rate was 48.15%, with 47.37% in the immune-tolerant phase and 50% in the grey zone phase. Among those who cleared HBsAg, 84.62% had ALT elevation prior to anti-HBsAg antibody (HBsAb) seroconversion, which occurred 28-400 days before HBsAg loss. While HBsAg and HBV DNA were cleared by 24 months in the HBsAg loss group, 23.08% of children remained HBeAg-positive. Notably, 61.54% developed detectable HBsAb prior to HBsAg loss. Children aged 3-7 years had significantly higher clearance rates than those aged 8-18 years. These findings support the effectiveness of PEG-IFN-α combined with nucleos(t)ide analogs in achieving high HBsAg loss rates in young, HBeAg-positive, ALT-normal chronic HBV children and adolescents, with immune activation potentially preceding ALT elevation, and offers valuable insights into the viral-immune dynamics during treatment, highlighting the potential of antiviral therapy in this population.

The significance of antibody to hepatitis B surface antigen in infection and clearance of hepatitis B virus

One of the key features of chronic hepatitis B virus (HBV) infection is the inability to mount sufficient and coordinated adaptive immune responses against HBV. Recent studies on HBV-specific B cells and antibody to hepatitis B surface antigen (anti-HBs) have shed light on their role in the pathogenesis of chronic hepatitis B (CHB). Anti-HBs is recognized as a protective immune marker, both for HBV infection clearance and following vaccination, and it is also considered an important indicator of functional cure for CHB. Notably, functional impairment of HBV-specific B cells may be reversible. The restoration of HBV-specific B cell function, along with the induction of an anti-HBs antibody response, is regarded as pivotal for terminating chronic HBV infection and achieving functional cure. This article reviews the significance of anti-HBs in both the infection and clearance of HBV, and discusses the potential of neutralizing antibodies and therapeutic vaccines as promising future strategies.

Identifying liver cirrhosis in patients with chronic hepatitis B: an interpretable machine learning algorithm based on LSM

BACKGROUND

Chronic hepatitis B (CHB) is a common cause of liver cirrhosis (LC), a condition associated with an unfavourable prognosis. Therefore, timely diagnosis of LC in CHB patients is crucial.

OBJECTIVE

This study aimed to enhance the diagnostic accuracy of LC in CHB patients by integrating liver stiffness measurement (LSM) with traditional indicators.

METHODS

The study participants were randomly divided into training and internal validation sets. Employing the least absolute shrinkage and selection operator (LASSO) and random forest-recursive feature elimination (RF-RFE) for feature selection, we developed both traditional logistic regression and five machine learning models (k-nearest neighbors, random forest (RF), artificial neural network, support vector machine and eXtreme Gradient Boosting). Performance evaluation included receiver operating characteristic curves, calibration curves and decision curve analysis. Shapley additive explanations (SHAP) was employed to improve the interpretability of the optimal model.

RESULTS

We retrospectively included 1609 patients with CHB, among whom 470 were diagnosed with cirrhosis. Cirrhosis was diagnosed based on histological confirmation or clinical assessment, supported by characteristic findings on abdominal ultrasound and corroborative evidence such as thrombocytopenia, varices or imaging from CT/MRI. In the internal validation, the RF model achieved an accuracy above 0.80 and an AUC above 0.80, with outstanding calibration ability and clinical net benefit. Additionally, the model exhibited excellent predictive performance in an independent external validation set. The SHAP analysis indicated that LSM contributed the most to the model. The model still showed strong discriminative power when using only LSM or traditional indicators alone.

CONCLUSIONS

Machine learning models, especially the RF model, can effectively identify LC in CHB patients. Integrating LSM with traditional indicators can enhance diagnostic performance.

Performance evaluation of the access anti-HBc IgM Assay on the DxI 9000 access immunoassay analyzer

This study evaluated the diagnostic and analytical performances of the Access anti-HBc IgM assay (Access assay) for use on the DxI 9000 Access Immunoassay Analyzer. Prospectively and retrospectively collected samples were tested with Access and a comparator assay with use of a second comparator for discrepant resolution to determine final anti-HBc IgM sample status. Specificity of Access was 100.00 % (99.65 - 100.00 %) on 1,098 anti-HBc IgM negative blood donor samples, 100.00 % (98.74 - 100.00 %) on 300 anti-HBc IgM negative hospitalized patient samples and 94.08 % (89.45 - 96.75 %) on 169 anti-HBc IgM negative acute/recent and chronic HBV infected patient samples. Sensitivity was 100.00 % (98.42 - 100.00 %) on 239 anti-HBc IgM positive acute/recent and chronic HBV infected patient samples. Seroconversion panels showed mean first day of detection 3.2 days earlier with Access than with the comparator assay. Maximum reproducibility on positive samples was 8.6 % coefficient of variance (CV) and 0.048 S/CO standard deviation (SD) on negative samples. The Access anti-HBc IgM assay demonstrated excellent diagnostic and analytical performances comparable to other current CE-marked anti-HBc IgM assays.

Real-world Prevalence of Hepatitis B Reactivation in Patients With Resolved Hepatitis B Receiving Rituximab and Non-rituximab-based Immunosuppressive Therapy Without Chemoprophylaxis

Background

Hepatitis B virus reactivation (HBVr) can occur in patients with resolved hepatitis B virus (HBV) infection receiving immunosuppressive therapy. The class of immunosuppression influences HBV reactivation (HBVr) risk, with B-cell depleting agents such as Rituximab conferring a higher risk. The presence of hepatitis B surface antibodies (HBsAb) may be protective against HBVr.

Objective

To compare the rates of HBVr amongst individuals with resolved HBV infection receiving rituximab and non-rituximab immunosuppressive therapy, without chemoprophylaxis. Our secondary objective was to explore the role of HBsAb in risk stratification for HBVr.

Methods

We retrospectively collected the data of patients with resolved HBV infection receiving immunosuppressants between 2014 and 2022. HBVr rates amongst patients receiving rituximab and non-rituximab therapy were compared. Logistic regression analysis was performed to identify risk factors for HBVr.

Results

148 patients with resolved HBV infection did not receive chemoprophylaxis. Of the 20 (13.5%) patients who developed HBVr, none developed HBV flare. 42 of the 148 (28.3%) patients received rituximab-based therapy. Patients who received rituximab had a higher risk of HBVr, 12(28.6%) vs 8(7.5%), P = 0.001. This was confirmed on multivariable analysis (OR 4.19 [C.I. 1.47-11.9], P = 0.007). HBsAb titres of above 100 mIU/ml were protective against HBVr (OR 0.04 [CI 0.001-0.84], P = 0.039) in the rituximab exposed cohort, but not in the non-rituximab exposed cohort.

Conclusion

The risk of HBVr was higher in patients receiving rituximab; however, no patient developed HBV flare. In patients with resolved HBV infection, the presence of HBsAb titres above 100 mIU/ml may confer additional protection against HBVr and can be used as part of risk stratification for HBVr. In such patients, close surveillance with on-demand therapy instead of chemoprophylaxis may be considered.

Emerging and potential use of CRISPR in human liver disease

CRISPR is a gene editing tool adapted from naturally occurring defense systems from bacteria. It is a technology that is revolutionizing the interrogation of gene functions in driving liver disease, especially through genetic screens and by facilitating animal knockout and knockin models. It is being used in models of liver disease to identify which genes are critical for liver pathology, especially in genetic liver disease, hepatitis, and in cancer initiation and progression. It holds tremendous promise in treating human diseases directly by editing DNA. It could disable gene function in the case of expression of a maladaptive protein, such as blocking transthyretin as a therapy for amyloidosis, or to correct gene defects, such as restoring the normal functions of liver enzymes fumarylacetoacetate hydrolase or alpha-1 antitrypsin. It is also being studied for treatment of hepatitis B infection. CRISPR is an exciting, evolving technology that is facilitating gene characterization and discovery in liver disease and holds the potential to treat liver diseases safely and permanently.

Serum Golgi Protein 73 as a Predictor of Virologic Response to Entecavir Antiviral Therapy in Patients with Chronic Hepatitis B and Liver Fibrosis: A Retrospective Study

PURPOSE

Golgi protein 73 (GP73) facilitates hepatitis B virus (HBV) replication, and it is associated with persistent infection in patients with chronic hepatitis B (CHB). However, the predictive value of serum GP73 (sGP73) for virologic response (VR) remains unexplored. This study evaluated the value of sGP73 in predicting VR in patients with CHB and liver fibrosis during initial antiviral therapy with entecavir (ETV).

METHODS

In total, 235 patients with CHB and liver fibrosis were included in this retrospective cohort study. The patients received antiviral therapy with ETV for 48 weeks, and sGP73 levels and virologic markers were examined every 12 weeks for 48 weeks. The performance of sGP73 for VR was evaluated using the receiver operating characteristic (ROC) curve method.

FINDINGS

Patients who achieved VR at 48 weeks exhibited significantly lower baseline sGP73. Correlation analysis revealed significant positive associations of baseline sGP73 with HBV DNA and alanine aminotransferase (ALT). Using a cutoff of 105.9 ng/mL, patients with baseline sGP73 ≤ 105.9 ng/mL had a significantly higher cumulative VR rate. In the performance evaluation of sGP73 in predicting VR at 48 weeks, the area under the ROC curve (AUC) was 0.770 [95% confidence interval (CI) = 0.711-0.822), which was higher than that for ALT (AUC = 0.624; 95% CI = 0.558-0.687) and HBV DNA (AUC = 0.626; 95% CI = 0.559-0.688).

IMPLICATIONS

This study demonstrated the predictive value of sGP73 for VR, suggesting its potential as a novel biomarker for predicting VR in patients with CHB. The correlation between changes in GP73 and HBV DNA levels may be related to inflammation.

Scoping Review on Strategies for Safe Nucleot(s)ide Analogue Discontinuation and Optimising Functional Cure in Chronic Hepatitis B

Chronic hepatitis B (CHB) remains a global health challenge, contributing to significant morbidity and mortality. While long-term nucleos(t)ide analogue (NA) therapy effectively suppresses viral replication, achieving a functional cure remains rare. Current treatment guidelines primarily recommend indefinite therapy. However, long-term NA use poses many challenges, prompting interest in finite therapy. Recent studies suggest that carefully selected patients may safely discontinue NAs, leading to a functional cure in some cases. This review evaluates the latest evidence on NA discontinuation, highlighting key factors influencing outcomes. This review synthesises established and emerging evidence on NA discontinuation in CHB. It explores early studies that identified quantitative HBsAg (qHBsAg) as a predictor of sustained response and HBsAg seroclearance, followed by systematic reviews and meta-analyses reinforcing finite therapy as a feasible approach. Advances in predictive modelling, incorporating biomarkers, have refined patient selection for safe NA withdrawal. Additionally, this review assesses the risks associated with NA discontinuation, highlighting the importance of identifying high-risk patients for hepatic decompensation. Ethnicity-specific qHBsAg cut-offs are also discussed, recognising variations in treatment response between Asian and Caucasian populations. Finite NA therapy is emerging as a viable approach for achieving functional cure. Future strategies should integrate liver fibrosis assessment to enhance patient selection before NA discontinuation. Optimising re-treatment approaches requires balancing timing, immune response, and qHBsAg kinetics to maximise HBsAg seroclearance. Clinical perspectives on NA discontinuation remain a key research priority, necessitating standardised guidelines and improved post-NA monitoring strategies to ensure safe and effective finite therapy in CHB management.

Pien Tze Huang plus entecavir improves hepatic fibrosis in Chinese patients with chronic hepatitis B

BACKGROUND

Pien Tze Huang (PTH), a well-established traditional Chinese medicine compound, has exhibited anti-hepatic fibrosis properties both in vitro and in vivo animal models, but the randomized clinical trials to evaluate anti-hepatic fibrosis efficacy of PTH are deficient. Chronic hepatitis B (CHB) is a leading cause of hepatic fibrosis in China. Although antiviral therapies have demonstrated significant effectiveness in arresting the progression of fibrotic disease, complete regression of established fibrosis is limited to only a subset of treated patients.

PURPOSE

To assess the efficacy of PTH in improving hepatic fibrosis in CHB patients.

STUDY DESIGN

We conducted a randomized, double-blind, placebo-controlled clinical trial involving 144 CHB patients with hepatic fibrosis. This study was carried out from September 2020 to April 2023. (Clinical Trials Registration: ChiCTR2000035128) METHODS: CHB patients with an Ishak score of 2-5 points were recruited from ten hospitals across China. Participants were randomized in 1:1 ratio to receive either oral PTH (0.6 g per dose, three times/day) or placebo for 48 weeks, in addition to the standard treatment of entecavir (0.5 mg/day). The primary endpoint was the change in Ishak score. Secondary outcomes included changes in Knodell HAI score, liver stiffness measurement, AST- to -platelet ratio index, Fibrosis-4 index and hepatic function indices.

RESULTS

Of the 144 randomized patients, 142 patients (71 in the PTH group and 71 in the placebo group) were included in the primary analysis. The PTH group exhibited lower Ishak score compared to the control group (2.37 ± 0.94 vs. 2.87 ± 1.04, F = 6.072, p = 0.015). Notably, in treatment-naive patients, the PTH group showed significant improvement in Ishak score post-treatment compared with the control group (2.13 ± 0.72 vs. 2.74 ± 1.07, F = 6.336, p = 0.014). However, no significant changes were observed in these parameters among patients already receiving antiviral therapy.

CONCLUSIONS

The combination of PTH and entecavir demonstrates significant improvement in hepatic fibrosis among CHB patients, especially those who are treatment-naive patients.

Efficacy and Safety of Tenofovir Plus Entecavir Combination Therapy Versus Tenofovir Monotherapy in Chronic Hepatitis B Virus Patients With Resistance or Partial Response to Entecavir: A Systematic Review and Meta-analysis

Background and objectives

Chronic hepatitis B virus remains a significant cause of liver disease in the developing world, leading to sequelae such as hepatocellular carcinoma. While entecavir (ETV) serves as a first-line treatment, its growing resistance rates underscore the need to explore viable alternatives. Tenofovir disoproxil fumarate (TDF) monotherapy and entecavir plus tenofovir (TDF + ETV) combination therapy are both employed as treatments, but one's efficacy over another is in question. This meta-analysis aims to investigate any primacy of either treatment.

Methods

We conducted a comprehensive literature search across PubMed/Medline, Embase, Cochrane Central, Web of Science, and China National Knowledge Infrastructure from inception till 7th October 2024. Studies comparing the safety and efficacy of TDF monotherapy versus TDF + ETV combination therapy in patients resistant to entecavir were considered. Data about the virologic response (VR), virologic breakthrough, HbeAg seroconversion, HbeAg/HbsAg seroclearance, and alanine aminotransferase normalization were extracted. Relative risks (RRs) and their corresponding 95% confidence intervals (CIs) were calculated, pooled, and analyzed in a random-effects model. P-value <0.05 was regarded as significant for all analyses.

Results

Nine studies, comprising 335 patients undergoing monotherapy and 352 patients undergoing combination therapy, satisfied the criteria. TDF + ETV combination therapy was found slightly advantageous to TDF monotherapy, stimulating a VR at 48 weeks (RR 1.081 95% CI: [1.001-1.167] P = 0.046, I2 = 0%), along with the HbeAg seroconversion rate (RR 1.711 95% CI: [1.005-2.913] P = 0.048, I2 = 0%). There were no significant adverse events in individual studies to warrant a meta-analysis.

Conclusions

TDF + ETV shows slightly better efficacy to TDF monotherapy over a 48-week treatment regimen, with minimal safety concerns. However, further high-quality studies like randomized controlled trials are needed to further solidify conclusions, with this meta-analysis only achieving borderline significances.

Registration

This review is registered on the PROSPERO database (ID: CRD42024581443).

Hope on the horizon: Emerging therapies for hepatitis D

Current treatment options for hepatitis D are limited, with pegylated interferon-alpha (PEG-IFNα) being the only therapy available in the Asia-Pacific region. However, PEG-IFNα has limited efficacy and significant side effects. Pegylated interferon lambda acts on interferon-lambda (Type III) receptors predominantly expressed in hepatocytes. In 2023, bulevirtide was approved in the European Union and Russia for treating chronic hepatitis D. This drug works by binding to and inhibiting the sodium taurocholate co-transporting polypeptide receptor on liver cells, which is the primary entry point for the virus. Recently, several new drugs have entered various stages of development, offering hope for improved hepatitis D virus (HDV) management. Two more viral entry inhibitors are HH003 and tobevibart. Other agents include nucleic acid polymers (REP 2139-Mg), prenylation inhibitors (lonafarnib), and RNA interference-based therapies (elebsiran). Emerging trials are now considering combination therapies, such as SOLSTICE, a Phase 2 clinical trial evaluating tobevibart alone or combined with elebsiran. The combination dosed monthly achieved > 50% virologic and biochemical response at 24 weeks of therapy. The efficacy and safety of these drugs will further be evaluated in ECLIPSE 1, 2, and 3 trials. With these new treatments on the horizon, the prospects for improved HDV patient outcomes are promising.

Review Article: Drug-Induced Liver Injury Associated With Antibody-Based Therapies in Haematologic Malignancies

BACKGROUND

Drug-induced liver injury (DILI) is a leading cause of liver damage. It is especially prevalent in haematologic malignancies, complicating treatment regimens and posing a risk for severe outcomes such as acute liver failure. Antibody-based therapies have significantly improved treatment outcomes. However, these therapies are increasingly associated with liver injury, posing challenges in clinical management.

AIMS

This review aims to examine the DILI associated with antibody-based therapies in haematologic malignancies, highlighting key mechanisms, risk factors, clinical management strategies, and identifying areas that require further research.

METHODS

We conducted a comprehensive review of the literature on DILI induced by antibody-based therapies, including monoclonal antibodies, antibody-drug conjugates, and T-cell redirecting antibodies, specifically in the context of haematologic malignancies.

RESULTS

DILI associated with antibody-based therapies varies from mild transaminase elevations to severe liver injury. Risk factors include pre-existing liver disease, genetic predisposition, and therapy-specific mechanisms such as immune-mediated liver damage or direct hepatotoxic effects. Current management strategies involve routine liver function monitoring, dose modifications, and therapy discontinuation in severe cases. However, standardised guidelines remain lacking.

CONCLUSIONS

DILI remains a major challenge in the use of antibody-based therapies for haematologic malignancies. While progress has been made in understanding risk factors and management strategies, further research is essential to optimise patient care and balance therapeutic efficacy with liver toxicity risks.

Hepatitis B surface antigen level identifies patients with inactive chronic hepatitis B from Asia with HCC risk below surveillance threshold

BACKGROUND

Chronic hepatitis B (CHB) is a major global health concern primarily due to hepatocellular carcinoma (HCC) development.

OBJECTIVE

This study aimed to identify patients with inactive CHB with negligible HCC risk using hepatitis B surface antigen (HBsAg) levels, which is the key to define partial HBV cure.

DESIGN

Data from 2674 patients with inactive CHB (non-cirrhotic, hepatitis B e antigen negative, normal alanine transaminase (ALT), HBV DNA <2000 IU/mL) in the ERADICATE-B and REVEAL-HBV cohorts were analysed. The primary endpoint was HCC development, with HBsAg levels used to identify patients with annual HCC risk <0.2%. Results were validated using the NTUH-iMD cohort.

RESULTS

Over a median follow-up of 26.3 years, 76 patients developed HCC. Among 989 patients with inactive CHB with HBsAg<100 IU/mL, the annual HCC incidence was 0.08% (95% CI 0.05% to 0.13%), lower than those with HBsAg≥100 IU/mL (adjusted HR 0.35, 95% CI 0.21 to 0.61). Their HCC risk was lower than the recommended threshold for HCC surveillance and was close to the risk of the general population. Even for older patients recommended for HCC surveillance, those with HBsAg levels <100 IU/mL were associated with HCC risk lower than the surveillance threshold. Moreover, patients with inactive CHB with negligible HCC risk could be identified by combining HBsAg <100 IU/mL and normal ALT levels, without the need for HBV DNA testing, as validated in the NTUH-iMD cohort.

CONCLUSION

Serum HBsAg levels <100 IU/mL effectively identify patients with inactive CHB with negligible HCC risk and limited viral activity, which is important in optimising surveillance strategies and defining partial HBV cure.

Non-invasive risk-based surveillance of hepatocellular carcinoma in patients with metabolic dysfunction-associated steatotic liver disease

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) affects over 30% of the general population and is the fastest growing cause of hepatocellular carcinoma (HCC). Current guidelines recommend HCC surveillance in patients with cirrhosis when annual HCC incidence exceeds 1% without specifying the role of non-invasive tests in patient selection.

OBJECTIVE

To define non-invasive test thresholds to select patients with MASLD for HCC surveillance.

DESIGN

A multicentre longitudinal study of adults with MASLD from 16 tertiary centres in the USA, Europe and Asia between February 2004 and January 2023. Primary outcome was incident HCC.

RESULTS

12 950 patients had Fibrosis-4 index (FIB-4) and liver stiffness measurement (LSM) (mean age 51.7 years; 41.1% male). At a median follow-up of 47.7 (IQR 23.3-72.3) months, 109 (0.8%) developed HCC. FIB-4 was below the low cut-off (<1.3 if aged <65 years and <2.0 if aged ≥65 years), between the low cut-off and <2.67, 2.67 to <3.25, and ≥3.25 in 66.3%, 23.9%, 3.4% and 6.4% of patients; the corresponding annual HCC incidence was 0.07%, 0.17%, 0.77% and 1.18%. As a stand-alone test, the annual HCC incidence exceeded 0.2% for LSM ≥10 kPa and 1% for LSM ≥20 kPa. If LSM was performed as a second step only among patients with FIB-4 above the low cut-off, the annual HCC incidence exceeded 0.2% for LSM ≥10 kPa and 1% for LSM ≥15 kPa.

CONCLUSION

HCC surveillance should be offered to patients with MASLD with FIB-4 ≥3.25 or LSM ≥20 kPa. When a two-step approach is adopted, LSM ≥15 kPa in patients with increased FIB-4 predicts a high HCC risk.

Update on the management of HDV infection: current events and perspectives

HDV infection has long been, and continues to be, a significant challenge. Chronic liver disease related to HDV is one of the most aggressive forms of liver disease, carrying a high risk of progression to cirrhosis and decompensated liver disease. Although an estimated 12 to 72 million people worldwide have been exposed to HDV, the prevalence of HDV-related conditions is believed to be underreported, and further epidemiological studies are needed to better understand its scope. In this context, screening for anti-HDV in all HBsAg-positive individuals could help identify undiagnosed cases of HDV, regardless of known risk factors. While certain groups are at higher risk for HDV infection, more than half of individuals with HDV infection have no identifiable risk factors. Simultaneously, the risk factors for severe disease progression remain poorly defined, although persistent and/or high viral load, along with elevated cytolysis indices, appear to be linked to a more severe disease prognosis. Once HDV infection is diagnosed, treatment becomes necessary, especially given the limited therapeutic options available. Until recently, interferon-α was the only treatment option, but it came with challenges, including poor tolerability and suboptimal virological response rates. In July 2020, the European Medicines Agency (EMA) approved Bulevirtide, a new drug for the treatment of HDV. Bulevirtide not only offered a novel therapeutic option for HDV but also marked a milestone in the history of HDV treatment. However, while this new drug represents a significant advance, there are still several aspects that need further clarification and exploration.

Improvement in renal function after switching from entecavir to tenofovir alafenamide in chronic hepatitis B patients with low estimated glomerular filtration rates

INTRODUCTION AND OBJECTIVES

Tenofovir alafenamide (TAF) and entecavir (ETV) are both considered renal-friendly nucleoside/nucleotide analogs (NAs). However, the difference between ETV and TAF in terms of renal function remains unclear. This study aims to compare the renal safety profiles of two antiviral medications directly and evaluate the impact of switching from ETV to TAF treatment on renal function in chronic hepatitis B (CHB) patients with low estimated glomerular filtration rates (eGFR).

PATIENTS AND METHODS

A total of 179 CHB patients who received TAF (n=84) or ETV (n = 95) between 2019 and 2023 were included in the study. Changes in eGFR levels between two treatment groups from baseline to 72 weeks were compared to measure the influence of these NAs on renal function.

RESULTS

At baseline, 84 patients were included in each treatment group after a 1:1 propensity score matching process. At week 48, a notable different changes in eGFR were observed between the two groups. Gender, baseline eGFR, and medication (TAF/ETV) were significantly correlated with eGFR abnormalities. Furthermore, eGFR abnormalities at week 48 led to the transition of 6 patients in the ETV group to TAF. eGFR significantly increased (83.60 ± 5.45 vs. 93.39 ± 9.88 mL/min/1.73 m2; p=0.031) and serum creatinine significantly decreased (81.47±11.36 vs. 74.9±10.67 μmol/L; p=0.046) from week 48 to 60. At week 48, the incidence of low-level viremia (LLV) was 19.0% in the ETV group and 16.7% in the TAF group, respectively (p>0.05). Pairwise comparisons revealed no significant difference in the percentage of LLV between the ETV continued group and the TAF continued group at week 48, 60, and 72. Additionally, there was also no significant difference in the proportion of LLV between the ETV+TAF combination group and the TAF+ETV combination group at week 48, 60, and 72.

CONCLUSIONS

There was a substantial difference in eGFR between ETV and TAF treatments at week 48. Gender, baseline eGFR, and medication (TAF/ETV) were all remarkably positive indicators of eGFR abnormalities. In patients receiving ETV, an early switch to TAF may result in the reversal of early-stage renal damage.

Performance of the cobas 5800 System for Hepatitis B virus DNA and Hepatitis C virus RNA quantification

Hepatitis B and C infections are an underdiagnosed global health problem. Measurement of HBV DNA or HCV RNA levels using nucleic acid-based molecular diagnostic assays has been established as the standard of care for assessing diagnosis, guiding the treatment decision, and evaluating responses to antiviral therapy. In the present study, we examined the performance of the cobas 5800 System for HBV DNA and HCV RNA quantification in a large series of patients chronically infected. Specificity of the cobas HBV and HCV Tests on the 5800 System was high (99.1 % and 100 %, respectively). Linearity using the AcroMetrix panels was excellent. Repeatability and intermediate precision coefficients of variation were within 5 %. Of the 334 clinical specimens tested in parallel on the cobas 5800 and cobas 4800 Systems for HBV and the m2000 RealTime or Alinity m Systems for HCV, only 12 (3.6 %) yielded discrepant results that were at or near the limit of quantification of the cobas 5800 assays. The correlation between viral load results was extremely high, and only weak bias were observed across the entire range of concentrations tested without clinical impact in patients who are eligible for antiviral therapy. This comparison study demonstrated equivalent performance of the new cobas 5800 System compared with other molecular platforms widely used in clinical practice for HBV DNA and HCV RNA quantification. The cobas 5800 System can be confidently used in clinical practice. A few clinical specimens with low viral loads may be missed. Further studies are warranted to confirm or refute this finding.

Immigration Factors and Monitoring of Chronic Hepatitis B Infection Among Foreign-Born: The FOCUS-HBV Multicentre Cohort

BACKGROUND

Immigrants are the largest subgroup living with chronic hepatitis B (HBV) infection in the United States. It is not well understood how immigration and associated social and cultural factors impact adherence to HBV monitoring.

METHODS

We conducted a multicentre multilingual survey among foreign-born adults with chronic HBV between 7/2021 and 4/2023. Participants were surveyed regarding (1) immigration factors, (2) acculturation and language preferences, (3) social determinants of health and (4) HBV-related clinical factors. The primary outcome was optimal adherence, defined as 100% of the time with at least annual testing of HBV DNA, ALT and ultrasound while under care. Logistic regression was used to examine survey factors associated with the outcome.

RESULTS

Two hundred and seventy-four foreign-born patients with HBV (median 57 years, 57% male) from 32 birth countries were included. Thirteen per cent had immigrated within the past 10 years, and 62% were US citizens. Nearly all (92%) reported seeing a specialist for HBV, with 72% currently on treatment. 44% of participants had optimal adherence to monitoring over a median of 6 years (2-7) under care. Factors associated with more optimal adherence on multivariate testing included non-English survey language (OR 2.32, 95% CI 1.15-4.66), non-US citizens (OR 2.05, 95% CI 1.01-4.15) and higher education (college vs. high school or less: OR 2.39, 95% CI 1.09-5.24). Medicare insurance (vs. private) was associated with less optimal adherence (OR 0.42, 95% CI 0.19-0.94).

CONCLUSION

Adherence to long-term monitoring is suboptimal among a diverse cohort of immigrants with chronic HBV. More efforts to engage and retain immigrants in care are needed.

Differential HBV RNA and HBcrAg patterns in untreated patients with chronic hepatitis delta

BACKGROUND & AIMS

Serum HBV RNA and hepatitis B core-related antigen (HBcrAg) levels have been proposed as useful biomarkers in the management of patients with HBV; however, their role in chronic hepatitis delta (CHD) is currently unknown.

METHODS

Consecutive untreated patients with CHD were enrolled in a cross-sectional study in three EU centers. Clinical and virological characteristics were collected. Serum HBV RNA and HBcrAg levels were quantified by an automated real-time investigational assay (Cobas® 6800, Roche Diagnostics, Pleasanton, Ca, USA) and by LUMIPULSE® G HBcrAg assay (Fujirebio Europe), respectively. In 18 patients with available liver biopsies, intrahepatic analyses were performed.

RESULTS

Overall, 240 patients with HDV were enrolled: median age 46 years, 62% male, 53% with cirrhosis, 57% nucleos(t)ide analogue treated, median ALT 70 U/L, median HBsAg 3.8 log10 IU/ml, 88% HBeAg negative, and median HDV RNA 4.9 log10 IU/ml. HBV RNA was positive (>10 copies/ml) in only 8% of patients (median 40 [13-82,000] copies/ml), whereas HBcrAg was ≥3 log10 U/ml in 77% (median 4.2 [3.0-8.0] log10 U/ml). By combining these biomarkers, three categories were identified: 23% double negative (HBV RNA/HBcrAg), 9% double positive (HBV RNA/HBcrAg) and 68% HBV RNA negative/HBcrAg positive. HBV RNA levels positively correlated with male sex and detectable HBV DNA, while positive HBcrAg correlated with higher HBsAg levels. Double-positive patients were younger, non-European, with elevated ALT and HDV RNA levels and detectable HBV DNA. Intrahepatic HDV RNA and HBV RNA were positive in most samples, while intrahepatic levels of covalently closed circular DNA were low.

CONCLUSIONS

In untreated CHD, most patients had undetectable HBV RNA but quantifiable HBcrAg ("divergent pattern") in the absence of HBeAg. Additional studies aiming to unravel the molecular mechanisms underlying these findings are warranted.

IMPACT AND IMPLICATIONS

Serum HBV RNA and HBcrAg (hepatitis B core-related antigen) are promising biomarkers of the transcriptional activity of covalently closed circular DNA in chronic HBV infection; however, their role in patients with HBV-HDV coinfection is unknown. At variance with what is commonly observed in HBV-monoinfected patients, HBV RNA was undetectable and HBcrAg detectable in the serum of most patients with HDV ("divergent pattern"). The understanding of the viral interplay between HBV and HDV is crucial to dissect the pathogenic mechanisms associated with the distinct phenotypes of patients with HDV.

Chronic Hepatitis B Patients Referred for Liver Transplantation After Nucleos(t)ide Analog Cessation

Nucleos(t)ide analogs (NAs) provide prolonged viral suppression with favourable clinical outcomes in chronic hepatitis B (CHB) patients. Characterisation of adverse hepatic events after NA cessation leading to liver transplantation (LT) is vital to the improvement of patient management and safety considerations. This is a retrospective case series of CHB patients who developed hepatic decompensation due to NA discontinuation and were referred for LT. Patients with hepatocellular carcinoma or coinfection were excluded. Of 11 CHB patients included (81.8% clinical jaundice, 63.6% ascites, 54.5% hepatic encephalopathy and 18.2% variceal bleeding), 45.5% underwent LT, 36.4% were waitlisted (1 active, 1 died, 2 delisted of whom 1 died), and 18.2% died after referral during the assessment period. Median age was 55.1 years, 81.8% were male, and 72.7% had cirrhosis at NA cessation. Reasons for NA withdrawal included nonadherence (81.8%) and physician discretion (18.2%). Median time from NA cessation to a decompensating event was 3.2 months, and from the decompensating event to referral was 16.0 days. This study shows that most patients experience decompensations soon after NA cessation and reinforces that patients should not discontinue treatment themselves. Physicians should very carefully select non-cirrhotic, adherent patients for NA withdrawal, after which close monitoring and timely retreatment are crucial.

Unmet needs in the clinical management of chronic hepatitis B infection

The hepatitis B virus (HBV) remains a global problem despite effective tools to prevent, diagnosis, and control it. Unmet needs are identifiable across its clinical care cascade, underlining the challenges providers face in delivering effective care for patients with chronic hepatitis B. The review herein will focus on three timely clinical issues in HBV. This includes efforts to optimize delivery of perinatal HBV care, improve HBV-related hepatocellular carcinoma risk stratification models, and clarify the role of finite therapy in the HBV treatment algorithm. Important developments within these three topics will be addressed with the goal to motivate further investigation and optimization of these treatment strategies for HBV.

Management of chronic hepatitis B in Uganda: A five-year experience following the initiation of a national sensitization and care campaign

Despite having the highest Hepatitis B Virus (HBV)-related mortality globally, sub-Saharan Africa (SSA) has been slow in its disease elimination campaign. We describe a 5-year experience in HBV management at a large facility in Uganda and how it can inform future management strategies. HBV-related patient data were abstracted from clinic records. Of 2664 patients, 1828 (68.6 %) had documented chronic HBV infection. Participants were young, mean age (±SD) 31.3 (±10.6) and equally split by gender. Overall, 423 (23.1 %) were on antiviral medications including 158/229 (69.0 %) with a sonographic diagnosis of cirrhosis and 130/282 (46.1 %) with Aspartate aminotransferase to Platelet Ratio Index (APRI) score ≥0.5.48/1828 (2.6 %) had Hepatocellular Carcinoma (HCC). In multivariable analysis, APRI score ≥0.5 [OR (95 % CI) = 1.76 (1.26-2.46), p < 0.01], elevated alanine aminotransferase (ALT) [OR (95 % CI) = 2.25 (1.35-4.47), p = 0.04], and HBV viral load ≥2,000IU/mL [OR (95 % CI) = 2.97 (1.68-5.22), p < 0.01] were predictors of cirrhosis/HCC. Also, an APRI score of ≥0.5 [OR (95 % CI) = 1.62 (1.19-2.22), p = 0.01], elevated ALT [OR (95 % CI) = 2.60 (1.23-5.49), p = 0.02], cirrhosis [OR (95 % CI) = 21.65 (9.26-50.59), p < 0.01], and viral load ≥2,000IU/mL [OR (95 % CI) = 6.62 (3.93-11.15), p < 0.01] were associated with antiviral use. Cirrhosis/HCC apparently occur at lower APRI scores in SSA suggesting need for urgent adoption of the 2024 WHO guidelines which provide for earlier initiation of anti-HBV therapy.

Dynamics of HBV biomarkers during nucleos(t)ide analog treatment: A 14-year study

BACKGROUND

Circulating HBsAg, HBV RNA, and hepatitis B core-related antigen (HBcrAg) are potential biomarkers for the response to nucleos(t)ide analog (NA) treatment discontinuation in patients with chronic hepatitis B (CHB). We retrospectively investigated the long-term kinetics of HBsAg, HBV RNA, and HBcrAg in HBeAg-negative patients treated with NA for up to 14 years in a prospective cohort study.

METHODS

Ninety-six patients (mean age 65 y, 77% male, 52% with cirrhosis, all HBV genotype D) who were undergoing first (n=33, group A) or second-line (n=63, group B) treatment with tenofovir disoproxil fumarate were included. HBV biomarkers collected during tenofovir disoproxil fumarate treatment were measured in 384 serum samples stored at -20 °C. The combined biomarker endpoints associated with functional cure following NA discontinuation included HBsAg <1000 IU/mL, HBV RNA <54 copies/mL, and HBcrAg <2 log U/mL.

RESULTS

Before NA treatment, HBV RNA and HBcrAg were detectable in 85% (mean 3.9±2.3 [range, 0-9.2] log10 copies/mL) and 80% (mean 4.3±1.9 [2-8.9] log10 U/mL), respectively, of the patients in group A. In groups A and B, the percentages of patients with detectable HBV RNA levels decreased to 53% and 34%, respectively, during years 8-10 of NA treatment, and to 29% in group B during years 11-14 to 29%. HBcrAg could be quantified in 2% of patients in group B NA treatment years 8-10. Combined biomarker endpoints were met at baseline and at years 1-4, 5-7, 8-10, and 11-14 of treatment by 3.3%, 12% and 14%, 13% and 38%, 26% and 29%, and 41% of patients, respectively.

CONCLUSIONS

HBV biomarker endpoints are associated with functional cure after the discontinuation of NA increase during long-term NA treatment.

Association of HDV infection and HCC, hepatic decompensation, and all-cause and liver-related death in a national cohort

BACKGROUND AND AIMS

HDV infection is the most severe form of chronic hepatitis. However, studies on outcomes and causes of death in a US-born population, with primarily horizontal transmission of HDV, are lacking. The aim of this study was to conduct a national study of patients with hepatitis D to understand the natural history and outcomes compared to patients with HBV infection.

APPROACH AND RESULTS

In a national cohort of 4817 veterans infected with HBV tested for HDV (99.6% US-born, 3.3% HDV-positive) over a 23-year period, we used multivariable models to identify the factors associated with a composite outcome of HCC, decompensation, and liver-related mortality, and all-cause mortality of patients with HDV compared to HBV mono-infection. HDV coinfection (vs. HBV mono-infection) was associated with a significantly higher incidence of composite liver-related outcomes at both 5 (23.84 vs. 7.98, p < 0.001) and 10 years (19.14 vs. 10.18, p < 0.001), respectively. The most common cause of death was liver-related (33.8% for HDV vs. 24.7% for HBV), followed by nonhepatic malignancies (15.6% vs. 14.8%), cardiac (11.7% vs. 15.2%), and lung disease (5.2% vs. 3.7%). In multivariable models, HDV was associated with an increased risk of composite liver outcomes (adjusted hazard ratio: 2.57, 95% CI: 1.87-3.52, p < 0.001) and all-cause mortality (adjusted hazard ratio: 1.52, 95% CI: 1.20-1.93, p < 0.001).

CONCLUSIONS

In a predominantly US-born cohort of veterans, HDV coinfection was associated with an increased risk of liver-related outcomes and all-cause mortality. Our findings support widespread testing for early identification of HDV.

Epidemiological Burden of Hepatitis Delta Virus in the United States

Hepatitis D virus (HDV) affects nearly 5% of people globally who are chronically infected with hepatitis B virus, according to the World Health Organisation. The prevalence of HDV in the United States is considered lower than in other countries. However, HDV seroprevalence studies of the US population are limited, and reported seroprevalences vary. To improve diagnoses, universal HDV testing of hepatitis B surface antigen (HBsAg)-positive specimens has been proposed. The objective of this study was to estimate the prevalence of HDV infection within the United States in HBsAg-positive specimens. Unique deidentified remnant HBsAg-positive specimens submitted for routine clinical testing to Quest Diagnostics, representing all 10 Health and Human Services (HHS) regions, were included. Reflex testing of HBsAg-positive specimens for HDV antibody testing, and further testing of positive specimens for HDV RNA, was conducted from July 2023 to June 2024 for 5251 HBsAg-positive specimens. The cohort was 45% female, with mean ages of 50.8 (M) and 49.4 (F) years. The seroprevalence of anti-HDV was 2.2% [95% CI: 1.8%-2.6%; range: 2.5%-4.1%]. Of 107 anti-HDV-positive specimens, 28% were positive for HDV RNA (viral load range: 94-7,480,000 IU/mL: n = 23; Detected < 40 IU/mL: n = 7). This is the first nationwide seroprevalence study examining HBsAg-positive samples collected from 10 HHS regions across the United States, which offers an overview of the prevalence of HDV in the United States through the use of HbsAg-positive remnant specimens in proportion to regional population sizes. Expanded screening for HDV would help identify patients who may benefit from HDV-related interventions.

Histological severity, clinical outcomes and impact of antiviral treatment in indeterminate phase of chronic hepatitis B: A systematic review and meta-analysis

BACKGROUND & AIMS

Current international guidelines recommend close monitoring and evaluation of patients with chronic hepatitis B (CHB) in the indeterminate phase, and treatment of patients at high risk of adverse outcomes. Clinical outcomes and the effect of antiviral therapy on the indeterminate phase remain unclear. We performed a systematic review and meta-analysis to study the incidence of adverse clinical outcomes including hepatocellular carcinoma (HCC), cirrhosis, and hepatic decompensation, and the effect of antiviral therapy, in the indeterminate phase.

METHODS

Two investigators independently searched Embase, MEDLINE, Web of Science and China National Knowledge Infrastructure from 1/1/2007 to 31/12/2023. Three investigators independently assessed study eligibility and quality. We included cohort studies and a randomised-controlled trial, allowing for calculation of the incidence rate of adverse clinical outcomes, and cross-sectional studies that reported the prevalence of moderate-to-severe inflammation and different degrees of fibrosis. Incidence rates and prevalence were pooled using generalised linear mixed-effects models and random-effects models, respectively.

RESULTS

One hundred and three studies (70 case-control studies [18,739 patients], 32 cohort studies [15,118 patients], and one RCT [160 patients]) were included. The annual incidence rate of HCC in patients in the indeterminate phase was 0.32% (95% CI 0.21-0.48%, I2 = 85.7%), and those of cirrhosis and hepatic decompensation were 0.67% (95% CI 0.30-1.49%, I2 = 94.3%) and 0.34% (95% CI 0.17-0.69%, I2 = 51.8%), respectively. The pooled prevalence of moderate-to-severe liver inflammation, significant fibrosis, advanced fibrosis, and cirrhosis was 40.7%, 39.7%, 17.9%, and 7.2%, respectively. Use of antiviral therapy was associated with a lower risk of HCC in patients in the indeterminate phase (adjusted incidence rate ratio 0.38, 95% CI 0.18-0.79, p = 0.009).

CONCLUSIONS

Patients in the indeterminate phase are at risk of developing advanced liver disease and HCC. Although inherent heterogeneity across studies limited the evidence to support expanding treatment to all patients in the indeterminate phase, antiviral therapy may reduce the risk of HCC development in high-risk subgroups.

IMPACT AND IMPLICATIONS

Current international guidelines recommend close monitoring and evaluation of patients with chronic hepatitis B (CHB) in the indeterminate phase, in whom antiviral treatment is not always indicated. Based on the systematic review and meta-analysis with significant heterogeneity across studies, patients in the indeterminate phase are at risk of developing hepatocellular carcinoma, cirrhosis, and hepatic decompensation. Meta-regression findings on platelet count, positive HBeAg, and age highlighted the importance of liver fibrosis assessment, accurate phase classification, and timely detection of phase transition to identify antiviral treatment indications, supporting current guideline recommendations. Antiviral treatment may reduce the risk of hepatocellular carcinoma in the high-risk subgroups of patients in the indeterminate phase.

PROSPERO REGISTRATION NUMBER

CRD42024537095.

Viral Hepatitis

Viral hepatitis poses a significant public health challenge. Five types (A, B, C, D, E) have distinct transmission, prognosis, and management. Hepatitis A (HAV), spread through fecal-oral contamination, is typically self-limiting with supportive therapy. Hepatitis B (HBV) is sexually transmitted but may also be spread perinatally. HBV can progress into cirrhosis or hepatocellular carcinoma. Hepatitis C (HCV), a bloodborne virus, can also cause chronic infection and severe liver disease. Vaccination can prevent HAV and HBV; HCV is curable with antiviral therapy but lacks a vaccine. Pregnant patients and those with HIV require special management considerations. Here, we review the pathogenesis, diagnosis, treatment, and prevention of viral hepatitis.

Hepatitis B Infection in Outpatients and Pregnant Women Visiting a Mission Hospital in Ghana

Millions of individuals worldwide suffer from hepatitis B, a serious, potentially fatal liver infection brought on by the hepatitis B virus (HBV). Although vaccines are available for HBV, infections continue to persist in Ghana. This study reports the prevalence of HBV infections in outpatients and pregnant women attending antenatal care at the Seventh-day Adventist (SDA) Hospital in Gbawe, Ghana. This retrospective cohort study involved the review of de-identified medical records of outpatients and pregnant women who visited the hospital between 2022 and 2024. Data on their HBV infection status, sex and age were analysed using R version 4.4.1. A total of 531 outpatients and 768 pregnant women visited the hospital during the study period. The prevalence of HBV infection was 7.5% in outpatients and 3.9% in pregnant women. It was observed that outpatients were more likely to be hepatitis B surface antigen (HBsAg) positive (OR = 2.0, 95%CI = 1.24-3.28, p = 0.005). It was also seen that HBV prevalence increased from 2022 to 2023 and decreased in 2024. There is a need for more educational campaigns to raise awareness of HBV infections, especially in pregnant women due to the risk of mother-to-child transmission. Furthermore, vaccinations need to be made affordable and easily accessible to the general population to ensure maximum coverage within the country.

Risk of HBV reactivation in HBV/HCV-co-infected HCV-treated patients: A single-center study

Hepatitis B virus (HBV) reactivation in patients with HBV/hepatitis C virus (HCV) co-infection due to direct-acting antiviral agent (DAA) therapy is a growing concern. This study focused on 47 patients with chronic hepatitis C (CHC) and positivity for HBV surface antigen (HBsAg) who were treated with interferon (IFN)-based therapy, DAA, or DAA after IFN-based therapy failure and followed for a median of 53 months. Here, we aimed to determine HBV reactivation rates and associated factors, the incidence of HBV and liver-related events, and the rate of sustained virologic response (SVR) for HCV. Fifteen (15/47, 31.9%) patients experienced HBV reactivation during or after HCV treatment. This reactivation occurred significantly more frequently in patients who received DAA treatment after IFN-based treatment failure than in those who received IFN-based treatment (IFN-based vs. DAA vs. DAA treatment after IFN-based treatment failure 11.8% vs. 35.3% vs. 53.8%, respectively; p = 0.046). The interval from HCV treatment initiation to HBV reactivation was shortest in the DAA group (4.2 months), followed by the DAA after IFN-based treatment failure group (6.4 months) and the IFN-based treatment group (44.5 months) (p < 0.001). One case of HBV-related hepatitis spontaneously resolved after 4 weeks. The rate of SVR for the entire cohort was 87.2%, with no significant difference in this regard among the IFN-based treated, DAA-treated, and DAA-treated after IFN-based treatment failure arms at 82.4%, 88.2%, and 92.3%, respectively. HBV reactivation in HBsAg-positive CHC patients is more common and occurs earlier in those who receive DAA treatment after IFN-based treatment failure than in those with IFN-based treatment. Therefore, all patients with CHC should be tested for HBV exposure prior to DAA treatment. In addition, HBsAg positive patients, especially those among whom have previously experienced IFN-based treatment failure, should be closely monitored for HBV reactivation during DAA therapy.

Effect of switching from prior Nucleos(t)ide Analogue(s) to Tenofovir alafenamide on lipid profile and cardiovascular risk in patients with Chronic Hepatitis B

INTRODUCTION

Tenofovir alafenamide (TAF) is recommended for chronic hepatitis B (CHB) treatment in international guidelines according to its efficacy and safety. However, in phase III study, an increased LDL-c was observed in those who were switched from Tenofovir disoproxil fumarate (TDF) to TAF. Limited data exists on whether lipid profiles change only in individuals who switched to TAF from TDF or from any nucleoside/nucleotide analogues (NUC). We investigated how switching to TAF affected lipid and cardiovascular outcomes in Thai CHB patients.

MATERIALS AND METHODS

We conducted a prospective observational study including CHB patients who had to switch from their prior NUC to TAF according to the national reimbursement policy in late 2022. All enrolled patients had lipid tests and transient elastography (TE) done at 0 and 48-week post-switch to TAF. Demographic data, prior NUC, liver biochemistry, controlled attenuated parameter (CAP) and liver stiffness (elastic modulus; E) data measured by TE were collected. The changes in lipid, Thai cardiovascular (CV) risk score, and TE results between 0 and 48-week were compared.

RESULTS

A total of 110 patients who were switched to TAF and completed 48-week follow-up were analyzed. The prior NUCs were as follows: 47 Lamivudine (LAM), 22 Entecavir (ETV), and 41 TDF-based. Baseline characteristics were similar between the three groups except for underlying hypertension was more frequent and baseline total cholesterol was lower in the TDF-based group. At 48-week post-switch, the median LDL-c changes were -2.45, -5.9 and +8.8 mg/dL (p<0.001), and total cholesterol changes were -4.5, -4 and +17 mg/dL (p<0.001), in the ETV, LAM, and TDF-based group, respectively. Whereas the changes in hepatic steatosis (measured by CAP), and liver stiffness (measured by E) as well as Thai CV risk score were not significantly different. No cardiovascular events occurred during follow-up.

CONCLUSION

Significant increase in LDL-c and total cholesterol after switching to TAF were observed only in patients with prior TDF, but not in those with prior ETV or LAM. Careful monitoring of lipids after the switch may not be universally needed. Data regarding long-term cardiovascular outcomes are warrant.

Development and validation of a new predictive model for the immune tolerance stage of chronic HBV infection based on the liver histopathological changes

OBJECTIVE

To identify clinical and viral indicators for the development of a new model to accurately differentiate the stages of chronic hepatitis B virus (HBV) infection based on histopathological changes in the liver.

METHODS

Clinical and liver pathology data from chronic hepatitis B (CHB) patients who underwent liver biopsy were retrospectively collected. The patients were allocated into test and validation groups. The area under the receiver operating characteristic (ROC) curve (AUC) was calculated to idneitfy the optimal diagnostic value for differentiating the stages of chronic HBV infection.

RESULTS

A total of 118 patients and 73 patients who met the diagnostic and inclusion criteria were selected as the test group and validation group, respectively. Multivariate analysis revealed that HBeAg was independently correlated with the IT and IC stages. The cutoff value of HBeAg used to quantitatively differentiate between IT and IC was 1335 S/CO. The AUC values were 0.921 (95% confidence interval (CI): 0.836-0.971) and 0.846 (95% CI: 0.726-0.967) in the test and validation groups, respectively. A new prediction model of the IT stage was established by using three indicators, namely, HBeAg, HBsAg and HBV DNA. The AUC values were 0.923 (95% CI: 0.864-0.982, p < 0.001) and 0.89 (95% CI: 0.787-0.994, p < 0.01) in the test and validation groups, respectively, when this prediction model was used. For the new model, CMA guidelines (2019 version), EASL guidelines (2017 version) and AASLD guidelines (2018 version), the error rates in the test group were 4.65%, 11.62%, 23.26%, and 46.51%, respectively, while the errors rates in the validation group were 20.0%, 25.0%, 40.0%, and 45.0%, respectively.

CONCLUSIONS

High levels of HBeAg, rather than HBeAg positivity, may serve as a predictor of the IT stage. A predictive model for the immune tolerance stage was established by combining three indicators. Compared with the recommended standards from multiple current guidelines, the new prediction model has a significantly lower error rate.

A global comparison of hepatitis B & C drug pricing

INTRODUCTION AND OBJECTIVES

Drug pricing is a major driver of healthcare spending in the United States (US) and the cost of medications in the US is up to three time higher than other countries. This cross-sectional study aims to investigate the current price differences between hepatitis B (HBV) and hepatitis C (HCV) antiviral therapies in the US as compared to peer high-income countries.

MATERIALS AND METHODS

Publicly available drug formularies for Canada, UK, Japan, France, Germany, Italy, and Australia were used to collect 2024 prices for seven HBV medications (lamivudine, adefovir, tenofovir disoproxil fumarate (TDF), tenofovir alafenamide fumarate, entecavir, peginterferon alfa-2a, emtricitabine/TDF) and seven HCV medications (sofosbuvir/velpatasvir, sofosbuvir/ledipasvir, sofosbuvir, ribavirin, elbasvir/grazoprevir, glecaprevir/pibrentasvir, sofosbuvir/velpatasvir/voxilaprevir). US prices were obtained from UpToDate®'s listed representative average wholesale price and Medicare Part D 2022 drug prices.

RESULTS

US prices for HBV originator medications were on average 4.71x (range 1.99-6.17x) the prices in the peer countries. US generic HBV drug prices for TDF, entecavir, and emtricitabine/TDF were on average 45% cheaper or 0.55x less than the average generic prices in peer countries (range 0.48-0.66x). US originator prices for HCV medications were on average 1.83x the prices in peer countries (range 0.63-2.66x).

CONCLUSIONS

HBV and HCV originator medications cost significantly more in the US compared to seven other major industrial countries. However, the introduction of HBV generic medications has lowered the cost of treatment for patients in the US. Future adoption of international reference pricing may help bridge remaining pricing disparities.

Cystathionine gamma-lyase as an inflammatory factor and its link with immune inflammation in hepatitis B virus-related liver disease

We aimed to explore the effectiveness of CTH as a serum inflammation biomarker for HCC. Enzyme-linked immunosorbent assay was used to detect serum levels of CTH, interleukin-6 (IL-6), C-reactive protein (CRP), and IL-10. The Scheuer scoring system was used to assess the liver inflammation grading (significant liver inflammation: ≥ G2 grade). CTH levels in the HCC group were significantly elevated (P < 0.0001). Of 146 patients, 58.22% exhibited significant liver inflammation. CTH levels in patients with significant liver inflammation were significantly higher than those in patients with no or mild liver inflammation (< G 2) (p < 0.0001). The area under the Receiver Operating Characteristic (ROC) curve for CTH in predicting significant hepatitis was 0.77 (sensitivity, 81.2%; specificity,62.3%). There was a significant positive correlation (r = 0.50, p < 0.05) between serum CTH levels and histopathological parameter G. The area under the ROC curve for CTH in predicting hepatocellular carcinoma was 0.83 (sensitivity, 64.6%; specificity, 83.3%). CTH and AFP improved the diagnostic accuracy of HCC. CTH levels significantly decreased 6 months post-operation (p < 0.05). The recurrence of HCC caused significant increases in CTH levels. Thus, CTH can serve as a serum inflammation marker for HCC.

Hepatitis surface B antigen clearance induced by long-term tenofovir disoproxil fumarate monotherapy in chronic hepatitis B treatment: a meta-analysis and longitudinal modeling analysis

BACKGROUND

Chronic hepatitis B (CHB) is a significant global health challenge, with tenofovir disoproxil fumarate (TDF) widely used as an effective treatment option. Despite TDF's efficacy in suppressing hepatitis B virus (HBV) DNA, it rarely achieves functional cure, requiring hepatitis B surface antigen (HBsAg) clearance or seroconversion, which are an optimal goal of CHB treatment. This study aimed to evaluate the long-term effects of TDF monotherapy on HBsAg clearance rates through a systematic review and meta-analysis, combined with a longitudinal modeling analysis to investigate HBsAg dynamics.

METHODS

Eligible studies published between January 1st, 2008, and September 28th, 2023, in PubMed, EMBASE, and Web of Science were included in the systematic review and meta-analysis. The longitudinal model was developed based on data from 123 subjects in a Phase III trial cohort.

RESULTS

Twenty-three studies were selected for meta-analysis. The summarized HBsAg clearance rate was near zero and unlikely to increase with extended treatment. The longitudinal model of HBsAg dynamic in CHB patients receiving TDF monotherapy showed a good fitting performance and extrapolation predictive ability. Model-based simulation confirmed that HBsAg clearance remained unlikely with prolonged therapy, with median HBsAg levels reducing by 21% after 168 weeks.

CONCLUSIONS

The consistency between meta-analysis and model simulation outcomes indicated that TDF monotherapy can achieve a limited reduction in HBsAg levels but did not result in functional cure, which reinforced the limited role of TDF monotherapy in comprehensive CHB management.

Distribution, Characteristics, and Natural History of Diverse Types of Indeterminate Chronic Hepatitis B: A REAL-B Study

BACKGROUND AND AIMS

Chronic hepatitis B (CHB) with indeterminate phase comprises a heterogeneous group of patients. We determined the prevalence of indeterminate CHB overall and characterised novel types and phase transition probabilities of novel types of indeterminate CHB.

METHODS

CHB patients were enrolled retrospectively from 24 centres (9 countries/regions). Indeterminate phase was defined based on the AASLD 2018 guidance.

RESULTS

The cohort included 8375 patients with a mean age of 45.0 ± 13.7 years, 22.5% HBeAg-positive, and median ALT and HBV DNA of 30 U/L and 4.3 ± 2.2 log10IU/mL, respectively. Of the total cohort, half (47.2%) were in the indeterminate phase; and of these, the most prevalent group among HBeAg-positive patients was Type 2 (ALT 1-2 × ULN, HBV DNA≥ 20,000 IU/mL; 12.6%), while in HBeAg-negative patients it was Type 6 (ALT

CONCLUSIONS

Indeterminate CHB can be classified into 10 types, with the most prevalent type being those with HBeAg-negative, HBV DNA ≥ 2000 IU/mL and ALT Collapse

Key Words

• HBV
• grey zone
• longitudinal
• long‐term follow‐up
• phase transition
• prevalence

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MESH Headings Collapse

Grants Collapse

Affiliation(s)

Rui Huang Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA Department of Infectious Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China Institute of Viruses and Infectious Diseases, Nanjing University, Nanjing, China
Ai-Thien Do Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA Digestive Health Associates of Texas, Dallas, Texas, USA The University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas, USA
Hidenori Toyoda Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, Ogaki, Japan
Jie Li Department of Infectious Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China Institute of Viruses and Infectious Diseases, Nanjing University, Nanjing, China
Satoshi Yasuda Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, Ogaki, Japan
Pei-Chien Tsai Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
Ming-Lun Yeh Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan Hepatitis Research Center, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
Huy Trinh San Jose Gastroenterology, San Jose, California, USA
Angela Chau Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA Weill Cornell Medical College, New York, New York, USA
Daniel Q Huang Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
Eiichi Ogawa Department of General Internal Medicine, Kyushu University Hospital, Fukuoka, Japan
Takanori Ito Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
Ritsuzo Kozuka Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
Masanori Atsukawa Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo, Japan
Sebastián Marciano Liver Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
Takashi Honda Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
Tsunamasa Watanabe Division of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Kawasaki, Japan
Norio Itokawa Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo, Japan
Carmen Monica Preda Department of Gastroenterology and Hepatology, Clinic Fundeni Institute, University of Medicine and Pharmacy "Carol Davila", Romania
Cheng-Hao Tseng Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Cancer Hospital/I-Shou University, Kaohsiung, Taiwan
Ana Barreira Liver Unit, Hospital Universitari Valle D'hebron and Universitat Autònoma de Barcelona, Barcelona, and CIBEREHD del Instituto Carlos III, Spain
Kaori Inoue Liver Center, Saga University Hospital, Saga, Japan
Hirokazu Takahashi Liver Center, Saga University Hospital, Saga, Japan Division of Metabolism and Endocrinology, Faculty of Medicine, Saga University, Saga, Japan
Haruki Uojima Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Japan Genome Medical Sciences Project, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
Keigo Kawashima National Institute of Infectious Diseases, Tokyo, Japan
Yao-Chun Hsu Division of Gastroenterology and Hepatology, Department of Internal Medicine, E-Da Cancer Hospital/I-Shou University, Kaohsiung, Taiwan
Raluca Ioana Marin Department of Gastroenterology and Hepatology, Clinic Fundeni Institute, University of Medicine and Pharmacy "Carol Davila", Romania
Irina Sandra Department of Gastroenterology and Hepatology, Clinic Fundeni Institute, University of Medicine and Pharmacy "Carol Davila", Romania
Masatoshi Ishigami Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
Jiayi Li Palo Alto Medical Foundation, Mountain View Division, Mountain View, California, USA
Jian Zhang Chinese Hospital, San Francisco, California, USA
Son Do The University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas, USA
Mayumi Maeda Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
Dong-Hyun Lee Division of Gastroenterology, Department of Internal Medicine, Good Gang-An Hospital, Busan, South Korea
Wan-Long Chuang Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan Hepatitis Research Center, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
Chia-Yen Dai Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan Hepatitis Research Center, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
Jee-Fu Huang Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan Hepatitis Research Center, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
Chung-Feng Huang Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan Hepatitis Research Center, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
Ramsey Cheung Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA Gastroenterology and Hepatology, The Palo Alto Veterans Affairs Health Care System, Palo Alto, California, USA
Maria Buti Liver Unit, Hospital Universitari Valle D'hebron and Universitat Autònoma de Barcelona, Barcelona, and CIBEREHD del Instituto Carlos III, Spain
Yasuhito Tanaka Department of Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
Man-Fung Yuen Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
Masaru Enomoto Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan Department of Transfusion Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
Adrian Gadano Liver Unit Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
Seng Gee Lim Director of Hepatology, Division of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore
Ming-Lung Yu Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan Hepatitis Research Center, College of Medicine and Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
Chao Wu Department of Infectious Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China Institute of Viruses and Infectious Diseases, Nanjing University, Nanjing, China
Mindie H Nguyen Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA

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Long-term effects of peginterferon-based therapy versus nucleos(t)ide analogue monotherapy in non-cirrhotic HBeAg-positive chronic hepatitis B patients

BACKGROUND & AIMS

The long-term clinical benefits of interferon (IFN)-based therapy compared to nucleos(t)ide analogue (NA) monotherapy in HBeAg-positive chronic hepatitis B (CHB) have not been well defined. This study aimed to evaluate the cumulative incidence of new-onset cirrhosis, serological responses, and hepatocellular carcinoma (HCC) development between these treatment strategies.

METHODS

Two independent cohorts of non-cirrhotic, HBeAg-positive CHB patients were analyzed: a treatment-naïve cohort (n = 686) and an NA-experienced cohort (n = 531). Patients received either IFN-based therapy or NA monotherapy. Propensity score matching (PSM) was employed to minimize intergroup heterogeneity. The primary endpoint was the cumulative incidence of new-onset cirrhosis.

RESULTS

After PSM, the 10-year cumulative incidence of new-onset cirrhosis was significantly lower in the IFN-based therapy group compared to the NA monotherapy group in both the treatment-naïve (3.3 % vs 20.0 %, p = 0.005) and NA-experienced (4.9 % vs 20.9 %, p = 0.034) cohorts. IFN-based therapy also resulted in significantly higher serological response rates across both cohorts, including HBeAg loss (treatment-naïve: 84.7 % vs 55.6 %; NA-experienced: 60.4 % vs 43.6 %, both p < 0.001) and HBsAg loss (treatment-naïve: 14.3 % vs 5.7 %, p = 0.006; NA-experienced: 10.2 % vs 1.3 %, p < 0.001). Subgroup analysis showed that patients receiving IFN-based therapy who achieved HBeAg loss within 96 weeks had the greatest long-term benefits, with lower cirrhosis incidence and higher HBsAg loss rates. Although the incidence of HCC was lower in the IFN-based group, the difference did not reach statistical significance (both p > 0.05).

CONCLUSIONS

IFN-based therapy provides superior long-term benefits over NA monotherapy in reducing cirrhosis risk and enhancing serological responses in HBeAg-positive CHB patients.

Long-Term Dynamic Changes of Alanine Aminotransferase Levels Are Associated With Liver-Related Events in Nucleos(t)ide Analogue-Treated Chronic Hepatitis B Patients in China

BACKGROUND

The role of alanine aminotransferase (ALT) dynamics during nucleos(t)ide analogue (NA) therapy in chronic hepatitis B (CHB) is unclear. We aimed to evaluate the correlation between ALT dynamics and liver-related events (LRE), and explore the optimal threshold of ALT during NA treatment.

METHODS

We enrolled 18,129 NA-treated patients, comprising 3104 patients from the Search-B study (NCT02167503) and 15,025 patients from a real-world cohort in Hong Kong. Latent-class mixed model (LCMM) was adopted to identify trajectory patterns of ALT during treatment. ALT value at the 95th percentile of the trajectory group with the lowest LRE risk was obtained as the optimal threshold.

RESULTS

During a median follow-up of 53.3 months, 1164 patients developed LRE with a 7-year cumulative incidence of 9.9%. In the Search-B cohort, LCMM recognised 3 trajectory groups with progressively increasing ALT levels, which were positively associated with LRE risk. Subsequently, the optimal thresholds for ALT were obtained as 23 U/L for men and 16 U/L for women. The 7-year cumulative incidence of LRE was 5.5% for ALT ≤ 23 or 16 U/L, significantly lower than that for ALT > 23 or 16 U/L but ≤ 40 U/L (10.8%; aHR = 2.0, p < 0.001), and ALT > 40 U/L (15.1%; aHR = 3.4, p < 0.001). Similarly, in the Hong Kong cohort, ALT > 23 or 16 U/L but < 40 U/L and ALT > 40 U/L also increased the LRE risk, with aHRs of 2.0 (p = 0.003) and 6.1 (p < 0.001), respectively.

CONCLUSION

On-treatment ALT levels were significantly correlated with the prognosis of CHB. ALT ≤ 23 U/L for men and ≤ 16 U/L for women were identified as the optimal thresholds during NA treatment, suggesting that CHB patients should strive for a lower ALT level beyond the traditional normal range.

Recurrence risk factors for chronic hepatitis B virus-infected patients who achieve functional cure with pegylated interferon-α-2b-based therapy: a multicenter pilot study

BACKGROUND

Hepatitis B surface antigen (HBsAg) clearance is an achievable treatment endpoint for chronic hepatitis B virus (HBV)-infected patients. Pegylated interferon-α (PEG-IFN-α) induces higher rate of HBsAg clearance than nucleos(t)ide analogues. However, the influencing factors associated with HBsAg recurrence have not been fully elucidated. The aim of this study was to evaluate the risk factors for recurrence in chronic HBV-infected patients who achieved functional cure with PEG-IFN-α-2b-based treatment.

METHODS

A multicenter retrospective study was conducted. All patients received PEG-IFN-α-2b-based therapy, achieved HBV DNA negativity and HBsAg clearance, and were followed-up for at least 48 weeks after discontinuation of medications. The demographic data, as well as virological, serological, and biochemical indicators, were collected at baseline, therapy cessation, and during followed-up. Logistic regression analysis was subsequently performed.

RESULTS

A total of 101 chronic HBV-infected patients who achieved HBsAg loss with PEG-IFN-α-2b-based therapy were enrolled. The median treatment time was 24.00 (14.50, 37.50) weeks, and the median consolidation time was 11.00 (0.00, 24.00) weeks. HBsAg recurrence was found in 16 patients after a median 70.00 (48.00, 96.00) week follow-up, with a cumulative recurrence rate of 15.84%. A higher platelet count was associated with a slightly increased HBsAg recurrence risk at therapy cessation, whereas a shorter consolidation time was associated with an elevated HBsAg recurrence risk during followed-up. The appearance of anti-HBs presented a robustly reduced HBsAg recurrence risk at both therapy cessation and followed-up. No HBV DNA positivity or occurrence of end-stage liver disease was observed during treatment or followed-up.

CONCLUSION

The cumulative HBsAg recurrence rate was 15.84% after discontinuation of medications in chronic HBV-infected patients who achieved functional cure with PEG-IFN-α-2b-based therapy. The presence of anti-HBs reduced the HBsAg recurrence risk.

CLINICAL TRIAL REGISTRATION

This trial is a part of ZhuFeng Project (ClinicalTrials.gov, identifier NCT04035837) and a part of E-Cure Study (ClinicalTrials.gov, identifier NCT05182463).

A universal point-of-care immunochromatographic test for the serodiagnosis of hepatitis D

Hepatitis D is estimated to affect 12 million people worldwide and is caused by the hepatitis D virus (HDV), a defective virus that requires the presence of the hepatitis B virus (HBV) for infection. Here, we report a new recombinant antigen (DTH10.1) to detect anti-HDV IgG antibodies, designed to include a consensus sequence of the HDV antigen, based on bioinformatic analysis of the eight HDV genotypes. Using serum samples from patients living in the endemic area of the Brazilian Amazon basin, the enzyme-linked immunosorbent assay (ELISA) based on this protein displayed a sensitivity of 90.6% (95% CI: 84.2%-94.5%) and a specificity of 100% (95% CI: 94.2%-100.0%), while a rapid immunochromatographic test (ICT) showed a sensitivity of 91.3% (95% CI: 85.0%-95.1%) and specificity of 99.0% (95% CI: 94.5%-99.95%). Commercial monoclonal antibodies for HBV surface antigen (HBsAg) detection were then added to the test, resulting in a multiplex ICT with a sensitivity of 87.1% (95% CI: 81.3%-91.4%) for HBsAg and 95.2% (95% CI: 90.0%-97.8%) for anti-HDV IgG and specificity of 100% (95% CI: 91.0%-100.0%) and 98.0% (95% CI: 92.9%-99.6%), respectively. Finally, the three tests were evaluated against a panel of 79 patient samples infected, covering the eight HDV genotypes. The results indicated that all the DTH10.1-based tests were able to detect anti-IgG HDV antibodies with high sensitivity and specificity, regardless of the infecting HDV genotype. In conclusion, the prototypes developed for serodiagnosis of HDV using the DTH10.1 recombinant protein are promising tools for the universal diagnosis of HDV infection.IMPORTANCEThe manuscript outlines the complete strategy for developing tools for the diagnosis of hepatitis D, including an enzyme-linked immunosorbent assay (ELISA), an immunochromatographic test (ICT), and a multiplex ICT for the simultaneous detection of hepatitis B virus surface antigen and anti-hepatitis D virus (HDV) IgG antibodies. All the tests described are capable of detecting all eight HDV genotypes with high accuracy.

Performance of the AASLD, EASL, and APASL Clinical Practice Guidelines in"grey zone"stages of Chinese patients with chronic hepatitis B

BACKGROUND/OBJECTIVE

Chronic hepatitis B (CHB) patients who do not meet any immunostaging criteria are categorized as the "grey zone" (GZ). However, there are discrepancies in the definition of the GZ in different areas.

AIM

To investigate the prevalence and clinical characteristics of Chinese GZ patients and to validate the application value of three international guidelines.

METHODS

Data from 807 naïve CHB patients with liver biopsies from seven Chinese centres were retrospectively collected. GZ patients were defined and compared across four guidelines: the Chinese guidelines, the American Association for the Study of Liver Diseases (AASLD) guidelines, the European Association for the Study of the Liver (EASL) guidelines, and the Asian Pacific Association for the Study of the Liver (APASL) guidelines.

RESULTS

When the Chinese guidelines were used, 38.79% of patients were categorized into the GZ, 78.91% of whom were indicated for antiviral therapy. The EASL guidelines yielded a greater proportion of GZ patients (50.56%) than did the APSAL (36.68%) and AASLD guidelines (33.21%). The APASL guidelines yielded a lower proportion of GZ patients who were indicated for antiviral therapy (42.57%) than did the AASLD (47.76%) and EASL guidelines (60.54%). According to the AASLD, EASL, APASL and Chinese guidelines, if liver biopsy was not performed, 13.06%, 31.86%, 0% and 64.54% of GZ patients were indicated for antiviral therapy, respectively.

CONCLUSIONS

GZ patients account for a significant proportion of CHB patients, with approximately half of them requiring antiviral therapy.

CLINICAL TRIAL REGISTRATION

NCT06041022.

Predictive factors and clinical outcomes in decompensated non-cirrhotic chronic hepatitis B patients treated with entecavir or tenofovir disoproxil fumarate

BACKGROUND & AIMS

Little is known about the short-term and long-term outcomes of non-cirrhotic chronic hepatitis B (CHB) patients who experience hepatic decompensation. Therefore, this study aimed to investigate the clinical outcomes of decompensated non-cirrhotic CHB patients.

METHODS

We conducted a retrospective study and enrolled a total of 304 decompensated non-cirrhotic CHB patients. Cox regression model was used to analyze factors associated with all-cause mortality. Additionally, the incidence of HBsAg seroclearance and its associated factors were estimated by the competing risk analysis.

RESULTS

The median follow-up time was 4.36 years (IQR 1.04-7.16). Out of the total enrolled patients, 63 (20.72 %) patients either died or underwent liver transplantation, and 14 patients achieved HBsAg seroclearance. Risk factors associated with 1-month, 3-month, and long-term all-cause mortality were the presence of ascites and hepatic encephalopathy, baseline HBV DNA levels, and MELD scores. The cumulative incidence of HBsAg seroclearance was 1.78 %, 3.72 %, 4.25 %, 5.68 %, 5.68 %, 8.28 %, and 8.28 % at the 1-year, 2-year, 3-year, 4-year, 5-year, 6-year, and 7-year follow-up, respectively. Independent predictors for HBsAg seroclearance were baseline alanine aminotransferase (ALT)≧ 25 times upper limit of normal (subdistribution hazard ratio [sHR] = 5.97; 95 %CI, 1.82-19.63; p = 0.0032) and HBV DNA <5 log10 IU/ml (sHR = 4.43; 95 %CI, 1.55-12.63; p = 0.0054).

CONCLUSIONS

The presence of ascites and hepatic encephalopathy, baseline HBV DNA levels, and MELD scores were associated with short-term and long-term all-cause mortality. Additionally, lower HBV DNA levels and higher ALT levels at baseline were independently predictive of sequential HBsAg seroclearance.

Viral oncogenesis in cancer: from mechanisms to therapeutics

The year 2024 marks the 60th anniversary of the discovery of the Epstein-Barr virus (EBV), the first virus confirmed to cause human cancer. Viral infections significantly contribute to the global cancer burden, with seven known Group 1 oncogenic viruses, including hepatitis B virus (HBV), human papillomavirus (HPV), EBV, Kaposi sarcoma-associated herpesvirus (KSHV), hepatitis C virus (HCV), human T-cell leukemia virus type 1 (HTLV-1), and human immunodeficiency virus (HIV). These oncogenic viruses induce cellular transformation and cancer development by altering various biological processes within host cells, particularly under immunosuppression or co-carcinogenic exposures. These viruses are primarily associated with hepatocellular carcinoma, gastric cancer, cervical cancer, nasopharyngeal carcinoma, Kaposi sarcoma, lymphoma, and adult T-cell leukemia/lymphoma. Understanding the mechanisms of viral oncogenesis is crucial for identifying and characterizing the early biological processes of virus-related cancers, providing new targets and strategies for treatment or prevention. This review first outlines the global epidemiology of virus-related tumors, milestone events in research, and the process by which oncogenic viruses infect target cells. It then focuses on the molecular mechanisms by which these viruses induce tumors directly or indirectly, including the regulation of oncogenes or tumor suppressor genes, induction of genomic instability, disruption of regular life cycle of cells, immune suppression, chronic inflammation, and inducing angiogenesis. Finally, current therapeutic strategies for virus-related tumors and recent advances in preclinical and clinical research are discussed.

The prevalence of infection and potential risk factors for HBV and HCV among healthcare workers not vaccinated against HBV: A study from a cancer center in Egypt, 2021-2022

BACKGROUND AND STUDY AIM

South Egypt Cancer Institute (SECI) is the largest oncology university hospital in Upper Egypt. HBV and HCV are amongst the most important viral infections in cancer patients due to their impaired immunity. Nosocomial infection is among the most important sources of infections of these viruses. However, estimation for the prevalence of HBV and HCV infections among healthcare workers (HCWs) dealing with oncology patients as well as identifying HCV genotypes have not been recently investigated.

METHODS

The study consisted of a survey of HCWs in direct contact with blood as a part of their daily work. HCV/Ab, HBsAg and anti-HBc IgM were detected in 505 employees, RT-PCR was performed on HCV-positive persons.

RESULTS

Prevalence was 7.5 % for HCV with marked drop in younger age group and 2.0 % for HBV. The age groups affected were mostly from 30 to < 40 for HBV and ≥ 50 years for HCV. Three-quarters of anti-HCV-positive were also positive by RT-PCR. Males had significantly more HBV infections than females. Gender didn't affect the rates of HCV infection.HCV genotyping was determined in 20 HCWs who were positive for HCV-RNA. Except for only one, all infections were HCV genotype 4. The commonest place for exposure to HCV was the pediatric inpatient wards (14.3 %), while operation rooms and adult inpatient wards were the highest exposure places for HBV (5.1 % and 2.6 %, respectively).

CONCLUSIONS

The marked drop in the prevalence of HCV infection, as well as the relatively lower prevalence of HBV infection among HCWs provides evidence for the effectiveness of infection control measures applied in healthcare over the past few years.

EASL Clinical Practice Guidelines on the management of hepatitis B virus infection

The updated EASL Clinical Practice Guidelines on the management of hepatitis B virus (HBV) infection provide comprehensive, evidence-based recommendations for its management. Spanning ten thematic sections, the guidelines address diagnostics, treatment goals, treatment indications, therapeutic options, hepatocellular carcinoma surveillance, management of special populations, HBV reactivation prophylaxis, post-transplant care, HBV prevention strategies, and finally address open questions and future research directions. Chronic HBV remains a global health challenge, with over 250 million individuals affected and significant mortality due to cirrhosis and hepatocellular carcinoma. These guidelines emphasise the importance of early diagnosis, risk stratification based on viral and host factors, and tailored antiviral therapy. Attention is given to simplified algorithms, vaccination, and screening to support global HBV elimination targets. The guidelines also discuss emerging biomarkers and evolving definitions of functional and partial cure. Developed through literature review, expert consensus, and a Delphi process, the guidelines aim to equip healthcare providers across disciplines with practical tools to optimise HBV care and outcomes worldwide.

Prevalence of opportunistic infections in Syrian inflammatory bowel disease patients on biologic therapy: a multi-center retrospective cross-sectional study

BACKGROUND

Hepatitis B, hepatitis C, cytomegalovirus (CMV), and tuberculosis (TB) pose significant risks to patients with inflammatory bowel disease (IBD) receiving biological therapy. However, data on the prevalence of these infections in Syria are scarce.

METHODS

We conducted a retrospective chart review of IBD patients receiving biologic therapy at Damascus Hospital and Ibn Al-Nafees Hospital, two major public institutions in Syria, between January 2021 and November 2024. A minimum sample size of 130 was estimated; however, all available records were reviewed.

RESULTS

Among 185 IBD patients (104 from Damascus and 81 from Ibn Al-Nafees), 51.4% had ulcerative colitis and 47.6% had Crohn's disease. The smoking prevalence was 9.2%, which was higher in Crohn's disease (5.9%) than in ulcerative colitis (3.2%). TST performed in 61.1% of patients, with 4.3% positivity, and interferon-gamma release assay (IGRA) in 8.7% (1.1% positive). Hepatitis B surface antigen (HBsAg) and anti-HBc antibodies were found in 2.7% and 5.4% of the patients, respectively, while hepatitis C seroprevalence was low (0.5%). CMV seropositivity was high in Damascus (50.8%), with two cases (1.1%) of CMV colitis. Biologic therapies included infliximab (42.7%), ustekinumab (24.3%), golimumab (10.8%), and adalimumab (6.5%). Data gaps, particularly in viral serology and TB screening, are notable.

CONCLUSION

This study identifies deficiencies in TB/hepatitis B screening (notably anti-HBs Ab) and elevated CMV seroprevalence among Syrian IBD patients receiving biologics, extending to immunosuppressed cohorts (rheumatology, dermatology, oncology). Insufficient screening heightens occult infection/reactivation risks, necessitating standardized pretreatment protocols to reduce morbidity in high-risk populations.

CLINICAL TRIAL NUMBER

Not applicable.

Double reflex testing improves the efficacy and cost effectiveness of hepatitis delta diagnosis in southern Spain

This study aims to evaluate the prevalence of undiagnosed hepatitis delta in southern Spain (Andalusia) and assess the effectiveness and cost-efficiency of implementing reflex testing for hepatitis D detection in HBsAg-positive patients. A multicenter ambispective study was conducted in 17 Andalusian hospitals. The retrospective phase (January 2018-June 2022) analyzed diagnostic processes for hepatitis delta in HBsAg-positive patients. The prospective phase (October 2022-March 2023) implemented reflex testing, performing anti-HDV serology on all HBsAg-positive patients without prior testing. HDV RNA testing followed for those who tested anti-HDV-positive. In the retrospective phase, out of 18,583 HBsAg-positive patients, anti-HDV tests were performed on 3,436 (18%), identifying 205 (6%) positive cases. HDV RNA was tested in 158 (77%) anti-HDV-positive patients, with 69 (44%) testing positive. In the prospective phase, out of 2,384 HBsAg-positive patients without prior anti-HDV testing, 2,293 (96%) were tested, identifying 109 (4.7%) positive cases. HDV RNA was analyzed in 97 (89%) anti-HDV-positive patients, with 30 (31%) testing positive. Reflex testing increased anti-HDV detection by 77%, resulting in a fourfold increase in detecting anti-HDV-positive patients and a threefold increase in detecting HDV RNA-positive patients, reducing undiagnosed HDV RNA-positive cases to 4% compared to 45% with clinical practice. Cost analysis indicated a saving of €265,954 with reflex testing. Reflex testing improves HDV detection, reduces costs, and simplifies diagnosis, making it an efficient strategy for managing chronic hepatitis D patients.

Real-world clinical data-driven modelling on the initiation time of antiviral prophylaxis among pregnant women with chronic hepatitis B infection

BACKGROUND & AIMS

The risk of mother-to-child transmission for pregnant women with chronic hepatitis B (CHB) still exists, especially for those with high HBV DNA levels. The guidelines for initiating prophylaxis for pregnant women with CHB vary across countries. We aimed to explore the latest prophylaxis initiation time for these women.

METHODS

We collected the real-world clinical data of 328 pregnant women aged 20-49 with CHB, who were treated with telbivudine or tenofovir disoproxil fumarate, from July 2010 to December 2020 in China. A mathematical model was developed to describe the viral kinetics of HBV after prophylaxis. We calculated the time required to reduce viral load below the threshold value of 5.3 log10 IU/ml. We derived the prophylaxis initiation time by subtracting the required time to threshold from the childbirth gestational week.

RESULTS

The median time for 328 women to reduce HBV DNA levels below the threshold of 5.3 log10 IU/ml was 4.2 (range: 0.2-12.8) weeks, corresponding to a prophylaxis initiation time of no later than 35.1 (25.2-41.4) weeks. Specifically, for women with viral loads >8.0 log10 IU/ml, prophylaxis should be initiated before 33.9 (25.2-39.5) weeks, and even before the lower bound of 25.2 weeks, to maximize clinical safety. For women with viral load >7.0 to ≤8.0 log10 IU/ml, prophylaxis should be initiated before 35.5 (28.6-39.8) weeks, and for women with viral load >5.3 to ≤7.0 log10 IU/ml, prophylaxis should be initiated before 36.2 (28.3-41.4) weeks.

CONCLUSION

Pregnant women with HBV DNA levels >5.3 to ≤8.0 log10 IU/ml can initiate prophylaxis before 28 gestational weeks. However, women with HBV DNA >8.0 log10 IU/ml could consider initiating prophylaxis before 25 weeks.

IMPACT AND IMPLICATIONS

This study investigates how long it takes to decrease maternal viral load below a threshold (5.3 log10 IU/ml) after receiving antiviral prophylaxis in pregnant women with different HBV DNA levels based on real-world clinical data and mathematical modelling, which provides quantitative evidence on the initiation time of antiviral prophylaxis. The results show that pregnant women with CHB infection at high HBV DNA levels (>8 log10 IU/ml) should initiate antiviral prophylaxis earlier to decrease the risk of mother-to-child transmission of HBV. Physicians can determine when to begin antiviral prophylaxis for those women according to their maternal HBV DNA levels. Our findings justify the initiation time of antiviral prophylaxis recommended by the Chinese guidelines and will offer new insights for other international guidelines.

The 2024 updated WHO guidelines for the prevention and management of chronic hepatitis B: Main changes and potential implications for the next major liver society clinical practice guidelines

Progress towards global elimination of hepatitis B virus (HBV) has been slow and most countries are far from reaching the elimination targets set out by the World Health Organization (WHO). The burden of chronic hepatitis B is mainly borne by resource-limited countries where only a minority of people living with HBV are diagnosed and treated, and international guidelines are hardly applicable in real-life. In March 2024, the WHO released its revised guidelines for the prevention and management of chronic hepatitis B. Simplification of care and expansion of treatment criteria represent the core of this revision. Whether and how these updated WHO guidelines will influence the next hepatitis B recommendations from the international liver societies (EASL, AASLD and APASL) remain uncertain. Yet, the European, American and Asian regions encompass multiple low, middle and intermediate-income countries with high HBV endemicity and vulnerable populations that should benefit from simplified clinical algorithms. Here, from an analysis of the WHO guideline development process and its new recommendations, we aimed to identify the anticipated areas of agreement and controversies with the next liver society hepatitis B guidelines, which will have to balance clinical risks and benefits for patients.